Category: Paeds

Time Critical Medications

Time Critical Medication (TCM) is scheduled medication that the patient is already on when they present to the Emergency Department (ED).

The medications are “time critical” because a
delayed or missed dose can result in harm with exacerbation of symptoms and the development of complications leading to an increased mortality.

Movement disorders – Parkinson’s / Myasthenia medication
Immunomodulators including HIV medication
Sugar (Insulin)
Steroids – Addison’s and adrenal insufficiency
Epilepsy – anticonvulsants
DOACs and warfarin

Its really important for our patients that these medications are prescribed and given while in ED/uSDEC/fSDEC.

If you are withholding these medication (which may be necessary) -please the reason for this clearly in the notes.

PDMedCalc has superseded Optimal

Paediatric Flow at HRI

There is rapidly growing evidence, outcomes for children are improved by early attendance at specialist sites. As there is NO onsite paediatric speciality provision at HRI. It has been agreed that children likely to benefit from early Paediatric/Neonatal care move to CRH as swiftly as possible. This will be done using the agreed pathway, to reduce treatment and speciality input delay.

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Head Injury

Background

  • Defined as any traumatic injury to the head other than superficial facial injuries.
  • The commonest cause of death and disability in people age 1-40 in the UK.
  • Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.

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Ingested Magnets

Ingestion of Strong Magnets is a TIME CRITICAL EMERGENCY

(Multiple Magnets OR a single Magnet and Metallic Objects)

Strong magnets  (such as Neodymium)

  • Now common place around the house
  • From; fridge magnets to toys and peicings

Ingested:

  • Intestinal injury can occur within 8-24 hours
  • However, symptoms may take weeks to develop
  • Symptomatic patients are a SURGICAL emergency

Detection:

  • 2 views – to determine number of magnets (if in doubt assume multiple)

RCEM recommendation (best practice)

Swallowed Foreign Body – Metal Detector

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Paediatric ECG

Use the following chart as a quick checklist to review what’s normal and what’s not in a paediatric ECG. 

Remember:

  • Lead V4R in under5’s
  • Manually calculate QTc
  • WPW needs referral for ablation – increase risk of sudden death

If in any doubt discuss with paediatric registrar/senior. If in need of urgent interven:on then contact the paediatric cardiology team in LGI.

1. Placement of Leads: Precordial Leads

In young children, the right ventricle normally extends to the right side of the sternum. To appropriately display right ventricular potentials, ECGs for children in the under five-year age group must include an alternate lead (‘V4R’) on the right side of the chest at a point analogous to the left sided V4.

2. P Waves:

3. Axis:

In utero- high pulmonary pressures and a relatively thick Right Ventricle (RV) -> Initial Right Axis on ECG is normal and resolves after the first 6 months of life

QRS Axis Deviation

  • Chest leads in wrong position

     

RAD:

  • Newborns
  • RVH secondary to Right ventricular outflow tract obstruction eg: Pulmonary
    Stenosis ,Tetralogy Of Fallot, Noonans (characterized by mildly unusual facial features, short stature, heart defects, bleeding problems, skeletal malformations, and many others)
  • RBBB

 

LAD:

  • LBBB
  • LVH secondary to LVOTO (Left Ventricular Outflow Tract Obstruction) e.g. Aortic Stenosis, HOCM

 

Superior Axis

  • AVSD (Atrio ventricular septal defect – Trisomy 21)
4. QTc:

Manually calculate QTc – HERE

Normal QTc:

  • Infants less than 6 months = < 0.49 seconds.
  • Older than 6 months = < 0.44 seconds.

QTc is prolonged in:

  • Hypocalcaemia
  • Myocarditis
  • Long QT syndromes such as Romano-Ward Drugs

QTc is short in:

  • Hypercalcaemia
  • Congenital short QT syndrome
5. Ventricular Hypertrophy

6. T waves:
  • The precordial T-wave configuration changes over time
  • For the first week of life, T waves are upright throughout the precordial leads.
  • After the first week, the T waves become inverted in V1-3 (= the “juvenile T-wave pattern”)
  • This T-wave inversion usually remains until ~ age 8; thereafter the T waves become upright in V1-3.
  • However, the juvenile T-wave pattern can persist into adolescence and early adulthood (= “persistent juvenile T waves”).

Tall, peaked T waves are seen in:

Hyperkalaemia, Dilated LV (volume overload), Benign early repolarisation

 

Flat T waves are seen in:

Normal newborns, Hypothyroidism, Hypokalaemia, Pericarditis, Myocarditis

7. ST Segment:

Some ST changes may be normal:

  • Limb lead ST depression or elevation of up to 1mm (up to 2mm in the left precordial leads).

  • J-point depression: the J point is depressed without sustained ST depression, i.e. upsloping ST depression

  • Benign early repolarisation in adolescents: the ST segment is elevated and concave in leads with an upright T wave.

 

 

Others are pathological:

  • A downward slope of the ST followed by a inverted T.

  • A sustained horizontal ST segment depression

     

 

Pathological ST segment changes are commonly associated with T wave changes and occur in:

  • Pericarditis.

  • Myocardial ischaemia or infarction.

  • Severe ventricular hypertrophy (ventricular strain pattern)

Thanks to the paediatric dept for supplying the guidance –  trust PDF here

Swallowed Foriegn Body

The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

Using the Metal Detector

Non-Hazardous Objects

Button Battery

Magnets

 

Sharp Objects

PDF copy – HERE