24 June 2020 - Paediatrics

Program

1000-1015hr – Welcome and log in to Microsoft teams, Trivia!

1015-1030hr – Recap of last week’s Paeds Regional Teaching

1030-1100hr – Seizures in Paediatrics – Ben Lee

1100-1130hr – Fever and Sepsis in Paediatrics – Max Grant

1130-1140hr – coffee break

1140-1230hr – APLS Quiz – Brendan

1230-1250hr – ECG/gas/image of the week – Alex/Mark/Matt

1250-1305 – lunch break

1305-1310hr – 5 min Tox – Paed theme - Jacqueline

1310-1400hr – SAQs - Jacqueline

1330-1500hr – Ultrasound group with Mark –please arrange direct, first dibs to those working at 3pm

 Key Learning Points

Paediatric Seizures

• A simple febrile seizure has all of the following:

  • Fever

  • Generalised tonic-clonic seizure

  • Duration < 10minutes

  • Complete recovery within 1 hour

  • No recurrence within the same febrile illness

• A complex febrile seizure is everything else (i.e. focal seizure, > 10 minutes, not recovered within 1 hour, recurrence)

• Note there is the concept of an afebrile febrile seizure. These occur in an acute infectious illness, particularly gastroenteritis, without a documented features but a seizure otherwise consistent with a simple febrile seizure

  
  

• WETFLAG is a common acronym that can be used as a memory aid for preparing to receive a sick child

  • W: Weight: 2 x (Age + 4)

  • E: Energy: 4J/kg

  • T: Tube: ETT: Age/4 + 4 (uncuffed tube - lower size for cuffed tube)

  • F: Fluids: 10-20mls/kg

  • L: Lorazepam (more likely to use midazolam 0.15mg/kg)

  • A: Adrenaline: 10mcg/kg

  • G: Glucose: 2mls/kg of 10% dextrose

    
    

• Recent studies have shown no difference in efficacy between valproate, levetiracetam, phenytoin as second line agents (but levetiracetam is often easier to administer for unfamiliar staff)
  
  

• We discussed the algorithm to managing status epilepticus in children a few weeks ago. Click here.

Fever and Sepsis in Children

To treat or not treat a fever? There are lots of approaches. Generally speaking, treat the child that is miserable or in pain (i.e. sore throat) rather than the temperature. In the ED, treating the fever often allows a better examination, a happier child and more satisfied parents. Often, a child that has been brought to the ED will warrant a dose of paracetamol/ibuprofen.

Sepsis Kills. RCH has a great clinical practice guideline that was recently updated. Check it out here.

Key principles in managing severe sepsis or septic shock

1. Early recognition/seeking senior help

2. Assess airway and breathing and administer oxygen if required

3. Rapid vascular access

4. Empiric antibiotic therapy

5. Carefully titrated fluid resuscitation

6. Early initiation of inotropes

7. Early involvement of critical care services

8. Source control

9. Frequent reassessment

APLS Quiz

All of the APLS algorithms are freely available. You can download the APP onto your smartphone for easy access when the sick child suddenly appears in the ED

 ECG of the Week

Thanks Kimson for the case.

A 60 yo male presented to the ED with pneumonia. He was febrile at 40 degrees but not hypoxic and able to be discharged home on oral antibiotics. A question was raised about the possibility of Brugada Sign.

There are three repolarisation patterns associated with Brugada syndrome when found in more than one right precordial leads (V1 to V3):

1. Type 1: It is characterised by a prominent coved ST-segment elevation displaying J-point amplitude or ST-segment elevation ≥2 mm, followed by a negative T wave.

2. Type 2: It has ≥2 mm J-point elevation, ≥1 mm ST-segment elevation and a saddleback appearance, followed by a positive or biphasic T-wave.

3. Type 3: It has either a saddleback or coved appearance, but with an ST-segment elevation <1 mm.

It should be stressed that type 1 is the only ECG diagnostic pattern of Brugada Syndrome, while types 2 and 3 should only be considered suggestive of the disease.

Brugada Sign (the ECG findings) without clinical features is of unknown significance.

Brugada Syndrome is considered when there is Brugada Sign and one of the following clinical features:

• Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT).

• Family history of sudden cardiac death at <45 years old .

• ECG Type 1 - Coved-type ECGs in family members.

• Inducibility of VT with programmed electrical stimulation .

• Syncope (and seizures?).

• Nocturnal agonal respiration.

In the above case, the ECG does not fit the criteria for Type 1 Brugada Sign. There is an incomplete RBBB and at the J point in V1 there is <2mm ST elevation. The patient did not have any of the clinical features of Brugada Syndrome. A subsequent ECG one hour later showed improvement of these findings. We know that fever can unmask Brugada Sign on ECG and the patient was referred to cardiology outpatients for further opinion.

Here is the link to the article by Professor Brugada

https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-7/Management-of-patients-with-a-Brugada-ECG-pattern#.Uy-DKq2SwzI

Image of the Week

A 76 yo female fell on her outstretched hand. Her X-rays are included below.

Right comminuted intra-articular distal radius

These xrays show a distal radius fracture. It is impacted with positive ulna variance, radial shortening, loss of radial height & radial inclination and dorsal angulation.

How do you know which of these need ED reduction if it is not obvious? This hospital has a distal radius fracture pathway available on the intranet. In summary fractures need reduction if any of the following are present:

• Neurovascular compromise

• Dorsal tilt > 10 degrees

• Radial shortening > 5mm

• Radial inclination < 15 degrees

If unsure, give the orthopaedic registrar a call.