Professional Documents
Culture Documents
Tube Issues
Blocked tube
Causes:
To unblock the gastrostomy tube, flush it with 10 - 20 ml of a carbonated drink such as mineral water
or diet cola. Sometimes the blockage can be aspirated out using a syringe.
Peri-stomal Issues
Related to the relative sizes of the tube and stomal tract. If the tube is too small for the opening, it may
need replacement with a larger tube.
Skin excoriation
Gastric secretions leaking around the gastrostomy can result in skin excoriation. There are two
methods of minimising irritation to the skin:
Granulation tissue
Granulation tissue usually occurs about 6 weeks post surgery. It may be caused by the tube moving
too freely. If this is the case an anchor device eg FlexiTrak can be useful.
Infections
Candida; under the skin flange, use topical antifungal preparations eg clotrimazole or nystatin.
Cellulitis(see photo); is normally due to staphylococcal infection (but can involve enteric
flora) and appropriate antibiotics should be given eg oral or intravenous flucloxacillin. If
the site is very swollen, the tube may have to be removed to relieve pain. If there is
discharge from the site, a skin/wound swab should be sent for microscopy and culture
prior to commencing treatment.
Urinary dipsticks are very sensitive and can be positive at <5 RBCs per high-power field.
Red or brown urine does not always indicate haematuria (haemoglobinuria, myoglobinuria, medication,
and food).
Urate crystals are commonly present in the urine of newborn babies. They can produce a red
discolouration of the nappy ("brick dust" appearance) which is sometimes mistaken for blood.
Blood in the urine may come from sources other than the urinary tract (eg vaginal haemorrhage, rectal
fissure).
Common causes for microhaematuria include in association with viral infections, UTI, Trauma, HSP.
If you find microscopic haematuria in the setting of an acute febrile illness, exclude UTI by urine culture
and arrange for the urine to be tested again after the acute illness has passed.
Common causes for macroscopic haematuria include the above. It is more likely to come from the
bladder or urethra.
Symptomless or "Benign Haematuria" in children without growth failure, hypertension, oedema,
proteinuria, urinary casts or renal impairment is a frequent finding.
In the emergency department it is important in evaluating a child with haematuria to identify serious,
treatable and progressive conditions.
Many children with isolated microscopic haematuria require no immediate investigation and simply
need to be checked to see if the problem persists. This should be arranged with the general
practitioner or through outpatient clinic if the family do not have a GP.
Introduction
Headache is a common symptom in children, affecting 80-90% by age 15. The common causes are
systemic illness with fever, local ENT problems, migraine and tension headache. Meningitis, raised
intracranial pressure (ICP) from tumours etc. and subarachnoid haemorrhage (SAH) are much rarer
causes but these need to be considered.
Assessment
History
It is useful to classify headache as acute or recurrent. The following list gives the causes and key
features to help make a diagnosis, based on careful history and examination:
Acute
Recurrent
See Headache Patterns (it may be helpful to show the child / family this chart and to ask them to
identify the pattern themselves)
Examination
Investigations
In the acute situation, the two most important questions to answer are:
Does the child need a CT scan of the head? Should a lumbar puncture (LP) be performed?
1. If the child has altered state of consciousness, focal neurological signs, raised blood pressure,
or papilloedema, there is a need for urgent assessment with consideration of CT scan of head
+/- acute management of raised ICP. (discuss with consultant).
2. Consider LP (in the absence of the contraindications) if concerned about meningitis or SAH.
May need CT scan first (discuss with consultant).
3. If there are no symptoms and signs suggesting raised ICP/SAH/meningitis and the story is
suggestive of migraine then treat symptomatically (see below).
4. If other causes apparent consider appropriate investigations. (eg. septic screen, urea,
carboxyhaemoglobin or lead level [wrist X-rays], blood sugar profile).
Management
If there is a specific diagnosis such as meningitis, SAH, tumour, systemic infection or local infection,
then treat as appropriate. Most recurrent headaches can be managed by a paediatrician and do not
need to be referred to a neurologist.
Migraine:
Abort attack
Avoid opiates
Initially simple oral analgesics such as paracetamol (20mg/kg stat then 15 mg/kg/dose 4H
(max 4g/day) or codeine (1 mg/kg/dose 4 hrly) or NSAID(ibuprofen 2.5-10mg/kg/dose 6-8
hrly)
Adolescents - 1g of aspirin, 1g of paracetamol, 10 mg of metoclopramide.
* If vomiting is a prominent feature in children over 10 years slow IV prochlorperazine (0.1-
0.2mg/kg).
In older children consider slow IV chlorpromazine (0.25-1mg/kg/dose: max 50mg).
Prophylaxis
Migraine headache
Migraine is a disorder that causes repeated headache. Some children get only occasional
attacks, while others get them more than once a week. The headaches can range from
being mild to very severe.
Migraines happen when blood vessels of the head and neck spasm or become narrow
(constrict). Minutes to hours later, the blood vessels enlarge (dilate). When they dilate,
they fill with blood which causes more pressure in the skull, and so, a headache.
Migraine headaches happens in about 6 out of 100 people. They are common in children.
In many cases they appear to run in the family.
Migraine is not a serious or life-threatening disorder. It is painful and annoying at the
time, but it is not usually a serious problem. About half of children who get migraines
will continue to have them when they are adults.
Dull or throbbing
All over or worse on the sides of the head
On only one side of the head
Severe or mild.
Doctors can usually make the diagnosis of migraine after carefully listening to the story
and examining your child. In a very small number of children, tests may be done to
exclude other causes of headache. Most children do not need any tests, and there are no
tests which prove the diagnosis of migraine.
Causes
Being tired
Bright lights
Loud noises
Relaxation after physical or mental stress
Muscle tension over a long time
Smoking, or breathing tobacco smoke
Missing meals
Drinking alcohol
Caffeine (found in coffee, many energy drinks and some medicines)
Menstrual periods
Using oral contraceptives (the pill)
Other conditions.
Food
In only a few children, migraine can be triggered or started by certain foods such as:
Food containing the amino acid tyramine (red wine, aged cheese, smoked fish, chicken livers,
figs, some beans).
Chocolates
Nuts
Peanut butter
Fruits (avocado, banana, citrus fruit)
Onions
Dairy products (milk, yoghurt, cheese)
Baked goods
Meats containing nitrates (bacon, hot dogs, salami, cured meats)
Foods containing monosodium glutamate (MSG), an additive in many foods
Any processed, fermented, pickled, or marinated foods.
However, for most children, changing the diet does not help.
Treatment
There is no cure for migraine. Anything that has triggered a migraine in the past should
be avoided if possible. The goals of treatment are to control your child’s symptoms and
prevent further migraines.
Care at home
Migrane headache is painful and annoying at the time, but it is not usually a serious problem.
There is no cure for migraine.
Anything that has triggered a migraine in the past should be avoided if possible.
Head injuries are common in children of all ages. Causes include falls, sporting accidents, road traffic
accidents and non-accidental injury.
Assessment:
Perform a primary survey and ensure that the child’s airway, cervical spine, breathing and circulation
are secure.
Rapidly assess the child’s mental state using the AVPU scale. Use firm supraorbital pressure as the
painful stimulus.
A Alert
V Responds to voice
P Responds to pain
Purposefully
Non-purposefully
Withdrawal/flexor response
Extensor response
U Unresponsive
Assess pupil size, equality and reactivity and look for other focal neurological signs.
View flowchart
Orientated
Spontaneous 4 5
Appropriate words or social smile, fixes, follows
Confused
To speech 3 4
Cries but consolable
Inappropriate words
To pain 2 3
Persistently irritable
Incomprehensible words
Nil 1 2
Restless & agitated
Nil
1
Nil
Motor response
Obeys commands 6
Localises to stimuli 5
Withdraws to stimuli 4
Abnormal flexion 3
Extensor responses 2
Nil 1
Management
No loss of consciousness
One or less episodes of vomiting
Stable, alert conscious state
May have scalp bruising or laceration
Normal examination otherwise
These children may be discharged from the Emergency Department to the care of their parents.
If there is any doubt as to whether there has been loss of consciousness or not, assume there has
been and treat as for moderate head injury.
Ensure the parents have clear instructions regarding the management of their child at home especially
to return to hospital immediately if their child:
Give parents a Head Injury Parent Information Sheet to reinforce your advice.
If, on the history from the parents and ambulance, the child is not neurologically deteriorating they may
be observed in the Emergency Department for a period of 4 hours with 30 minutely neurological
observations (conscious state, PR, RR, BP, pupils and limb power).
The child may be discharged home if there is improvement at 4 hours to normal conscious state and
no further vomiting (child should be able to tolerate oral fluids in the Department). Head Injury Parent
Information Sheet should be given to the parents.
A persistent headache, large haematoma or possible penetrating wound may need further
investigation, discuss with consultant.
If the child is still drowsy or vomiting at 4 hours or there is any deterioration during this time, discuss
with a neurosurgeon regarding admission and further investigation.
Prevent secondary brain insults by maintaining a patent airway, adequate ventilation and
oxygenation and avoiding hypotension.
Cervical spine immobilisation should be maintained even if the lateral cervical spine x-ray is
normal.
Ensure early neurosurgical and ICU intervention.
In consultation with the neurosurgeon consider measures to decrease intracranial pressure:
Nurse 20-30 degrees head up (only after correction of shock)
Ventilate to a pCO2 35mmHg
Consider mannitol 0.5-1g/kg IV
Ensure adequate blood pressure
Control seizures (see Convulsions guidelines)
Arrange urgent head CT.
Head injury
Children have many bangs to the head and it can be difficult to tell whether they are serious or not. If
your child has received an injury to the head, you should see a doctor.
A head injury is any knock to the head that causes lumps, bruises, cuts or more severe injuries to your
child's head. Many head injuries are not serious and simply result on a bump or bruise. Occasionally
head injuries can result in damage to the brain.
Your child has had a hard bang to the head, such as falling off something high or from a car
accident.
Your child losses consciousness.
Your child seems unwell and vomits several times after.
The symptoms of head injuries are used to determine how serious it is. Head injuries can be classified
into minor, moderate or serious.
You should call an ambulance immediately if your child has a severe head injury.
Most children with minor head injury make a full recovery. Most small knocks just cause bruising and
pain for a short while.
Apply ice or a cool wash to the area injured to help reduce the swelling.
If your child has a cut, apply a clean dressing and press on it for about 5 mins. Cuts to the
head will often bleed a lot.
Headache. Your child may have a headache. Give paracetamol every 4-6 hours if needed to
relieve pain
Vomiting. Your child may have vomited once but if vomiting continues, go back to your
doctor.
Drowsiness. Immediately after the head injury your child may be sleepy.
There is no need to keep your child awake if they want to sleep. If your child does go to sleep,
wake them every half to one hour to check their condition, and their reaction to familiar things.
You should do this until they are no longer drowsy and have been awake and alert for a few
hours.
Some questions you could ask are:
- Do they know where they are?
- Do they know familiar people’s names?
- Do they know which day it is?
- Or if they are very young: Do their reactions seem appropriate? ie. Reaching out for a
dummy. Are they interactive and not too irritable?
If you have any difficulty waking your child, take them to the nearest emergency
department or call an ambulance.
If your child's behaviour is very different to their normal behaviour, or the pain does not go away, go
back to your doctor.
Follow up
Some problems that may result from a minor head injury can be hard to detect at first. In the next few
weeks parents may notice:
Irritability
Mood swings
Tiredness
Concentration problems in their child
Behavioural changes.
Talk to your doctor if you are worried about any of these signs.
If your child has received an injury to the head, you should see a doctor.
Apply ice or a cool wash to the area injured to help reduce the swelling.
Henoch-Schonlein Purpura
Introduction
purpuric rash on the extensor surfaces of limbs (mainly lower) and buttocks,
joint pain/swelling and
abdominal pain.
Abdominal pain or arthralgia sometimes precede the rash.The commonest age group is 2 - 8 years.
The cause is unknown but there may be a recent history of an upper respiratory tract infection.
Assessment
Investigations
Urine analysis should be performed, and if haematuria is present the sample should be sent for
microscopy to quantify the RBC count.
Management
All patients presenting with a purpuric rash must be seen by a consultant or registrar, even if the child
does not appear unwell.
Disposition
If discharged from the ED then it is imperative that appropriate follow-up is arranged to ensure
adequate symptom control and resolution of the disease. Short term support can occur in the ED but
follow-up care should soon be transferred to the GP (emphasise the need for ongoing BP and urine
review in the letter) or a paediatrician - an appointment may be made in the General Medical
Outpatient Clinic. The rash is usually the last manifestation to remit and appears to worsen if the child
is very active. Some recommend an annual BP and urinalysis for life.
As the renal involvement can present up to six months after the initial presentation the urine should be
checked regularly for that period. The blood pressure should be checked twice during that time. If the
child has persistent renal involvement they should be referred to a paediatrician, or paediatric
nephrologist for long term follow up.
Henoch-Schönlein Purpura causes blood vessels to get inflamed (irritated and swollen). This
inflammation is called vasculitis. It usually affects the small blood vessels in the skin causing a rash
that is called purpura. It can also affect blood vessels in the intestines and the kidneys.
The cause of HSP is unknown. It might be triggered by bacterial or viral infections, medicines, insect
bites, vaccinations or exposure to chemicals or cold weather. It occurs most often in the spring, usually
after an upper respiratory infection, like a cold.
HSP usually affects children from two to ten years of age, but it can happen in anyone. HSP itself is
not contagious. Doctors don't know how to prevent HSP yet.
Skin rash. The rash looks like small bruises or small reddish-purple spots. It's usually on the
buttocks, on the legs and around the elbows.
Swelling. Many children with HSP also have swelling over the backs of the feet and hands,
and the scrotum in boys.
Pain in the joints (such as the knees and ankles).
Stomach pain.
Blood in the stool (poo) or urine, caused by the blood vessels in the bowel and the kidneys
becoming inflamed. Serious kidney problems don't happen very often, but they can occur.
In rare cases, an abnormal folding of the bowel called intussusception can occur. This causes
a blockage in the intestines that may need surgery.
Treatment
There is no specific treatment for HSP. Medicines can help your child feel better or treat an infection
that may have triggered HSP.
Fortunately, HSP usually gets better without any treatment. Painkillers (eg paracetamol) or anti-
inflammatory medicines (eg ibuprofen) can help the joint pain. Your doctor may recommend a drug
called prednisolone (cortisone). This can help people with severe stomach pains or very painful joints.
It may also be helpful in preventing kidney problems.
Usually, HSP gets better on its own and doesn't cause lasting problems. About half of people who had
HSP once will get it again. A few people will have kidney damage because of HSP. This may occur in
the first week or so of illness, but there may be a delay of weeks or months before it appears. Your
doctor will want to check urine samples and blood pressure several times after the HSP goes away to
check for kidney problems. These checks should go on for at least six months and some doctors
recommend a BP and urine check every year for life.
HSP causes inflammation of the small blood vessels in the skin causing a rash.
HSP can also affect blood vessels around the kidneys and intestines.
HSP occurs most often in children from 2-10 years.
The cause is unknown.
Paracetamol and anti-inflammatory drugs help painful joints and general discomfort.
Prednisolone may be prescribed.
Return to your doctor for increasing pain,swelling, blood in the stools (poo) or urine or if you
are worried at all.
Long term follow-up for urine and blood pressure checks are very important.
Return to your doctor or the hospital if your child gets increasing stomach pains or swelling, blood in
the stools or urine, or if you are worried for any other reason.
NOTE: Transient synovitis is a diagnosis of exclusion (see conditions below and Acutely Swollen Joint
Guidelines). Symptoms of irritable hip overlap with those of septic arthritis, if there is any doubt as to
the diagnosis then consultation with orthopaedics should be sought.
Perthes disease
Investigations
FBE
Usually normal in the above conditions
ESR
Usually normal in the above conditions
Xray
Normal in transient synovitis
Density of femoral head, patchy osteolysis with variable degree of femoral head
deformity in Perthes.
"Frog Lateral" x-rays of the affected hip will reveal slipped capital femoral epiphysis.
Ultrasound
In consultation with orthopaedics -may show fluid in transient synovitis
Bone scan
In consultation with orthopaedics.
Disposition
Children with transient synovitis may be managed with simple analgesics and bed rest.
Occasionally these patients may require admission for bed rest and traction.
All patients with Perthes disease and Slipped Capital Femoral Epiphyses should be referred to
orthopaedics.
HSV Gingivostomatitis
Background
Assessment
Diagnosis
Management
Analgesia
Specific treatment
Notes
Background
Primary Herpes simplex virus (HSV) infection in children is usually asymptomatic or non- specific.
Herpetic gingivostomatitis is the most common specific clinical manifestation, occurring in 25% to 30%
of cases
Assessment
Diagnosis
Management
Analgesia
Pain relief is of paramount importance in HSV gingivostomatitis
Topical analgesics are effective but may be expensive eg Xylocaine Viscous®, Lignocaine gel
2%®
Regular analgesics such as paracetamol seem to have little effect, although Codeine
containing medications may be beneficial eg Painstop®
Specific Treatment
Notes
Central nervous system involvement, although rare, can occur with HSV and should be
considered in patients who are unusually lethargic or who have abnormal neurological
findings see flow chart
Appendix
Material required:
(Available from the RCH Virology Lab 8th floor)
Method of collection:
4. After the vesicular fluid is removed for isolation, lift the loose flap of skin and roll the second
sterile swab back and forth across the base and under the flap. Holding a clean 3 well slide by
the frosted end, painted side up, smear the sample onto the wells. Use a circular motion and a
new surface of the swab for each well. (Shown in Diagram 2).
5. Immerse and break the second swab into Viral Transport Medium for viral isolation studies.
Hydrocarbon Poisoning
See also General Management of Acute Poisoning Guideline
Assessment
a. Asymptomatic
o Observe 6hours
o Discharge if remains asymptomatic
o Arrange review by LMO the following day
b. Symptomatic
o If develops respiratory symptoms (aspiration), do CXR & O2 saturation
o Give O2 to maintain saturation > 94%
o If stable, admit to general medical ward
o If increasing O2 requirements or increased respiratory distress contact I.C.U. (5212)
o If altered conscious state at any time contact I.C.U. (5212)
Hypernatraemia
Definition
Background
Assessment
Signs are more severe with acute rapidly developing hypernatraemia than with chronic
hypernatraemia. Chronic hypernatraemia is often well tolerated because of cerebral compensation.
Severe symptoms mainly develop when the serum [Na+] > 160mmol/l.
Signs
The true degree of dehydration (as assessed by recent weight loss) is often underestimated if an
assessment is based on external clinical signs of dehydration alone. In hypernatraemia the child
appears sicker than expected for the clinical signs of dehydration that are present. Shock occurs late
because intravascular volume is relatively preserved. Signs of hypernatraemic dehydration tend to be
predominately those of intracellular dehydration and neurological dysfunction:
Lethargy
Irritability
Skin feels "doughy"
Ataxia, tremor
Hyperreflexia, Seizures, reduced GCS
Management
If the patient is "shocked", volume resuscitation with 0.9% saline as required with 20ml/kg bolus/es.
Too rapid reduction of the sodium in hypernatraemia can cause cerebral oedema, convulsions
and permanent brain injury. The aim is to lower the serum [Na+] slowly at a rate of no more than
12mmol/L in 24 hours, (0.5mmol/L/hour).
A slower rate will be required for children with chronic hypernatraemia (present for more than 5 days).
Calcium and glucose need to be checked as hypernatraemia, can be associated with hypocalcaemia
and hyperglycaemia, these conditions need to be corrected concurrently.
After initial resuscitation, replace the deficit plus maintenance slowly at a uniform rate over 48 hours.
Use nasogastric oral rehydration solution (Gastrolyte), but remember that Gastrolyte has a
sodium concentration of 60mmol/L. Carefully regulate fluid intake, do not rely on the child or
parent to regulate intake. If the serum sodium falls too rapidly slow the rate or rehydration or
change to intravenous fluids.
After initial resuscitation, aim to replace deficit and maintenance with 0.9% NaCl + 5% dextrose over
72 - 96 hours.
Notes
If seizures or other signs of cerebral oedema occur during treatment, check the serum sodium. If
there has been a rapid fall it may be necessary to give hypertonic saline to partially reverse the
reduction in serum sodium. Seizures may be due to venous sinus thrombosis or cerebral infarction. Do
a contrast CT scan.
Measure ongoing losses (except urine) and replace ml for ml with normal saline.
Hypertension
These values are for children on the 50th centile for height
BP Centile Charts
Boys Chart
Girls Chart
Causes
Essential hypertension
Obesity may complicate the accurate measurement of blood pressure and be a contributing factor.
Secondary causes
Assessment
Investigation
Further investigations may include: urinary catecholamines, chest X-ray, ECG, renal ultrasound,
gluconate scan, plasma renin pre- and post- captopril, thyroid function tests, cortisol / aldosterone
levels, 17-hydroxy progesterone, renal angiography.
Management
Asymptomatic hypertension
No treatment required acutely. Investigate and manage as out-patient. Refer to General Paediatric
Outpatient Clinic.
Antihypertensives
Pyloric Stenosis
Background
Hypertrophic Pyloric Stenosis (HPS) is due to progressive thickening of the circular muscle of the
pylorus. This leads to gastric outlet narrowing.
Risk Factors:
Male
Firstborn
Caucasian
Parental history of HPS (higher if mother affected)
Assessment
History:
Vomiting
progressively more forceful and may be projectile
non-bilious
blood stained in up to 10% of cases
Usually don't have diarrhoea
Often hungry afterwards
Weight loss or inadequate weight gain
Examination:
Investigations:
Take blood for FBE, U&E, Acid-Base, Glucose (bilirubin if jaundice present)
Hypochloraemic Hypokalaemic Metabolic Alkalosis may be seen.
If diagnosis not yet established, abdominal ultrasound is the investigation of choice (95%
sensitive).
Management
Fluid resuscitation may be necessary with 10-20ml/kg boluses of normal saline, for patients
with moderate to severe dehydration
Commence IV Fluids (0.45% Saline / 5% Dextrose + 10mmol KCl / 500mls) at 100mls/kg/day
initially. Review after 4-6 hours (see below).
Stop oral feeds
Insert a nasogastric tube if vomiting continues despite stopping feeds. Replace nasogastric
losses with IV normal saline
Repeat U&E, Acid-Base 4-6 hourly initially and adjust fluid accordingly. The aim for most
infants should be to fully correct fluid and electrolyte deficits within 48 hours.
Initial KCl may be required if significant hypokalaemia
Replace deficit, in addition to maintenance, in those infants who are clinically dehydrated
(weight is a good marker of the degree of dehydration)
Notes
Correction of HPS is not an emergency, and should not be undertaken until normal
electrolytes and pH have been restored and the infant is rehydrated
It is particularly important to fully correct serum bicarbonate before theatre because of the risk
of hypoventilation/ apnoeas post-operatively in the setting of metabolic alkalosis.
Operation is Ramstedt's Pyloromyotomy (may be done laparoscopically in some cases)
Feeding is usually restarted within 6 hours post-op. Some children will continue to vomit for
several days. Infants are usually discharged within 3 days.
Re-stenosis can occur, but is uncommon (1-2%).
See Parent handout
Hypoglycaemia Guideline
Background
Beyond the neonatal period, hypoglycaemia is defined as a blood glucose less than
2.5mmol/l.
There should be a low threshold for performing a dextrostix in the acutely unwell child.
Assessment
Effects
Causes
Measure height and weight. Look for midline defects, micropenis, optic nerve hypoplasia
(hypopituitarism), cataracts (galactosaemia), hepatomegaly (glycogen storage disease) and
hyperpigmentation (adrenal insufficiency).
Hemihypertrophy, exomphalos, macroglossia and transverse ear creases (Beckwith
syndrome).
Investigation
Blood
Urine
Management
Symptomatic hypoglycaemia should be treated with an i.v. bolus of 1-2ml/kg 25% Dextrose (0.25-
0.5g/kg Dextrose). The expected maintenance infusion rate is 3-5ml/kg/hr of 10% Dextrose (6-
8mg/kg/min). A required infusion rate of 10-20mg/kg/min is consistent with hyperinsulinism.
Notes
Hyperinsulinism is the commonest cause of hypoglycaemia under two years old. This
diagnosis is excluded by ketonuria.
"Accelerated starvation" (ketotic hypoglycaemia) classically manifests itself between the ages
of 18 months and 5 years, and generally remits spontaneously before 8 or 9 years of age. A
presumptive diagnosis is made by documenting a low blood sugar in association with
ketonuria, ketonaemia and typical symptoms of hypoglycaemia. The definitive diagnosis is
established by demonstrating an inability to tolerate a provocative ketogenic diet, or a fast.
Susceptible or affected children develop severe hypoglycaemia and ketosis on this diet within
24 hours.
Hyponatraemia
Definition
Background
Prevention
Special attention should be paid when administering intravenous fluid to children with conditions
associated with high ADH levels and impaired free water excretion (see above). (see IV Fluids
guideline)
Assessment
Most children with mild to moderate hyponatraemia are asymptomatic or manifest the symptoms of the
underlying disease (bronchiolitis, meningitis etc). The symptoms and signs of severe hyponatraemia
are predominately neurological:
Headache
Nausea, vomiting
Lethargy or irritability
Hyporeflexia
Decreased conscious state
Seizures
If Na+ <130 mmol/L: measure serum potassium, chloride, urea, creatinine and glucose.
Management
The ideal rate of serum sodium correction depends on the presence and severity of symptoms.
Correction that is too rapid (>8 mmol/L Na+/24h) can result in cerebral demyelination, especially of the
pons, with risk of severe and lasting brain injury. This is especially a risk if hyponatraemia has been
present for more than 5 days and is rapidly corrected.
Active correction of hyponatraemia (e.g. with 3% NaCl) is not necessary. Allow the plasma sodium
concentration to rise at no more than 8 mmol/L per day using the guidelines below, based on hydration
state. Continue correction to 135 mmol/L.
1. The child with normal or increased volume status
Try nasogastric rehydration. When using Gastrolyte, remember that it contains 60mmol/L of sodium;
rapid re-hydration may make the Na+ fall faster than is safe.
If NG rehydration is not possible or results in a too rapid fall in sodium give iv 0.9% NaCl (see severe
dehydration below).
Give iv 0.9% NaCl (plus 5% glucose) until the child can take enteral feeds.
Hyponatraemia occurs because high plasma glucose increases serum osmolarity, causing a shift of
water from the intracellular space into extracellular fluid. The reduction in blood glucose after
beginning treatment may correct the hyponatraemia, through a shift of water back to the intracellular
space. However if the serum sodium fails to increase as the glucose falls hyponatraemia should be
actively corrected. This will prevent a reduction in serum osmolality, which carries an increased risk of
cerebral oedema. Using 0.9% NaCl solution as the fluid for DKA resuscitation will generally maintain
the osmolarity. (see DKA guideline).
Background
ITP is an acquired thrombocytopenia due to immune mediated shortened circulating platelet survival in
the absence of other disturbances of haemostasis or coagulation. In most childhood ITP platelet
autoantibodies are absent.
1. Acute (~ 90%): self limiting disease (sometimes preceded by a viral syndrome) with
spontaneous resolution within 6 months (usually within 2 months).
2. Chronic (~ 10%): does not remit within 6 months.
Management
Without active treatment, most patients platelet counts will return to a level at which normal activity can
be recommenced within 4-6 weeks. Oral steroids bring up the platelet count more quickly than occurs
spontaneously but there is no evidence for an effect on significant morbidity, risk of chronic ITP, or
mortality.
At RCH, the on-call General Paediatric consultant is responsible for deciding on the treatment
plan.
Most patients with a platelet count > 20,000 x 106/l and some of those with a platelet count < 20,000 x
106/l can be managed as outpatients with no specific treatment. The following criteria must be met:
a. If the diagnosis of ITP is not certain (eg. the blood film result is not available) or any other of
the above criteria are not met, then admission under the General Medical unit of the day is
necessary.
b. The decision as to whether to treat patients who do not have active bleeding will be made by
the unit consultant.
Treatment As An Inpatient
a. Any patient with ITP who has active bleeding (oral, aural, nasal, rectal, etc) even if resolved
should be admitted and considered for oral prednisolone (2-4 mg/kg/day for 2 weeks then
tapered).
Normal human immunoglobulin is also effective but is not usually used for initial treatment
(Administration of Intragam Guideline)
Notes
In some cases, thrombocytopenia will redevelop months or years after the first episode has resolved.
These relapses or recurrences are usually precipitated by viral infections. Provided the first episode
remitted spontaneously without complication and the patient has been well with a documented normal
platelet count between episodes, these cases can be managed as for acute ITP.
Chronic ITP
Ongoing thrombocytopenia after a 6 month period denotes chronic ITP. A history of bruising from
infancy should prompt suspicion of one of the rare congenital thrombocytopenias. Careful inspection of
the blood film and tests of platelet function will serve to exclude other diagnoses. Bone marrow
examination may behelpful in confirming chronic ITP.
The disease is caused when the spleen and lymph tissues produce antibodies against platelets.
Antibodies are proteins that are produced by the immune system. The antibodies destroy the platelets
in the spleen. We do not fully understand why the body produces this reaction. In children, the disease
is sometimes preceded by a viral infection (eg a cold), and this seems to be a trigger for the production
of abnormal antibodies.
ITP is more common in children than adults. ITP occurs in 1 out of every 10,000 children, so it is
still quite rare.
It is important for you to know that the risk of any serious complication from ITP is very low.
In most children the condition will settle down quite quickly. The platelet count is often up to safe levels
within a week or two, but it may take longer to fully return to normal. In a very small number of children
the platelet count does not return to normal even after 6 to 12 months, and further treatment may be
advised.
Bruising
Nosebleeds or mouth bleeding
Petechial rash (pinpoint red spots) on the skin
Treatment
There are several treatment options which your childs doctor will discuss:
No treatment - this is a good option for many children. The condition will get better
spontaneously.
Steroids (prednisolone) - this can raise the platelet count more quickly than would occur with
no treatment.
Intravenous gamma globulin - sometimes used, but may have side effects
Your doctor will discuss the best treatment option for your child. You may need to attend for blood
tests every few days to monitor the progress of the condition. It is important that you attend follow up
appointments.
Care at home
Children with ITP should not take aspirin or ibuprofen (another pain killer), because this may
provoke bleeding. Paracetemol is quite safe.
While the platelet count is very low, your child may be advised to not do activities which might
cause bruising or bleeding (eg stay off the climbing equipment, bicycles etc) .
As the platelet count rises, more activity will be allowed, but contact sports, cycling and other
rough physical activity may need to be avoided until your child's doctor advises.
Bleeding disorder when the blood has difficulty clotting because of a shortage of platelets
More common in children than adults
Most cases will settle quickly with no treatment
Serious complications are very rare
Birth HepB
DTPa-IPV
2 Hib-HepB Pneumococcal Rotavirus
(Infanrix-
months (Comvax) (Prevenar) (Rotateq)7
IPV)
DTPa-IPV
4 Hib-HepB Pneumococcal Rotavirus
(Infanrix-
months (Comvax) (Prevenar) (Rotateq)
IPV)
DTPa-IPV
6 Pneumococcal Rotavirus
(Infanrix- 1 6
months (Prevenar) (Rotateq)
IPV)
12 Hib-HepB MMR Meningo
months (Comvax) (Priorix) C2
(Neisvac C)
18 Varicella
months (Varilrix) 3
DTPa-IPV
MMR
4 years (Infanrix-
(Priorix)
IPV)
Varicella
year 7 HepB 5
(Varilrix) 4
dTpa
year 10
(Boostrix)
^ Back to schedule
See also
New Vaccines
Rotavirus vaccine fact sheet (for providers)
The Rotavirus vaccine was registered for use in Australia last year, and the Pharmaceutical Benefits
Advisory Committee (PBAC) recommended it be included in a National Immunisation Program. It is
likely that the vaccine will be funded and commence as part of the National Immunisation Program in
2008. Administration of a course of Rotavirus vaccination is recommended for all infants in the first
half of the first year of life, and currently this can be purchased from a pharmacy with prescription or
by sending the patient and family to the RCH Immunisation Service.
The Human Papilloma Virus (HPV) vaccine is registered for boys aged 9-15 years and girls aged 9-26
years. There is no current funding for boys and from April 2007 the Australian Government is funding
the vaccine for girls and women aged 9-26 years. The following age categories will be targeted from
April 2007;
12-13 years as part of a Year 7 secondary school program (which will be ongoing)
13-18 years (catch-up secondary school immunisation program, funded for 2 years)
18-26 years (catch-up funded for 2 years)
Children who are due or overdue for their immunisations can be safely and effectively immunised
during their hospital stay or at the time of an outpatient presentation.
Background
How should we do it?
Where should we do it?
Immunisation procedure
Background
8-10% of Australian infants, and up to 15% of older children are not up-to-date with their
immunisations
All vaccines can be safely given while an inpatient. Oral polio should be given at the time of
discharge, or IPV (injectable polio vaccine) can be used.
All children presenting to the hospital should have an immunisation history taken.
If parents are unsure about previous immunisations check the child’s Personal Health
Record (yellow book) or contact the Australian Childhood Immunisation Register
(ACIR) on 1800 653 809 (NB parent’s consent and child’s Medicare number are
required for this)
Children who are not up-to-date should be offered the appropriate vaccines while still in
hospital.
True contraindications to immunisations are very rare, and can be discussed with a nurse
from the Immunisation Service.
See Catch-up immunisation for information on planning a catch-up schedule
All vaccines on the schedule are available in the after hours drug room (in the fridge)
Immunisations and their batch numbers should be documented on Treatment orders sheet.
In Outpatients
Children can be immunized in the Immunisation Drop-in Centre near the front entrance during
working hours
Contact the Immunisation nurses on ext 6599 or page 4330 (intranet only)
On the Wards
Immunisation Procedure
Intravenous Immunoglobulin
Intravenous Immunoglobulin (IVIG) is used in the management of an increasingly wide range of
diseases. IVIG is primarily used as a source of antibody replacement in primary
immunodeficiencies and to modulate the immune system in autoimmune and inflammatory diseases.
Intragam P is the primary IVIG supplied within Australia and is manufactured by CSL from the plasma
of Australian volunteer blood donors. Due to a marked and sustained increase in the use of IVIG, CSL
is no longer able to supply enough Intragam P to meet demand. The National Blood Authority has
sourced an overseas IVIG (Octagam) that will be utilised during times of shortage of Intragam P.
Octagam is now stocked and distributed by the Australian Red Cross Blood Service (ARCBS).
Patients currently receiving Intragam P for ongoing conditions will continue to receive Intragam P
whenever possible. New patients will be issued either Intragam P or Octagam depending on
availability of stocks, with an attempt to maintain individual patients on the same products.
Administration
Do not use after expiry date. If the product is turbid by transmitted light or contains any sediment it
must not be used. Allow it to reach room temperature prior to infusion. IVIG does not need to be mixed
or diluted with any solution - it is given in pure concentrated form. It is not necessary to flush the line
with saline between different batches. The IV line may be flushed through with 20mls of normal saline
at the completion of the infusion to ensure the whole dose is administered.
Administration Rate
Intragam P
Start at 1ml/kg/hr (60mg/kg/hr) and increase at 30 min intervals up to 4ml/kg/hr (240mg/kg/hr), with a
maximum rate of 240ml/hr.
Octagam
Start at 1ml/kg/hr (50mg/kg/hr) and increase at 30 min intervals up to 5ml/kg/hr (250mg/kg/hr), with a
maximum rate of 250ml/hr.
The total dose of IVIG varies with the indication (for example the typical dose in Kawasaki disease is
2g/kg). In general, doses are rounded up so that all the vials opened are administered.
The maximum rates listed above should never be exceeded
Observations
Weight must be obtained on all patients prior to commencing IVIG therapy in order to correctly
calculate the dose required.
baseline
30 minutes into infusion
Thereafter TPR every 30-60 min, depending on the condition of the patient.
All patients receiving blood products should be observed during the first 15 min of the infusion.
Rate
Patients on long term IVIG replacement therapy for the management of a medical condition may
commence infusion of IVIG at the maximum dose if this has been previously tolerated.
Observations
Patients on long term IVIG replacement require the following observations prior to the commencement
of the infusion and at the completion of the transfusion.
TPR
Blood Pressure
Ongoing observations during the infusion will depend upon the general condition of the patient but are
not required as a routine as patients in the Day Medical Unit are under close nursing observation.
Reactions
If anaphylaxis occurs STOP the infusion and give adrenaline 1:10,000 0.1ml/kg IM stat and oxygen
Anaphylaxis guideline
Other reactions tend to be related to the rate of infusion and are most likely to occur during the first
hour of the infusion. If the rate is too fast, the patient may experience some of the following symptoms:
Dyspnoea
Bronchospasm/Chest tightness
Flushing
Fever/Chills
Hives/Rash
Changes in BP
Headache
Vomiting/Nausea
Abdominal pain
Back pain/Arthralgia
Severe coughing
At the first sign of any of these symptoms turn off the infusion and notify the doctor.
For mild reactions, when symptoms have ceased, the infusion may be recommenced at a slower rate.
Documentation
This information is important should the patient have a reaction to the infusion, or if there is a need to
trace recipients of certain batch numbers at a later date.
Intraosseous Access
Notes
Intraosseous (IO) access is an effective route for fluid resuscitation, drug delivery and laboratory
evaluation that may be attained in all age groups and has an acceptable safety profile.
Indications:
Complications:
Equipment
Alcohol swabs
18G needle with trochar (at least 1.5 cm in length)
5 ml syringe
20 ml syringe
Infusion fluid
Procedure
Post-Procedure Care
Intraosseous infusion should be limited to emergency resuscitation of the child and discontinued as
other venous access has been obtained.
Intussusception Guideline
See also: Abdominal Pain Guideline
Assessment
History
The child appears to have intermittent pain which is colicky, severe and may be associated
with the child drawing up the legs.
Episodes typically occur 2-3 times/hour and may increase over the next 12-24 hours
During these episodes of crying the child may look pale.
(note: many other causes of infant crying are associated with facial redness rather
than pallor).
Pallor and lethargy may be the predominant presenting signs, may be persistent
rather than episodic, and in some the crying episodes may not be very vigorous.
Vomiting is usually a prominent feature (but bile stained vomiting is a late sign)
Bowel motions
blood and/or mucus
classic red currant jelly stool is a late sign
diarrhoea is quite common and can lead to a misdiagnosis of gastroenteritis
there may be a preceding respiratory or diarrhoeal illness
Examination
Pallor, lethargy - may be intermittent, and may look well in between episodes
Abdominal mass - sausage shaped mass RUQ or crossing midline in epigastrium or behind
umbilicus, palpable in about two thirds of children.
Distended abdomen later in the course
Stool
Bloody stool/occult blood positive
PR unnecessary if good evidence of intussusception; abdominal mass or PR
bleeding, but otherwise should be done for signs of PR blood or mass.
Signs of an acute bowel obstruction
Hypovolaemic shock is a late sign
Investigations
Management
Secure IV access
Most children will require fluid resuscitation with normal saline 20mls/kg IV
Keep nil orally
Pass nasogastric tube if bowel obstruction on AXR
Iron Poisoning
See also General Management of Acute Poisoning Guideline
Important ingestion is the amount of elemental iron not the iron salt
Assessment
Symptoms
Investigations
Asymptomatic patients:
If tablet ingestion do AXR, if clear and asymptomatic for 8 hours no tests are needed.
If >60mg/kg ingested need serum iron levels (see below)
All symptomatic patients should have the following investigations:
ABG/CBG
Glucose
serum iron (serial levels every 4 hours)
FBE
U&E & Cr
X-match and clotting profile performed.
AXR is helpful in evaluating gastrointestinal decontamination after treatment if tablets have
been ingested.
Management
Charcoal is of no benefit.
Decontamination of choice is whole bowel irrigation with colonic lavage solution
30ml/kg/hr until rectal effluent clear (only if bowel sounds present).
Chelating agent available Desferrioxamine ( Desferrioxamine-iron complex usually turns
urine orange/red) .
Supportive therapy to maintain adequate blood pressure and electrolyte balance is essential
a. Asymptomatic
o If tablet ingestion do AXR,
o If >60mg/kg ingested need serum iron levels 4 hourly until falling.
o If AXR reveals tablets, or capsules ingested, whole bowel irrigation with colonic
lavage solution 30ml/kg/hr until rectal effluent clear.
o Observe until 8 hrs post ingestion if asymptomatic discharge, if symptomatic treat as
below.
b. Symptomatic
o whole bowel irrigation with colonic lavage solution 30ml/kg/hr until rectal effluent clear
o Investigations as above.
o I.V. fluid resuscitation, and potassium and glucose administration as necessary.
o If altered conscious state, shock, severe acidosis (pH <7.1), or worsening symptoms
commence Desferrioxamine 15 mg/kg/hr I.V.
All patients being considered for Desferrioxamine or with worsening symptoms must be
referred to ICU (5212).
Assessment
Unconjugated
Conjugated - pale stools / dark urine, raised conjugated bilirubin (>25% total or >25umol/l)
Biliary atresia
Choledochal cyst
Neonatal hepatitis (congenital infection, alpha-1 antitrypsin deficiency; often idiopathic)
Metabolic (galactosaemia, fructose intolerance - ask about sucrose/fructose in
food/medication)
Complication of TPN
Notes
1. Physiological jaundice. Jaundice is very commonly noted in the first 2 weeks of life. It is part of
a normal physiological process and affects 50 to 70% of babies. Mild jaundice with onset after
24 hours of life and which is fading by 14 days needs no investigation or treatment.
2. Breast milk jaundice is the most common cause of prolonged jaundice but other causes
should be eliminated before making this diagnosis. A breast-fed baby with prolonged
unconjugated jaundice, normal stool and urine colour, normal FBE/film/Coombs who is well
and thriving probably has breast-milk jaundice. Do not stop breast feeding. Suggest review in
General Paediatrics clinic if not improving or any changes - especially stool colour.
3. Conjugated hyperbilirubinaemia must be excluded as the causes of this pattern need urgent
evaluation and treatment. Surgery for biliary atresia is most successful when the condition is
diagnosed and treated early. Don’t forget to ask about the colour of urine and stools. View a
dirty nappy yourself if possible.
Notes
Kawasaki disease is a systemic vasculitis that predominantly affects children < 5 years of age.
Although the specific aetiological agent remains unknown, it is believed that Kawasaki disease is a
response to some form of infection (though it is not transmitted from person to person).
Diagnosis is often delayed because the features are similar to those of many viral exanthems.
4 out of 5 of:
polymorphous rash
bilateral (non purulent) conjunctival injection
mucous membrane changes, e.g. reddened or dry cracked lips, strawberry tongue, diffuse
redness of oral or pharyngeal mucosa
peripheral changes, e.g. erythema of the palms or soles, oedema of the hands or feet, and in
convalescence desquamation
cervical lymphadenopathy (> 15 mm diameter, usually unilateral, single, non purulent and
painful)
and exclusion of diseases with a similar presentation: staphylococcal infection (e.g. scalded skin
syndrome, toxic shock syndrome), streptococcal infection (e.g. scarlet fever, toxic shock-like syndrome
not just isolation from throat), measles, other viral exanthems, Steven's Johnson syndrome, drug
reaction and juvenile rheumatoid arthritis.
The diagnostic features of Kawasaki disease can occur sequentially and may not all be present at the
same time. Moreover, it is recognised that some patients with Kawasaki disease do not develop
sufficient features to fulfill the formal diagnostic criteria. Clinical vigilance and recognition of this
possibility are necessary to recognise these "incomplete" or "atypical" cases. This is important
because the atypical cases are probably at similar risk of coronary complications and require
treatment. Other relatively common features include arthritis, diarrhoea and vomiting, coryza and
cough, uveitis, gall bladder hydrops. Some patients get myocarditis..
Investigations
Other tests are not diagnostic or particularly useful. The following may be seen:
neutrophilia
raised ESR + CRP
mild normochromic, normocytic anaemia
hypoalbuminaemia
Elevated liver enzymes
Thrombocytosis and desquamation appear in the second week of the illness or later. Their absence
earlier does not preclude the diagnosis.
Management
Intravenous immunoglobulin (2 g/kg over 10 hours; preferably within the first 10 days of the
illness but should also be given to patients diagnosed after 10 days of illness if there is
evidence of ongoing inflammation - eg fever, raised ESR/CRP)
Administration of Intragam Guideline
Follow up
Paediatric follow-up should be arranged on discharge. At least one further echocardiogram should be
performed at 6-8 weeks. If this is normal, no further examinations are needed.
Notes
Ketamine is a potent sedative, amnestic, analgesic and anaesthetic agent. It has relatively little effect
on the respiratory centre at the doses used.
The airway is to be managed by a doctor approved for this purpose by the Emergency
Department.
Dissociation - the patient passes into a trance like state with the eyes open but not responding
Catalepsy - normal or slightly increased muscle tone is maintained.
Analgesia - excellent analgesia is typical
Amnesia is usually total
Airway reflexes are maintained.
Cardiovascular state - Blood pressure and heart rate tend to increase slightly.
Nystagmus is typical
Patient Selection
Indications:
Children aged over 12 months - there is an increased risk of airway complications in children
less than 12 months and particularly less than 3 months.
Short painful procedures especially those requiring immobilisation. Examples of these
include: lacerations - especially of the face, and fracture reduction.
Contraindications:
Procedure
Staff required:
Presedation
The procedure should be explained to the caregivers and child including an explanation of the
effects of Ketamine.
Written informed consent must be obtained.
Baseline observations should include BP, PR, RR and O2 saturation.
Encourage the child and parents to talk (dream) about happy topics. This helps minimise
unpleasant emergence phenomena.
Adjunctive agents
These may all be mixed in the same syringe for intramuscular or intravenous injection.
Administration:
IM:
Route of IM IV
Administration
Advantages No IV necessary Ease of repeat
dosing, slightly faster
recovery
Clinical onset 5 minutes 1 minute
Effective sedation 15-30 minutes 10-20 minutes
Time to discharge 100 -140 minutes 90-120 minutes
(average)
Monitoring
Each patient should have pulse oximetry and cardiac monitoring, and a nurse in attendance
until recovery is well established.
Close observation of the airway and chest movements is necessary.
Post Procedure
Recovery
Discharge Instructions
Careful family observation and no independent ambulating for at least two hours.
Lacerations
Background
Minor lacerations are extremely common in childhood, and there are a variety of different methods of
management available. It is important when active treatment is required that this is undertaken in a
way which allows the best functional and cosmetic result, with the least distress to the child. The worst
surgical results are achieved in children who are "uncooperative" or terrified. All children with
lacerations should be fasted from arrival.
Assessment
Are there likely to be other injuries? (eg. head / cervical spine in falls, eye in facial trauma or
teeth with mouth injuries).
Is the wound likely to be contaminated by dirt or foreign bodies?
Is there injury to deeper structures (eg. tendons, nerves)? In the face, remember facial nerve,
parotid / lacrimal ducts, medial canthus of the eye. If a deep laceration cannot be examined
adequately to exclude damage to such structures, general anaesthesia may be required.
Is blood supply impaired? If a flap or area of soft tissue distal to the laceration appears dusky
or poorly perfused, the wound requires specialist assessment. Areas with end-arteriolar
supply (extremities such as the tip of the nose, finger tips, and ear lobes) require special care.
Do not use local anaesthesia with adrenaline on such wounds.
Management
Before embarking on treatment in a child, consider whether you have the necessary resources for
optimum surgical result and experience for the child eg. sedation, analgesia, anaesthesia, appropriate
experience, time & instruments, assistance (medical and nursing). If in any doubt discuss with
Emergency Registrar or Consultant. Plastic surgical consultation may be advisable.
Sedation
Anaesthesia
Adequate anaesthesia is necessary for complete examination, cleansing and repair of wounds.
1. Topical anaesthesia
o ALA (adrenaline/lignocaine/amethocaine) 0.1 ml/kg.
o EMLA or AnGel applied to the wound (most effective on limb wounds)
2. Local anaesthesia
o eg. 1% lignocaine with adrenaline slowly infiltrated into the wound, (care should be
taken not to use adrenaline on finger tips)
3. Regional block
o eg. infiltrate nerve proximal to injury (ring block digits - use plain lignocaine, no
adrenaline) Nitrous oxide may facilitate a more comfortable injection.
4. Bier's Block (i.v.)
o To be done by doctor of appropriate training only - see Bier's Block guideline.
Cleaning Wounds
Superficial Wounds
Deep Wounds
Those which require exploration should be anaesthetised first to allow more thorough
cleaning. Foreign bodies must be removed. Grease can be removed using Bacitracin or
Polysporin ointment.
Thorough irrigation with saline under pressure (with a 19 Ga needle on a 10-20 ml syringe) is
advisable
Gravel Rash
Bitumen and dirt is ground into the skin and there is associated skin abrasion. After
anaesthesia, scrub with a brush to remove ground in dirt and prevent tattooing. Small area -
local anaesthetic. Larger areas - general anaesthetic.
Ragged Wounds
Glass Injuries
These should be x-rayed if there is the possibility of retained glass. If glass fragments are
present, the wound needs exploration. All haematomas should be evacuated as glass is
usually found within.
Closure
a) Non-surgical
b) Surgical
NB: Young or anxious children will require sedation prior to wound repair See sedation guideline
Scalp
Bleeding may be profuse, but usually ceases with firm digital pressure along the
margins of wound. Comb hair out of wound (vaseline often helps). It is not usually
necessary to shave much hair.
Close in 2 layers:
GALEA 3/0-5/0 Chromic Cat Gut (CCG) or PDS (absorbable)
SCALP 4/0-5/0 Nylon (Removal of sutures [ROS] ~7 days)
Forehead
Minimal debridement. Do not shave eyebrow
Superficial scratches should be cleaned only and left to epithelialise (± steristrips)
Sutures 5/0, 6/0 Nylon (ROS 5-7 days) or Fast gut or Vicryl absorbable sutures
Cheek
Check for fractures (zygoma, blow out of orbit) and involvement of facial nerve and
muscle.
Ophthalmology opinion if hyphaema or "closed eye with swelling".
Close as for forehead
Eyelids
If involving the lid margin then refer to Ophthalmology.
Look for tarsal plate involvement - refer Ophthalmology
Simple lacerations can be glued or sutured under low tension. Use 6/0 Vicryl or Fast
Gut absorbable sutures.
Lips
Superficial lacerations can be closed in Emergency by person with appropriate
experience if the child is cooperative. Otherwise will need GA and Plastic surgical
repair.
NB: Need accurate approximation of vermilion border and skin. Sutures: skin - 6/0
Nylon (ROS 5 days) or Fast Gut (absorbable); mucosa and muscle - 4/0 CCG, Vicryl
Lacerations of the inner lip rarely need any intervention.
Lacerations of the gum margin (e.g. degloving injury) need referral to Dental or Facio-
Maxillary.
Limbs
Immobilise area of laceration and joint above and below, following repair eg. plaster
slab or sling.
Upper Limbs: May require arterial tourniquet control. 4/0, 5/0 Nylon. Deep sutures
4/0 PDS.
Lower Limbs: Debridement important. Do not close if under undue tension especially
pretibial,
ROS 7-10 days.
Trunk
Debridement can be more generous. Fat layer: 3/0 PDS. Skin: 4/0, 5/0 Nylon. ROS
10-14 days.
Palate
Beware: sharp objects in the mouth may injure the posterior pharynx. Consult with
senior staff.
These rarely require suturing unless gaping widely, extending through posterior free
margin or continuing to bleed.
Tongue
Most lacerations do not require suturing. However, if the laceration is large, extending
through the free edge, full thickness or associated with ongoing bleeding, Plastics
opinion is necessary.
Ear
If full thickness involving cartilage, needs Plastic opinion.
Tetanus Prophylaxis
Antibiotics
Antibiotics are not indicated for simple lacerations. They are usually given for bites and wounds with
extensive tissue damage, or massive contamination, but are secondary in importance to the initial
decontamination of the wound. Recommended antibiotics are procaine penicillin 25-50 mg/kg i.m.
once and augmentin (10-20 mg amoxycillin/kg) 8-hourly for 5 days.
Indication
Children over 5 yrs with forearm fractures requiring manipulation - some younger children if very
cooperative. Distressed or non-compliant children may be better treated Under GA.
Preparation
Prior to X-Ray
All LAMP procedures are to be ED admissions. A yellow form should be taken to the ward
clerks to be processed. Informed consent must be obtained from parents.
Procedure must be performed in Proceedure Room with full resuscitation equipment. Check
all Equipment.
Notify radiology to ensure availability of staff prior to commencing.
Procedure
The child may be discharged from the ED after the cuff is released.
Arrange plaster check LMO on the following day.
Organise Fracture Clinic and X-ray appointment at 5-7 days.
Complete yellow Discharge Summary and operative notes on Surgical Short Stay form.
Notes
Indications, Contraindications, Complications
Equipment
Analgesia, anaesthesia and sedation
Procedure
Post-procedure care
Notes
Lumbar puncture may be performed as part of the initial work up of a sick child, or later in the course of
an illness once the child has stabilised if there were initial contraindications. It is preferable to obtain a
CSF specimen prior to antibiotic administration, however this should not be unduly delayed in a child
with signs of meningitis or sepsis.
You must always discuss with a senior registrar or consultant before doing a lumbar puncture.
Indications:
You must always discuss with a senior registrar or consultant before doing a lumbar puncture.
Do not do a lumbar puncture if the child is so sick that you will give antibiotics for meningitis
even if the CSF is normal is normal on microscopy.
The clinical findings that suggest you should give dexamethasone and antibiotics
immediately, and delay lumbar puncture for 1-2 days until the child is improving are ...
Complications:
Informed verbal consent should be obtained. This should include a discussion of the benefits
of the procedure in terms of possible diagnoses and potential complications. Complications of
LP may include:
The LP Parent Information Sheet may be useful in talking to parents about the procedure. (See below)
Analgesia, anaesthesia and sedation
Monitoring:
Monitor all sedated or seriously ill children with continuous pulse oximetry
Equipment
Spinal Needles
22G bevelled spinal needles with stylet (the use of needles without a stylet has an
associated risk of spinal epidermoid tumours)
see Spinal needles for a guide to needle size and insertion distance
Consider 25G pencil point needles for older children/adolescents (eg Whitacre 25G 9cm
available in ED at RCH)
Pencil-point (blunt) needles reduce the risk of headache in adults, however the
evidence is not convincing in children. Their use may be appropriate in adolescents.
Procedure
The most important determinant of a successful lumbar puncture is a strong, calm, experienced
assistant to hold the patient. Position of the patient is critical.
Position:
Lumbar puncture may be performed with the child lying on their side or sitting up.
Aim for maximum flexion of the spine (curl into fetal position), but avoid over flexing the neck,
especially in infants as this may cause respiratory compromise. Ask an adolescent to slouch
rather than bend from their hips.
Ensure that the plane of the back is exactly at 90 degrees to the bed (ie not leaning towards
or away from you). Make sure the hips and shoulders are in line
Draw an imaginary line between the top of the iliac crests. This intersects the spine at
approximately the L3-4 interspace (mark this if necessary)
The conus medullaris finishes near L3 at birth, but at L1-2 by adulthood
Aim for the L3-4 or L4-5 interspace
Preparation:
Lumbar Puncture:
Position the needle in the midline with the bevel pointing towards the ceiling (lateral decubitus
position) or to the side (sitting).
Pierce the skin with the needle and pause. Wait for the child to stop wriggling
Reorientate (ensure that back is vertical, needle is parallel to the bed and perpendicular to the
back). Aim for the umbilicus (ie slightly cephalad).
Advance the needle into the spinous ligament (increased resistance). Continue to advance
the needle within the ligament until there is a fall in resistance. Remove the stylet. If CSF is
not obtained replace the stylet and advance the needle slightly then recheck for CSF.
An alternative technique is to remove the stylet once the needle is in the ligament and
advance very slowly without stylet watching for CSF to flow back. This has the
advantage of making it harder to go unintentionally past the subarachnoid space.
If the needle meets resistance, withdraw the needle slowly whilst watching for CSF. If
none is obtained, replace the stylet, re-orient the needle and re-try.
If blood stained fluid is obtained collect some for culture. If it clears it can be used for
a cell count. If it fails to clear another attempt at a different level may be required.
See Spinal needles for a guide to insertion distance
If CSF is flowing, collect into 2 numbered sterile tubes (5-10 drops each is usually adequate)
Replace the stylet (this may reduce risk of headache), and remove the needle and stylet.
Apply brief pressure to the puncture site
Send specimens urgently to the lab for microscopy, protein, glucose, culture. (NB CSF
glucose estimation is most useful if there is a synchronous plasma glucose). see CSF
Interpretation
Post-Procedure Care
Cover the puncture site with a band-aid or occlusive dressing (eg Tegaderm)
Bed-rest following lumbar puncture is of no benefit in preventing headache in children or adults.
Lumbar puncture
A lumbar puncture is a test where a doctor uses a needle to get fluid out from the back. (This fluid is
called "spinal fluid" or "CSF"). Your child lies on his or her side and is held still. A doctor puts a needle
between the bones of the lower back. It does not go near the spinal cord. Lumbar Punctures are also
sometimes called a "spinal tap" or "LP".
This test is usually done to find out if your child has infection of the fluid around the brain (meningitis).
It is the only way to know for sure if your child has meningitis or not. If your child has meningitis they
will need other tests and treatment in hospital. Occasionally lumbar punctures are done for other
reasons.
It is an uncomfortable and sometimes painful test. Your child will be held still, and babies and small
children do not like this and often cry. We can help to numb the skin with some cream or with an
injection. We may be able to give your child some medicine to make them less scared and worried.
Lumbar puncture is a very safe test. Sometimes we are not able to get fluid and may have to try more
than once. A small number of children may have a headache or backache for a day or two after the
test. The risk of any serious complications (bleeding or infection, damage to nerves) is extremely
small.
Do I need to do anything special after the lumbar puncture?
Your child can be bathed normally. If there is a band-aid or dressing on your child's back it can be
taken off the next day. If they have a headache or sore back they can have some paracetamol
(Panadol).
Lumbar punctures are the only way to be sure if your child has meningitis or not.
It is a very safe test.
Airway threat
Hypoxaemia:
Tachypnoea
Tachycardia or bradycardia:
Hypotension:
Age BP (systolic)
Term-3 months <50
4-12 months <60
1-4 years <70
5-12 years <80
12 years+ <90
Notes
Some of the values for respiratory rate, heart rate and blood pressure are outside the normal
ranges for age: they represent concerning levels that may indicate serious illness, and that require
expert review.
It is also important to look for worsening trends in vital signs and report these.
Meningitis Guideline
Background
Assessment
Management
Therapy summary
Antibiotics
Steroids
Admission to ICU
General Measures
Notification
Contact chemoprohpylaxis
Notes
Follow-up
Viral Meningitis
Background
The usual organisms causing bacterial meningitis in children over 2 months of age are
Streptococcus pneumoniae,
Neisseria meningitidis
Haemophilus influenzae type b (Hib ᄋ uncommon after age 6).
Group B streptococcus,
E. coli and other Gram-negative organisms,
Listeria monocytogenes,
S. pneumoniae,
N. meningitidis
Haemophilus influenzae type b.
Note: This guideline is not for use in children with spinal abnormalities or ventriculo-peritoneal shunts
etc. where the neurosurgical team should be consulted
Assessment
Infants with meningitis frequently present with non-specific signs and symptoms such as
fever, irritability, lethargy, poor feeding and vomiting.
The fontanelle may be full.
Older children may complain of headache or photophobia.
Neck stiffness may be present (not a reliable sign in young children).
A purpuric rash is suggestive of meningococcal septicaemia.
It is important to examine for spinal and cranial abnormalities such as dermal sinuses which
may have predisposed the child to meningitis.
Investigations
You must always discuss with a senior registrar or consultant before doing a lumbar puncture.
Management
Therapy (summary)
<4 Cefotaxime 50 No
weeks</strong/> mg/kg (2 g) iv
6H,
Benzylpenicillin Substitute Vancomycin
60 mg/kg iv 15 mg/kg (500 mg) iv 6H
12H (wk 1 of for Penicillin
life) 6-8H (wk
2-4 of life),
Gentamicin
Antibiotics
Cefotaxime can be substituted with Ceftriaxone 100 mg/kg (max 2gm) iv daily
Chloramphenicol may be used in children with a type 1 hypersensitivity to cephalosporins.
Continue empiric treatment until cultures are known to be negative or an organism and its
sensitivity pattern are known. A positive culture result with sensitivities should lead to
narrower spectrum treatment:
Organism Antibiotics
Steroids
Current evidence suggests that steroids protect against neurological sequelae from bacterial
meningitis (particularly deafness) and may reduce mortality.
The benefit is probably greatest if steroids are given at least 15 minutes before the first dose
of antibiotics.
Accordingly, children (>4 weeks old) who are being treated for possible meningitis (who have
not yet received parenteral antibiotics, or who have received their first dose less than 1 hour
ago) should be given dexamethasone.
Steroids should be ceased if a decision is made to cease antibiotic treatment for meningitis before 4
days (eg if cultures are negative at 48 hours, and CSF microscopy not supportive).
From a practical point of view, it may be appropriate to give dexamethasone at the time of lumbar
puncture in children who are felt to be very likely to have meningitis.
Convulsions should be treated quickly in a child with suspected / confirmed meningitis. An already
compromised brain may be further damaged by the metabolic demands of a fitting brain and
compromised breathing and circulation during the convulsion
Give oxygen 6-8 litres by face mask. Nurse on the side. Suction to clear the oropharynx, and place an
oral airway as necessary. If the child is apnoeic use bag and mask ventilation and immediately call
ICU.
Do a blood glucose stick test. Treat hypoglycaemia (<3 mmol/L) with 2 ml/kg of 25% glucose iv as a
slow bolus.</p/>
If convulsion continues for 2 minutes, give diazepam 0.2 mg/kg iv over 30 seconds, or 0.4 mg/kg pr. If
continues after further 5 minutes, repeat diazepam 0.4 mg/kg iv over 30 seconds and notify ICU and
the Medical Consultant.
If the convulsion ceases after diazepam, load with phenytoin (15 mg/kg iv over one hour).
Do a neurological examination: if focal deficit, very bulging fontanelle or poor conscious state notify
ICU and organise a CT scan.
Monitor conscious state, oxygen saturation, blood pressure and continuous ECG.
Admission to ICU
Admission to ICU should be discussed with the ICU consultant in the following circumstances:
Fluid Management
General measures
Neurological observations including blood pressure should be performed 15 minutely for the
first two hours and then at intervals determined by the childᄋs conscious state.
Weight and head circumference should be monitored on a daily basis.
Control seizures Early consultation with intensive care unit is necessary for any child who is
experiencing a deterioration in conscious state, haemodynamic instability or seizures.
Electrolytes and glucose should be checked 6-12 hourly until the serum sodium is normal
(and/or the child is no longer on IV fluids).
Ensure adequate analgesia (eg paracetamol) for children in the recovery phase who may
have significant headache.
Fever persisting for more than 7 days This may be due to nosocomial infection, subdural
effusion or other foci of suppuration. Uncommon causes include inadequately treated
meningitis, a parameningeal focus or drugs.
Notification
All cases of presumed or confirmed Neisseria meningitidis disease should be urgently notified to the
Department of Human Services by telephone on 1300 651160 (fax 1300 651170) (after hours pager
03 9625 5000, pager number 46870).
Haemophilus influenzae type b, and streptococcus pneumoniae are also notifiable diseases.
Link to DHS info on meningococcus
Link to DHS notifications (include form)
Contact Chemoprophylaxis
It is important that prophylaxis be given early to both the index case and contacts.
Rifampicin may cause orange-red discolouration of tears, urine and contact lenses, skin
rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral
contraceptive pill and should not be used in pregnancy or severe liver disease.
At RCH, a supply of rifampicin capsules and syrup is kept in the ICU pharmacy cupboard
(bottom shelf right hand side). Immediate families members may be given free supplies (click
here for info).
There is a Parent Information Sheet which gives details of meningococcal infection and the
use of rifampicin.
Notes
Follow-up
All children with bacterial meningitis should have a formal audiology assessment 6-8 weeks
after discharge (earlier if there are concerns regarding hearing).
Neurodevelopmental progress should be monitored in outpatients.
Viral Meningitis
Meningococcal infection
Meningococcal infection is caused by a bacteria germ called meningococcus. Meningococcus can
cause serious infections including:
These infections can develop very quickly, and are deadly in about 1 in 10 cases. For others, the
infection can cause disabilities that affect them for life. Many people carry the bacteria in their noses
and throats without getting sick. We call them healthy carriers. These carriers can spread the bacteria
to other people. The meningococcus is spread by tiny drops of fluid from the nose and throat through
coughing, sneezing and spluttering, sharing eating and drinking utensils. It is not easy to get infected
because the bacteria do not live long outside the body.
Signs and symptoms
Your child may only have some of these symptoms, or may not have them all at once.
High fever
Severe headache
Stiffness and pain in the neck, shoulders, back, and other muscles
Skin rash of small bright red spots or purple bruises
Dislike of bright lights (photophobia)
Lethargic, drowsy or confused
Nausea and vomiting (feel sick)
Babies
Fever
High pitched moaning cry
Fretful or agitated
Refusing feeds or vomiting
Being difficult to wake
Pale or blotchy skin
Rash of red-purple spots or bruises
Symptoms will show up within 2-10 days (usually 3-4 days) after your child has been in contact with
meningococcus. Symptoms often begin suddenly.
Treatment
If your child has symptoms of meningococcus they will be treated in hospital with antibiotics.
Early treatment with antibiotics is the key to saving their life.
Diagnosis is not always easy to make in the beginning. If your child is sent home by the
doctor or hospital and becomes worse or doesn’t improve, take them straight back to the
nearest hospital.
If your child has been in contact with a person who has meningococcus they may need antibiotic
treatment. Contacts may include:
Somebody who lives in the same house and shares meals and living space.
A person who has contact with your child's mouth or nose secretions. This can happen by
using the same eating and drinking utensils, glasses, and plates or through kissing (remember
boyfriends/girlfriends) or by sharing cigarettes.
A person who has done medical treatments like giving mouth-to-mouth resuscitation on your
child.
Children sharing toys, such as in group day care centres, family day care, or in nurseries.
By law, doctors treating patients with suspected or confirmed meningococcal disease must notify the
Department of Human Services (The Health Department). They will probably contact you for more
information. Your doctor and the Department of Human Services will let you know who should have
antibiotic treatment.
Antibiotics - Rifampicin
Rifampicin is the antibiotic medicine that is most often used to get rid of the meningococcus germ from
the throat of contacts. This will prevent it being passed on to other people. Usually two doses are
given each day for two days.
Any contacts who need to take antibiotics must tell their doctor if they:
These people should not take rifampicin. There are other medicines they can take.
Body secretions such as, urine, stool (poo), saliva, sputum (spit), sweat, and tears, may turn
red or orange in color. This is only temporary.
Stomach aches, vomiting, diarrhea, headaches, dizziness, or pain in the arms and legs.
These symptoms will go away after the medicine is finished.
Soft contact lenses may be permanently stained red or orange. They should not be worn until
48 hours after finishing the medicine.
Birth control pills may not work properly when taking rifampicin.
Taking rifampicin does not guarantee prevention of the illness. Therefore, if any of the
above symptoms for meningococcal infection develop, that person must seek urgent
medical attention.
Have your child vaccinated against meningococcal C disease. The vaccine provides over
90% protection against meningococcal C disease. Please discuss all side effects with your
doctor.
Children of parents who smoke are at a greater risk of getting meningococcal disease. For
help to quit smoking, call the Quitline on 131 848.
These infections can develop very quickly, and can be deadly in about 1 in 10 people. Others
are affected for life.
If your child has been in contact with a person who has meningococcus they may need
antibiotic treatment.
Symptoms will show up within 2-10 days (usually 3-4 days) after your child has been in
contact with meningococcus.
If your child is sent home by the doctor or hospital and becomes worse or doesn’t improve,
take them straight back to the nearest hospital.
Notes
Clinical presentation
Common presentations
The usual presentation is with any of fever, malaise, myalgia, arthralgia, nausea, vomiting,
headache, and reduced conscious state. In infants, fever and listlessness or prostration may
be the main features.
Petechiae or purpura are present in most, but not all, patients.
Any child with meningococcal disease, including one who appears non-toxic, may deteriorate rapidly.
Management
Consult ICU for all cases of acute meningococcaemia, and those with meningitis <2years of age.
Isolate cases (if possible) until they have had >12 hours antibiotic treatment.
Antibiotics
Take blood (or marrow) for culture if possible and immediately administer cefotaxime (50mg/kg/dose
- max 3g, 6 hourly). Chloramphenicol may be used in children with a type 1 hypersensitivity to
cephalosporins.
Fluids
For meningitis alone, careful fluid management is important as many children have increased ADH
secretion. See meningitis guideline.
ICU management
Give methylprednisolone (10mg/kg) before (or within 30 minutes) first dose of antibiotics.
Microbiological
If possible blood culture should be obtained prior to, or very soon after, commencing antibiotics.
The other investigations should be obtained within the following hour if possible.
Blood smear Smear 1 drop onto a microscope slide for Gram stain
Some of these investigations will guide your patient's management, the rest will help with public health
and contact management. Please ensure all specimens are transported to RCH with the patient if
possible. Meningococcus is sensitive to cold - ensure cultures are transported to laboratory incubator
ASAP.
Urinary or CSF "rapid antigen" testing is not recommended because of poor sensitivity and specificity.
The laboratory may under some circumstances elect to test CSF antigens when the results may affect
public health responses, but these results should not be used to guide the clinical decisions in the care
of individual patients.
Other
Later problems
Small vessel thrombosis / tissue loss - involve Plastic Surgery early. Analgesia is important for
skin necrosis or peripheral gangrene. Opiate infusions may be needed.
Reactive arthritis or pericarditis may occur in a few patients between days 3 to 7.
Fever persisting for more than 7 days -This is common and may be due to: tissue damage (if
there is extensive vasculitis), nosocomial infection, subdural effusion (in the case of
meningitis), other foci of suppuration, or reactive complications. Uncommon causes include
inadequately treated meningitis, a parameningeal focus or drugs.
The Infectious Diseases service (ID Fellow – page 5787) would be pleased to hear about all cases and
is available for consultation as needed.
Notification
All cases of presumed or confirmed Neisseria meningitidis disease should be urgently notified
to the Department of Human Services by telephone on 1300 651160 (fax 1300 651170) (after
hours pager 03 9625 5000, pager number 46870).
Contact chemoprophylaxis
All intimate, household or daycare contacts who have been exposed to index Case within 10
days of onset.
Any person who gave mouth-to-mouth resuscitation to the index Case.
The index case should also receive prophylaxis if penicillin only was used
RCH usually provides prescription for immediate family members and DHS supplies other
contacts.
Prophylaxis is provided free from the hospital pharmacy and families should contact
DHS if they have any problems obtaining free supplies outside RCH
DHS contact: Infectious Disease Unit: Nurse 03 9637 4124, Medical Officer 03 9637 4127
Infants and children>1 month of age,
Rifampicin 10 mg/kg po 12 hourly (max 600 mg) for 2 days
Adults
Rifampicin 600 mg 12 hourly for 2 days
Infants < 1 month of age
Rifampicin 5 mg/kg po 12 hourly for 2 days
Pregnancy / contraindication to Rifampicin
Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) intramuscularly as a single dose
Rifampicin causes orange-red discolouration of tears, urine and contact lenses, and may also cause
skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive
pill and should not be used in pregnancy, breastfeeding women, or severe liver or renal disease.
At RCH, a supply of rifampicin capsules and syrup is kept in the ICU pharmacy cupboard (bottom shelf
right hand side). Immediate families members may be given free supplies (click here for info).
There is a Parent Information Sheet which gives details of meningococcal infection and the use of
rifampicin.
Follow-up
See meningitis guidelines for meningitis follow-up. All children with meningococcaemia should be
followed up either in outpatients or by a local paediatrician. Those with extensive skin disease may
also require input from plastic surgeons, pain specialists, and psychiatrists or counsellors.
Metabolic Disorders
Background
Metabolic disorders or inborn errors of metabolism (IEM) result from a block (partial or
complete) to an essential pathway in the body's metabolism. There are a large number of
conditions included in this group of disorders.
Management of metabolic disorders can be very complicated and should always involve close
liaison with a metabolic physician.
Most of these disorders are inherited as autosomal recessive.
Many metabolic disorders present in the newborn period or shortly thereafter. Patients may
present later, for example during intercurrent illnesses.
High index of suspicion required to make diagnosis as the clinical presentation of most
metabolic disorders is non-specific.
History
A metabolic disorder may present differently depending on the age of the child:
Neonatal period:
poor feeding/suck or vomiting
hypotonia
respiratory compromise/apnoea
progressive encephalopathy and seizures
clinical picture often mistaken for sepsis
Childhood:
recurrent unexplained vomiting with severe dehydration
stroke like episodes
acute liver or renal failure
cardiomyopathy
unexplained encephalopathy and seizures
Assessment
Look for
CNS Effects - irritability, changes in consciousness, movement disorder, hypotonia, seizures,
coma
GIT- poor feeding, vomiting/ dehydration, prolonged jaundice
Developmental- motor/cognitive delay or regression
Is there a metabolic acidosis?
Is there Hypoglycaemia?
Is there ketosis?
Is there hyperammonaemia?
Causes
General appearance (e.g. Marfanoid habitus in Homocystinuria), unusual odour (e.g. musty in
Phenylketonuria (PKU)), ocular involvement (e.g. cherry red spots in Tay Sachs disease),
cataracts (e.g. galactosaemia), hepatosplenomegaly (e.g. Hurler syndrome)
Investigations
Blood, urine and CSF samples collected at the time of presentation may be diagnostic
Blood
Acid-base: capillary sample
Glucose and lactate: fluoride oxalate tube, 1ml
Ammonia: heparinized tube (1ml)- immediately to lab on ice
Ketones and free fatty acids: fluoride oxalate tube (2 ml)
Electrolytes (including calcium, phosphate, magnesium) plain gel tube (1 ml)
Amino acids; heparinised (1 ml sent on dry ice)
Insulin, cortisol, growth hormone: plain gel tube (3-4 ml)
Full blood count and film (EDTA tube 0.25 ml)
Blood drops onto a Guthrie test card (for acyl-carnitine profile)
Leave to dry in room air. Do not store in a plastic envelope.
Blood volumes required in different tubes (total approximately 10mls):
capillary acid-base sample (180ul- fill tube)
Fluoride oxalate (grey) tube- 3ml
Heparinised (orange) tube-2 ml (on ice)
Plain gel (brown) tube- 5 ml total (2ml on dry ice)
EDTA (pink) tube- 0.25 ml
Urine
Ward test for pH, ketones, protein, glucose, reducing substances
5-20ml for amino acids and organic acids
CSF
Glucose, protein, lactate (0.5ml) and amino acids (0.5ml clear CSF- sent to lab
immediately on dry ice)
Management
Notes
The interpretation results of the blood acid-base state, glucose, ketones and ammonia will
help classify the type of metabolic disorder.
Interpretation of laboratory results - RCH Clinical Handbook 7th Edn, 2003, Blackwell Science.
Metabolic Conditions (p475)
Organic acidaemia , N or N or
Ketolysis defects, MSUD^ N or N or N
FA oxidation defects N or N or N or N or
Hyperinsulinaemia N N N or
Pituitary/adrenal deficiency N N
N = Normal
^MSUD= Maple Syrup Urine Disease
Seek advice from Metabolic Physician if there is a suspected metabolic disorder or if there is a
child with a known metabolic disorder who presents acutely unwell.
Death of a child with a suspected metabolic disorder See Death of a child with a suspected
metabolic disorder
Molluscum Guideline
Background
Molluscum is a common viral infection of childhood — it is usually a benign and self limiting infection of
the skin. Spread is by direct contact, including auto-inoculation. The incubation period is unknown. A
child may develop a few or a great many lesions. Most cases resolve spontaneously within 6-9
months, butlesions can persist for more than a year.
Assessment
Management
The treatment depends on the age of the child, the location of the lesions and any secondary changes.
Most children do not require treatment. Complete resolution will happen when an immune
response develops, which may take from 3 months to 3 years.
Secondary eczema should be treated with an appropriate topical steroid (e.g.mometasone
furoate 0.1% (Elocon) under medical supervision). Use sparingly for short periods of time.
Individual lesions can be removed by cryotherapy or curettage, with or without topical
anaesthesia.
These methods are usually not appropriate for younger children.
Other treatments may stimulate the immune response:
benzoyl peroxide 5% daily to small areas and covered with the adhesive part of a
dressing.
aluminium acetate solution (Burrow’s solution 1:30) for large areas
imiquimod 0.1% cream (expensive and evidence to support its use is limited)
Note: Scarring may be worse following these treatments than with conservative
management.
Molluscum
Molluscum is a common skin problem causing small, harmless raised spots.The spots can
be present for a few weeks to several months or more than a year. It is caused by the
Molluscum Contagiosum Virus (MCV). This virus only lives in humans. It is contagious
and can be spread from person to person or to different areas in the same person. It can
also be spread by children sharing baths or pools; by bath toys and on towels. Usually it
does not need any treatment. Good personal hygiene can help prevent it spreading.
At first the molluscum spots look like pimples. Then they become round, pearl coloured lumps that
have a white mark or core in the centre of them. They are usually between 1 to 5 mm in size, but can
be as big as 1 - 2 cm wide. Usually they are on the nappy area, tummy, face, arms and legs.
Molluscum spots usually heal without scarring, although a small 'chicken pox' type scar is possible.
Scarring is slightly more likely with more aggressive treatment. Molluscum spots are painless but can
be itchy - scratching can also cause scarring.
How is it spread?
Molluscum is spread from skin to skin contact when touching the molluscum lumps. Sharing towels
and face cloths is another common way to spread the virus. Swimming in pools can also spread it to
other children through the pool water. It can take weeks to months from when your child has contact
with the molluscum virus to when the spots appear.
Treatment
Most of the time, Molluscum does not need any treatment. The spots usually disappear over a period
of time as the body fights and kill the virus. A small number of children can have the spots for several
months.
No one treatment is effective for all children. More aggressive treatment may cause scarring and so it
is best to try simple treatments first. Simple treatments are designed to irritate the spots. This is to
encourage the body's immune system to recognize the virus and destroy the infected cells.
1. Tape stripping
Cover the spots with an occlusive tape such as duct tape or elastoplast. The tape is left on for
2 days and then pulled off. This irritates the spots. This may need to be done several times to
try to remove the central core of the spot.
2. 'Irritating solutions'
If tape stripping by itself is not effective, also applying an irritating solution such as Benzac gel
(benzoyl peroxide 10%) or Retin-A (tretinoin cream) to the spots can help. The solution makes
the spot become inflamed and needs to be applied carefully to avoid the surrounding skin.
The tape stripping then needs to be done each day. See your family doctor first.
3. Aluminium acetate (Burow's solution)
If the above two steps do not work, a weak solution of aluminium acetate (Burow's solution)
diluted with water (1 part Burow's solution and 29 parts water) can be gently dabbed on to the
spots after the shower. Allow the solution to dry, then apply the Benzac or Retin-A and then
cover with tape. Repeat once every day.
4. Remove the central core(older children only)
In older children, squeezing or removing the central core may help to speed the
disappearance of the spots. See your family doctor or dermatologist.
5. Liquid nitrogen freezing
Liquid nitrogen is applied to the spots every 2-3 weeks. There is a higher risk of mild scarring.
Please see your family doctor or dermatologist.
6. Other creams
Other creams are available to treat Molluscum. There is also a slightly higher risk of mild
scarring. Please see your family doctor or dermatologist.
Sometimes the skin around the lumps can get a rash like eczema and the skin can become
infected. Sometimes antibiotics are used for this skin infection. The antibiotics do not treat the
molluscum spots themselves. Sometimes the molluscum is treated because it is irritating your child
and because it is easily seen by other people.
At home care
Strict attention to hygiene is very important. Children with Molluscum should do the
following:
Have a shower instead of a bath. The Molluscum virus can live and spread in the bath water
to other parts of the body.
Wash and dry any bath toys every day after use. Bath toys can spread the virus.
Be careful drying your child dry after their shower. The virus can be spread on the towel - try
to dry areas with the spots last.
Do not share baths with other children.
Do not go into swimming pools until the spots have gone away.
Do not share towels, face washers (flannels) or clothing.
Wash your hands after touching the Molluscum spots.
Children with Molluscum can go to school and play with other children, as clothing usually
covers the affected areas.
Nappy Rash
Background
Nappy rash is a dermatitis confined to the area covered by the nappy. It is most commonly
characterised by confluent erythema of the convex surfaces of the buttocks, the areas of skin in
closest contact with the nappy and it spares the groin folds.
The relative contribution of each factor may vary between cases. It is not generally helpful to
distinguish between these causes of Primary Irritant Napkin Rash as the treatment principles do not
depend on this.
Treatment
Differential diagnosis
Seborrhoeic dermatitis - Non-itchy salmon pink flaky patches may appear on the face, trunk
and limbs and involves skin folds.
Atopic dermatitis
Psoriasis- sharply demarcated, non-scaly, bright erythematous plaques either isolated or
similar lesions in other intertriginous areas such as the axilla etc,
Perianal streptococcal cellulitis - localized well-demarcated erythema that covers a circular
area 1-2 cm radius around the anus with fissuring and macerated skin. Can present with
painful defecation and/or constipation.
Zinc deficiency - sharply defined, red, often extensive, anogenital rash. Look for perioral, peri-
nasal and acral (hand and foot) dermatitis, alopecia, diarrhoea, and failure to thrive.
Threadworms - In older children, threadworms (Enterobius vermicularis) are a common cause
of an itchy anogenital rash. Look for the worms at night and treat with oral mebendazole.
Langerhans' cell histiocytosis - a chronic inguinal or anogenital rash, with brownish/red scale
and petechiae, which is often erosive and unresponsive to treatment. A scaly, papular,
eruption on the scalp or trunk may appear. Purpura, fever, diarrhoea or hepatosplenomegaly
may be present.
Malabsorption syndrome - Malabsorption from any cause (e.g. cystic fibrosis) can present with
diarrhoea, erosive dermatitis and failure to thrive. There may be a progressive intractable
napkin rash contributed to both by the diarrhoea and by secondary nutritional deficiencies
Crohns disease Parent Information Sheet (Print version - PDF)
Nappy rash
The most common cause of nappy rash in babies is irritation. Constant moisture,
occlusion and rubbing cause damage to the skin. This is further irritated by bacteria,
yeasts (eg Candida or thrush), detergents, urine (wee) and faeces (poo).
The skin in the nappy area looks red and raw. It can be generally red, or spotty in
appearance, particularly at the edges of the rash.
The body's creases are not usually involved.
It can be sore or itchy when the area is wiped.
Your baby may be unsettled or irritable.
Care at home
A good quality disposable nappy is best. These allow the moisture to be absorbed quickly,
keeping the skin dry. Whilst cloth nappies are good for the environment, they do not take up
moisture as well as disposables.
Nappies should be changed often (about 5-7 times a day in babies under 12 months),
reducing the contact of urine and faeces with the skin.
At each nappy change your baby's bottom should be gently wiped with cotton wool or 'Chux'
type cloths, dampened with luke-warm water. Baby wipes can be quite irritating and should
not be used.
A barrier cream should be thickly applied at each nappy change. This will prevent the
moisture and irritants from reaching the skin. Zinc paste is the best or white soft paraffin. If the
cream wipes off too easily, try another brand, as the idea is to create a barrier. These creams
are available from your Pharmacy, or may be prescribed by your doctor.
Try to let your child have as much time without the nappy on as possible.
Talcum powder should not be used on nappy rash.
Be aware that other conditions may look like nappy rash and these may not respond to the
treatment for nappy rash. If the rash is not improving, see your local doctor or
dermatologist.
Treatment / preparations
Nappygoo - The Royal Children's Hospital's own nappy rash cream, developed by and
available from the RCH Pharmacy Department.
If prevention is not successful, a medicated cream such as an antifungal (eg Canesten,
Daktarin, Nystatin) or hydrocortisone (eg Sigmacort 1%) may be necessary. Do not use any
stronger cortisone creams in this area unless your doctor tells you to.
Antiseptics should not be used on nappy rash.
See your doctor if the rash does not improve within 1-2 weeks.
Infection Viral
Bacterial Streptococcal Pneumoniae
Haemophilus Influenzae (non typeable)
Moraxella Catarrhalis
Allergic Seasonal
Perennial
Chemical
Obstructive Adenoidal
Hypertrophy
Foreign Body
Anatomical anomalies
Immunodeficiency
Ciliary dysfunction
(Cystic Fibrosis)
Acute Bacterial Sinusitis
This usually follows a viral infection. Mucosal inflammation and thick secretions block the normal sinus
drainage resulting in secondary bacterial infection.
Symptoms Signs
Headache
Fever
Diagnosis in younger children is more difficult as the signs and symptoms are non specific. Persistent
nasal discharge (beyond 10 days) is usually the predominant symptom. There are a number of causes
of this presentation including sequential URTI's, allergic rhinitis and adenoidal hypertrophy.
Complications
Orbital Complications:
Periorbital cellulitis , orbital cellulitis
(see Orbital Cellulitis Guideline)
Intracranial Complications:
Cerebral abscess, cavernous sinus thrombosis, meningitis, encephalitis, subdural / epidural
empyema
Investigations
CT is the imaging modality of choice. Air-fluid levels, opacification and mucosal thickening may be
seen, however, these findings are non-specific.
Culturing nasal secretions is not indicative of sinus flora and is therefore not helpful. The 'Gold
Standard' would be sinus puncture for culture. This is invasive and painful and should only be done in
an ENT setting.
Treatment
2nd line amoxycillin/clavulanic acid (if pt has had amoxycillin in the last
month)
The addition of steroid sprays, decongestants, or antihistamines to antibiotic treatment has been
shown to have no benefit in sinusitis.
Needle Thoracocentesis
Notes
Equipment
Analgesia, anaesthesia and sedation
Procedure
Post-procedure care
Notes
Needle aspiration (thoracocentesis) is now an established initial intervention in selected patients with
primary spontaneous pneumothorax (see Primary Spontaneous Pneumothorax)
Indications:
Relative contraindications:
Equipment
Dressing pack
Aspiration device
Large bore cannula (12 or 14 gauge)
Central venous catheter (CVC) or Pigtail catheter are alternatives
20ml or 50ml syringe
3 way tap
Antiseptic solution
1% lignocaine ampoule
Sleek and Tegaderm x 2
Analgesia and local anaesthesia are mandatory except with tension pneumothorax, which is
immediately life-threatening.
Procedure
Post-Procedure Care
Reassess ABCs
Background
Assessment
Neonates
All infants less than 4 weeks old must be seen by an Emergency Registrar or Consultant.
Clinical acumen will not reliably distinguishing ‘well’ from ‘sick’ infants in this age group.
Assessment
The following presenting features are associated with a higher risk of serious illness in young infants:
Fever
Full sepsis evaluation and admission should be considered for any neonate with T >38. Investigations
should be performed in the neonatal unit unless there is undue delay or the infant is to be admitted to
a general ward.
Feeding
If the volume taken in the previous 24 hours is less than 50% of normal.
Urine output
Less than 4 wet nappies in 24 hours indicates a significant decrease in fluid intake.
Peripheral circulation
Generalized pallor of recent onset, mottling, cold periphery or sluggish capillary return (capillary refill
time > 2 seconds).
Responsiveness
Activity
Breathing difficulty
The signs of respiratory distress in the neonate are tachypnoea (RR > 60/min), recession, expiratory
grunt, nasal flaring and cyanosis.
Apnoea
Defined as a pause in respiration of > 20 seconds. May be central (eg. prems), obstructive (eg. URTI
with pharyngeal mucous, GOR, blocked nose) or combined.
Vomiting
Any vomiting in excess of normal post-feed possiting must be treated seriously in the neonate.
Cyanosis
Seizures
Severe jaundice
Nephrotic Syndrome
Nephrotic syndrome is a clinical disorder characterised by oedema, proteinuria, hypoalbuminaemia
and hypercholesterolaemia. Minimal change glomerulonephritis accounts for 80 - 85% of nephrotic
syndrome in childhood.
Presentation
Oedema is the primary feature. This may be subtle (peri-orbital region, scrotum or labia) or
gross and include in addition, peripheral oedema of the limbs and sacrum. Ascities and
pleural effusions may be present when oedema is gross.
History is often of weight gain, poor urine output and sometimes of discomfort as a result of
the oedema. A history of preceding upper respiratory tract infection or diarrhoea may be
present.
Examination should confirm the presence of oedema, assess peripheral perfusion and blood
pressure. Examination should include a search for signs suggesting the onset of
complications such as infected ascites, renal vein thrombosis (eg enlarged renal mass, loin
tenderness and marked heamaturia) and cerebral vein thrombosis.
Urinalysis should always be included to make the diagnosis as other causes of oedema such
as protein losing enteropathy or cardiac failure may occur.
Infections The altered immune system in patients with nephrotic syndrome is responsible for
their enhanced risk of infection. Penicillin during oedematous phases is effective prophylaxis.
Thrombosis Renal, femoral, cerebral, pulmonary thrombosis may occur in nephrotic patients
due to hypovolaemia, high platelet counts and loss of antithrombin III. Thus low dose aspirin is
recommended in oedematous nephrotic patients.
Acute renal impairment This is due to renal hypoperfusion. Albumin is the treatment (see
below).
Investigation
1. Urinalysis
A finding of +++ or ++++ is usual on dipsticks. The degree of proteinuria is variable.
Proteinuria is usually of the selective type. Microscopic haematuria is present in 15 - 20% of
patients with minimal change nephrotic syndrome. Red blood cells and granular casts may
suggest the alternative diagnosis of chronic glomerulonephritis as the underlying cause for
nephrotic syndrome.
2. Estimating proteinuria
A timed collection of urine for protein excretion is not necessary when the diagnosis is clear.
3. Routine biochemistry
Urea and electrolytes, creatinine, total protein, albumin, globulin, cholesterol.
Treatment
1. Admit to hospital for first presentation. In the case of relapses consult with treating physician.
2. Intravenous albumin is indicated for anuria, hypotension, poor skin perfusion with skin mottling
or poor capillary return. These are all indicators of a depleted vascular space. Give only in
consultation with treating consultant. Give 20% albumin 5 ml/kg (1 g/kg) over 4 hr i.v. Beware
of the possibility of hypertension and pulmonary oedema. Frusemide should only be given if
the peripheral perfusion markedly improves following the albumin or there are signs of
pulmonary oedema or hypertension.
3. Gross genital oedema causing discomfort may also be an indication for albumin. Frusemide 1
mg/kg i.v. should be given 2 hr later.
4. Free fluid intake.
5. Diet with no added salt.
6. Oral penicillin 12.5 mg/kg/dose bd (prophylaxis) while oedematous. If the child is profoundly ill
or appears to have sepsis use cefotaxime 50 mg/kg/dose 6-hourly to a maximum of 2 g/dose
(to cover Strep pneumoniae, H influenzae and E coli).
7. Low dose aspirin (10 mg/kg alternate days).
8. Strict fluid balance.
9. Daily weight.
10. Corticosteroids
Prednisolone
UNDER REVISION
Relapses
Over 75% of patients will experience at least one relapse, usually in the setting of an intercurrent
illness. A relapse is defined as proteinuria ++++ or +++ for 4 days. Lower levels of transient proteinuria
with fever do not require re-treatment.
UNDER REVISION
Note - at RCH these guidelines are for use in the Emergency Dept. For use in other areas see
also Procedural Sedation Guideline
Backgroud
Nitrous oxide has been used for many years in obstetric care during labour. It has both analgesia and
amnestic properties. It has a quick onset of action and fast offset which makes it ideal for use in an
emergency department. It has no sedative properties and thus must be used on patients who are co-
operative (i.e. >4yrs of age).
It comes as a pre-mixed 50:50 combination of nitrous oxide and oxygen on a demand triggered
system, or as a continuous flow via a mixer (maximum concentration is 70% NO:30% O2).
Indications
fracture manipulation
abscess incision and drainage
injection of local anaesthetic
removal of foreign bodies from ear / soft tissues
other painful procedures
Contraindications
Procedure
Pre-procedure
Make sure the oxygen and nitrous oxide tubing are connected to their respective outlets
Attach filter and appropriate mask to the circuit
Add a few drops of flavouring as needed
Make sure the suction is connected to the "bassoon" on the machine and is on low suction
only
Procedure
Patient should self-administer Nitrous Oxide for a few minutes immediately prior to
commencement of painful procedure, with a doctor supervising. A harsh sound is heard on
inspiration if the gases are flowing properly.
Procedure is performed with patient continuing to breathe Nitrous Oxide for the duration of the
painful part of the procedure and 1 minute after painful part of procedure is finished.
Post- procedure:
Turn the cylinder valve to closed position. The regulator valve will not go back to zero until the
line from the regulator to the face mask is emptied.
Patient may be discharged after the procedure is complete if the patient is back to their pre-
procedure mental status.
Presentation
Management - Orbital Cellulitis
This is a surgical emergency. After consultation with the ENT surgeons and ophthalmologists, an
urgent CT scan should be arranged to differentiate those patients with an associated abscess (usually
subperiosteal) from those without. This should be discussed with the radiologist who will ask for
coronal views. Imaging should pay particular attention to the orbital and frontal regions as the abscess
may be small.
Surgical drainage of an abscess results in decompression of the orbit and obtains infected material for
Gram stain and culture.
Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Over 5 years Staph
aureus is more common. Haemophilus influenzae type b is less common since HiB immunisation.
Recommended antibiotics
Lumbar puncture is contraindicated in patients with orbital cellulitis until after the CT scan has been
performed, even in the absence of features of raised intracranial pressure, since intracranial extension
may be silent.
Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Strep pyogenes and
Staph aureus are likely if there is a contiguous skin lesion. Rarely Haemophilus influenzae may be the
cause particularly in children under five who are not fully immunised.
Recommended antibiotics
Mild Amoxycillin/Clavulanate
(400/57 mg per 5 mL)
0.3 mL/kg (11 mL) po 12H
In children who are systemically unwell it may be reasonable to use both cefotaxime and flucloxacillin
initially. Any child in whom there is a reasonable suspicion of primary skin infection, or who is not
improving on cefotaxime alone should have flucloxacillin added. Failure to respond in 24-48 hours may
indicate orbital cellulitis or underlying sinus disease. Treat as for orbital cellulitis.
When improving, and no organism identified change to augmentin 25 mg/kg/dose, 8-hourly (maximum
500 mg/dose) for 7 days.
Prophylaxis
If Haemophilus influenzae type b is isolated, rifampicin prophylaxis should be given as for meningitis,
that is, if a child aged 5 years or less lives in the same household as the index case or if the index
case is < 2 yr, then prophylaxis should be given to the entire household, including the index case.
Parents who are pregnant should not be given rifampicin. Patients should be warned that rifampicin
will colour the urine tears and other secretions orange, orange tears may discolour contact lenses.
Rifampicin induces the metabolism of the oral contraceptive pill making this form of contraception
unreliable.
Doses:
In the absence of local and systemic signs of infection eg temperature or tenderness, periorbital
erythema may be an allergic reaction rather than periorbital cellulitis.
Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly involve the lower
limbs. Both are most commonly caused by Staphylococcus aureus but can be caused by group A b -
haemolytic streptococci and Haemophilus influenzae. Children with sickle cell anaemia are prone to
infection by salmonellae.
Features
Investigations
FBE, ESR (may be useful for monitoring progress), blood culture, xray (often normal, but may
exclude trauma, etc), Bone Scan.
NB Consultation and treatment should not be delayed while waiting for a bone scan
Management
Causes:
viral (25%)
Streptococcus pneumoniae (35%)
non-typable strains of Haemophilus influenzae (25%)
Moraxella catarrhalis (15%).
Assessment
Note: A child with otitis media can also have serious bacterial infection such as septicaemia or
meningitis. If systemically unwell, consider coexistent causes of sepsis - do not accept otitis media
as the sole diagnosis in a sick febrile young child without elimination of a more serious cause.
(See febrile child guideline)
History:
fever, ear pain (irritability in pre-verbal children) +/- anorexia, vomiting, lethargy.
Examination
The usual middle ear landmarks (handle of malleus, incus, light reflex) are not well seen.
The tympanic membrane (TM) is dull and opaque, and may be bulging. The TM colour varies
but is characteristically yellow-grey.
On pneumatic otoscopy TM mobility is reduced.
There may be associated signs of URTI, such as coryza, red tonsillopharynx, cough etc. The
features suggest the infection is viral.
Many febrile or crying children have red TMs (just as they have red cheeks). A red TM alone
is not acute otitis media.
It is not usually necessary to remove wax from the ear canals of febrile children
Complications
Management
Most cases of AOM in children resolve spontaneously. Antibiotics provide a small reduction in pain
beyond 24 hours in only about 5% of children treated. The modest benefit must be weighed against
the potential harms related to antibiotic use, both for the individual patient (adverse effects) and at a
population level (resistance pressure). It has been shown that not using antibiotics for otitis media is
acceptable to parents if the reasons are explained clearly.
Pain is often the main symptom, so adequate analgesia is very important Analgesia guideline.
Paracetamol 20-30 mg/kg for 2-3 doses/day should be given if pain is significant. Short-term use of
topical 1% lignocaine drops applied to the tympanic membrane seems anecdotally to be very effective
for severe acute ear pain. Decongestants, antihistamines and corticosteroids have not been shown to
be effective in AOM.
Ear infections are very common in small children. Most ear infections involve the middle ear. This is
called otitis media.
Babies and young children get more middle-ear infections than older children because the tubes
connecting the middle ear to the throat (the Eustachian tubes) are shorter and more horizontal. This
makes it easier for germs to reach the middle ear from the nose and throat. The Eustachian tube is
also softer in children and gets blocked easily.
This often happens as part of a virus infection (eg common cold), which is very common in early
childhood. It is normal to have some fluid in the middle ear, which usually drains down in to the throat.
When the Eustachian tube is blocked, this fluid doesn't drain so well and air doesn’t get up into the
middle ear space as well as it should.
Signs and symptoms
Because of the pain, toddlers can become extremely irritable and hard to deal with.
They may have more tantrums.
They may pull at their ears or shove their finger inside their ear.
Children may also vomit, lose interest in eating, seem to have no energy and have trouble
hearing.
Sometimes pus will break through the eardrum so you see a thick yellow discharge from the
ear. When this happens children often feel better as the painful pressure from the fluid inside
the ear is gone. The burst eardrum usually heals without treatment.
Middle ear infections often happen with a cold (sometimes called an upper respiratory tract
infection or URTI), with a runny nose and sore throat.
Usually they have a fever - sometimes a fever is the only symptom.
Care at home
Antibiotics are not required every time the doctor notices a child has an ear infection. They
may cause side-effects. Ask the doctor if antibiotics are really necessary.
Following an ear infection, children may have some fluid in the middle ear for a few weeks. You may
notice your child has some trouble hearing during this time. The fluid will usually clear up over a couple
of months. If your child continues to be irritable or does not seem to be hearing well, see your doctor.
It can be very common for small children to have several ear infections in one year.
Antibiotics are not always needed.
There may be some fluid in the middle ear for several weeks or months after the infection.
This is normal, and usually clears up on its own.
Glue Ear
Most children will have an occasional ear infection which will get better quickly and are not usually
serious. A number of children who have recurrent ear infections will develop otitis media or 'glue ear'.
Glue ear is when children have sticky fluid in their middle ear behind the ear drum. This may last for
many weeks or months. It often follows one or more middle ear infections, although it sometimes
happens when there does not seem to have been an infection. The fluid in the middle ear makes it
harder for your child to hear. When this lasts for a long time hearing and speech development may be
affected.
Glue ear will usually become less common as your child gets older.
Treatment
You should take your child to visit a paediatrician (children's doctor) or ear, nose and throat (ENT)
specialist if:
OR
Your child has persistent fluid in the middle ear that affects their hearing.
At this visit the doctor will discuss the following treatment options for your child.
No treatment
If your child is not bothered by the fluid, often no treatment is needed. It usually goes away by itself
over time.
Antibiotics
A 2-3 week course of antibiotics is sometimes prescribed to kill any remaining germs. This may help
the fluid clear.
Surgery
If the fluid still persists and is affecting your child’s hearing over many months, a brief operation may
be suggested. Small ventilation tubes (called “grommets”) are put into your child's ear during the
operation. These tubes help fluid drain from the middle ear.
Your child's hearing must be also be tested properly by a hearing specialist called an
audiologist.
Care at home
Always try not to smoke in the home or around your child. Any cigarette smoke that your child
breathes harms the eustachian tube in th ear so the fluid cannot drain away.
Using dummies for long periods can also make things worse, so only use them for settling
your baby.
If your child complains of pain you may need to give them some pain relief, such as Panadol.
Glue ear is caused by frequent ear infections or fluid in the middle ear.
Glue ear often needs no treatment.
Sometimes a small operation can help drain the fluid from the ear.
Hearing and speech development can be sometimes affected if glue ear is persistent.
In the acute phase the most important tasks are to identify those conditions
requiring more than just symptomatic treatment, and to ensure that those being
treated symptomatically have appropriate follow-up.
FBE
ESR/CRP
Disposition
Patients with the following conditions should be referred to the appropriate in-patient unit:
Joint trauma (orthopaedics)
Intra-articular bleeds (orthopaedics/haematology)
Joint sepsis (orthopaedics)
Suspected malignancy (haematology-oncology)
Other (general medicine)
In many cases there may not be a clear diagnosis by the end of the child’s assessment in the
emergency department - the results of some investigations may not be available for days, and others
may help only in ‘ruling-out’ certain conditions. For such children, symptomatic outpatient treatment
with non-steroidal anti-inflammatory drugs (eg. naproxen) with careful follow-up is appropriate. These
children should be followed closely until their symptoms resolve or the diagnosis becomes clear.
Any child with symptoms not resolved after four weeks or any child in whom NSAIDs do not provide
adequate relief of symptoms should be re-evaluated.
Fracture
Pulled elbow
Joint pathology
Infective process
Neurological lesion
Radiology:
Pay particular attention to the supracondylar fat pads, the radial neck and the distal radius as bony
injuries in these areas are the most common differential diagnoses.
Paracetamol Poisoning
See also General Management of Acute Poisoning Guideline
Activated charcoal 1g/kg immediately if less than 1 hour since ingestion of tablets or
capsules. (Not useful for liquid ingestions as fully absorbed within 20-30 mins).
Serum paracetamol level at (or as soon as possible after) 4 hours post ingestion will
determine the need for N- acetyl cysteine administration (see nomogram below)
There is nothing to be gained by measuring serum paracetamol before 4 hours
N-acetyl cysteine treatment should not be started unless the nomogram indicates a potentially
toxic paracetamol level
If N-acetyl cysteine treatment is required, do APTT/INR and baseline LFT’s upon insertion of
IV.
N-Acetyl cysteine (see chart)
Loading dose 150mg/kg in N/2 saline and 5% dextrose (10mls/kg) IV over 1hr.
Infusion 10mg/kg/hr in N/2 Saline and 5% Dextrose (at half maintenance rate) for 20
hrs, longer if >10 hrs post ingestion or encephalopathic.
Monitor hydration and treat as indicated.
Note
Anaphylactoid reactions to N-Acetyl cysteine may occur (wheeze, rash): stop the infusion for
30 minutes & give promethazine (phenergan) 0.2 mg/kg i.v. then recommence infusion at half
the previous rate. Increase the rate slowly over time until the desired rate is again reached.
Notes
Assessment
Diagnosis is largely clinical - usually made on the basis of history and observation of coughing
spasms.
History
There is generally a history of dry cough and nasal discharge for approximately one week
(coryzal phase), followed by a more pronounced cough which may occur in spells or
paroxysms (paroxysmal phase).
Vomiting often follows a coughing spasm.
Young infants may develop apnoea.
Other family members frequently also have a cough (70 – 100% of household contacts are
usually infected).
Examination
Often, there are no clinical signs. Children are usually well between coughing spasms.
Investigations
Diagnosis
Managment
Hospital admission
Infants less than 6 months of age, and older infants and children who are unwell require hospital
admission.
Antibiotics
Treatment with macrolide antibiotics reduces the period of infectivity but has not been shown
to alter the course of the illness unless commenced before the paroxysmal phase.
When treated with antibiotics, the period of infectivity usually lasts 5 days or less after
commencement of therapy.
Control of case
The child should be excluded from school and from the presence of others outside the home
(especially infants and young children) until he/she has received at least 5 days of a 7-day
course of clarithromycin.
NOTE: A child who has been coughing for more than 21 days is no longer infectious;
therefore antibiotic treatment and school exclusion are not necessary.
Vaccination
Unimmunised or partially immunised children diagnosed with pertussis are still required to
complete the pertussis immunisation schedule.
Treatment of Contacts
Vaccination
Close contacts under 7 yrs of age who are not up to date with their pertussis immunisation
should be given DTPa as soon after exposure as possible.
Antibiotics
Antibiotics should be given to all household contacts and to other contacts in high-risk settings who
have had direct contact with an infectious case i.e:
Infants <12 months of age who have not received 3 documented doses of pertussis-
containing vaccine (maternal antibodies do not protect against pertussis).
Any unvaccinated or partially vaccinated person with chronic cardio-respiratory illness.
Any women in the last month of pregnancy.
NOTE: Antibiotics should be given within 14 days * of the recipient’s first contact with an infectious
case.
(*In special circumstances, such as a high-risk exposure for an infant contact, antibiotics may be given
within 21 days of first contact with an infectious case.)
School exclusion
Unimmunised siblings less than 7 years of age and unimmunised close child care contacts must be
excluded from school or child care for 14 days from the last exposure to infection, or until they have
taken 5 days of a 7 day course of antibiotics. A child who has received <3 doses of a pertussis-
containing vaccine should be considered unimmunised.
Notification
Notify all cases (suspected or confirmed) to the Communicable Diseases Section, DHS, Victoria. Tel:
1300 651 160 or Fax: 1300 651 170.
Sore Throat
See also: febrile child guideline
A sore throat is an extremely common symptom that frequently results in a medical consultation and
prescription of antibiotics. The commonest cause of a sore throat in children is a viral illness. 15 – 30%
of children with a sore throat will have Group A streptococcal (GAS) pharyngitis. Bacterial causes for
sore throat other than GAS are rare.
Currently there is controversy regarding the appropriateness of antibiotic therapy for GAS pharyngitis
in a population where acute rheumatic fever is rare.
Assessment
view flowchart
Notes:
Patients with wheeze and air trapping, most commonly have bronchiolitis or asthma:
All neonates who are unwell, or have a temperature > 38C, should have a chest X-ray as part of
a septic workup: Management of Pneumonia - flowchart 1
Management of Pneumonia - flowchart 2
Return to Pneumonia Guideline
Assessment
Most episodes occur at rest. Consider PSP in patients with the following:
Symptoms
Acute onset of chest pain - Severe and/or stabbing pain, radiating to ipsilateral shoulder and
increasing with inspiration (pleuritic)
Sudden shortness of breath
Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less
commonly observed.
Signs
Imaging Studies
See Algorithm
Notes
Background
Assessment
Most episodes occur at rest. Consider PSP in patients with the following:
Symptoms
Acute onset of chest pain - Severe and/or stabbing pain, radiating to ipsilateral shoulder and
increasing with inspiration (pleuritic)
Sudden shortness of breath
Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less
commonly observed.
Signs
Imaging Studies
Management
See Algorithm
Notes
Alkalis
Anticonvulsants
Antihistamines/antihistamine-decongestant Preparations/Sympathomimetic Agents
Benzodiazepines
Camphor
Ethanol
Eucalyptus Oil / Essential Oils
Hydrocarbons
Iron
Paracetamol
Salicylates
Theophylline
Tricyclic Antidepressants
TOXNET
General Principles
Assess:
The poisons information centre may provide useful information on toxins and doses found in various
products, phone 131126.
Management
Airway
Breathing
Circulation
Removal of poison (if necessary)
Emesis
No role in the hospital setting
Activated Charcoal
The treatment of choice for most ingestions. Most effective when given within first hour.
Contraindications:
Patients with altered conscious state
The following agents:
Ethanol/glycols
Alkalis
Boric acid
Lithium
Iron compounds
Potassium and other metallic ions
Fluoride
Cyanide
Hydrocarbons
Mineral acids
Whole Bowel Irrigation has a limited role in treatment of some slow release preparations
Gastric Lavage has a very limited role in treatment and should not be used without
consultation.
Specific antidotes may be available and serum drug levels may help in treatment decisions
All intentional self poisonings in adolescents require admission under the adolescent unit after
discussion with their on-call consultant.
1. Introduction
The RCH Procedural Sedation Guideline provides hospital staff with the minimum
standards for use of sedation of patients outside theatre, ICU, ER and NNU. This
Guideline relates to the use of oral agents, inhaled nitrous oxide and intravenous
midazolam. Other techniques may be employed in critical care areas and according to
Hospital Guidelines for specific procedures. This Guideline is intended for use in patients
who are generally healthy or have only mild systemic disease. Sicker patients should not
be sedated without the involvement of staff from the Children’s Pain Management
Service (CPMS).
Sedation is a continuum ranging from minimal anxiolysis to a state of deep sedation. The
response to sedative drugs is not always predictable, so staff need to be prepared to deal
with a patient who becomes more sedated than intended. Excessively sedated patients
may lose their protective airway reflexes and be at risk of adverse effects including
hypoventilation, apnoea, airway obstruction, aspiration and cardiovascular impairment.
Define the patients who are appropriate to receive minimal to moderate sedation for
procedures.
Outline the staffing levels required to safely administer the sedation for procedures and
indicate which agents need specifically accredited staff members for administration and
monitoring of the child.
Summarise the minimum standards for procedural sedation including patient monitoring and
observations.
For all stages of the procedure (before, during and after) appropriate non-pharmacological
pain management techniques is also required.
The drugs used and their administration should be less noxious than the procedure itself.
If at any time you have uncertainties about the patient's suitability for sedation, or
about your own capabilities to conduct the procedure safely - discuss with CPMS
(Children’s Pain Management Service) before proceeding.
2. Goals of Sedation
3. Definition of Terms
Sedation Period: The period of time commencing with the administration of sedative
drugs and ending when the patient has recovered to the point where he or she meets
the end of the sedation criteria (observations are within normal limits, patient returns to
baseline sedation score).
NOTE: It is possible for patients to progress from a state of moderate sedation into
a state of deep sedation/obtundation.
A drug-induced state of depressed consciousness from which the patient is not easily
aroused.
Deep sedation may be accompanied by partial or complete loss of protective airway reflexes.
Patients are usually unable to respond purposefully to physical stimulation or verbal
commands.
Competent staff member: a staff member who has the knowledge, skills and training
to:
Indications
Examples of suitable procedures for which procedural sedation is indicated: Lumbar
puncture, bone marrow aspiration, wound dressing care, dental extraction,
echocardiography, electrophysiological studies, diagnostic radiology, IV access,
intercostal catheter removal, skin biopsy.
The procedure should not be complex, very painful or prolonged (? beyond 30 minutes).
It is unreasonable to expect sedation to be sufficient in these situations. Patients who are
extremely anxious prior to the procedure may need special consideration. General
anaesthesia may be required instead.
Risk assessment
Increased risk of delayed gastric emptying or vomiting (which may increase risk of aspiration)
e.g. bowel obstruction or gastro-oesophageal reflux
Significant respiratory disease e.g. upper airway obstruction, airway infection, apnoea, exacerbation
of asthma, pneumonia
Abnormal conscious state/risk of raised ICP e.g. head injured, meningitis, space occupying lesion
Age less than or equal to 2 years (for nitrous oxide and IV midazolam)
A patient with a condition which results in ‘trapped gas’ should not receive nitrous oxide,
as it will expand the gas filled cavity e.g.lung cyst, bowel obstruction, middle ear
disease, pneumothorax
The treating medical team who request the patient to have the procedure with sedation
will usually perform a patient assessment.
prior illnesses and conditions (refer to risk assessment and exclusion criteria )
drug history
drug allergies (recorded on Medication Chart)
pathology results e.g. platelet count prior to lumbar puncture
last food/fluid intake (refer to Fasting times)
previous sedation experiences and drugs used
accurate weight (recorded on Medication Chart)
vital signs
6. Fasting
IV midazolam and nitrous oxide: 6 hours solids, 4 hours breastfeed, 2 hours clear
fluids
Adequate preparation and education of the patient and family should be provided - provide
age appropriate information about the procedure and any sensations to expect.
Sedation handout must be discussed with patient/parents (www.rch.org.au/kidsinfo)
Non-pharmacological techniques should be planned and employed during procedures to
complement and sometimes prevent the need for drug sedation
Parents should be encouraged to be present during the procedure to allay anxiety and they
should be taught to coach their child effectively in the use of coping methods. — Procedure
Pain Management Guideline.
8. Consent
Informed and written consent for BOTH sedation and the procedure are to be obtained by
medical staff.
A Registered Nurse may also obtain informed consent for BOTH the sedation and the
procedure if:
9. Staffing
A minimum of two staff should be present for procedures for which a child is sedated.
The other staff member must be responsible for administration of the sedative drug and continuously
responsible for observation for the duration of the "Sedation Period". The appropriate training for this
staff member will vary according to the sedative agent given.
10. Medications
The Venue:
Should ideally be a hospital treatment room with appropriate lighting (adequate lighting for the
procedure and patient observation) and minimal noise.
Facilities for observation should be available and used until the child has recovered from
sedation to a point where it is safe to be discharged from that area.
The child should have an appropriate size bed or trolley.
Sedated patients should not be left to wait in corridors or waiting rooms and ideally not
transported within the hospital.
The Equipment:
The TWO staff members involved in the procedure (the proceduralist and the person administering the
sedation) will confirm the following corresponds with the Consent Form MR132:
For further information refer to the ‘Consent Checking Procedure’ and/or the ‘Patient Identification’
Policies.
4 Deep sedation: deep sleep, rousable only with deep or significant physical
stimulation.
5 Unrousable.
14. Documentation
15. Transport
If patients in the "Sedation Period" need to be transported, use a trolley with suction and oxygen, bag
and mask apparatus available and pulse oximetry. They should be accompanied by a competent staff
member who must be continuously responsible for observation of the patient’s heart rate, airway
patency, adequacy of ventilation, and level of sedation, and be able to initiate resuscitation procedures
and know how to call for additional help.
Patients under deep sedation should not usually be transported during the sedation period unless
clinically necessary.
Line of sight nursing, observation and recording sedation score (+/- vital signs) can cease
once when the patient meets the following criteria:
If the patient is returning from the treatment room to the general ward, ensure that the allocated staff
member has a handover about the sedation and procedure performed.
For Outpatients:
Discharge home may be considered (provided other medical factors permit) when the
patient meets End of Sedation Criteria as well as the following criteria:
Pulled Elbow
History:
Examination:
Differential Diagnosis:
Diagnosis
Treatment
Reduction manoeuvres
supination/flexion manoeuvre
Notes:
You must obtain a definitive diagnosis by culture of urine obtained in a sterile fashion (MSU,
SPA, CSU - see below).
UTI cannot be diagnosed on symptoms alone, nor by culture of urine from a bag specimen.
Urinary dipstick testing is only a screening test for UTI. It has poor sensitivity and specificity
(see below).
Finding a UTI in a sick child does not exclude another site of serious infection (eg meningitis).
Remember that 2% of young children will have asymptomatic bacteruria and this may not be
the cause of this acute presentation. Organisms may spread from urinary tract to elsewhere
including meninges.
Do not omit an LP in a sick child just because you have found a UTI.
Prior antibiotic therapy may lead to negative urine culture in patients with UTI. The laboratory
will test for antibacterial activity in the urine.
Assessment
History
Features are often non-specific such as fever, irritability, poor feeding, and vomiting.
More specific features may include loin or abdominal pain, frequency and dysuria. These are
often absent in younger patients. Some children with urinary tract infections may look quite
well, while others may appear very unwell.
Examination
Is often normal other than the presence of fever. Loin or supra-pubic tenderness may be
present
Treatment
Any child who is unwell, and most children under 6 months, should be admitted for i.v.
antibiotics. Include blood culture, electrolytes and consider an LP.
A shocked child will require fluid resuscitation.
Discuss children with known underlying urinary tract abnormalities with registrar or consultant.
Gentamicin 7.5 mg/kg (240 mg) iv daily and benzylpenicillin 50 mg/kg (3g) iv 6 hourly for
children over 1 month of age. Remember gentamicin levels.
If oral medication is appropriate
Trimethoprim 4mg/kg (150mg max) BD
(only tablets generally available) or
For 1 week
For children who are still in nappies: A prophylactic dose of antibiotic eg. co-trimoxazole
(200/40 mg in 5 ml) 0.25 ml/kg in a single daily dose, or nitrofurantoin 3 mg/kg at night should
be maintained until the child is seen for follow up.
Investigation
Renal ultrasound is usually performed in young children after first UTI, especially those under 4 years
of age. The main purpose of ultrasound is to exclude urinary tract obstruction.
The following patients should have a renal ultrasound prior to discharge from
RCH:
All others (ie most cases) should have their ultrasound performed as an outpatient.
Usually the most practical and convenient arrangement is for the ultrasound to be
performed earlier on the day of outpatient follow-up.
Micturating cysto-urethrogram (MCU) may be necessary but the decision to perform this
invasive and sometimes distressing investigation needs to be individualised. The value of
demonstrating vesicoureteric reflux in assisting future management is controversial. It is
currently a matter of physician preference. It may be done in children under 6 months of
age (especially boys), and may be necessary for older children according to
circumstances. MCU should not be arranged from the Emergency Dept. and discussion of
the pros and cons of this with the parents can be undertaken at outpatient review.
Follow up
Refer all children with proven UTI for follow up in the General Paediatric Clinic, or by the child's own
paediatrician.
Specimens
Urine bag
Useful for collecting urine for screening purposes in children who cannot void on request (approx. 0-3
years). Wash genitalia with water and dry before application of the bag. Test urine with a dipstick for
leucocytes and nitrites. If positive for either, obtain definitive specimen by SPA (or CSU if SPA fails). If
clinical suspicion is high, send definitive specimen for culture regardless of dipstick result. A negative
dipstick result does not exclude a UTI. Do not send bag specimens for culture in acute presentations.
Antibiotics should not be given unless a definitive urine specimen has been obtained.
For children too young to obtain an MSU, and with a high probability of UTI, or who are unwell
warranting more invasive investigation.
Click here to learn how to do an SPA, including the use of bedside ultrasound
Any growth from SPA urine usually indicates infection (but note possible contamination by skin
commensals or faecal flora may produce a mixed growth).
Catheter Specimens
Can be obtained from children who can void on request. Wash genitalia with water and dry. The first
few mls to be voided are not collected then a specimen is obtained.
A pure growth of > 108 CFU/litre indicates infection. A pure growth > 105 may indicate early infection
and requires a repeat specimen.
Dipsticks can detect urinary protein, blood, nitrites (produced by bacterial reduction of urinary nitrate),
and leucocyte esterase (an enzyme present in white blood cells).
They are a screening test only. If you really suspect UTI - send a specimen for micro and
culture.
Remember
Testing your child’s urine is the only way to know for sure if they have a UTI. Older
children can get their urine from a ‘clean catch’. This is done by collecting part of the
urine flow as your child passes urine into the toilet. In younger children urine is usually
collected directly from the bladder. It can be done either with a needle through the
stomach into the bladder (bladder tap), or through a catheter tube passed up the urethra.
Although urine can be collected in babies using an adhesive bag, these are not suitable for
diagnosis of UTI as they are often contaminated by germs from the skin.
Urine specimens are first usually tested with a dipstick. This can provide clues to the
presence or absence of UTI, but a final diagnosis can only be made by sending the urine
to the laboratory for culture. Culture results may take 24 to 48 hours.
If the dipstick test suggests a UTI, then treatment may be started. The diagnosis and
treatment may be changed once the culture results are available from the laboratory. You
may be asked to call to discuss the results and treatment in 1-2 days. See factsheet: Urine
tests.
Tests
Tests are usually done to look for a problem with the bladder or kidneys. Most children
will have an ultrasound scan. This is a simple and painless test much like the scans that
some women have during pregnancy.
There are other tests that are needed in a small number of patients. Your doctor will
discuss these with you.
Treatment
Antibiotics are the main treatment. They can be taken by mouth. Young infants, or
children who are very unwell with a UTI, should be admitted to hospital for antibiotics
directly into a vein by intravenous therapy (IVT).
Care at home
Your doctor may recommend that your child stays on a low dose of antibiotic to try and
prevent another UTI. This is often suggested for children who are still in nappies or who
have had frequent UTI’s.
It is possible that your child might get another UTI even if your child is on a low dose of
antibiotics.
You should take your child to a doctor immediately for a urine test if your child:
1. Develops any symptoms that might suggest another UTI (see above).
2. Is unwell with a fever without another obvious cause.
Follow up
Most children with UTI make a good recovery and have no future problems. In a very
small number of children, there may be kidney problems or high blood pressure. Your
doctor will discuss the necessary tests and how to monitor for this.
It is sensible for anyone who has had a UTI in the past to have a check on their blood
pressure and a urine test every year, once they reach adolescence.
It is important that any pregnant woman who has had a UTI in the past mention this fact
to her obstetrician.
Urine tests
A urine test is the only way to know for sure if your child has a urine infection. Urine infections cause
children to have high temperatures and become unwell. Sometimes they can make children seriously
ill, especially babies and young children.
Urine infections cannot be diagnosed with urine from a bag specimen. It is important that
the urine is obtained from your child in a germ-free (sterile) way. If your child has a urine
infection they may need other tests and treatment[i1] . See factsheet: Urinary tract
infection.
Babies and small children can't wee into a pot when asked. There are four possible ways
to get urine in babies:
1. Bag specimen
A bag is stuck to the skin inside the nappy to catch urine. This is easy, but sometimes the bag
leaks and it takes several attempts to get some wee. The other problem is that germs from the
skin may get into the urine. This makes it look like your child has an infection even if they don't
really.
2. "Clean-catch"
A parent tries to catch some urine when the baby does a wee. It is very hard to know when a
baby is going to wee, and it can be hard to catch the wee. Germs from the skin can still get
into the urine.
3. Catheter
A tube is put into the bladder through the urethra (the hole where the urine comes out). This is
a better test, but sometimes germs from the skin may still get into the tube when it is being put
in. Babies may cry when they are being held still for the test.
4. Supra-pubic aspirate (SPA)
A doctor puts a needle through the skin of the lower stomach. The needle goes into the
bladder and the doctor can get urine out. Germs from the skin can't get into the urine.
The test needs a needle and can hurt. The doctor may not be able to get urine, if the
bladder is not very full. SPA is the "cleanest", and the best test for working out if your
child has a urine infection. See factsheet: Suprapubic aspirate.
Older children who can wee when asked can collect a midstream urine (MSU)
specimen. This is done by collecting part of the urine flow as your child passes urine into
the toilet. The urine should be collected half way through going to the toilet.
Your child lies down on his or her back and needs to be held still. A doctor puts a needle through the
skin of the lower stomach. The needle goes into the bladder and the doctor can get urine out. It is the
best way to get urine from babies and small children to look for infection.
Babies and small children can’t wee into a pot when asked. There are other ways to collect urine
although they are not suitable to determine if your child has an infection or not. See factsheet: Urine
tests.
Bag specimen. A bag is stuck to the skin inside the nappy to catch urine.
"Clean-catch". A parent tries to catch some urine when the baby does a wee.
Catheter. A tube is put into the bladder through the urethra (the hole where the urine comes
out).
SPA is the "cleanest" and the best test for working out if a child really has a urine infection. If your
child has a urine infection they may need other tests and treatment . See factsheet: Urine
infections.
If your baby or child’s bladder is not full, the doctor may not be able to get any urine with an SPA.
Sometimes we can do an ultrasound of the bladder to help work out if there is enough urine inside
before an SPA is done.
If we can’t get any urine with an SPA we can either wait a little while and try again, or do a catheter.
With an SPA your baby has a needle through the skin, and this hurts about as much as a blood test.
SPAs are usually very quick. Sometimes we can help numb the skin with some cream (but this takes
45 minutes to work).
SPAs are the best way to get urine from babies and small children to look for infection.
They are a very safe test and problems are rare.
There are other ways to collect urine although they are not suitable to determine if your child
has an infection or not.
Upper Airway
Chest Xray
Respiratory Indications:
Inhaled foreign body - most lodge in intrathoracic tracheobronchial tree. Need films in full
inspiration and expiration to demonstrate air trapping or collapse.
Chest trauma - Rib views seldom indicated. Xray to look for air leak, haemothorax or wide
mediastinum.
Pneumothorax - Full inspiratory films adequate.
Asthma - little information gained from xrays. Consider if:
diagnosis unclear
SEVERE attack - not responding to standard therapy
possible air leak.
NB. Focal signs +/- fever are most likely due to mucus plug and viral illness rather
than pneumonia.
CXR NOT to be done routinely pre-operatively at any age.
Cardiac Indications
Remember:
Large thymic shadow is normal under the age of 2 years.
Heart size
normal cardio-thoracic ratio 0.5 ( infants up to 0.6 )
need ECHO to detect presence of pericardial fluid.
Heart murmurs - If careful examination suggests innocent murmur - there is no need for
urgent CXR in the Emergency Department - but arrange appropriate follow up.
Hypertension - CXR is seldom useful.
Limb Xrays
"Fast-Tracking" x-rays via triage assessment: these should be ordered after medical
assessment of injured limb to determine the most approprate views and avoid unecessary x-
ray of entire limb.
Comparative and Stress Views These are rarely necessary and should not be routinely
taken. They may be useful to elucidate complex #’s (after orthopaedic consultation) if
standard films are unclear.
Specific Indications/Contraindications
Trauma
X Ray if signs and symptoms suggest bone injury (pain, tenderness, swelling,
ecchymosis, limitation of movement, pain on weight-bearing, refusal to use arm
(unless clearly a pulled elbow), crepitus and limb deformity. If none of the above - XR
is not justified.
Follow up films after reduction of a displaced # should be done to assess position.
In cases of trauma with clinical impression of a fracture, but a normal XR - may
require Bone Scan to confirm diagnosis.( eg. stress # or toddler #)
Pulled Elbow
If mechanism of injury and examination suggest subluxation of the radial head then
XR is unneccesary.
Non accidental injury (to be seen by registrar or consultant )
Complete Skeletal Survey if child < 2yr to determine type, number and age of
fractures.
If child > 2yr it should be limited to sites of clinically suspected injury.
± Bone Scan (if < 2yr) - can complement bone survey to demonstrate other #’s not
previously demonstrated.
Suspect NAI if:
metaphyseal #
marked or unusual epiphyseal separation
# of spine or ribs
unexplained skull # ± intra cranial injury
Osteomyelitis
Early XR often shows no bony abnormality but may have deep soft tissue swelling.
Bone scan will demonstrate an abnormality earlier than XR.
Septic Arthritis
Normal XR ( ± bone scan ) does not exclude septic arthritis. Ultrasound may be
useful to demonstrate a joint effusion and soft tissue abnormality.
Metabolic disorders eg. rickets - XR of one forearm and wrist is most useful.
Indicated for:
Suspected bowel obstruction
perforation
intussusception
Foreign Bodies
Ingested opaque FB require a single survey AP film that includes entire GIT- to
establish that object has passed through the oesophagus. Routine follow-up films
NOT indicated unless clinical symptoms develop. ( see Ingested Foreign Body
protocol)
Unecessary AXRs
If unsure whether AXR would be helpful - ask consultant or registrar for advice
AXR not indicated for:
Vague central abdominal pain.
Gastroenteritis.
Haematemesis.
Pyloric stenosis.
Uncomplicated appendicitis.
AXR generally not indicated for - chronic constipation.
( in the Emerg. Dept setting ) - encopresis or enuresis.
Urinary Tract Imaging
Bacteriologically proven UTI usually requires abdominal US +/- MCU (see Urinary
Tract Infection protocol).
Suspected Abdominal Mass
Initial investigation - plain AXR and ultrasound, then further as indicated - IVP, CT
scan
Blunt Abdominal Trauma
Need early assessment by General Surgery to direct imaging as indicated.
Head Trauma
Skull X-ray (SXR) is a poor indicator of intracranial injury and with few exceptions has
little to offer in the management of head injury in infants and children. Children with
clinical findings of only mild head trauma do not have a statistically increased risk of
intracranial injury.
Indications for SXR
NAI ( more sensitive than Bone Scan )
Depressed fractures
Penetrating injury
Large boggy vault hematoma
CT scan - ( after neurosurgical consultation ) - useful for rapid diagnosis of suspected
intracranial injuries and is the the preferred investigation if clinical evidence of
intracranial injury eg. -in abnormal / deteriorating conscious state. Clinical
deterioration is usually an indication for repeat CT examination.
Headaches
Clinical evaluation is the most important factor in determining the need for imaging.
SXR rarely gives useful information.
CT scan indications
Abnormal neurological signs.
Unexplained decrease in visual acuity.
Headaches with seizures.
Marked change in behaviour.
Enlarging head.
Symptoms of raised intracranial pressure.
Increasing frequency of unexplained headaches.
Afebrile Seizures
Plain SXR is not indicated.
CT scan indications
Persistant abnormal neurological signs/impaired consc.state.
Focal EEG findings.
Failure to respond to anticonvulsant therapy.
Neurocutaneous lesions.
Abnormal Size / Shape Of Skull
Clinical examination is usually sufficient to diagnose abnormality of the skull.
Large head - rapidly enlarging head needs imaging-US or CT scan.
Small head - nearly always pathological secondary to abnormal brain growth.
Evaluate with CT scan as an outpatient procedure.
Premature Craniosynostosis - results in abnormal skull shape.
Initial investigation - SXR to evaluate sutures. ( consult with neurosurgery )
Spinal Xrays
Trauma
Indication for XR:
High force of injury
Specific neck pain OR bony tenderness of spinous process(es)
Altered conscious state following trauma.
Cervical Spine:
Need to include 3 views: AP, lateral, odontoid
Note:
> 12 yr - usually lower spine C4-7 injuries
< 12 yr - usually upper spine C1-3 injuries
(see also Cervical spine Guideline)
Unconscious trauma patient:
Immediate lateral view of whole Cx spine ( in hard collar) will demonstrate ~ 95%
injuries. AP film will detect the remainder. If doubt consider CT scan. If neurologically
normal consult orthopaedics. If neurological signs present consult neurosurgery.
NB. Down Syndrome children have increased risk of C1-2 instability.
Thoraco-Lumbar Spine
Children will localise the level of the injury poorly, therefore imaging the full length of
thoraco-lumbar spine may be necessary. If neurological signs present do a CT scan.
Emergency Restraint
Jump to Procedure
Principles
Physical restraint and emergency sedation should only be used when other reasonable
methods of calming the patient down are unsuccessful. If a patient who is acting out does
not need acute medical or psychiatric care s/he should be discharged from the hospital
rather than restrained.
When restraint is required a coordinated team approach is essential, with roles clearly defined
and swift action taken.
Unless contraindicated, sedation should usually accompany physical restraint.
Indications
Aggressive and combative behaviour in a patient who requires urgent medical or psychiatric care,
which is:
Crisis prevention. Anticipate and identify early irritable behaviour (+ past history). Involve
mental health early for assistance (intake worker; after hours - on-call psychiatry registrar).
Provide a safe "containing" environment. This includes a confident reassuring approach by
staff without added stimuli.
Listen and talk.
Offer planned "collaborative" sedation (eg oral)
Note: If staff do not think they will be able to safely restrain the patient or manage the threat, then the
Police should be called.
Procedure
anaphylactic reactions
respiratory depression
cardiovascular - hypotension, tachycardia.
extrapyramidal reactions (dystonia) may occur with major tranquillizers, particularly as the
benzodiazepine is wearing off. These is treated with benztropine (0.02mg/kg IV or IM) or
repeated small doses of diazepam.
Explain
Disposition
Following restraint the patient must have a complete medical and mental health assessment
to guide subsequent management.
In some cases certification and transfer to an in-patient mental health facility may be required
(Section 9 of the Mental Health Act 1986).
Consider the need for on-going physical restraint.
Consider the need for on-going sedation.
Document
Debriefing.
The need to restrain an aggressive patient is fortunately a rare event, but can be extremely distressing
for staff involved. A formal debriefing session should be arranged, ideally chaired by an objective
facilitator who was not involved in the restraint process.
Resuscitation
RCH Medical Emergency Team (MET) - call Emergency Drug & Fluid
criteria Calculator
Management of VT/VF or asystole/PEA ID badge size Resuscitation
(Algorithm) Card
Cardiorespiratory Arrest
Signs of shock, cyanosis, bradycaradia / tachycardia, apnoea or increasing tachypnoea are warning
signs and an indication for urgent resuscitation. See MET call criteria
The majority of arrests in children are due to hypoxia, hypotension and acidosis. The most common
dysrhythmias are severe bradycardia, pulseless electrical activity or asystole. Ventricular arrhythmias
(Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) are seen with pre-existing
cardiac disease (cardiomyopathies, hereditary prolongation of QT interval, congenital heart disease),
poisoning (eg. tricyclic antidepressants) and low voltage electrocution (less than 1000 volts), and may
occur during resuscitation. SVT may cause shock in newborn infants.
Initial Management
Assessment and Management of the airway and breathing are the initial priorities.
Check breathing
Bag valve mask ventilation
Assessment
A - Airway
Position the head - neutral position (<1 year old), or sniffing position ( 1 year of age)
Open airway - Head tilt and chin lift, or jaw thrust
Use oropharyngeal airway if required.
B - Breathing
Artificial Ventilation
Endotracheal Intubation
C - Circulation
If there are no signs of circulation, i.e. no pulse, slow pulse (<60) or you are not sure,
commence external cardiac compression, and determine the cardiac rhythm - display the ECG
Resuscitation algorithm
Click to see full size algorithm
During resuscitation
Hypoxaemia
Hypovolaemia
Hypo/hyperthermia
Hypo/hyperkalaemia
Tamponade
Tension pneumothorax
Toxins/poisons/drugs
Thrombosis
Atropine
for persistent asystole / bradycardia
(20mcg/kg) (min 100mcg, max 600mcg)
Lignocaine
Never give lignocaine after Amiodarone
Amiodarone is the preferred agent
Same indications as Amiodarone. Dose (1mg/kg) (0.1ml/kg of 1%)
Magnesium Sulphate
For hypomagnesaemia or for polymorphic VT (torsade de pointes)
50% solution: 0.05-0.1ml/kg (0.1-0.2mmol/kg) (max 2 g)
Infuse over 5 mins.
Sodium bicarbonate, calcium, and doses of adrenaline >10mcg/kg/dose have no place in routine
resuscitation.
Other issues
It is not a priority in initial resuscitation attempts, and obtaining a sample should not distract
from other resuscitation manoevres.
Arterial (and to some extent venous) blood gas analysis can help determine degree of
hypoxaemia, adequacy of ventilation, degree of acidosis, and presence of electrolyte
abnormalities such as hyopmagnesaemia.
Ensure airway and breathing are managed effectively including intubation if not already
performed. Do not extubate. Use adequate sedation and analgesia.
Ventilate to normo carbia
Circulation - maintain adequate blood pressure with use of inotropes as needed. Monitor for
further arrhythmias.
Aim for core temperature of 35 degrees (do not actively warm if core temp >32 degrees)
Ongoing anti arrhythmic
Ensure normo glycaemia
Salicylates Posioning
See also General Management of Acute Poisoning Guideline
Assessment
Investigations
Serum salicylate level at presentation (on patients requiring treatment), and 2 hrly if
symptomatic or enteric coated preparation. (Need to call the RCH lab to get test run urgently
as it is sent to RMH for analysis)
Urea & electrolytes, creatinine, acid-base, glucose.
Management
a. Asymptomatic
o Charcoal 1g/kg (if <1 hour since ingestion unless enteric coated preparation)
o Observe 6 hours & discharge if still asymptomatic
o If enteric coated preparations, serial salicylate levels (2 hourly)
o Admit if levels have not plateaued at 6 hours post ingestion
o I.V. bicarbonate infusion 1mmol/kg/hr to correct any acidosis (pH <7.3)
b. Symptomatic
o All symptomatic patients require urgent medical assessment and investigations as
above.
o Charcoal 1g/kg unless altered conscious state (protect airway first)
o I.V. fluid resuscitation to correct dehydration (use N. Saline)
o I.V. bicarbonate infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg, (keep
urine pH >7.5)
o Potassium replacement as required
o Worsening symptoms, convulsion, coma, contact I.C.U. (5212) for respiratory
support ± haemodialysis
o Salicylate level >7mmol/l following an acute poisoning contact I.C.U. for consideration
of haemodialysis.
Septic Shock
1. Any child at risk of sepsis and septic shock should be reviewed by the Unit Registrar
2. Failure to respond to initial fluid resuscitation should be considered an indication for
immediate referral to Intensive Care
3. If nursing staff on the ward are unable to obtain a medical registrar quickly they should
contact ICU directly
1. Tachycardia
2. Tachypnoea and or desaturation in air
3. Increasing Systolic to Diastolic difference
4. Poor peripheral perfusion (cold extremities with prolonged
capillary refill)
5. Alteration in conscious state eg confusion
6. Metabolic acidosis - do not attempt to do an arterial blood
gas in thrombocytopaenic patient without discussion with
the Unit Registrar
If a child has suspected sepsis with features of circulatory or respiratory insufficiency, give
OXYGEN 8 L/min via face mask and monitor saturation with a pulse oximeter
If there is no IV access, put in an IV (contact ICU if any difficulty)
Give a BOLUS of 20 ml/kg NORMAL SALINE intravenously
A second bolus of 20 ml/kg may be given if there is no improvement in heart rate or perfusion
in 10 MINUTES
If the signs of circulatory or respiratory insufficiency resolve with
20-40 mlkg of saline - continue to monitor the child closely on the ward
If they do not resolve refer the child to intensive care (Ext 5211) Sickle Cell Disease
Guideline
Sickle cell disease is caused by structurally abnormal haemoglobin (Hb S) that causes a rigid distorted
red blood cell (sickle cell).
There are 3 common types
1. Infection
2. Dehydration
3. Hypoxia
4. Sedatives and local anaesthetics
At some stage in early childhood, patients become functionally asplenic and thus at risk for infection
particularly by encapsulated organisms (e.g. pneumococcus). Patients are generally on penicillin
prophylaxis and folate supplements, and have had pneumococcal polysaccharide vaccine.
Some patients are now on hydroxyurea to prevent sickling crises. These patients may develop
neutropenia, which increases their risk of sepsis. Some patients may have a degree of
cardiomyopathy; thus fluid resuscitation should be used with caution, and signs of fluid overload
looked for closely.
Patients with sickle cell disease may present with the following problems
Fever
Vaso-occlusive crisis
Acute chest syndrome
Acute splenic sequestration
Aplastic crisis
Stroke
Priapism
Many of these presentations require urgent treatment, and discussion with the Haematology
Consultant on-call is mandatory.
Background
Patients are functionally asplenic and thus at greater risk for invasive disease particularly by
encapsulated organisms (e.g. pneumococcus).
Assessment
Management
Background
All episodes of pain should be treated initially as vaso-occlusive disease. Other diagnoses may need
to be considered later. Pain may be limb, back, chest (see specific guideline) or abdominal.
NB Chest pain should be treated as an acute chest syndrome and not simply as a vaso-occlusive
disorder.
Assessment
Usually present as bone pain (e.g. arm or leg pain) but maybe back or abdominal pain. Most
patients will be able to tell you this is pain similar to previous episodes. Formal pain scale
should be used to quantify their degree of pain.
Is there associated fever or dehydration?
What analgesics have already been given (home or other hospital)?
What analgesics do the patient or family feel are required for this episode?
Consider other aetiologies after treating for pain (e.g. cholecystitis, appendicitis, osteomyelitis)
Management
Mild pain
Background
Sickle cell disease can produce an acute illness related to infarction of the lung tissue. Usually
associated with lower respiratory symptoms, hypoxaemia and a new infiltrate on CXR. Chest pain and
hypoxaemia may be the only signs.
Chest pain should be treated as an acute chest syndrome and not simply as a vaso-occlusive disorder.
Assessment
Patients should have respiratory rate, oximetry and temperature documented on arrival.
Degree of pain should be quantified on an appropriate pain scale
Hypoventilation is common due to pain.
Management
Background
This is defined as a haemoglobin drop of at least 20gm/l below patient’s baseline level with an acutely
enlarged spleen. Mild to moderate thrombocytopenia is often present. Reticulocyte count is equal to or
greater than patient’s usual baseline. Consider co-existent aplastic anaemia if reticulocyte count is low.
Most common in infants and young children. It has a high mortality rate
Assessment
Clinical presentation
pallor
lethargy
hypotension
increased splenic size
Management
1. Investigations
o Cross match
o FBE including platelet count
o Reticulocyte count
o Blood and urine cultures if febrile; CXR if febrile and respiratory symptoms
2. While waiting for blood, give 0.9% Saline to treat hypovolaemia. (10-20ml/kg) NB careful in
patients who have pre-existing cardiomyopathy
3. Suggest initial transfusion of 10 ml/kg of packed red cells for patients with haemoglobin
<50gm/l or signs of shock.
4. Do not raise Hb above baseline, since the spleen will shrink and autotransfusion will occur.
This will result in an increase in the percentage of HbS and risk of stroke (due to
hyperviscosity)
5. Treat with antibiotics if febrile (see fever & sickle cell), and analgesics for pain (see vaso-
occlusive disease)
Background
Acute illness associated with Hb below baseline for that patient and associated with a substantially
decreased reticulocyte count (usually <1%). Usually associated with acute infection in particular
parvovirus.
May be associated with enlarged spleen as well (see sequestration)
Assessment
Patients present with onset of pallor over a few days, tiredness and lethargy.
May be associated with fever
Management
Background
hemiparesis
monoparesis
aphasia or dysphasia
seizures
cranial nerve palsies
coma
Assessment
Management
Priapism is prolonged painful erection of the penis often starting in the early hours of the morning.
Occurs in 2 forms (a) stuttering episodes which last 2-4 hrs but are often recurrent and may precede a
severe episode (b) severe attack lasting longer than 4 hrs and can result in impotence.
Recurrent episodes should be evaluated by haematology in outpatients.
Assessment
Management
Notes
Simple measures should be tried first at home, particularly if less than 3-4 hrs since onset:
Smoking parents
The facts
Parent smoking is an important child and adolescent health issue. Children with a parent who smokes
have a significantly increased risk of disease, hospitalisation, SIDS, and a doubled risk of that child
taking up smoking themselves in adolescence.
Quitting smoking is a process that occurs over time, not an event. Smokers rarely just stop- there are
many small steps a smoker needs to go through to move from thinking about quitting to actually trying
to give up. If done sensitively, brief advice from a health professional can help to move them along that
path towards quitting. In the adult health setting, a doctor's routine recommendation to a smoking
patient that they should quit has been shown repeatedly to lead to a small but significantly increased
likelihood of smoking cessation.
What to do
2. If a parent smokes, let them know you/ the hospital believes parent smoking is an important
child health issue (The majority of parents who smoke expect that health professionals will
address their smoking). Do this sensitively [See examples: suggested lines] so as to keep
them engaged on the subject; the danger is leaving them more resolved that they will continue
to smoke!!
3. If parents seem interested in quitting, give them what help you can. If you do not have the
knowledge, skills and time to do much (ie. the majority of us!) refer them on to an expert. GP's
and the Quitline (131 848) are the sources of help parents say they most prefer. We have a
downloadable letter for the family's GP and a quickfax form for the quitline for you to use.
Positively reinforce any efforts that a parent is making towards smoking cessation (see links).
Supraventricular Tachycardia (SVT)
Assessment
Symptoms
Signs
Investigations
Management
Monitor with continuous ECG trace and frequent measurements of blood pressure
If necessary apply oxygen 10 litres / min by face mask
If child is shocked (ie. hypotensive, poor peripheral perfusion, impaired mental state) proceed
to direct current cardioversion (see below)
If child is not shocked treat with intravenous adenosine
Call ICU. Ensure experienced staff and full resuscitative measures are present
Ensure child is on oxygen, and has intravenous access
Administer diazepam intravenously if there is any chance of awareness
DC revert using a synchronized shock of 1 joule/kg,
An unsynchronized shock is necessary for ventricular fibrillation or polymorphic ventricular
tachycardia
Vagal manoeuvers. Valsalva if child old enough; gag or icepack/iced water for infants - apply to face
for a maximum of 30 seconds. Do not use eyeball pressure.
Intravenous adenosine
Insert cannulae into a large proximal peripheral vein (the cubital fossa is ideal) with three way
tap attached
Draw up starting dose of adenosine 0.1 mg/kg. If necessary dilute to 1 ml with normal saline.
Don't draw up the adenosine until after inserting the IV. Adenosine is expensive and in some
cases IV insertion alone will lead to reversion to sinus rhythm.
Draw up 10 ml saline flush
Turn on the ECG trace recorder
Administer adenosine as a rapid IV push followed by the saline flush
Repeat procedure at 2 minutely intervals, until tachycardia terminated, increasing the dose of
adenosine by 0.05mg/kg each time up to a maximum of 0.3 mg/kg (max dose 18mg).
Perform 12 lead ECG post reversion
The recorded strip at the time of conversion to sinus rhythm should be inspected and saved, for
concealed pre-excitation which may only be revealed during the first few beats after conversion to
sinus rhythm. After a patient has been reverted a 12 lead ECG should be performed to look for pre-
excitation and other abnormalities.
Rapid re-initiation of tachycardia is not uncommon, mostly due to premature atrial contractions
stimulated by the adenosine. If this occurs consider trying adenosine again.
Side effects including flushing and chest tightness/discomfort are not uncommon. These are usually
brief and transient. Rarely atrial fibrillation or prolonged pauses may occur.
Disposition
Syncope
Definition
Brief, usually sudden loss of consciousness and muscle tone caused by cerebral ischaemia or
inadequate oxygen or glucose to the brain.Features
Cause
Vasovagal (fainting)
Orthostatic or postural hypotension
Cardiac
Structural (e.g. critical aortic stenosis, Tetralogy of Fallot, atrial myxoma etc)
Arrhythmia (e.g. prolonged QT**, AV block , sick sinus syndrome)
Respiratory (e.g. cough, hyperventilating, breath holding)
Metabolic (e.g. anaemia, hypoglycaemia, hysteria etc)
** Long QT syndrome
Children with long QT syndrome are prone to polymorphic ventricular tachycardia (‘torsades de
pointes’) that may cause syncope, seizures and sudden death. The syndrome should be suspected if
events are precipitated by exercise, stress, swimming or noise. Events may also occur during sleep. It
is important to take a thorough family history and to routinely obtain an ECG to look for a long QTc
when investigating syncope.
The diagnosis cannot be excluded just because the QT interval is normal on an ECG. In
addition, other “cardiac electrical myopathies” with similar symptoms may have an
entirely normal ECG. If there is any reason to suspect long QT syndrome, then
discuss with Cardiologist on call.
Management
Follow up
The recommendations for the management of tetanus-prone wounds remain the same.
compound fractures
deep penetrating wounds
wounds containing foreign bodies (especially wood splinters)
wounds complicated by pyogenic infections
wounds with extensive tissue damage (eg. contusions or burns)
any wound obviously contaminated with soil, dust or horse manure (especially if topical
disinfection is delayed more than 4 hours).
Re-implantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and
cleaning of the tooth is conducted to increase the likelihood of successful re-implantation.
Tetanus
History of tetanus Type of vaccine Tetanus
vaccination wound booster immunoglobulin
(see below)
< 5 years
since last All wounds NO NO
dose
Clean minor
5-10 years NO NO
3 or more wounds
since last
doses All other
dose YES NO
wounds
> 10 years
since last All wounds YES NO
dose
Clean minor
YES NO
wounds
< 3 doses or uncertain
All other
YES YES
wounds
Can use a diphtheria/ tetanus toxoid vaccine (ADT® ) if pertussis vaccination is contraindicated.
Theophylline Poisoning
See also General Management of Acute Poisoning Guideline
Beware, many slow release preparations may cause toxicity after many hours
Beware, sudden deterioration may occur with arrhythmias or convulsions
Assessment
CNS
Agitation, hyperventilation, headache, convulsions
Cardiovascular
Arrhythmias
GIT
nausea & vomiting (may be intractable), thirst, diarrhoea
Investigations
Management
a. Asymptomatic
o Charcoal 1g/kg
o Observe 4 hours. If no symptoms, discharge if not slow release medication.
o If ingestion of slow release preparation, admit for observation and serial drug levels
b. Symptomatic
o Charcoal 1g/kg initially unless altered conscious state (protect airway first) then
0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr.
o Cardiac monitoring
o I.V. fluid resuscitation & maintenance of adequate hydration is vital
o If depressed conscious state, arrhythmias or intractable vomiting contact I.C.U.
(5212) as likely to need intubation
o Severe intoxication may require haemoperfusion
o If agitated, may need sedation with a benzodiazepine or phenobarbitone.
Prior to Arrival
Ensure senior emergency medical and nursing staff are aware of all the available details.
Delegate specific tasks to appropriate individuals.
Notify the Intensive Care Unit registrar and the Surgical registrar on call
Notify other specialist registrars as appropriate (eg. neurosurgery, orthopaedics)
Notify other departments as appropriate (eg. radiology, blood bank)
Check the resuscitation equipment and prepare intravenous lines and fluids
If possible estimate the child’s weight using the formula (Age + 4) x 2 and calculate:
a. The amount of fluid bolus at 20 ml/kg
b. The endotracheal tube size (age/ 4) + 4
c. Any other drugs likely to be needed
On Arrival
Immediately perform a primary survey by assessing and managing the child’s airway, cervical
spine, breathing and circulation.
Obtain a history from the parents or ambulance officers if possible eg. type of trauma, speed
of the vehicle, height of the fall, restraints or safety equipment used, whether other people
were injured.
Assess the child’s airway whilst protecting the cervical spine. The cervical spine should be
immobilized initially by in-line stabilisation, followed by the rapid (gentle) application of a
properly fitted hard collar, sandbags and tape (see Cervical Spine guideline)
If the airway is inadequate, apply a jaw thrust manoeuvre, clear any obstruction using suction
under direct vision and consider intubation.
Breathing
Circulation
Assess the child’s circulatory state by observing
a. the pulse rate, skin colour, capillary refill time, blood pressure
b. the effects of an inadequate circulation (respiratory rate, mental state)
Establish intravenous access with two cannulae that are as large as practicable - ideally one
situated in each cubital fossa.
If an IV cannula is unable to be sited rapidly consider the use of an intraosseous needle
inserted into a non-traumatised leg.
As the IV is inserted take blood for a blood sugar, FBE, cross match and lipase.
If circulation is inadequate give a fluid bolus of 20 ml/kg of normal saline.
Tamponade any continuing external haemorrhage.
If the circulation continues to be unstable, repeat the fluid bolus using normal saline or a
colloid solution. If a third bolus is necessary consider using whole blood and arrange early
surgical intervention
Assess mental state by determining the child’s best response to a painful stimulus, observing
their posture and examining the pupillary reflexes
The response to pain is determined by squeezing one ear lobe hard and observing the best
response to that stimulus (eg. flexion of one arm and extension of legs is recorded as flexion
to pain)
Note whether the child:
A is alert, or
V responds to voice, or
P responds to pain by localizing appropriately, flexing limbs or extending limbs to
pain, or
U is unresponsive.
Monitor
Respiratory rate, heart rate, blood pressure, oxygen saturation and rectal temperature.
Response to pain and pupillary light reflexes
5-12
20 – 25 80 - 120 90 – 110
years
Temperature
Minimize hypothermia by limiting exposure of the body during examination, and by warming
all ongoing fluids.
Radiology
Secondary Survey
Analgesia
Pre-travel advice and vaccinations are provided for children and their parents.
We are pleased to offer this service to existing and new patients of the hospital and their families. We
are also happy to see hospital staff individually and their families.
Some travel vaccines are expensive and will need to be bought on the day (Wood Pharmacy offer
discounts to Staff members, and reduced prices for patients as well).
For many overseas trips it is worthwhile being seen at least 6 weeks before departure to allow
adequate time for the various vaccines to be given and for their effectiveness to develop.
We are also happy to see children or families who have returned from overseas and who are unwell,
possibly related to travel acquired infection.
Tricyclic Overdose
See also General Management of Acute Poisoning Guideline
Assessment
Symptoms
Anticholinergic
vomiting, blurred vision, ataxia, tachycardia, urinary retention
Antiadrenergic
vasodilatation
Sodium Channel blockade
widened QRS (>0.12 ms)
QT prolongation
reduced cardiac contractility & hypotension
CNS Depression
drowsiness, coma, convulsions
Management
Urticaria
Assessment
Physical Examination
Differential Diagnosis of Urticaria
Investigations
Management
Resources
Pruritic, elevated skin lesions surrounded by erythematous base commonly described as "hives"
Due to transient extravasation of plasma into the dermis. It is a common condition - 25% of individuals
will have it at some stage.
Deeper subcutaneous extension is much less common and termed angioedema. It involves face
(eyelids, lips, tongue), hands and feet, and sometimes other areas ( trunk, genitalia, mucous
membranes ).
Assessment
Medications including antibiotics like penicillin, cefaclor (5-21 days after commencing
course),amoxycillin,etc
Infections include viruses and bacteria
Foods are infrequent causes (may include nuts, eggs, shellfish, strawberries, tomatoes, and
cow’s milk.)
Bites and stings include bees, wasps, scorpions, jelly fish and spiders.
Physical triggers may include pressure, cold, exercise and rarely water.
Physical Examination:
Localised or generalised
Well circumscribed but often coalescent
May be intensely pruritic with excoriation
Vary in size from tiny flat papules to large raised plaques
Flat centre with raised erythematous edge
Diagnostic feature is polymorphic appearance and transience of individual lesion.
Observe for dyspnoea or dysphagia the first few hours after urticaria
Erythema multiforme
Rare differentials
Mastocytosis
Flushing
Juvenile Rheumatoid Arthritis
Vasculitis — Henoch Schonlein purpura
Pityriasis rosea (early lesions)
Investigations
Initial investigations of chronic urticaria include FBE, Differential, ESR and ANA.
Management
Hives
Hives are slightly raised patches of skin. These raised patches are called wheals. They
are more red or more pale than the surrounding skin and occur in groups on any part of
the body. They are often itchy, but sometimes also sting. Each wheal lasts a few hours
before fading without trace. New areas may develop as old areas fade. Often the wheals
join together to form larger swellings. The area of affected skin can vary in size from
quite small to as large as a dinner plate.
Urticaria is the medical word for hives. Hives are very common - one out of every four
people will have hives at some time in their life.
Hives will usually go away within a few days. If your child continues to have hives for
more than 6 weeks this may need investigation. Treatment includes avoiding known
triggers (ie things known to cause the hives) and medicines. Triggers may be different
for each child.
Anaphylactic shock
Usually, the skin rash looks or feels unpleasant but is harmless. However, sometimes a
more serious allergic reaction known as anaphylactic shock can happen. This is a
medical emergency and an ambulance should be called immediately.
If your child has experienced anaphylactic reactions in the past you may be advised to
have ready access to adrenaline. Your child could also wear a Medi-alert pendant or
bracelet, to let other people know what may cause them to have an allergic reaction.
Discuss this with your GP.
Causes
Often it's impossible to find out what triggers hives in children. Usually no tests are
needed. Hives is a type of skin rash that is an allergic reaction. This means the immune
system responds to a substance as if it were toxic.
Hives occur when blood plasma leaks from the blood vessels into the skin. This happens
when a chemical called histamine is released.
Allergic reactions.
Insect bites.
Virus infections.
Chemicals in foods and medicines.
Treatment
The best treatment for hives is to find and remove the cause or trigger. This is not always
possible. For most people, each attack of hives will become more severe and intense if
they are repeatedly exposed to the same trigger.
This type of skin rash is an allergic reaction, which means the immune system responds to a
substance as if it were toxic.
Treatment options include avoidance of known triggers, and medications - such as
antihistamines and corticosteroids.
Background
The most common inherited bleeding disorder affecting 0.1 - 1% of the population. Caused by a
deficiency (either quantitative or functional) in von Willebrand Factor (vWF). Deficiency of vWF causes
inadequate platelet adhesion and secondary deficiency of Factor VIII. Affects males and females
equally.
Characterised by easy bruising, bleeding from mucous membranes (particularly epistaxis, oral
mucosa, menorrhagia) and post-op bleeding.
Notify Haemophilia Nurse (pager 4800) of patients presenting to Emergency between 0800 - 1630,
Monday to Friday. Notify Haematologist on call of patients presenting after hours with bleeding
problems.
Assessment
Assess type and severity of vWD, if known. Refer to RCH Emergency Department alert system for
individual treatment plan.
Management
DDAVP (desmopressin)
Patients with mild to moderate Type 1 vWF can be treated with DDAVP when there is
documented evidence in the medical record of safe and satisfactory response (DDAVP
challenge). At RCH DDAVP challenge is performed from around 5 years of age.
Occasionally effective in Type 2 vWD, never effective in Type 3 vWD.
Expect two to three fold increase in Factor VIII/vWF level.
Generally not recommended in young children (< 3 years) due to documented reports of
hyponatraemia and seizures. Relatively contraindicated in children with previous seizure
disorders.
DDAVP Dose: 0.3 microgram/kg (max 20 microgram) in 50mls 0.9%NaCl given by
intravenous infusion over at least 30 minutes. (Available as 4microgram/ml injection).
1. Introduction
Childhood obesity and overweight now rivals asthma as Australia's most prevalent
chronic childhood condition. Over one quarter of Victoria’s children are overweight,
with up to 10% fulfilling criteria for obesity. The prevalence is even higher in children
presenting to tertiary paediatric hospitals. However the prevention and management of
childhood obesity is not adequately addressed despite a rapid rise in its prevalence.
This guideline is to be used by medical, nursing and allied health staff at the RCH to
assist them in assessing and addressing issues of weight and obesity in
patients. It provides a simple but evidence based clinical approach for the identification
of childhood overweight and obesity and an opportunistic approach to addressing these
issues with the family and patient.
The recommendations contained in this guideline do not include a definitive course of management for
childhood overweight and obesity but outline the process of referral and include links to appropriate
resources.
2. Definition of terms
Body Mass Index: Body Mass Index (BMI) is currently seen by health professionals as
the most appropriate measure of adiposity in children.
Calculating Body Mass Index: BMI is calculated by dividing the weight (kg) by the
height squared (m2). However calculated BMI values need to be compared with age and
sex reference standards due to BMI changes that occur in normal growth.
3. Background
Much greater risk of adult obesity (a 5 yr old who is obese has 8 times increased risk of adult
obesity)
Psychosocial morbidity (bullying, teasing, lower self esteem, poorer socioeconomic prospects)
Range of physical morbidities: type 2 diabetes, hypertension, dyslipidemia, non-alcoholic
steatohepatitis, orthopaedic disease, obstructive sleep apnoea infertility
The large increase in the prevalence of obesity in the last three decades points to
widespread environmental and lifestyle changes. And while studies suggest many
children will have a genetic predisposition to the development of obesity, it is rare to
identify specific chromosomal or genes defects.
Genetics At least 5 single gene defects have been found but these are all extremely rare
and all are associated with severe and very early onset obesity and should prompt referral
for further assessment.
Other risk factors for obesity: early infant feeding, parental obesity, parental
encouragement of children to eat, lower socioeconomic status.
4. Assessment
The Body Mass Index (BMI) is recommended as a practical measure of overweight and
obesity in children
Therefore calculated BMI values need to be compared with age and sex reference
standards.
1. Calculate BMI using the BMI calculator. (You will need to know the patients weight and
height)
2. Download and print BMI for age percentile charts (Below)
3. Compare and chart BMI on percentile chart
BMI for Age percentile charts recommended for use in Australia are developed by the CDC in the US
The issue of obesity as an important health concern is often not addressed in the clinical
setting. Once you have noted that the child is overweight you may address the issue
using the following approach
Note: The RCH weight Management Clinic currently has a 6 month waiting period for a
first appointment. It is hoped that a current review of Weight Management Services at
RCH will lead to an increase in clinical resources.
Parental Perception
We know that approx 50% of parents of obese children do not perceive that their child is
overweight. It is therefore useful to gauge their opinion and experience of this issue as
this can shape the ensuing discussion eg ‘What do you think about Sarah’s weight?’
1. They (and she!) may respond that they are aware and concerned about the issue. This is
when you can discuss specific behaviour changes (see below) and arrange referral.
2. They may instead state that they think her growth is fine. Then your goal is to raise their
awareness of the health issues, not necessarily to solve the problem!
Frame discussion of overweight in terms of health talk about ‘the healthiest weight for
Sarah’. You could respond: ‘Let’s take a look at where Sarah should be on the weight for
height chart and I can explain why I am concerned. At 5, Sarah is the weight of an
average 8 yr old. This has implications for her future health. We need to slow the rate at
which Sarah is putting on weight, and help her grow into her weight’
1. Aim for ‘lifestyle’ exercise: using the stairs, walking to school, walking the dog
2. Involve the whole family (everyone can benefit regardless of weight status)
3. Use after school time to get outdoors and be active
4. Decrease screen based activities (TV,Computer,Playstation)
5. Have bikes, helmets and balls ready to go by the door!
1. Water is the best drink for kids: cut out cordial, soft drink, fruit juice
2. Better to eat the fruit rather than drink fruit juice
3. Low fat (2%fat) milk (<500mls/day) is preferred for children over 2 years of age
4. Importance of breakfast, regular meals and healthy snacks
5. Basic food label reading and awareness of the ‘traps’ ie ‘no fat’ might mean large
amounts of sugar and therefore the same number of calories
6. Serving sizes ( does the 5 yr old get served as much as Mum or Dad?)
7. Planning ahead, avoiding regular take-away
6. Management
The aim of this guideline is to provide clinicians with an approach for identifying and
addressing issues of overweight and obesity in the clinical setting. Weight management
is most successful when addressed in the context of the whole family
Background
There are a number of different dressings and techniques available for managing wounds. The
majority of wounds in children are acute trauma or surgical wounds.
to reduce pain,
to apply compression for haemorrhage or venous stasis,
to immobilise an injured body part,
to protect the wound and surrounding tissue
to promote moist wound healing.
Assessment
mechanism of injury; associated blood loss; risk of contamination; deeper structure damage;
tetanus status;
consider Non accidental Iinjury;
underlying chronic illness or disability.
underlying nerve, vessel and tendon damage. This requires assessment of movement while
exploring the wound (especially in palmar or hand wounds).
Assess tissue damage or loss
Investigation
Management
Dressing Choices