Category: Paeds

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

Paediatric Blast Injury

Save the Children, have published a used full guide on management on blast injuries in children. Taking you through pre-hospital, ED and inpatient care.

Although blast injury is rare in the UK it’s worth a read as an adjunct to APLS/ATLS training.

  • Recognising “Blast Lung” – which may be subtle initially and develop over hours (p51)
  • Prophylactic antibiotics
  • Compartment syndrome and fasciotomy (p105)
  • Burns Fluids and escharotomies (p112)

Ful Guide[PDF] – HERE

paed blast injy manual