Gastrostomy - Common problems

Tube Issues

Blocked tube

Causes:

Poorly crushed medications

Not flushing gastrostomy tube when feeds are completed
Feed too thick or containing lumps of powder
Vitamised food being put down tube
Leaving formula in the tube to curdle

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

Leakage around the tube

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.

Other possible causes include:

1. Deflated or ruptured balloon.

This can be checked by attempting to drain the balloon. If there is no fluid the balloon may be
deflated or have burst. Injecting water into the balloon and then checking if the volume is the
same when draining will indicate if there has been a rupture. If the balloon has burst the tube
will need replacing. The only sure way to tell is to remove the tube.
2. Tube deterioration or damage
Tube may need replacement.
3. Tube Migration
The tube may have migrated down the stomach and the balloon is not flush with the gastric
mucosa. Putting gentle traction on the tube and then adjusting the retention disc to fit snugly
against the abdominal wall may help.

Skin excoriation

Gastric secretions leaking around the gastrostomy can result in skin excoriation. There are two
methods of minimising irritation to the skin:

1. Use of a barrier ointment (better than cream)

o Recommended products include Calmoseptine™ ointment, Ilex™ barrier ointment, or
a zinc ointment.
o If the site is affected by thrush, do NOT use a zinc based product as this may worsen
the infection. Suitable alternatives include Orabase™ or Coloplast™ paste.
2. Medications to halt gastric acid production.
o Ranitidine and/or Omeprazole.
 Red, irritated, swollen, oozing skin surrounding a gastrostomy can be treated with:

A foam dressing, gauze or Sofwick to absorb excess ooze

Topical Magnesium + aluminium hydroxide preparations (eg Mylanta)
Hydrocolloid powder to aid in stopping bleeding and absorb excess moisture
A thin hydrocolloid dressing (eg Duoderm wafer) to protect and aid in healing of excoriated
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.

Options to treat granulation tissue:

A foam dressing to apply pressure to reduce granulation.

Silver nitrate application daily (to granulation tissue only)
Application of a steroid cream

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.

These should only be prescribed by the treating unit. Haematuria

Haematuria is the presence of red blood cells in the urine. The presence of 10 or more RBCs per high-
power field is abnormal.

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.

Larger view of flowchart

Headache

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

Systemic with fever general illness (e g flu, pneumonia, septicaemia)

Local sinusitis, dental caries, otitis media
Trauma head injury
Meningitis reduced conscious level, toxicity, photophobia, neck stiffness
SAH sudden onset, severe occipital pain; possible reduced conscious level, neck stiffness

Recurrent

Migraine: aura, nausea, vomiting, pallor, family history

Tension: throbbing pain (involving neck muscles) at end of day
Behavioral: family/social/school problems (may be difficult to identify)
Raised ICP: morning headaches +/- vomiting, worse on or coughing/sneezing/bending,
progressively worsening, personality or behavioral changes, focal neurological symptoms
 (Others - Benign intracranial hypertension, systemic hypertension, uremia, recurrent
hypoglycemia, recurrent seizures, lead or CO poisoning)

See Headache Patterns (it may be helpful to show the child / family this chart and to ask them to
identify the pattern themselves)

Examination

As part of the examination it is important to document the following:

ABC: blood pressure, heart rate

General: toxic, unwell, temperature, rash.
Neurology: conscious level, fundi, visual fields, cerebellar signs, neurocutaneous stigmata,
neck stiffness, cranial bruits.
Local causes: cervical lymphadenopathy, teeth, sinus, ears.
Growth and puberty: head growth, height, weight, growth velocity, pubertal status.

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

(Refer to General Paediatric Outpatient Clinic for long term management)

Consider beta blockers, pizotifen, calcium channel blockers

Non-pharmacological interventions (eg. avoidance of triggers, relaxation) often play an
important role in prevention. Parent Information Sheet on Migraine Headache (Print
version - PDF)

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.

Signs and symptoms

Headache, which may be:

Dull or throbbing
All over or worse on the sides of the head
On only one side of the head
Severe or mild.

The headache commonly lasts 6 to 12 hours. Your child may also:

Have loss of appetite

Feel sick - have nausea or vomiting
Look pale
Feel tired
Have stomach pain.

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

Many things can trigger or start migraine headaches:

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

Regular meals and sleep patterns are very important.

Resting in a quiet, dark room may reduce how severe the symptoms are when a headache
happens.
Paracetamol (Panadol, Dymadon, etc) may reduce pain if taken at the beginning of the
headache.
 Alternative therapies, including relaxation techniques, can help some children.
There are other drugs that can be used to treat attacks of migraine and also drugs that can be
used to help prevent attacks. Your doctor will discuss these with you.
Most children do not need preventative drugs – ie drugs to stop the migraine starting. In
general, drugs to prevent migrane are only used for children who get very frequent migraine
headaches that interfere with going to school etc.

Key points to remember

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 Injury Guideline

Assessment
Level Of Consciousness - Glasgow coma scale
Management
Minor Head Injuries
Moderate Head Injury
Severe Head Injury

Emergency Drug & Fluid Calculator

See also Major trauma guidelines

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

Perform a secondary survey looking specifically at:

Neck and cervical spine – deformity, tenderness, muscle spasm

Head – scalp bruising, lacerations, swelling, tenderness, bruising behind the ear (Battles sign)
Eyes – pupil size, equality and reactivity, fundoscopy
Ears – blood behind the ear drum, CSF leak
Nose – deformity, swelling, bleeding, CSF leak
Mouth –dental trauma, soft tissue injuries
Facial fractures
Motor function – examine limbs for presence of reflexes and any lateralising weakness
Perform a formal Glasgow Coma Score
Consider the possibility of non-accidental injury during secondary survey especially in infants
with head injury.
Other injuries (see major trauma guidelines)

Gain as much information as possible regarding the incident. Specifically determine:

Time, mechanism and circumstances of injury

Loss or impairment of consciousness and duration
Nausea and vomiting
Clinical course prior to consultation – stable, deteriorating, improving
Other injuries sustained

Level Of Consciousness - Glasgow coma scale

Eye opening Verbal Response

(modifications for small children in red)

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

Minor Head Injuries:

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:

becomes unconscious or difficult to rouse

becomes confused
has a fit
develops a persistent headache
repeatedly vomits
develops any bleeding or watery discharge from the ears to nose

Give parents a Head Injury Parent Information Sheet to reinforce your advice.

Moderate Head Injury:

Brief loss of consciousness at time of injury

Currently alert or responds to voice. May be drowsy
Two or more episodes of vomiting
Persistent headache
Up to one single brief (<2min) convulsion occurring immediately after the impact
May have a large scalp bruise, haematoma or laceration
Normal examination otherwise

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.

Severe Head Injury:

More than a brief loss of consciousness at time of injury

Decreased conscious state – responsive to pain only or unresponsive
CSF leak from nose or ears
Localising neurological signs (unequal pupils, lateralising motor weakness)
Signs of increased intracranial pressure:
Uncal herniation: Ipsilateral dilated non-reactive pupil due to compression of the
oculomotor nerve
Central herniation: Brainstem compression causing bradycardia and hypertension
Penetrating head injury
Seizures (other than single brief (<2 min) convulsion occurring immediately after the impact)
Initial Management of Severe Head Injury:

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.

Seek medical help immediately if:

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.

Signs and symptoms

The symptoms of head injuries are used to determine how serious it is. Head injuries can be classified
into minor, moderate or serious.

A severe head injury is when your child:

Has lost consciousness for more than 30 seconds.

Is drowsy and does not respond to your voice.
Has other significant head injury signs, such as unequal pupils, arm and leg weakness.
Has something stuck in their head.
Has a second fit or convulsion, other than a single brief one when the injury happened.

You should call an ambulance immediately if your child has a severe head injury.

A moderate head injury is when your child:

Has lost consciousness for less than 30 seconds.

Is alert and responds to your voice.
Has vomited 2 times or more.
Has a headache.
One brief fit may have happened straight after the injury.
May have a large bruise, lump or cut on the head.
Your child should be watched closely in hospital for at least 4 hours after a moderate head
injury.

A minor head injury is when your child:

Has not lost consciousness.

Is alert or interacts with you.
May have vomited, but only once.
May have bruising or cuts on their head.
Otherwise normal.

Treatment of minor 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.

Problems to watch for in the next day or two:

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.

Go back to your doctor or hospital immediately if your child has:

Unusual or confused behaviour.

Severe or persistent headache which is not relieved by paracetamol (irritability in a baby).
Frequent vomiting.
Bleeding or discharge from the ear or nose.
A fit or convulsion, or spasm of the face or arms or legs.
Difficulty in waking up.
Difficulty in staying awake.
If you are worried for any reason.

Key points to remember

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.

Other sources of information

In an emergency call '000' for an ambulance.

Preventing Falls (pdf)

Henoch-Schonlein Purpura

Introduction

HSP typically presents with the triad of

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

Purpura: If atypical distribution or the child is unwell, consider meningococcaemia,

thrombocytopenia, or other rare vasculitides.
Joint Pain: Swelling and arthralgia of large joints are often the patient’s main complaint. In
most situations this pain resolves spontaneously within 24-48 hours.
Abdominal pain: Uncomplicated abdominal pain often resolves spontaneously within 72 hours.
However serious abdominal complications may occur including intussusception, bloody stools,
haematemesis, spontaneous bowel perforation, and pancreatitis.
Renal disease: Haematuria is present in 90% of cases, but only 5% are persistent or
recurrent. Less common renal manifestations include proteinuria, nephrotic syndrome,
 isolated hypertension, renal insufficiency and renal failure (<1%). Renal involvement may only
present during the convalescent period.
Subcutaneous oedema (scrotum, hands, feet, sacrum): This can be very painful.
Rare complications - pulmonary and CNS involvement

Typical rash distribution

Investigations

Urine analysis should be performed, and if haematuria is present the sample should be sent for
microscopy to quantify the RBC count.

Other investigations may include:

Full blood count

Urea, electrolytes with creatinine
Blood culture

Management

All patients presenting with a purpuric rash must be seen by a consultant or registrar, even if the child
does not appear unwell.

Document the child’s blood pressure

Consider a surgical consult if abdominal features are prominent. Testicular torsion can be
hard to differentiate from the pain of vasculitic testicular pain.
There are some data to support the use of prednisolone. It may prevent the development of
long term renal complications. Consider prednisolone 1mg/kg for two weeks in all cases (not
just those with haematuria). The use of prednisolone will also treat abdominal and joint pain
and is particularly helpful for the oedema.
Indications for admission:

abdominal complication. Arrange early surgical consultation.

renal complication eg nephritis, nephrotic syndrome

Also consider admission for symptomatic treatment:

severe joint pain – treatment is bed rest and analgesia

abdominal pain
painful subcutaneous oedema

Disposition

Give the family a Parent Information Sheet on HSP

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-Schonlein Purpura (HSP)

What is Henoch-Schönlein Purpura (HSP)?

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.

Signs and symptons

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.

Key points to remember

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.

When to come back

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.

The Acutely Painful Hip

The causes of an acutely painful hip include many of the entities which must be considered for any
acutely swollen joint (See Acutely Swollen Joint Guidelines). However there are several conditions
which are unique to the hip and for which any child presenting with hip pain must be carefully
evaluated.

Irritable Hip (transient synovitis)

Commonest reason for a limp in the pre-school age group.

Usually occurs in 3-8 year olds
 History of recent viral URTI (1-2 weeks)
Child usually able to walk but with pain
Child otherwise afebrile and well
Mild-moderate decrease in range of hip movement - especially internal rotation.
Severe limitation of hip movement suggests septic arthritis.

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

Avascular necrosis of the capital femoral epiphysis.

Age range 2-12 years (majority 4-8yrs)
20% bilateral
Present with pain and limp
Restricted hip motion on examination

Slipped Capital Femoral Epiphysis

Late childhood/early adolescence.

Weight often > 90th centile.
Presents with pain in hip or knee and associated limp.
The hip appears externally rotated and shortened.
There is decreased hip movement - especially internal rotation.
May be bilateral.

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

See also: Specimen collection site

IV fluid guideline
 Pharmacopoeia on line

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

Condition is usually self limiting

General course is 10 -14 days
Virus readily transmitted through direct contact
Ensuring adequate hydration and analgesia are the mainstays of treatment
There is little role for the use of antiviral medications except in certain circumstances

Assessment

See flow chart

Diagnosis

The diagnosis is clinical in the majority of cases

Typical herpetic gingivostomatitis usually does not require lab confirmation
Where confirmation is required (immunocompromised host or contact), direct
immunofluorescence (DIF) and cell culture of scrapings from the base of the lesion should be
performed (See how to take swab for HSV)
Serology is rarely helpful

Management

See flow chart

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

Aciclovir is not recommended in immunocompetent hosts with typical herpetic

gingivostomatitis
Topical aciclovir is generally not effective
Specialist advice should be sought regarding immunocompromised patients

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

HSV Stomatitis flowchart

Specimen collection guide for Herpes Simplez & Varicella Zoster virus detection

Material required:
(Available from the RCH Virology Lab 8th floor)

1. Two sterile swabs

2. One vial of Viral Transport Medium, (pink medium)
3. One painted 3-well glass microscope slide.

Method of collection:

1. Puncture the vesicle with a sterile swab / needle.

2. Collect as much of the vesicle fluid as possible by absorbing onto a sterile dry swab. (Shown
in Diagram 1)
 3. Immediately immerse and break the swab into Viral Transport Media for viral isolation studies.

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

Hydrocarbons Include: Petrol Lubricating Oil

Kerosene Furniture Polishes
Lighter Fluid 2 Stroke Fuel
Mineral Turpentine Dielsel Fuel
Paraffin Oil White Spirit

Assessment

main complication is Aspiration Pneumonitis

C.N.S. toxicity can be evident (either depression or excitement)

Symptoms: coughing, choking, respiratory distress

ataxia, drowsiness, coma, convulsions
persistent burping (particularly seen after petrol ingestion)
Management

Keep nil orally charcoal is contraindicated

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

Hypernatraemia is defined as a serum [Na+] > 150mmol/l.

Definition Serum [Na+]

(mmol/l)
Hyponatraemia < 135
Normal 135 - 149
Moderate Hypernatraemia 150 - 169
Severe Hypernatraemia > 169

Background

Uncommon in Paediatrics, it can be either secondary to

Water loss in excess of sodium (Most common)

Diarrhoea, especially with continuing hyperosmolar feeding (such as Polyjoule)
Severe burns
Impaired renal concentrating ability (osmotic diuresis)
Water deficit
Inability to obtain/swallow water
Impaired thirst drive (e.g. Hypothalamic lesion)
Diabetes insipidus
Gain of sodium
Ingestion of large quantities of sodium (inappropriate making up of formula/home
made rehydration solution)
Iatrogenic sodium administration (hypertonic saline, sodium bicarbonate)
If the cause of the hypernatraemia is central diabetes insipidus contact the Endocrinology team for
advice on management.

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.

Moderate hypernatraemic dehydration, [Na+] 150 - 169 mmol/L.

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.

If needing intravenous rehydration use 0.45% NaCl + 5% dextrose or 0.9% NaCl + 5%

dextrose. Add maintenance KCl once urine output established.
 Check U&E's and glucose one hourly, if serum sodium is falling faster than 1 mmol/hr slow
rate of infusion by 20%. Recheck the serum sodium in 1 hour. If after 6 hours of rehydration
therapy the sodium is decreasing at a steady rate then check the U&Es and glucose 4 hourly.

If there are persistent neurological signs then consider cerebral imaging.

Severe hypernatraemic [Na+] > 170

Contact and consider admission in PICU.

After initial resuscitation, aim to replace deficit and maintenance with 0.9% NaCl + 5% dextrose over
72 - 96 hours.

Table for fluid replacement when hypernatraemia is associated with dehydration

Weight Moderate hypernatraemia Severe hypernatraemia (serum

(kg) (serum [Na+] 150 –169) [Na+] > 170)Rate of fluids ml/hr,
Rate of fluids ml/hr, using using 0.9% NaCl +5%
0.45% NaCl+ 5% dextrose(replacing deficit over
dextrose(replacing deficit over 96hrs)
48hrs) (calc on 10% dehydrated)
(calc on 7% dehydrated)
4 22 21
5 27 25
6 33 30
7 38 35
8 44 40
10 55 50
12 62 56
14 68 62
16 75 68
18 82 75
 20 90 80
22 96 87
24 100 90
26 105 95
28 110 98
30 114 100
32 120 105
34 124 110
36 128 113
38 133 117
40 138 122
45 150 132
50 160 142
55 175 152
60 187 162
65 195 168
70 200 173

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.

Consider peritoneal dialysis if the serum [Na+] > 180mmol/l.

Measure ongoing losses (except urine) and replace ml for ml with normal saline.

Hypertension

Upper 95th Centile for BP

Systolic Diastolic Systolic Diastolic

Age
Boys Boys Girls Girls
 6 114 74 111 74
7 115 77 113 76
8 116 79 115 78
9 118 80 117 79
10 119 81 119 80
11 121 81 121 80
12 123 82 123 81
13 126 82 124 81
14 128 83 126 82
15 131 83 127 83
16 134 84 128 84
17 136 87 129 87

These values are for children on the 50th centile for height

BP Centile Charts

Boys Chart

Girls Chart

Note: BP measurements repeated on several different occasions are required to diagnose

hypertension. The cuff bladder should cover at least 3/4 of the child’s arm length, and the child should
be quiet and calm.

Causes

Essential hypertension

Obesity may complicate the accurate measurement of blood pressure and be a contributing factor.

Secondary causes

Renal (75%) - post-infectious glomerulonephritis, chronic glomerulonephritis, obstructive

uropathy, reflux nephropathy, reno-vascular, haemolytic uraemic syndrome, polycystic kidney
disease
Cardiovascular (15%) - coarctation of the aorta
 Endocrine (5%) - phaeochromocytoma, hyperthyroidism, congenital adrenal hyperplasia,
primary hyperaldosteronism, Cushing syndrome
Other (5%) - neuroblastoma, neurofibromatosis, steroid therapy, raised intracranial pressure.

Assessment

Appearance - Cushingoid, obese

Height and weight
Upper and lower limb BP measurement
Skin: Cafe-au-lait spots, neurofibromas, hirsutism, vasculitis
Fundoscopy: hypertensive retinopathy
CVS examination: left ventricular hypertrophy, murmurs (particularly interscapular)
Abdomen: renal / adrenal masses, renal bruits
Full neurological examination

Investigation

Initially: urine analysis, urine microscopy, urea and electrolytes, creatinine

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.

Acute severe hypertension

These patients require admission to ICU for urgent treatment.

Hypertensive encephalopathy presents as severe headache, visual disturbance and vomiting,

progressing to focal neurological deficits, seizures and impaired conscious state, with grossly elevated
BP, papilloedema and retinal haemorrhages. These patients almost always have chronic renal disease
and are on dialysis. The differential diagnosis includes uraemic encephalopathy and metabolic
disturbance. BP should be lowered in a controlled fashion, with anticonvulsants given for seizures.

Antihypertensives

Choice includes (list not exhaustive):

Sublingual / oral nifedipine:

tabs - 0.5 - 1.0 mg/kg/dose (max. 40 mg) 12-hourly
Side effects include tachycardia, flushing and fluid retention.
Intravenous labetalol:
0.2 mg/kg initially; later 0.4 mg/kg by slow push every 10 min up to 3 - 4
mg/kg (max. 100 mg) total dose. Avoid if there is heart failure, asthma or
bradycardia.
 Intravenous hydralazine:
0.1 - 0.2 mg/kg (max. 10 mg) stat, then 4 - 6 micrograms/kg/min (max
300micrograms/min).
Hydralazine may cause tachycardia, nausea and fluid retention.
Oral captopril:
0.1 mg/kg initially, increasing to a maximum of 1 mg/kg (max. 50 mg).
Thereafter 0.1-1.0 mg/kg/dose 8-hourly. Captopril is usually effective within 30 - 60
min.

Pyloric Stenosis

See also: Diarrhoea & Vomiting

Background

Hypertrophic Pyloric Stenosis (HPS) is due to progressive thickening of the circular muscle of the
pylorus. This leads to gastric outlet narrowing.

The condition usually presents between 2 and 6 weeks of age.

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:

Assess degree of dehydration

Weigh and plot on growth chart with previous weights if available
Look for jaundice (1-2% of infants with HPS)
Look for gastric peristalsis (waves of muscle contraction across the abdomen passing from
the left upper quadrant to the right lower quadrant).
Feel for a pyloric mass (best felt in the right upper quadrant with the infant supine.
Approximates the size and shape of an olive. Best felt from left side. Wait for several
minutes.)
 Signs may be more obvious following a feed

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

Pyloric Stenosis flowchart

...

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

CNS Effects - irritability, coma, depressed level of consciousness, convulsions.

 Adrenergic overdrive - tremor, jitteriness, pallor, sweating.

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

Glucose and lactate: fluoride oxalate tube, 1ml

Insulin, cortisol, growth hormone: plain tube (2-4 ml)
Ammonia: heparinized tube (1ml)
Ketones and free fatty acids: fluoride oxalate (BLF) tube (1ml)
Amino acids, electrolytes: heparinised (1-2ml) - if enough blood available
Acid-base: capillary sample
Blood drops onto a Guthrie test card (for acyl-carnitine profile)

Urine

Ward test for ketones, glucose, reducing substances

10-20ml for amino acids and organic acids

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.

All patients with hypoglycaemia presenting to Emergency require admission.

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

Hyponatraemia is defined as serum sodium <135mmol/L. It represents an excess of water in relation

to sodium in extracellular fluid. Symptoms are likely with Na <125 mmol/L or if the serum sodium has
fallen rapidly.

Background

The main causes of hyponatraemia in children are:

Administration of hypotonic fluids, intravenous or enteral (e.g. excessively dilute formula or

0.18% NaCl)
Conditions with impaired free water excretion and high anti-diuretic hormone levels
Meningitis, encephalitis, pneumonia, bronchiolitis, sepsis
Surgery, pain, nausea and vomiting
Gastrointestinal fluid losses

Less common but important causes are:

Adrenal insufficiency (Congenital Adrenal Hyperplasia, Addison's Disease )

Defect in renal tubular absorption, including obstructive uropathy
Psychogenic polydipsia

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)

Never give 0.18% NaCl or 5% dextrose in water iv as maintenance fluids

Give enteral feeding, rather than iv fluids, wherever possible, and include the volume of
enteral fluid in calculations of fluid intake.
Use 0.9% NaCl (normal saline) plus dextrose as 'maintenance fluid' for any child who has:
A brain injury of any sort (meningitis, encephalitis, trauma, febrile convulsion)
Any other condition associated with impaired free water excretion (see above) where
the child has a serum sodium of <138mmol per L.
Give fluid volumes that take into account the reduced volumes required in children with
impaired free water excretion.
For children who are on more than 50% iv maintenance fluids check the serum electrolytes
prior to starting fluids and at least once in the following 12 hours.
Electrolytes may need to be checked more frequently if the starting sodium was abnormal.
Pay attention to major changes in sodium even when it is still within normal range.

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

Assess the patient's hydration state. (see Gastroenteritis guideline)

If Na+ <130 mmol/L: measure serum potassium, chloride, urea, creatinine and glucose.

Measure the urinary sodium and osmolarity.

In the presence of hyperlipidaemia (e.g. nephrotic syndrome) or hyperpoteinaemia, some laboratories

produce falsely low measurements of serum sodium (this is not the case at RCH). This is sometimes
called pseudohyponatraemia. Contact your laboratory.

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.

The hyponatraemic child with seizures or CNS depression

Notify ICU urgently.

Resuscitation (ABC) and intravenous anticonvulsants as clinically indicated. Hyponatraemic
seizures often respond poorly to conventional anticonvulsants, and sodium correction should
not be delayed. The sodium should be raised until it reaches 125mmol/L or until seizures
stop, whichever occurs first.
Use intravenous 3% NaCl solution. It is stored in the resuscitation trolleys on the wards, in
the ICU and ED. Give 4ml/kg of 3% NaCl. Give over 15-30 minutes. This will raise the
serum sodium by 3 mmol/L and will usually stop the seizures. 3% saline is hypertonic and
should be given through a central venous line where possible.
Measure the serum sodium after the first bolus. Ongoing seizures and persistent
hyponatraemia will require more 3% NaCl.
Many children with hyponatraemia and seizures will have other reasons for seizures (fever,
meningitis, hypoglycaemia), and these should also be addressed
After the seizures have resolved the total sodium correction (including the bolus) should not
exceed 8 mmol/L per day (e.g. from 122-130mmol/L).
Measure electrolytes every 2 hours until stable, then every 4-6 hours until the serum sodium
is normal and the child is off iv fluids

The child with no symptoms of hyponatraemia

Management of children without specific symptoms of hyponatraemia depends on volume status.

They may be normally hydrated, moderately dehydrated or severely dehydrated (see Gastroenteritis
guideline).

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

Restrict water to slowly remove the increased body water.

Do not use hypotonic solutions (see prevention, above)
See, for example, meningitis fluid guidelines.

2. The child with moderate dehydration and serum sodium 130-135mmol/L

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).

3. The child with severe dehydration or serum sodium <130mmol/L

Give iv 0.9% NaCl (plus 5% glucose) until the child can take enteral feeds.

Measure electrolytes every 4 hours until stable, whether on iv or nasogastric rehydration.

Hyponatraemia and severe hyperglycemia

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).

Idiopathic Thrombocytopenic Purpura

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.

Patients fall broadly into two categories:

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.

Most children present with bruising and petechiae alone.

In some instances there is oral bleeding, epistaxis, rectal bleeding or haematuria.
Morbidity in ITP is usually minimal and parents need to be reassured of this.
The incidence of intracranial haemorrhage is much less than 1%, and very rare in true
uncomplicated ITP.
Assessment

The clinical diagnosis of ITP depends on there being manifestations of thrombocytopenia

without other abnormal findings, in particular no pallor, lymphadenopathy or
hepatosplenomegaly.
Confirmation rests on the adequate exclusion of other causes of thrombocytopenia. The most
important conditions to exclude are acute leukaemia, other marrow infiltrative conditions and
aplastic anaemia. An FBE (including blood film) will usually confirm the diagnosis.
A bone marrow aspirate is an invasive procedure with some morbidity in children who bruise
easily, and is only necessary if the diagnosis is uncertain. It is rarely necessary in
uncomplicated ITP.

Management

Initial treatment options include no treatment and oral steroids.

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.

a) Conservative Outpatient Management

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:

The diagnosis is unequivocal. No pallor, hepatosplenomegaly or lymphadenopathy; isolated

thrombocytopenia without anaemia, leucopenia or blood film changes.
There is no active bleeding. Bruising and petechiae in isolation, without mucosal,
gastrointestinal or renal tract bleeding.
The child is otherwise well.
Social circumstances allow confidence about the degree of parental supervision and relative
safety of the home environment, particularly for younger children.
There is ample opportunity for parental reassurance and education in the Emergency Dept.
Follow up is guaranteed within a few days by the on call General Paediatric consultant, who
must be contacted and agree with the management plan.

b) Conservative Inpatient Management

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)

Avoid aspirin and non-steroidal anti-inflammatory drugs.

Notes

Acute, relapsing ITP

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.

Rarely, splenectomy is required (success rate 70-80%).

Idiopathic Thrombocytopenic Purpura (ITP)

ITP is a bleeding disorder resulting from a shortage of platelets in the blood. Platelets are the blood
cells that help clot the blood, and if a child has a shortage of platelets then he or she will bruise easily
and may have other bleeding problems.

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.

Signs and symptoms

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.

Key points to remember about ITP

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

Current Immunisation Schedule (from 1 November 2005)

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)

1. Premature infants require an additional vaccine at 6 months:

infants born < 28 wks give Hib-hepB; infants born 28 - 32 wks give HepB
2. Meningococcal C vaccine is funded for all 1-19 year olds. It can be given < 1 yr but is not
currently funded (2-6 mo 3 doses; 6-12 mo 2 doses).
3. Varicella vaccine is funded for infants aged 18 months. It can be given at 12 months of age
on the same day as MMR vaccine or 4 weeks later.
4. A catch-up dose of varicella vaccine is given to students in Year 7 who have not had
chickenpox or varicella vaccine.
5. Adolescents aged 11-15 years who have not previously had hepatitis B vaccine are given 2
doses 4-6 months apart (using adult formulation).
6. Influenza vaccine can be given to any infant > 6 months. Children in certain risk groups are
highly recommended annual influenza vaccine. Children < 9 years require 2 doses in the first
year they receive the vaccine. Doses vary according to age - see The Australian
Immunisation Handbook 8th Edition page 170.
7. Routine catch-up of primary vaccination is not recommended, do not give rotavirus vaccine
beyond the following age limits, 1st dose by 12 weeks of age and 3rd dose by 32 weeks of
age. Minimum interval between doses is 4 weeks.

^ Back to schedule

See also

Immunisation Handbook 8th Edition online

Immunisation fact sheets for parents and providers
Summary of recent changes to the schedule

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.

HPV vaccine fact sheet (for parents)

HPV vaccine fact sheet (for young women)
HPV vaccine fact sheet (for providers)

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)

Opportunistic Immunisation Guideline

See Recommended Immunisation Schedule (Immunisation Service Home

also: page)
Immunisation Resources for Clinicians
Immunisation Parent Information

Catch-up immunisation schedule for newly arrived refugees

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.

How should we do it?

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

Where should we do it?

In the Emergency Department

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

All vaccines can be obtained from pharmacy

Immunisations and their batch numbers should be documented on standard Drug charts

Immunisation Procedure

For Immunisations on the Schedule

1. Assess for contraindications — run through Pre-immunisation checklist

2. Obtain consent from parents (print out parent information sheets if desired)
3. Write vaccine on drug chart or emergency treatment orders
4. Obtain vaccine (see above)
5. Administer vaccine
6. Complete child’s yellow book, or give parents a letter with names and batches of vaccines
given
7. Complete notification form to ACIR
o Hospital notification form (complete for all immunisations given in the hospital and
forward to the immunisation service) — information will be forwarded to ACIR. NB
notification form is provided with immunisations which are supplied by the pharmacy,
or can be printed.
o Australian Childhood Immunisation Registry (ACIR) form (for immunisations provided
outside the hospital)
o NB if outside the hospital, and ACIR forms are not available — print off a copy of the
hospital notification form, and fax or post to ACIR (FAX 08 9214 8163)

Vaccines not on the schedule (eg Rotavirus)

 1. Is child eligible for hospital to fund vaccine? Discuss with consultant and /or Immunisation
Service.
2. If so — obtain DUC (drug usage committee) approval
1. DUC form (intranet only)
 Department funded Vaccines
2. Form checked by immunisation service. Contact the Immunisation nurses on ext
6599 or page 4330. (intranet only)
3. Immunisation provided as above
3. If child is not eligible, and parents wish to purchase vaccine these can be obtained via the
immunisation centre. Contact the Immunisation nurses on ext 6599 or page 4330. (intranet
only)

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.

About the products

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.

Patients with IgA deficiency should be prescribed Intragam P.

Caution: Intragam P and Octagam have different concentrations of IVIG.

The medical order must specify:

the brand of IVIG to be given (Intragam P or Octagam)

the dose in grams
the volume in mls
the rate of infusion

Description Intragam P Octagam

Solution, in vial sizes:

Solution, in vial sizes:
2.5g in 50mls
Presentation 3g in 50mls
5g in 100mls
12g in 200mls
10g in 200mls

Concentration 60 mg per ml 50 mg per ml

 Northern hemisphere
Source
Australian volunteer donors remunerated
Plasma
and volunteer donors

Hepatitis C, Hepatitis B, HIV, Hepatitis C, Hepatitis B, HIV,

Plasma testing
HTLV-I/II ALT

Viral Safety 2 viral inactivation steps 2 viral inactivation steps

Key additives Maltose Maltose

In hospital blood bank. In hospital blood bank.

Storage Refrigerated at 2-80C for up to Stored below 250C for up to
2 years. 2 years.

May be flushed with sodium

May be flushed with sodium
Compatibility chloride 0.9% or glucose
chloride 0.9% or glucose 5%.
5%.

IgA level < 0.4mg/g protein < or equal to 2mg/g protein

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.

TPR and Blood Pressure at:

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.

Long Term Replacement Therapy

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.

Intragam P maximum 240mls/hr

Octagam maximum 250mls/hr

Observations

Weight at baseline to calculate the dose required

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

Anaphylaxis is a rare but documented adverse effect of IVIG.

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

A record should be kept in the patient history of the following:

The date of the infusion

Patient's observations and general condition during the infusion
Amount given
Product name, Batch Number and Expiry Date of each bottle used (place a sticker with batch
number on the drug or IV fluid chart if available)

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

See also: Resuscitation

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:

IO access is the recommended technique for circulatory access in cardiac arrest.

In decompensated shock IO access should be established if vascular access is not rapidly
achieved (if other attempts at venous access fail, or if they will take longer than ninety
seconds to carry out.)
The exception is the newborn, where umbilical vein access continues to be the preferred
route.
Contraindications:

Proximal ipsilateral fracture

Ipsilateral vascular injury
Osteogenesis imperfecta

Complications:

Failure to enter the bone marrow, with extravasation or subperiosteal infusion

Through and through penetration of the bone
Osteomyelitis (rare in short term use)
Physeal plate injury
Local infection, skin necrosis, pain, compartment syndrome, fat and bone microemboli have
all been reported but are rare

Equipment

Alcohol swabs
18G needle with trochar (at least 1.5 cm in length)
5 ml syringe
20 ml syringe
Infusion fluid

Analgesia, Anaesthesia, Sedation

Local anaesthesia may be required if the patient is conscious.

Procedure

Identify the appropriate site

Proximal tibia: Anteromedial surface, 2-3 cm below the tibial tuberosity
Distal tibia: Proximal to the medial malleolus
Distal femur: Midline, 2-3 cm above the external condyle
 Prepare the skin
Insert the needle through the skin, and then with a screwing motion perpendicularly / slightly
away from the physeal plate into the bone. There is a give as the marrow cavity is entered
Remove the trocar and confirm position by aspirating bone marrow through a 5 ml syringe.
Send marrow blood for laboratory sampling (suitable for most standard laboratory values, pH,
pCO2, HCO3-, and ABO and Rh typing.)
Marrow cannot always be aspirated but it should flush easily.
Secure the needle and start the infusion (this needs to be manually administered as boluses
with the 20 ml syringe.)

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

Research study in progress - please click here

Intussusception is the invagination of a proximal segment of bowel into the distal bowel lumen. The
commonest occurrence is a segment of ileum moving into the colon through the ileo-caecal valve. It
may occur at any age but commonly occurs in the 2 month to 2 year age group with a peak incidence
at 5 to 9 months.

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

Plain abdominal Xray

Performed to exclude perforation or bowel obstruction
A normal AXR does not exclude intussusception
Signs of intussusception on a plain Xray include:
1. Target sign - 2 concentric circular radiolucent lines
usually in the right upper quadrant
2. Crescent sign – a crescent shaped lucency usually View flowchart
in the left upper quadrant with a soft tissue mass
Gas insufflation enema (or contrast enema)
Diagnostic investigation of choice if high level of suspicion
This intervention is both diagnostic and therapeutic
Ultrasound scan
Useful if there is a suggestive history but no mass palpable or signs on plain AXR
See flow chart
 Blood tests
Blood glucose
Blood group and hold prior to theatre
FBE and U&E’s may be useful if child looks unwell

Management

If shocked see resuscitation guidelines

Involve surgeons early

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

Patients Requiring Treatment

Ingestion of 20 mg/kg elemental iron.

Ingestion of an unknown quantity.
Any symptomatic patients

Assessment

Symptoms

Initial symptoms are usually:

nausea, vomiting, haematemesis, diarrhoea
Fever is common
Other Symptoms are related to fluid shifts from intravascular to extravascular compartments
and cellular hypoxia:
tachycardia, vasoconstriction, hypotension, shock
Metabolic Acidosis can occur
Beware the pale child

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.

A Summary Of Patients Requiring Chelation Therapy

1. Any patient with symptoms of altered conscious state, hypotension, tachycardia or

tachypnoea, or worsening symptoms irrespective of ingested dose or serum iron level.
2. Consider desferrioxamine in patients with symptoms who have serum iron levels > 60
micromol/l

All patients being considered for Desferrioxamine or with worsening symptoms must be
referred to ICU (5212).

Jaundice in Early Infancy

Assessment

Investigation Of The Jaundiced Baby

View flowchart

Causes Of Neonatal Jaundice

Unconjugated

Breast milk jaundice - 3-5% of breast fed babies

Prematurity - exaggerated physiological pattern; may last 4 weeks
Bruising / cephalohaematoma – breakdown of heme
Haemolysis (Rhesus, ABO, G6PD or PK deficiency, spherocytosis) - early onset for ABO,
Rhesus
Sepsis - rarely presents with jaundice alone (occasional for UTI); usually unwell
Metabolic (eg. hypothyroidism) - prolonged jaundice, can be mixed conjugated/unconjugated
Polycythemia - delayed cord clamping, twin to twin transfusion
Gilbert / Crigler-Najjar - rare, usually present as prolonged jaundice
GI obstruction (eg. pyloric stenosis)

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.

4. Phototherapy or rarely exchange transfusion may be necessary in a baby with severe

unconjugated jaundice associated with prematurity, haemolytic disease, or rare disorders
such as Crigler-Najjar. Outside these conditions unconjugated jaundice is unlikely to lead to
CNS or hearing problems, and no treatment is usually necessary.
Kawasaki Disease Guideline

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.

The diagnostic criteria for Kawasaki disease are:

Fever for 5 days or more, plus

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.

Click to view photos & description

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

All patients should have

ASOT / Anti DNAase B

 Echocardiography (at least twice: at initial presentation and, if negative, again at 6 - 8 weeks).
Platelet count (marked thrombocytosis common in second week of illness)

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

Patients require admission to hospital if Kawasaki Disease is diagnosed or strongly suspected.

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

Aspirin 3 - 5 mg/kg once a day for at least 6 to 8 weeks.

Some give a higher dose (10mg/kg 8 hourly for the first few days) but this probably adds
nothing over immunoglobulin.

Provide the Kawasaki Disease Parent Information Sheet.

Parent Information Sheet (Print version - PDF)

Parent Information Sheet (HTML version)

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.

Ketamine Use in the Emergency Department

See also: Nitrous Oxide Guideline

Analgesia & Sedation Guideline

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.

Characteristics of Ketamine Dissociative State

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

Potential Side Effects:

Unpleasant emergence phenomena - more common beyond mid adolescence.

Hypersalivation.
Transient laryngospasm
Transient apnea or respiratory depression
Emesis
Recovery agitation
Random purposeless movements, muscle twitching and rash are common.

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:

Children under 12 months

Food within four hours.
Chest infection /URTI or lung disease including active asthma.
History of previous airway surgery or congenital anomaly.
Procedures that will stimulate the posterior pharynx.
Cardiovascular disease including hypertension.
Head injury with LOC, altered conscious state or vomiting.
Poorly controlled seizure disorder.
Glaucoma or acute globe injury.
Psychosis, Porphyria.
Thyroid disease.

Procedure

Staff required:

Airway doctor - must be approved by the Emergency Department

Nurse
 Doctor for the procedure.

Resuscitation equipment must be readily available.

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

Atropine 0.02mg/kg to a maximum of 0.6mg can be used to diminish hypersalivation.

Midazolam 0.02 mg/kg may be added to ameliorate emergence phenomena in children over 5
years old.

These may all be mixed in the same syringe for intramuscular or intravenous injection.

Local anaesthetic agents may be used but are rarely required.

Administration:

IV: (with local anaesthetic cream)

Especially useful for procedures longer than 15-20 minutes

The Ketamine dose of 1-1.5 mg/kg is given slowly over (1-2 min) as more rapid administration
is associated with respiratory depression.
Further incremental doses of 0.5mg/kg may be given if sedation is inadequate or longer
sedation is necessary.
Atropine and Midazolam may be given prior to or with the Ketamine.

IM:

Ketamine can be safely used without i.v. access.

3-4 mg/kg Ketamine with atropine and Midazolam mixed in the same syringe.
A repeat dose of 2-4 mg/kg may be given after 10 minutes if sedation is inadequate.

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

Nil orally until fully alert

Nurse in a quiet area with minimal noise and physical contact, allow dim lighting if possible,
and do not stimulate prematurely.
When patient is able to ambulate and verbalise at a level consistent with their pretreatment
functioning then they may be discharged home.

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

See Sedation Guideline

Anaesthesia

See Sedation Guideline

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

Can be cleansed with saline or aqueous chlorhexidine.

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

Trim edges of wound where the viability is in doubt.

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

Dressing only (see wound dressing guideline)

Simple lacerations (small, superficial wounds which are not gaping or contaminated)
can be managed with dressings alone.
Puncture wounds are usually best left open although they may require exploration or
debridement if deep or contaminated.

Tissue adhesive ("Dermabond glue")

Can be used on wounds which have clean edges, do not require deep sutures and
are not under tension.
Best for wounds of less than 3cm in length with edges easily held together.
Do not use on mucosal surfaces.
If glueing the forehead or in the vicinity of the eye, the eye should be padded to avoid
any glue dripping into the eye or onto the eyelashes.
Oppose the edges of the wound and apply very small amount of glue to the surface,
holding the edges together for 30 secs.
Do not allow glue to enter wound itself (non-absorbable - acts as foreign body).
Generates heat (may be uncomfortable if applied too thickly).
Care should be taken not to apply too much tissue glue and to avoid placement over
currently bleeding wounds as the polymerisation is exothermic and the patient will
notice a heat sensation. The tensile strength of the bond will be reduced also.
Does not require removal; comes off in 1-2 weeks.

Adhesive strips ("Steristrips")

May be adequate in simple lacerations which require opposition of slightly separated
wound edges.
They do not remain in place for long periods, and should not be used if there is
movement or tension across the wound.
Prepare skin with tincture of benzoic compound to aid adhesion.
Place strips with sufficient space between each to allow drainage of fluid from the
wound to avoid infection.
Keep dry for 72 hours.

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.

Digits & Hand

Subungual Haematoma:
Usually caused by blunt trauma to the finger tip.
If < 50% of nail bed - treat with ice and analgesia only
If > 50% and significant pain - then burn hole in nail to relieve the pressure
Small lacerations of finger tips with skin loss are very common.
Areas of skin loss up to 1 cm2 are treated with dressings and heal with good
return of sensation. Any greater degree of tissue loss should be referred for
plastic surgical opinion.
Partial-amputation / crush injury.
Need to assess the integrity of the nail bed - if damaged needs plastic
surgery repair. X-ray to look for fracture of distal phalynx. A fracture implies
damage to the nail bed. Discuss management with Plastics.
Palm:
Be careful in assessing wound especially in very young children as deeper
structures (eg nerves and tendons) may be involved. If in doubt consult
Plastics.
Compound injuries (i.e. fracture and laceration) should have antibiotic cover.

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

See Management of tetanus-prone wounds

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.

Local Anaesthetic, Manipulation and Plaster (LAMP)

Doctors must discuss previous experience and training in this procedure with the Director of the
Emergency Department before proceeding, and should be fully familiar with the equipment used.

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

Give adequate pain relief

Painstop 1.0mL/kg
or Pethidine 1.0-1.5mg/kg IM
or Morphine 0.1-0.2 mg/kg IM
Keep child nil orally.
Put EMLA/amethocaine on both hands.

Once decision is made to proceed to LAMP

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

Two doctors must be present.

Apply a tourniquet to the affected arm.
Insert an i.v. cannula (not a butterfly) into a distal vein of both arms
Elevate the arm above the level of the child’s heart for 1 minute with compression of the
brachial artery.
 Inflate the tourniquet cuff to 200 mmHg. This reading is maintained throughout the procedure
and remains the responsibility of the second attending doctor.
Infuse Lignocaine 0.5% 0.6mls/kg (3 mg/kg); max dose 40ml.
Commence manipulation only after full anaesthesia has been obtained (usually.takes 5-10
minutes).
Note: Nitrous oxide or intravenous opiate may be useful as an adjunct in some children.
Apply plaster to the forearm (below elbow).
Arrange portable post-reduction film in ED. If possible wait until the X-ray is available to
assess the position post-manipulation before releasing the tourniquet.
Release the tourniquet cuff.
Note: Not to be released before 20 minutes after lignocaine infusion.
Complete the plaster cast (above elbow).

After the 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.

Lumbar Puncture Guideline

See also: Meningitis

CSF Interpretation
LP Parent Handout
References for LP Guideline

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:

Suspected meningitis or encephalitis

See Meningitis, febrile convulsion, fever
Suspected Sub-arachnoid haemorrhage with a normal CT
Contraindications:

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 ...

Coma: absent or non-purposeful response to painful stimulus - squeeze ear-lobe hard

for up to one minute. A child over 3 months of age should push you away and seek a
parent.
Signs of raised intracranial pressure. Eg abnormal pupillary responses, unilateral or
bilateral motor posturing or papilloedema (NB papilloedema is an unreliable and late
sign of raised ICP in meningitis; a bulging fontanelle in the absence of other signs of
raised ICP, is not a contraindication).
Cardiovascular compromise / shock
Respiratory compromise
Focal neurological signs or seizures
Recent seizures (within 30 minutes).
Coagulopathy/thrombocytopenia
Local infection (in the area where an LP would be performed)
The febrile child with purpura where meningococcal infection is suspected.

Assessment prior to LP for contraindications?

CT Scans if focal neurological signs

CT Scans are not helpful in most children with meningitis.
A normal CT scan does not tell you that the patient does not have raised ICP.
Herniation may occur even in the presence of a normal scan.
See flow diagram Lumbar puncture, imaging and antibiotics

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:

Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common)

Post-dural puncture headache (fairly common) - up to 5-15%
Transient/persistent paresthesiae/numbness (very uncommon)
Respiratory arrest from positioning (rare)
Spinal haematoma or abscess (very rare)
Tonsillar herniation (extremely rare in the absence of contraindications above)

The LP Parent Information Sheet may be useful in talking to parents about the procedure. (See below)
Analgesia, anaesthesia and sedation

Non-pharmacological techniques should be used where possible, including explanation (in an

older child), distraction, and the presence of a parent.
All children should have some form of local anaesthetic for lumbar puncture.
Use topical anaesthetic cream (AnGEL) except where specimens are required
urgently
Subcutaneous lignocaine may be used in addition to or instead of topical anaesthetic.
Use up to 0.4ml/kg of 1% (4mg/kg)
Oral Sucrose should be used for infants <3 months (see <a
href="/clinicalguide/cpg.cfm?doc_id=5144"/>Analgesia guideline)
Sedation, including nitrous, should be considered for children older than 6 months with normal
conscious state

Monitoring:

Monitor all sedated or seriously ill children with continuous pulse oximetry

Equipment

At least one trained assistant to hold the child

Sterile gloves
Sterile drapes and procedure tray
Skin preparation: povidone iodine solution (Betadine) or chlorhexidine
Local anaesthetic lignocaine, 2ml syringe, 25G needle
CSF tubes (2)
Spinal needle (see below)
NB Spinal manometry is not routinely performed in children during lumbar puncture.

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:

Wash hands and aseptically put on sterile gloves

Prepare the skin with povidone-iodine or chlorhexidine and set up sterile drapes.
Allow adequate time for the skin preparation to dry
Take the tops off the tubes, ensuring that they remain sterile.
Infiltrate the skin with 1% lignocaine using a 25G needle

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".

Why does my child need a lumbar puncture?

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.

What happens during a lumbar puncture?

Does it hurt?

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.

What are the risks?

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).

Key points to remember about having a lumbar puncture

Lumbar punctures are the only way to be sure if your child has meningitis or not.
It is a very safe test.

MET Criteria - Call 777 for help

Read more about the RCH Medical Emergency Team (MET) here

Staff Member or parent worried about patient's clinical state

Airway threat

Hypoxaemia:

SpO2 <90% in any amount of oxygen

SpO2 <60% in any amount of oxygen (cyanotic heart disease)

Severe respiratory distress, apnoea or cyanosis

Tachypnoea

Age Respiratory rate

Term-3 months >60
4-12 months >50
1-4 years >40
5-12 years >30
12 years+ >30

Tachycardia or bradycardia:

Age Heart rate too Heart rate too

 slow fast
Term-3
<100 >180
months
4-12 months <100 >180
1-4 years <90 >160
5-12 years <80 >140
12 years+ <60 >130

Hypotension:

Age BP (systolic)
Term-3 months <50
4-12 months <60
1-4 years <70
5-12 years <80
12 years+ <90

Acute change in neurological status or convulsion

Cardiac or respiratory arrest

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

See also: Fluids in Meningitis guideline

Use of Vancomycin in meningitis
Lumbar Puncture Guideline
CSF Interpretation
 Meningococcal infection
Coma
Convulsions in children with meningitis
Febrile Child under 3 years

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).

Organisms to consider in infants under 2 months of age include

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.

Lumbar puncture (LP)

see Lumbar Puncture guideline, CSF Interpretation guideline
Blood tests
Full blood count/differential
Glucose, urea and electrolytes
Blood cultures

Management

Therapy (summary)

Age Antibiotics Steroids If Strep.

Pneumoniae suspected

>2 months Cefotaxime 50 Dexamethasone

add Vancomycin 15
mg/kg (2 g) iv 0.15 mg/kg, iv
mg/kg (500 mg) iv 6H
6H 6H

4 weeks-2 Cefotaxime 50 Dexamethasone

months mg/kg (2 g) iv 0.15 mg/kg, iv
6H, 6H Substitute Vancomycin
Benzylpenicillin 15 mg/kg (500 mg) iv 6H
60 mg/kg iv 4H for Penicillin
and
Gentamicin

<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

N. meningitidis Benzylpenicillin 50mg/kg/dose (max 3g), iv 4 hourly for 7

days (Penicillin-sensitive)

S. pneumoniae Benzylpenicillin 50mg/kg/dose (max 3g), iv 4 hourly for

minimum of 10 days (Penicillin-sensitive)

Haemophilus Cefotaxime 50mg/kg/dose (max 3g), iv 6 hourly for 7-10

influenzae type b days

Other If an organism is not isolated, but significant CSF

pleocytosis is present, a minimum of 7 days treatment with
intravenous cefotaxime is recommended.

Prolonged therapy will be required for neonatal and Gram-

negative bacillary meningitis.

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.

Give Dexamethasone 0.15mg/kg iv 6 hourly for 4 days

Wait 15 minutes before giving antibiotics after the first dose.
Antibiotics must not be delayed more than 30 minutes after a decision is made to treat.

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 in children with 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.

Check laboratory blood glucose, acid base and electrolytes.

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:

age less than 2 years

coma
cardiovascular compromise
intractable seizures
hyponatraemia

Fluid Management

see Fluids in Meningitis Guideline

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

see Contact Chemoprophylaxis Table

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

CSF findings may be suggestive (see CSF interpretation guideline).

Admission is required if the diagnosis is in doubt and/or antibiotics or intravenous hydration
are required.
Ensure adequate analgesia Parent Information Sheet (Print version - PDF)

Meningococcal infection
Meningococcal infection is caused by a bacteria germ called meningococcus. Meningococcus can
cause serious infections including:

Meningitis, an infection of the covering of the brain and spinal cord.

Septicaemia, serious infections of the blood.
Infections in other parts of the body (such as in the joints).

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.

Children and adults

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

In newborns and babies, the typical symptoms may be hard to detect.

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.

Anyone showing signs of meningococcal infection needs to see a doctor immediately.

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.

Treatment for contact people

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:

Take medicine for epilepsy.

Take medicine for blood thinning.
May be pregnant or are breastfeeding.
Have a history of liver or kidney disease.
Have had a reaction to rifampicin in the past.

These people should not take rifampicin. There are other medicines they can take.

Side effects of rifampicin

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.

Follow instructions for taking rifampicin carefully.

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.

Prevention of meningococcal infection

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.

Key points to remember

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.

Acute Meningococcal Disease

See also: Fever and petechiae/purpura guideline

Meningitis guideline

Notes

IV antibiotics should be given as soon as possible whenever meningococcal disease is

suspected (im, or intraosseus, if iv access can not be obtained). Blood cultures should
preferably be taken before the antibiotics are given. If this will lead to a delay of more than 5
minutes, then give antibiotics immediately.
Cefotaxime or ceftriaxone are the first choice antibiotics (at RCH use cefotaxime). If
unavailable, use benzyl penicillin.
Other bacteriological investigations (see below) can be useful if collected early but should not
delay antibiotic therapy.

Emergency Drug & Fluid Calculator

Clinical presentation

Common presentations

meningitis (see also meningitis guideline).

meningococcaemia (classically as fever + purpura but can be non-specific septic
presentation)

Meningitis and meningococcaemia commonly occur together.

Examples of rash. Click her to see full size

Less common presentations

 arthritis
pneumonia
pharyngitis
occult bacteraemia.

Features of acute meningococcaemia

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

All patients should be admitted to hospital under General Medicine.

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

Gain intravenous access (or intraosseous access if iv not possible).

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.

When meningococcal infection is confirmed (including sensitivities), this may be changed to iv

benzylpenicillin 50mg/kg/dose – max 3g, 4 hourly for 7 days.

Fluids

Meningococcaemia is often associated with hypovolaemia, give 20 ml/kg of normal saline.

More fluid will often be needed to improve blood pressure and peripheral perfusion (40 ml/kg or more
in the first hour is common).

For meningitis alone, careful fluid management is important as many children have increased ADH
secretion. See meningitis guideline.

ICU management

Consider intubation early.

Give methylprednisolone (10mg/kg) before (or within 30 minutes) first dose of antibiotics.

Consider hydrocortisone 1mg/kg 6 hourly - especially if on inotropes.

Consider immunoglobulin 0.5g/kg over 2 hours.

Investigations

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 curlture if no BC bottles available, a plain sterile "clotted" tube

may be used

Blood smear Smear 1 drop onto a microscope slide for Gram stain

2-5 mls of blood in This will be used for meningococcal PCR

EDTA tube

Throat swab In transport medium

Lumbar puncture Contraindicated in the initial management of the child

with fever & purpura
Appropriate in suspected meningitis (without purpura)
when no other contraindications exist .

Other as appropriate eg joint aspirate for culture and PCR

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

Full blood count/differential

Glucose, urea and electrolytes
PT/APTT, DIC screen if appropriate

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).

Link to DHS info on meningococcus

Link to DHS notifications (include form)

Contact chemoprophylaxis

It is important that prophylaxis be given within 24 hours to contacts.

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

See also: Hypoglycaemia

Seizures
Resuscitation

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

Parental history- consanguineous parents, previous unexplained neonatal deaths or Sudden

Infant Death Syndrome (SIDS), family history (e.g. relatives with undiagnosed 'syndrome'),
ethnic group (certain diseases only)

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

Presentation may also be more insidious:

Developmental delay or regression
Coarsening of features and skeletal changes
Psychiatric disorders
An acute metabolic disturbance following a recent dietary change e.g. introduction of
solids, fasting or following excessive physical activity
Food craving or refusal

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

Acute management as per resuscitation guidelines (ABC) if required See Resuscitation

Consult with Metabolic Physician and check ED patient alert system
Intravenous or nasogastric tube fluids to correct dehydration and replace ongoing losses (e.g.
vomiting, diarrhoea)
Ensure adequate amount of calories for age and weight to avoid catabolism (e.g. glucose
solution 10%, intralipid etc.)
Hypoglycaemia and/or seizures treated as per guidelines See Hypoglycaemia
 Intravenous medications to chelate or divert toxic metabolites, or replenish deficient
metabolites, depending on metabolic problem (e.g. Carnitine, Arginine, Na-Benzoate, vitamins
etc)
Haemofiltration in ICU may be required if there is a rapid deterioration due to accumulation of
toxic metabolites

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)

Metabolic condition pH Glucose Ketones Ammonia

Urea cycle defects N or N N

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

Characteristic clinical features:

 Firm, pearly, dome-shaped papules with central umbilication. Lesions are usually 1-3 mm in
diameter, but can grow to 1-2 cm.
Presentation to a doctor is often prompted by the development of eczema in surrounding skin.
Recognition can be difficult as these changes can obliterate the primary lesions, however a
carefully taken history of the initial lesions is usually diagnostic.
Lesions can occur anywhere, particularly in flexures and areas of friction. Lesions may occur
in the anogenital region and are not usually associated with sexual abuse.
Molluscum on eyelid margins can cause chronic conjunctivitis, often unilateral.

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.

Lesions often become inflamed but antibiotics are rarely necessary.

Children with molluscum should not be isolated or restricted in their activities. Avoiding
sharing towels or bathing together may reduce the spread to siblings.

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.

Signs and symptoms

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.

Key points to remember

Molluscum spots are caused by a virus.

It is spread from person to person by touching the Molluscum. It is also easily spread through
bath or pool water, bath toys and towels.
It is not life threatening.
The spots can last for weeks to months.
Treatment is not always needed.
Careful hygiene can help reduce the spread of the infection.

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.

Nappy rash is not one distinct diagnosis, but is a multifactorial problem.

Factors which contribute to Primary Irritant Napkin Rash:

Excess skin hydration

water in urine & stool
nappy change frequency
Skin trauma
friction between nappy and skin.
Irritants
ammonia (produced from urine by urea splitting organisms in faeces)
faeces (especially diarrhoea)
soap & detergent residue
agents present in Nappy Wipes
napkin powders & creams
Candida albicans (present in faeces and infects damaged moist skin)

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

Use disposable nappies.

Increase the frequency of nappy changing and cleansing the skin.
Use disposable towels or face washers soaked in water or olive oil to cleanse the area.
Application of a barrier cream at every change. Effective barrier creams include zinc paste,
white soft paraffin and vaseline. Apply extremely thick and should not be removed completely
after each nappy change, rather apply another layer over the top.
Letting the child spend as long as possible without a nappy on, lying on a soft absorbent sheet
that is changed as soon as it is wet. Sunlight plays a role.
If there is associated candidal infection, leading to erythema in the folds and satellite pustules
then topical anti-candidal therapy (an imidazole or nystatin) should be applied. This therapy is
often combined with 1% hydrocortisone to reduce the associated inflammation.
Consider differential diagnosis (see below)

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).

Nappy rash is made worse by:

Runny, loose poo (diarrhoea).

Not changing the nappy often enough.
Plastic pants.

Most children grow out of nappy rash with toilet training.

Signs and symptoms

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.

When to come back

See your doctor if the rash does not improve within 1-2 weeks.

Key points to remember

Prevention is most important.

A good quality disposable nappy is best.
Many rashes can occur in the nappy area. Some of these are conditions which can be found
on any area of the body (eg eczema, psoriasis), whilst others are directly related to the
wearing of a nappy.

Persistent Nasal Discharge ('Rhinosinusitis')

Rhinosinusitis is inflammation of the epithelial lining in the paranasal sinuses. It is common in children
and is probably under-diagnosed, however it resolves spontaneously in the majority of cases.

There are a number of causes;

Infection Viral
Bacterial Streptococcal Pneumoniae
Haemophilus Influenzae (non typeable)
Moraxella Catarrhalis
Allergic Seasonal
Perennial
Chemical
Obstructive Adenoidal
Hypertrophy
Foreign Body

If recurrent or severe, consider rarer causes:

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

Nasal discharge (purulence is of little

Inflamed nasal mucosa
significance)

Pus exuding from the middle

Nasal obstruction
meatus

Maxillary transillumination (over

Maxillary toothache
9yo)

Unilateral facial pain Associated middle ear changes

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.

CT is not used routinely but may be indicated in the following situations:

failed medical management

possible orbital / intracranial complication
if surgery is being contemplated

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

1st line amoxycillin (15mg/kg/dose tds) for 10days

(Cephalexin if penicillin allergic)

2nd line amoxycillin/clavulanic acid (if pt has had amoxycillin in the last
month)

If orbital / IV flucoxacillin (50mg/kg/dose 6 hourly) and IV cefotaxime

intracranial (50mg/kg/dose 6 hourly) and refer to
signs ophthalmolgy/neurosurgery

The addition of steroid sprays, decongestants, or antihistamines to antibiotic treatment has been
shown to have no benefit in sinusitis.

Surgery is very rarely needed.

Needle Thoracocentesis

See also: Primary Spontaneous Pneumothorax

Chest Drain (Intercostal Catheter) Insertion

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)

It is the only acceptable immediate intervention in cases of tension pneumothorax

Tension pneumothorax is a clinical diagnosis. There is a 10 - 20 % chance of causing
a pneumothorax if thoracocentesis is attempted and the child does not have a
pneumothorax. This procedure must be followed up by chest x-ray, and will require a
chest drain if the patient is ventilated.

Indications:

Primary spontaneous pneumothorax

Tension pneumothorax

Relative contraindications:

Thoracocentesis should be only be considered in consultation with a senior emergency physician in

the following:
 Spontaneous pneumothorax in patients with underlying lung disease
Traumatic pneumothorax without tension

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, Anaesthesia, Sedation

Analgesia and local anaesthesia are mandatory except with tension pneumothorax, which is
immediately life-threatening.

Use local anaesthetic or EMLA/ANGEL

Consider oral or parenteral analgesia pre- and post-procedure

Procedure

Place patient on continuous cardiac monitoring and pulse oximetry

Patient position
Place trauma patient in a head-up, supine position
All other patients should be placed in 45-degree, sitting position
Palpate landmark (the upper border of the 3rd rib in the midclavicular line) and antiseptically
prepare the area
Attach a 5ml syringe to the catheter device
Puncture the skin at the level of above landmark
Carefully insert the needle at a slightly downwards angle into the pleural space while
aspirating the syringe
 In tension pneumothorax, often you will hear a pop or feel a change of resistance
Withdraw the needle while gently advancing the cannula downwards into position
Secure cannula/CVC with tape/tegaderm
Attach 3 way tap and 50ml syringe
Drain until no further drainage or to a maximum of 30ml/kg (max 2.5l)

Post-Procedure Care

Reassess ABCs

Consider need for further analgesia

Plan for chest drain (intercostal catheter insertion) in patients with tension pneumothorax
Organise appropriate patient disposition
Trauma guideline
Primary Spontaneous Pneumothorax guideline

Needle Stick Injury

Background

All hospital acquired needlestick injuries require an Incident Report form

During business hours contact the staff health nurse pager 6663
After hours contact the emergency department consultant/night registrar.

Assessment

Community acquired needlestick injury:

Follow first aid measures as outlined below

Source is usually unknown
Consider hepatitis B:
If vaccinated check antibody levels
If unvaccinated then give 1st dose vaccine and consider immunoglobulin
< 2 yr: 100 units
2 - 10 yr: 200 units
> 10 yr: 400 units
Consider tetanus:
If immunised within 5 years then no action required
If booster 5-10 years; give CDT/ADT
If > 10 years give CDT/ADT
If unimmunised/unknown then 3 dose vaccination
Take blood from the patient and store. (This blood will be tested only if follow up testing is
positive)
Arrange follow-up in Infectious Diseases outpatients in 6 weeks or earlier if counselling is
required.
 If source known and HIV, hepatitis B or C positive then contact Infectious Disease
Fellow/Consultant via switchboard.

Neonates

Neonates - Recognition Of Serious Illness

Neonates at particular risk of serious illness include:

Low birth weight babies (preterm or small for gestational age)

Those with a previously recognised medical problem eg. congenital anomaly
Babies from socially disadvantaged families.

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

Poor response to stimulation; a weak cry.

Activity

Decreased activity/movement and increased sleeping.

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.

Bile-staining indicates bowel obstruction (eg. malrotation with volvulus).

Cyanosis

Seizures

Severe jaundice

Risk of bilirubin encephalopathy, particularly if haemolytic.

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

If oedema recurs also restart penicillin and aspirin.

Nitrous Oxide - Oxygen Mix

See also: Ketamine Guideline

 Analgesia & Sedation Guideline

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

Head injury with LOC or altered conscious state

Chest injury or suspicion of pneumothorax
Current acute asthma episode

Procedure

Pre-procedure

Patient should be kept nil orally prior to the procedure

Either two doctors or a senior nurse & doctor are required - one giving the Nitrous Oxide and
the other performing the procedure.

Entonox (i.e. demand valve)

Check cylinder has a tight seal to the regulator pipe.

Can use either an appropriate sized mask or mouth piece.
Connect the mask / mouth piece to the filter and then attach filter to the demand valve.
Turn the cylinder to the open position and the regulator will record the amount of Nitrous
Oxide left in the tank (if less than 500 KPa then cylinder needs changing).

Continuous Flow Meter

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

Entonox (i.e. demand valve)

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.

Continuous Flow Meter

Turn black knob to allow black bag to inflate.

Start with 100% oxygen and have patient breathe regularly through mask; adjust amount of
flow to maintain the bag as being full but not over distended. Bag should empty with patients
breath.
Decrease concentration of oxygen with central knob without adjusting the black flow knob.
The flow of nitrous and oxygen will be automatically adjusted
Continue decreasing the oxygen (which increases the nitrous) until desired effect felt (ie
between 30-50% oxygen (ie 50-70% nitrous))
If using more than 50% nitrous then allow patient to breathe 100% oxygen for 2-3 minutes
after procedure has 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.

Periorbital & Orbital Cellulitis

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

i.v. cefotaxime 50 mg/kg/dose 6-hourly (maximum 2 g/dose)

and
i.v. flucloxacillin 50 mg/kg/dose 6-hourly (maximum 2 g/dose).

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.

Management - Periorbital Cellulitis

Investigation of these patients should include FBE, blood cultures.

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.

Haemophilus bacteraemia-induced periorbital cellulitis and Haemophilus meningitis occasionally

coexist. The decision as to whether a lumbar puncture should be performed should be a clinical one.

Recommended antibiotics

Mild Amoxycillin/Clavulanate
(400/57 mg per 5 mL)
0.3 mL/kg (11 mL) po 12H

Moderate Flucloxacillin 50 mg/kg (2 g) iv 6H

Severe, Flucloxacillin 50 mg/kg (2 g) iv 6H

or <5y & not Hib immunised and

Cefotaxime 50 mg/kg (2 g) iv 6H

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:

< 1 month: 10 mg/kg once daily for 4 days

> 1 month: 20 mg/kg once daily for 4 days
Adults: 600 mg once daily for 4 days
All children aged < 5 yr who have not been immunised against Hib should be vaccinated. If children
are < 2 yr and have had a documented Haemophilus infection they should be immunised.

Local allergic reactions

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 & Septic Arthritis

See also: The Acutely Swollen Joint

Hip Pain
Upper limb non-use

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

There is considerable overlap in the presentation of osteomyelitis and septic arthritis

Osteomyelitis Septic arthritis

Acute onset of limp / non-
Subacute onset of limp / non-weight
weight bearing / refusal to use
bearing / refusal to use limb
limb
Localised pain and pain on
Pain on movement and at rest
movement
Limited range / loss of
Tenderness
movement
Soft tissue redness / swelling may
Soft tissue redness / swelling
not be present & may appear late
often present
+/- Fever
Fever

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

Refer to Orthopaedics if osteomyelitis/septic arthritis suspected or confirmed

 Septic arthritis requires urgent aspiration +/- arthrotomy and washout* Flucloxacillin 50mg/kg
(max 2g) 6 hourly IV (for total 7 days)
Elevate and immobilise limb

Acute Otitis Media

Acute otitis media (AOM) is a common problem in early childhood É 2/3 of children have at least one
episode by age 3, and 90% have at least one episode by school entry. Peak age prevalence is 6-18
months.

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

Perforation of the TM results in purulent otorrhoea, and usually relief of pain.

Febrile convulsions are commonly related to AOM.
Suppurative complications such as mastoiditis, suppurative labyrinthitis or intracranial
infection (meningitis, extradural or subdural abscess, brain abscess) are very uncommon in
our population.
Other potential complications include facial nerve palsy, lateral sinus thrombosis, and benign
intracranial hypertension.

Serous otitis media ("glue ear")

Serous middle ear effusion commonly persists for several weeks or even months following an episode
of AOM. This may be recurrent, even in the absence of identifiable episodes of AOM, and often causes
conductive hearing loss. The long-term effects on language, literacy and cognitive development are
unclear. Parental smoking is an important avoidable risk factor. The use of dummies should be limited
to settling, as prolonged use has been shown to be associated with otitis media.

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.

The following flow-diagram provides a recommended management scheme:

Ear infections & otitis media

What is 'otitis media'?

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

Babies and toddlers may suffer intense ear pain.

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

If your child is in pain give them a pain-reliever such as Paracetamol or Painstop.

If you think your child may have an ear infection see your doctor. Many cases of middle ear
infection in children clear up on their own, without antibiotics, over a few days.
In some cases a short course of antibiotics may be prescribed, particularly if the child is very
young or very unwell.

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.

Key points to remember

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.

Signs and symptoms

Many children with glue ear do not have any symptoms.

Some children have problems hearing, they may want to have things repeated, talk loudly or
have the television up loud. Parents or teachers may notice this, especially in noisy situations
such as classrooms.
Your child may have some pressure or pain in the ear from time to time.
In smaller children, hearing difficulties may affect their speech development.
Some children seem to be more irritable and have problems sleeping when they have fluid in
the middle ear.
A few children with glue ear seem to have problems with balance.

Treatment

You should take your child to visit a paediatrician (children's doctor) or ear, nose and throat (ENT)
specialist if:

Your child is having frequent ear infections.

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.

Key points to remember about glue ear

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.

The Acutely Swollen Joint

Acutely swollen joints may reflect local pathology (eg. trauma, sepsis) or
generalised pathology localised to a joint(s) (eg. vasculitis, post-infective
arthritis). The differential diagnosis is wide and making a precise diagnosis in the
acute situation can be difficult. Often the diagnosis only becomes apparent with
time and initial treatment is on a presumptive basis. For a significant number of
patients this involves symptomatic measures only.

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.

Notes on investigations click to see

flow chart

FBE

Leukocytosis/left shift often found in sepsis and in many reactive arthritides

Usually normal in HSP and serum sickness
Often have thrombocytosis and mild anaemia in JCA
Cytopenias and absence of thrombocytosis in presence of elevated inflammatory markers
suspicious of malignancy

ESR/CRP

Usually elevated in sepsis

Usually normal in HSP
Often elevated in reactive/post infectious arthritis
 Elevated in JCA and often in leukaemia

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)

Consider outpatient referral to Rheumatology if:

Symptoms for >4 weeks

A significant joint effusion
Significant limitation of activity
Multiple joint involvement
Evidence of joint contractures
Vasculitis other than HSP

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.

Upper Limb Non-Use

Acute loss of upper limb movement usually reflects local pathology

Fracture
Pulled elbow
Joint pathology
Infective process
Neurological lesion

Do not forget to examine the clavicle

click to view full size

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

Patients Requiring Treatment (administration of charcoal)

acute ingestion of 150mg/kg or more

ingestion of unknown quantity
ingestion of 100mg/kg or more if known liver disease, anorexia, alcohol abuse, CF, or on
anticonvulsant or barbiturate therapy, or recent high intake of paracetamol.

Management (see flow diagram***)

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.

Nomogram For Paracetamol Poisoning

Check you are using the correct units micromols/Litre

A level of over 1300 at 4 hours requires treatment (1000 for high risk patients)
(for acute single dose ingestions only - multiple doses over time need an individualised
approach - seek advice)
N-Acetyl cysteine (NAC) infusion chart

Weight(Kg) Loading dose Infusion dose Infusion rate

NAC (mg) NAC (mg) in (mls per hour) for
In mls of N/2 saline 1 litre of N/2 saline 20 hours
+ 5% dextrose +5% Dextrose approx half
Give over 1 hour maintenance rate
6 900mg in 60 mls 5000 12
8 1200mg in 80 mls 5300 15
10 1500mg in 100 mls 5000 20
15 2250mg in 150 mls 6000 25
20 3000mg in 200mls 6600 30
25 3750mg in 250 mls 8300 30
30 4500mg in 300 mls 8500 35
35 5250mg in 350 mls 10000 35
40 6000mg in 400 mls 10000 40
45 6750mg in 450mls 11250 40
 50 7500mg in 500 mls 11100 45
55 8250mg in 500 mls 12200 45
60 9000mg in 500 mls 12000 50

Click here to view full size pdf file (21KB)

Whooping Cough (Pertussis)
Notes
Assessment
Diagnosis
Management
Treatment of contacts
Notification

Notes

Caused by the bacterium Bordetella pertussis.

Infants less than 6 months of age are at greatest risk of complications (eg. apnoea, severe
pneumonia, encephalopathy) and death.
Can occur in immunised children but illness is generally less severe.
Patients are infectious just prior to and for 21 days after the onset of cough, if untreated.
The cough may persist for months.

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

A nasopharyngeal aspirate for immunofluorescence and culture is the investigation of choice.

The organism is usually undetectable after 21 days, or if effective antibiotic therapy against B.
Pertussis has been commenced.
Serology rarely affects clinical management.

Diagnosis

Laboratory confirmation is not necessary for diagnosis.

Clinical diagnosis can be made on the basis of
an acute presentation with features as outlined above
a longer history of cough lasting 14 days without another apparent cause and any
one of: paroxysms; whoop; or post-tussive vomiting.

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.

Who should be treated?

In general antibiotics should be considered for

Any child admitted to hospital.
 Any child with a history of cough for less than 14 days (treatment in these cases will
reduce the period of school/day-care exclusion.)

The recommended antibiotic is

Clarithromycin 7.5 mg/kg twice daily for 7 days.

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

Contacts - Who should be treated?

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.

The recommended antibiotic is

Clarithromycin 7.5 mg/ kg twice daily for 7 days

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.

Link to DHS notifications (include form)

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

Antibiotic treatment of group A streptococcal pharyngitis

Antibiotic Dosage Duration Notes

Penicillin Children (< 10 10 days
(phenoxymethyl) years) 250mg
orally bd
Children (> 10 10 days
years) 500mg
 orally bd
Erythromycin 20 mg/kg (max 10 days
Use if child allergic to penicillin
250 mg) orally bd
Procaine penicillin 50 mg/kg (max 1 dose Use if child unable to tolerate oral
1.5 g) IM medications.Follow injection with course of
oral penicillin
Benzathine G 20 mg/kg (max 1 dose Use if child unable to tolerate oral
penicillin G 900 mg) IM medications
Pneumonia Guideline

In A Previously Well Child Aged More Than One Month

Consider pneumonia in infants and children with:

Fever and cough (or difficulty breathing);

tachypnoea, nasal flaring, lower chest indrawing or recession, consolidation or effusion:
persistent fever;
fever and upper abdominal pain;

Notes:

Chest X-ray (AP) should be performed to confirm or exclude pneumonia

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

Primary Spontaneous Pneumothorax

See also: Chest Drain Guideline

Needle Thoracocentesis Guideline
Background

Primary spontaneous pneumothorax (PSP) is a pneumothorax occuring in patients without underlying

chronic lung disease when there is no provoking factor, such as trauma, surgery, or diagnostic
intervention.

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

General appearance may be normal

Sweating, tachypnoea, tachycardia (most common finding)
Splinting chest wall to relieve pleuritic pain
Asymmetric lung expansion - mediastinal and tracheal shift to the contralateral side with a
large pneumothorax
Decreased or absent breath sounds
Hyperresonance on percussion

Imaging Studies

Chest radiograph (confirms pneumothorax)

A linear shadow of visceral pleura with lack of lung markings peripheral to the
shadow may be observed, indicating collapsed lung.
In supine patients, deep sulcus sign with radiolucency along costophrenic sulcus may
help to identify occult pneumothorax.
Mediastinal shift toward the contralateral lung may also be apparent.
Small pleural effusions are commonly present and increase in size if the
pneumothorax does not reexpand.
CT scan is not recommended for routine use.
Methods to estimate the fractional size of pneumothorax are controversial:
Any estimate of size should be performed in conjunction with a senior doctor in
the emergency department.
There are currently two methods described in adults:
If lateral edge of lung is > 2cms. from thoracic cage, then this implies
pneumothorax is at least 50%, and hence large in size.
or
Calculate the ratio of the transverse radius of the pneumothorax (cubed) to
the transverse radius of the hemithorax (cubed).
To express the pneumothorax size as a percentage, multiply the fractional
size by 100.
Management

See Algorithm
Notes

Small pneumothorax is equivalent to <30%

This protocol excludes:
Age < 12 years
Underlying lung disease
CF
Chronic neonatal lung disease
Asthma
Others
Trauma
Foreign body inhalation
All discharged patients should have appropriate follow-up - please discuss with ED consultant
or fellow.
Primary Spontaneous Pneumothorax

See also: Chest Drain Guideline

Needle Thoracocentesis Guideline

Background

Primary spontaneous pneumothorax (PSP) is a pneumothorax occuring in patients without underlying

chronic lung disease when there is no provoking factor, such as trauma, surgery, or diagnostic
intervention.

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

General appearance may be normal

Sweating, tachypnoea, tachycardia (most common finding)
Splinting chest wall to relieve pleuritic pain
Asymmetric lung expansion - mediastinal and tracheal shift to the contralateral side with a
large pneumothorax
Decreased or absent breath sounds
Hyperresonance on percussion

Imaging Studies

Chest radiograph (confirms pneumothorax)

A linear shadow of visceral pleura with lack of lung markings peripheral to the
shadow may be observed, indicating collapsed lung.
In supine patients, deep sulcus sign with radiolucency along costophrenic sulcus may
help to identify occult pneumothorax.
Mediastinal shift toward the contralateral lung may also be apparent.
Small pleural effusions are commonly present and increase in size if the
pneumothorax does not reexpand.
CT scan is not recommended for routine use.
Methods to estimate the fractional size of pneumothorax are controversial:
Any estimate of size should be performed in conjunction with a senior doctor in
the emergency department.
There are currently two methods described in adults:
If lateral edge of lung is > 2cms. from thoracic cage, then this implies
pneumothorax is at least 50%, and hence large in size.
or
 Calculate the ratio of the transverse radius of the pneumothorax (cubed) to
the transverse radius of the hemithorax (cubed).
To express the pneumothorax size as a percentage, multiply the fractional
size by 100.

Management

See Algorithm
Notes

Small pneumothorax is equivalent to <30%

This protocol excludes:
Age < 12 years
Underlying lung disease
CF
Chronic neonatal lung disease
Asthma
Others
Trauma
Foreign body inhalation
All discharged patients should have appropriate follow-up - please discuss with ED consultant
or fellow.

Acute Poisoning - Guidelines For Initial Management

See also the following Poisoning Guidelines:

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:

Type of ingestion (drug, preparation)

Time of incident
Amount of ingestion (include all medication that was potentially in the bottle or packet when
calculating)
Weight of child
Is the ingestion potentially harmful?
Beware of the possibility of mixed overdose
Beware of the possibility of inaccurate dose reporting on history taking
If mixed or undetermined ingestion Paracetamol level should be done.

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 acts of deliberate self harm must be taken extremely seriously.

All intentional self poisonings in adolescents require admission under the adolescent unit after
discussion with their on-call consultant.

If unexplained symptoms exist a urinary drug screen may be indicated..

Sedation - Procedural Sedation Guideline

1. Introduction
2. Goals of Sedation
3. Definition of Terms
4. Indications, risk assessment and exclusion criteria
5. General patient assessment
6. Fasting
7. Preparation of the child and parent
8. Consent
9. Staffing
10. Medications
11. Preparation of venue and equipment
12. ‘Time Out’ and ‘Positive Identification’
13. Observation and Monitoring
14. Documentation
15. Transport
16. End of sedation criteria
17. Discharge criteria
18. Links
19. Acknowledgements

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.

The goal of this guideline is to:

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

to minimise physical discomfort or pain for procedures

to control behaviour, particularly movement
to minimise psychological disturbance & distress
to maximise the potential for amnesia
to administer sedation in a safe manner

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).

Minimal sedation (‘anxiolysis’) — Sedation Score 1 (UMSS)

 A drug-induced state during which patients may respond normally to verbal commands
Cognitive function and coordination may be impaired
Respiratory and cardiovascular functions are minimally affected.

Moderately sedated ("conscious sedation") — Sedation Score 2 (UMSS)

A drug-induced state of depressed consciousness with preserved airway protective reflexes.

Patients may be somnolent/sleeping but easily aroused with light tactile stimulation or simple
verbal command.

NOTE: It is possible for patients to progress from a state of moderate sedation into
a state of deep sedation/obtundation.

Deep sedation — Sedation Score 3 (UMSS)

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.

IMPORTANT: If the aim of sedation is for 'deep sedation' it should only be

administered by senior staff in ED, ICU, NNU or Dept of Anaesthesia and Pain
Management. Deep sedation’s associated risks are indistinguishable from those of
general anaesthesia. Patients receiving deep sedation should also have an IV line in
place and remain in that speciality location for the full duration of the sedation period.
They should not be transported during the sedation period.

Competent staff member: a staff member who has the knowledge, skills and training
to:

observe the patient’s level of sedation

perform observations (vital signs)
maintain airway patency
know how to call for additional help when required and commence resuscitation if required
in the pharmacology of the sedative agents to be used, their adverse effect profiles, and the
use of appropriate antagonist agents.

Accredited staff member: a staff member who has:

attended the Royal Children’s Hospital Procedural Sedation lecture.

successfully completed the Royal Children’s Hospital Sedation package.
safely administrated nitrous oxide/IV midazolam on 3-5 occasions, as assessed by designated
nitrous oxide educator.
participates in annual re-accreditation.

4. Indications, risk assessment and exclusion criteria

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

Sicker patients should not be sedated without consulting Children’s Pain

Management Service (CPMS). The risk assessment will provide you with some
guidance. Any risk identified below, needs to be discussed with CPMS. If in doubt
also consult CPMS — pager 5773.

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

Significant cardiovascular impairment e.g. pulmonary hypertension, cardiomyopathy, hypovolemia

Abnormal conscious state/risk of raised ICP e.g. head injured, meningitis, space occupying lesion

Acute systemic infection e.g. sepsis

Prior adverse event

Prior allergic reaction

Patient receiving opioids or other sedative agents

Age less than or equal to 6 months (for oral agents)

Age less than or equal to 2 years (for nitrous oxide and IV midazolam)

(Refer to Record of Sedation for Procedure MR56S)

Exclusion criteria for nitrous oxide

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

(Refer to Record of Sedation for Procedure MR56S)

5. General Patient Assessment

The treating medical team who request the patient to have the procedure with sedation
will usually perform a patient assessment.

The following should be included in the 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

For ward patients and outpatients fasting times are:

Oral agents: 2 hours solids and liquids

IV midazolam and nitrous oxide: 6 hours solids, 4 hours breastfeed, 2 hours clear
fluids

7. Preparation of the child and parent

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:

the Registered nurse is competent/accredited for the prescribed sedation agent

a Registered Nurse is responsible for performing the procedure (i.e. it is not a medical
procedure)
Refer to RCH Consent - Informed Policy

9. Staffing

A minimum of two staff should be present for procedures for which a child is sedated.

One staff member is responsible for performing the procedure.

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.

For oral agents: 2 staff required, 1 competent RN or medical staff member

For nitrous oxide: 2 staff required, 1 accredited staff member

For IV midazolam: 2 staff required, 1 accredited staff member

10. Medications

Patients should not receive sedative drugs prior to arrival at hospital.

All sedative agents should be recorded on Medication Chart (MR52)
If appropriate, local anaesthetic cream (e.g. AnGel) may be used to help limit the amount of
sedation and analgesia required.
Adequate analgesia should also be provided.

11. Prepare venue and equipment

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:

Prepare procedure equipment before patient enters the room.

Ensure emergency equipment is present and functioning
suction device
appropriate size bag and mask
O2 available and means to deliver it
pulse oximetry
blood pressure monitoring (IV midazolam only)
resuscitation trolley
Ensure a distraction box is available with age appropriate toys/distraction agents.
12. ‘Time Out’ or ‘Positive Identification’

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:

The patient's identity checked via ID band or positive identification

The procedure to be performed and sedation agent to be given.
Mark procedure side if applicable.

For further information refer to the ‘Consent Checking Procedure’ and/or the ‘Patient Identification’
Policies.

13. Observations and Monitoring

Prior to the sedation

Document baseline vital signs on observation chart (MR 77 or MR52B) immediately

prior to commencing sedation.

During sedation period

Drugs administered by competent/accredited staff member.

For oral agents, the patient must remain in-line of sight to the nurse throughout the Sedation
Period. Document sedation score on observation chart every 5 minutes (MR77 or MR
52B).
If sedation score e 2, record 5 minutely observations: SpO2, HR, RR (and BP for IV
midazolam)

Sedation Score - University of Michigan Sedation Score (UMSS)

1 Awake and alert.

2 Minimally sedated: may appear tired/sleepy, responds to verbal

conversation and/or sound.

3 Moderately sedated: somnolent/sleeping, easily aroused with light tactile

stimulation or simple verbal command.

4 Deep sedation: deep sleep, rousable only with deep or significant physical
stimulation.

5 Unrousable.

14. Documentation

Complete ‘Record of Sedation for Procedures’ (MR56S)

Ensure a consent form is signed (also refer to Consent - Informed policy)
 Sedative drugs must be prescribed on the patient’s Hospital Medication Chart (MR52)
Monitor observations (as above) and record on the observation chart (MR77 or MR52B)

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.

16. End of Sedation Criteria

Line of sight nursing, observation and recording sedation score (+/- vital signs) can cease
once when the patient meets the following criteria:

Observations are within normal limits

Patient returns to baseline sedation score or mental status.

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.

17. Additional Criteria for Discharge

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:

Satisfactory travel arrangements and supervision for patient confirmed

Post sedation handout should be discussed with parents. Safety and injury prevention
highlighted.

Pulled Elbow
History:

Age: usually 1 to 4 years old

In 50%: no history of a "pull" on the arm

Examination:

not using the affected limb

elbow in extension and the forearm in pronation
distressed only on elbow movement
 no swelling, deformity or bruising of the elbow or wrist
on palpation tenderness is usually absent (remember the clavicle)
marked resistance and pain with supination of the forearm.

Manipulation during triage or xray may reduce the subluxation.

Differential Diagnosis:

See upper limb non-use guideline

Diagnosis

Clinically established with a classic history and examination.

Plain radiographs are indicated when a differential diagnosis is suspected:
significant tenderness, swelling, bruising or deformity
reduction fails

Treatment

Perform a reduction manoeuvre (see below)

expect distress and pain
a click may be felt over the radial head
review after ten minutes
if reduction fails, consult with senior medical staff

Reduction manoeuvres

Either of the following methods may be effective

pronation/ flexion manoeuvre

sit the child on the parent's lap

apply pressure over the radial

head
 fully pronate forearm and then
flex the elbow

supination/flexion manoeuvre

sit the child on the parent's lap

apply pressure over the radial

head
 supinate the forearm

flex the elbow

Urinary Tract Infection Guideline

Notes
Assessment
Treatment
 Investigation
Specimens
Dipstick Urine Test
Other Resources

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

co-trimoxazole (200/40 mg in 5 ml) 0.5 ml/kg (20ml max) BD or

Cephalexin 15mg/kg (500mg max) TDS.

For 1 week

Check antibiotic sensitivities and adjust therapy in 24 to 48 hours.

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

All children with first UTI

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:

Those less than 6 months of age (especially boys).

Those who are particularly sick (needs consent of medical consultant)

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.

Supra-pubic aspiration (SPA)

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

Always send for culture

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

Useful after failed attempt at SPA.

SPA remains the preferred method.
Always send for culture. Discard first few drops of urine.
Any growth >103CFU/litre indicates infection.

Midstream urine (MSU)

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.

Dipstick Urine Test

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

Blood and protein are unreliable markers of UTI

Not all organisms produce nitrites and nitrites take time to develop in urine and so have poor
sensitivity. They may appear in other infections.
Not all patients with UTI have pyuria. Leucocyte esterase can only be detected with relatively
high WBC counts in urine. So the test has low sensitivity.
Leucocytes from local sources (vagina, foreskin) may contaminate urine. Leucocytes appear
in the urine in many other febrile illnesses eg URTI, pneumonia, etc. So the specificity is low.
Overall combined sensitivity for both nitrites & leucocytes is around 50%. i.e.
Dipsticks may miss a significant proportion of infections. Always send the specimen
for culture if UTI is suspected.

Urinary tract infection (UTI)

A urinary tract infection is an infection in the urine. It may affect the bladder and
sometimes the kidneys. UTI is quite common, particularly in young children who are still
in nappies. It can also occur in older children. It is usually caused when germs from the
poo, which are on the skin, get into the urethra (the tube from which urine passes out of
the bladder). This can happen to any baby and is not due to poor washing or changing.

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.

Signs and symptoms

Pain on doing wee.

Frequently passing urine.
Passing urine before getting to the toilet (incontinence or wetting).
Pain in the lower part of the stomach.
Smelly urine.
Fever.
 In young children UTI may cause a fever or general unwellness without any of the above
symptoms.

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.

In some children, a Micturating Cysto-Urethrogram (MCU) is done. This test involves

putting a catheter into the bladder through the urethra. Dye is injected through the
catheter and X-Ray pictures are taken. Some children find it unpleasant and frightening
and may need sedation. The test is done mainly to look for a condition known as urinary
reflux (sometimes called VUR). Discuss the test with your doctor.

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.

For more information

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.

What ways can you get urine?

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.

Key points to remember

 Urine infections can be serious in babies and children.
A urine test is the only way to know for sure if your child has a urine infection.
If your child has a urine infection they may need other tests and treatment.

Suprapubic Aspirate (SPA)

Suprapubic aspirates are sometimes also called ‘bladder taps’ or ‘SPAs'. It involves getting urine
directly from the bladder to look for infection (germs).SPA’s are a very safe test and problems are rare.
They are usually done in younger children.

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.

What other ways can you get urine?

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.

Does an SPA always work?

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.

Does an SPA hurt?

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).

Are there any risks?

SPAs are a very safe test and problems are rare.

Sometimes you may see a little blood in the urine for a day or so.
The risk of any damage to the bowel from the needle is extremely small.
Care at home

There is no special care after the test.

Your baby can be bathed normally.

Key points to remember

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.

Radiology Guidelines in Emergency

Upper Airway
Chest Xray
Limb Xrays
Abdominal X Rays (AXR)
Intracranial And Skull Imaging
Spinal Xrays

Upper Airway

Acute Epiglotitis/Croup: the diagnosis is made clinically NOT radiologically.

Inhaled Foreign Body: If not obstructed, likely that FB has passed into intrathoracic airways.
RARELY, if sharp and may have perforated, imaging may be indicated.
Retropharyngeal Abscess: look for widened prevertebral shadow (normal prevertebral width
equal to vertebral body width at C4 level).

Chest Xray

Respiratory Indications:

Suspected Lower Respiratory Tract Infection.

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

Clinical cardiomegaly or heart failure.

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.

Abdominal X Rays (AXR)

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.

Intracranial And Skull Imaging

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:

compromising the provision of urgent medical treatment (physical or psychiatric);

placing the patient at risk of self-harm; or
placing staff at risk.

Alternative means of calming a patient

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)

Contra-indications to physical restraint and emergency sedation

Safe containment possible via alternative means

Inadequate personnel/setting/equipment
Situation judged as too dangerous eg. patient has a weapon.
Known adverse reaction to drugs usually used (eg neuroleptic malignant syndrome)

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

1. Establish roles, including defining person in charge (usually attending doctor).

2. Assemble team. Person in charge to assemble team of 7 people.
Staff generally to be drawn from: ED (eg 2 doctors, 2 nurses), 3E (1 nurse, adolescent unit
registrar), PSAs (1-2), and security (1-2).
3. Draw up drugs.
Drugs of preference are midazolam 5 mg, and haloperidol 5mg (draw up together).
Ensure benztropine available.
 4. Secure the patient quickly and calmly.
At least 5 people are required - one for the head, and one for each limb. Roles must be
assigned before approaching the patient.
5. The patient should be prone, with hands and feet held flexed behind back.
6. Administer midazolam 5 mg (onset rapid) and haloperidol 5mg (onset 15-20 minutes) by
intramuscular injection into lateral thigh.
Beware the risk of needle-stick injury. Further titrated doses of 0.1 mg/kg may be required
(preferably iv).
7. Sedated patients must have continuous O2 saturation monitoring.
They must have a nurse present continuously, with close observation of conscious state,
respiration, HR, BP, and temperature.

Complications of emergency sedation include:

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

Explain the procedure to the parents/carers if possible.

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

Document fully in the patient's unit record:

the indication for chemical + physical restraint.

patient's response to sedation
on-going observations
Incident report - extremely helpful in auditing these events

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

Click to see full size algorithm

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.

Call for help

Dial 777 for MET call

Stimulate and assess response

Airway opening manoeuvers

Check breathing
 Bag valve mask ventilation

Assess for pulse and signs of circulation

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

Signs of respiratory inadequacy

If respiration is adequate, administer oxygen by facemask at 10 l/min.

Do not use self-inflating bags in spontaneously ventilating patients.They are designed to deliver O2
only if squeezed.

If the child is not breathing, commence artificial ventilation.

Artificial Ventilation

Select the appropriate sized resuscitator bag

Infant up to 2 years - 500 ml bag
Child/adult > 2 years - 2 litre bag
Select an appropriate sized mask.
Obtain an airtight seal
O2 flow rate of 10-15 l/min and attachment of a reservoir assembly will give nearly 100% O2.
An oropharyngeal airway will facilitate maintenance of the airway and bag and mask
ventilation.
Brief suction of the mouth and pharynx if needed, using a yankeur sucker under direct vision
Ventilate to have normal chest rise and fall. Do not over ventilate
Intubation should only be attempted by those credentialed and skilled to do so

Endotracheal Intubation

Select the correct tube size:

Age Weight (kg) Tube size (mm) Length at lip (cm)

Newborn 3.5 3.0 8.5
2 months 5 3.5 9
6 months 8 4.0 10
1 year 10 4.0 11

Older than 1 year: Tube size (mm) = (age in yr/4) + 4

Length at lip (cm) = (age in yr/2) + 12

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

Signs of circulatory inadequacy

External cardiac compression

DO NOT interrupt except for defibrillation.

Place the child on a firm surface. If on a bed, place the cardiac massage board under the
patient, not under the mattress
Apply massage to the lower half of the sternum in all patients including newborns
Compress sternum 1/3 the depth of the chest.
Use the hand technique that allows you to achieve this - see examples pictures:
With large children use the "heel" of one hand with the other superimposed.
For small children use the heel of one hand
For infants use two fingers.
For newborn infants the best technique is a two-handed hold in which both thumbs
compress the sternum.
Gain IV or IO access as soon as possible - at least the second dose of adrenaline should be
given via this route
Frequent changes of personnel (every few minutes) is desirable
During resuscitation do not stop to check for a pulse unless the ECG shows an organised
rhythm.
After DC shock continue CPR for 2 minutes prior to checking rhythm.

Resuscitation algorithm
Click to see full size algorithm

During resuscitation

Correct treatable causes

Hypoxaemia
Hypovolaemia
Hypo/hyperthermia
Hypo/hyperkalaemia
Tamponade
Tension pneumothorax
Toxins/poisons/drugs
Thrombosis

Other drugs to consider

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

Blood gas analysis

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.

Post resuscitation care

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

Examples: Aspirin and aspirin containing drug compounds

Oil of Wintergreen
Dencorub

Assessment

Symptoms Tinnitus, vomiting, hyperventilation, lethargy, coma, seizures,

hyperthermia, dehydration, hypoglycaemia, non cardiogenic
pulmonary oedema
Initial respiratory alkalosis (may be transient), followed by
paradoxical aciduria (pH <6), then metabolic acidosis
& hypokalaemia (± ongoing respiratory alkalosis).

Patients Requiring Treatment

Acute ingestion 150mg/kg

All symptomatic patients
Ingestion of unknown quantity

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

Emergency Drug & Fluid Calculator

Ward Management of Early 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

Does this child have early septic shock?

Features of circulatory and respiratory insufficiency are

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

sickle cell anaemia (SS disease) is the most common

sickle ß Thalassemia
sickle haemoglobin C disease

Acute crises may occur spontaneously or precipitated by

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.

Fever & sickle cell disease

Background

Patients are functionally asplenic and thus at greater risk for invasive disease particularly by
encapsulated organisms (e.g. pneumococcus).

Assessment

If pain is also present, then treat as Vaso-occlusive disease first

Cough, dyspnoea looking for signs of acute chest syndrome
Look for other sites of infection (e.g. osteomyelitis)
Check Immunisation status, penicillin prophylaxis, use of hydroxyurea
 Assess:
Degree of pallor
Evidence of systemic or local infection
Evidence of shock (poor capillary refill, tachycardia, hypotension etc)
Spleen size (compared to baseline)

Management

1. Give high flow oxygen

2. Obtain FBE (including reticulocyte count)
3. Obtain blood culture. Urine culture and culture other sites, as indicated.
4. Obtain chest X-ray if respiratory signs or symptoms, or high fever with no focus of infection
5. Consider parenteral antibiotic(s) (flucloxacillin 50mg/kg 6 hourly + gentamicin 7.5mg/kg
(6mg/kg if >10yrs) daily; do not delay for FBE or urine culture results
6. Consult on-call Haematology Consultant
7. All children with fever > 38.5 degrees should be admitted

Painful Vaso-Occlusive Crisis

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

Start analgesics promptly to provide effective relief of pain.

Mild pain

Paracetamol (20mg/kg) + codeine (1mg/kg)

Push oral fluids
If not settling then add ibuprofen 10mg/kg
If still not settling then move to severe pain

Moderate to severe pain

Give high flow oxygen.

 Take blood for FBE, Reticulocyte count, cross match and bilirubin.
Give bolus of 10-20mls/kg of 0.9% (Normal) Saline followed by maintenance rate (including
oral intake) of 5% Dextrose & 0.45% (1/2 Normal) Saline. Patients with cardiomyopathy will
require less fluid.
Recommended analgesics:
Morphine 0.05 mg/kg/dose IV. Repeat as necessary (see analgesia and sedation
guideline)
Some patients may require higher individual doses, based on prior history or may
benefit from continuous infusion via PCA (Patient Controlled Analgesia).
May need blood transfusion using WBC filtered blood
Discuss with Haematologist on call

Acute Chest Syndrome

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.

NB This is a life threatening illness and patients may deteriorate quickly

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

1. Give high flow oxygen

2. Maintain and treat airway, breathing and circulation problems first
3. Maintain hydration with IV + oral intake at maintenance rate
4. Treat pain aggressively by giving adequate analgesia to control pain (see VOC guideline)
5. Obtain chest xray
6. All patients with chest pain should be admitted, irrespective of CXR findings
7. Cross match for possible exchange or simple transfusion
8. Consider broad-spectrum antibiotics (see fever and sickle cell guideline)
9. Consult Haematology urgently and prior to transfusion or admission

Acute Splenic Sequestration

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)

Aplastic Crisis & Sickle Cell 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

1. Give high flow oxygen

2. Maintain and treat airway, breathing and circulation problems first
3. IV + oral fluids at maintenance rates – do not add potassium to i.v. fluid
 4. Transfuse patient if symptomatic anaemia or Hb < 50gm/l (usually 5ml/kg over 4 hrs). The
blood product used should be WBC filtered and, if the patient is on hydroxyurea should be
irradiated also. Close observation for fluid overload. Transfusion may need to be repeated.
5. Treat fever and pain as required (see fever and VOC guidelines)
6. Discuss with on-call Haematologist

Stroke & Sickle Cell Disease

Background

Acute neurological events occur in about 10% of patients with Hb SS.

These can present as

hemiparesis
monoparesis
aphasia or dysphasia
seizures
cranial nerve palsies
coma

Can occur suddenly or as a complication of acute chest syndrome or aplastic crisis

NB. Consider other causes as well (see coma and seizure guidelines)

Assessment

Document the neurological examination, noting previous deficits

Assess

temperature (see fever & sickle cell guideline)

Glucose level
Level of consciousness (AVPU or GCS)

Management

1. Give high flow oxygen

2. Maintain and treat airway, breathing and circulation problems first
3. Investigations:
o FBE
o Cross match
4. Arrange for partial exchange transfusion but remember not to over transfuse (e.g. Hb <
100gm/l)
5. Obtain CT without contrast. CT scan is to exclude intracranial haemorrhage
6. Notify on-call Haematologist urgently.
7. May need admission to ICU for immediate exchange transfusion

Priapism & Sickle Cell Disease

Background

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

Length of current episode

Associated symptoms – fever, dysuria, dehydration or pain at other locations.
History of prior episodes and the previous treatments and effectiveness
Symptoms of obstructive sleep apnoea.

Investigations (should not wait for results before treating patient)

Check FBE and reticulocyte count

Cross match
Cultures and CXR as required

Management

1. Administer intravenous fluids at maintenance rate.

2. Give analgesia – Morphine 0.05mg/kg IV titrated to effect
3. Encourage emptying of the bladder; catheterize, if unable to empty bladder.
4. Do not use ice or ice packs
5. Consult General Surgery (Urology) and Haematology if priapism has lasted more than 3-4 hrs
(may require aspiration and drainage)
6. If no response to treatment, arrange for partial exchange transfusion.
7. Admit under Haematology Unit

Notes

Simple measures should be tried first at home, particularly if less than 3-4 hrs since onset:

Push oral fluids

Analgesia
Urination
Moderate exercise
Take a bath or shower

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.

Diseases in children associated with parent smoking include:

Croup, bronchiolitis and pneumonia in infants

 Wheezing illnesses and asthma
Otitis media, tonsillitis and the need for surgery for both
Anaesthetic complications
Serious bacterial infections such as meningococcal disease
Possibly vascular phenomena such as Perthes Disease

How do smokers quit?

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

1. Ask ALL parents about smoking

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

Infants - pallor, dyspnoea, poor feeding.

Older children - palpitations , chest discomfort

Signs

Regular tachycardia - HR usually 180-300/min

Hypotension may be present.
Heart failure, especially infants.

Investigations

12 lead ECG showing regular narrow complex tachycardia.

Consult cardiology urgently if tachycardia is broad complex or irregular.

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

Shocked Child - Direct Current Cardioversion

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

Stable Child – Vagal Manoeuvers And Adenosine

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

Should be administered only by experienced staff. Alert ICU before use.

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.

Adenosine is contra-indicated in adenosine-deaminase deficiency (rare immune deficiency) and

patients taking dypyridamole (Persantin). Care is required in asthma, as it may cause brochospasm.

If these measures fail to revert the SVT consult Cardiology.

Disposition

A follow up plan should be made in consultation with cardiology.

Syncope

Definition

Brief, usually sudden loss of consciousness and muscle tone caused by cerebral ischaemia or
inadequate oxygen or glucose to the brain.Features

lasts only a few seconds

child limp and unresponsive
tonic-clonic movements can occur with prolonged unconsciousness
patient back to normal on awakening

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.

It is important to diagnose long QT syndrome because the risk of death can be

substantially reduced by simple treatment. Even if the child has died, the diagnosis can
often be made by genetic studies on autopsy specimens, and investigation of relatives.
The condition is usually autosomal dominant.

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

Common causes are vasovagal and orthostatic hypotension.

History of the surrounding events is important.
Orthostatic hypotension usually occurs on standing suddenly.
Vasovagal associated with environmental or emotional stresses.
Structural cardiac lesion more likely if syncope is exertional.
Examine patient for cardiac anomaly (e.g. murmur, heaves etc)
Investigations should include an ECG - look for dysrrythmias;
short/abnormal PR interval (eg Wolff-Parkinson-White syndrome); and
prolonged QT syndrome.
If there is any reason to suspect long QT syndrome, then discuss with Click to view
Cardiologist on call.
Click here for help with ECG interpretation
If unconsciousness lasts more than a few seconds and patient not fully awake immediately
after the event then consider seizures as a cause (see table).
Patient may need an EEG to clarify this issue.Hysterical syncope generally occurs in front of
an audience, patients do not hurt themselves and there is associated moaning or non
rhythmical jerking.

Follow up

All patients who have unexplained syncope should be reviewed in outpatients.

Differentiating syncope from Seizures

Syncope Seizures Hypoglycaemia

Period of Usually seconds Frequently Usually over a
Unconsciousness 5mins or longer few mins
Incontinence Absent May be present Absent
Confusion on Absent Marked for 20- Usually, slow to
waking 30 mins improve
Tonic-Clonic Occasionally & brief Frequently Frequently
movements particularly if present absent
unconsciousness is
prolonged
EEG Normal Frequently Normal
abnormal if
done soon
 after event
Management of tetanus-prone wounds
The new Immunisation Schedule recommends that 10-yearly tetanus boosters are no longer required
up until the age of 50, provided that the primary series of 3 vaccinations plus 2 boosters have been
given.

The recommendations for the management of tetanus-prone wounds remain the same.

Types of wounds likely to favour the growth of tetanus organisms include:

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.

Wounds must be cleaned, disinfected and treated surgically if appropriate.

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

A combination vaccine should be used in order to boost community protection against

pertussis:
Please note that CDT and Tetanus Toxoid vaccine are no longer available.

< 8 years old DTPa-IPV (Infanrix-IPV®)

> 8 years old dTpa (Boostrix®)

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

Patients Requiring Treatment

Acute ingestion of 10mg/kg

Any ingestion while on maintenance theophylline
Ingestion of unknown quantity
All symptomatic patients

Investigations

Theophylline levels should be determined on all patients requiring charcoal

Serial levels are required at 2 hours then every 2 hours until peak reached or decline
demonstrated.
If slow release preparation has been taken:
admit, continue levels at 4 hourly intervals after decline or plateau to ensure detection of
secondary peak
Seizures are common at levels >330 micromol/L
Haemoperfusion commonly needed at levels > 550 micromol/L.
U&E, Cr and Glucose on all patients.

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.

Major paediatric trauma - The primary survey

Emergency Drug & Fluid Calculator

See also the secondary survey

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.

Airway and the Cervical Spine

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

Apply oxygen 10 l/min by face mask.

Assess the child’s breathing by observing:
a. the work of breathing (recession, respiratory rate, accessory muscle use)
b. the effectiveness of breathing (oxygen saturation, chest expansion, breath sounds)
c. the effects of inadequate respiration (heart rate, mental state)
If breathing is inadequate, exclude a tension pneumothorax, use positive pressure ventilation
with bag/valve/mask and consider intubation.
Insert a large oro-gastric tube to treat and prevent gastric dilatation.

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

Disability (Mental State)

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

Normal Physiological Values:

Age Resp. rate Heart rate Systolic blood

(breaths per (beats per pressure
minute) minute) (mm Hg)

<1 year 30 – 40 110 - 160 70 – 90

2-5 years 25 – 30 95 - 140 80 – 100

5-12
20 – 25 80 - 120 90 – 110
years

>12 years 15 – 20 60 - 100 100 – 120

Temperature

Minimize hypothermia by limiting exposure of the body during examination, and by warming
all ongoing fluids.
Radiology

Arrange for cervical spine, chest and pelvic X-rays.

If there is NO clinical suspicion of a pelvic injury AND the child has a normal conscious state
the pelvic X-ray may be omitted.
Arrange additional radiology as indicated

Secondary Survey

Click here to read details of the secondary survey

Analgesia

RCH Travel Clinic

The RCH Travel Clinic is now in full-swing!
The Infectious Diseases Unit of the Department of General Medicine runs this weekly clinic.

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.

A medical referral is required and all patients are bulk-billed.

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

Symptomatic patients require urgent medical assessment

Management

Charcoal 1g/kg unless altered conscious state (protect airway first)

Require ECG, cardiac monitoring
Asymptomatic: observe for 6 hours post ingestion and discharge if have a normal ECG just
prior to discharge
All symptomatic patients should be admitted
If widened QRS on ECG commence Sodium Bicarbonate infusion 1mmol/kg/hr, after initial
slow bolus of 2mmol/kg
If altered conscious state, widened QRS or arrhythmia contact I.C.U. (5212) & protect airway

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 ).

Acute Urticaria (<6 weeks) Chronic Urticaria (/>6 weeks)

Assessment

Explore events a few hours or days before onset of rash.

A specific cause is not identified in most of the cases (Idiopathic)

Other causes are

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:

Erythematous raised skin lesion (Wheal)

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

Anaphylaxis is a medical emergency — sudden onset of urticaria, angioedema, dyspnoea or

hypotension . Treat immediately

If recurrent angioedema without wheals, think of C1 esterase inhibitor deficiency.

Blotchy rash typical of urticaria

Urticarial lesions with typical clear skin in centre. These are not "target lesions"

Differential Diagnosis of Urticaria

Erythema multiforme

How to distinguish? EM is:

Usually not itchy

Does not move around - individual lesions perist for days
Has target lesions with a central papuler, blister, purpura or ulcer.
Often has mucosal involvement

Rare differentials

Mastocytosis
Flushing
Juvenile Rheumatoid Arthritis
Vasculitis — Henoch Schonlein purpura
Pityriasis rosea (early lesions)

Investigations

Investigations are usually not indicated for acute urticaria

Initial investigations of chronic urticaria include FBE, Differential, ESR and ANA.

Management

Remove identifiable cause if any

Cool Compresses
Explanation, information and reassurance
Manipulation of diet is not indicated.
Anti-histamines to alleviate itching
Promethazine (Phenergan)
0.2-0.5mg/kg/dose (adult 10-25mg) 6-8H IV, IM or oral.
Contraindicated for children less than 2 years old
or
Cetirizine (Zyrtec) 0.2mg/kg/dose (adult 10mg) 12-24H oral.
Contraindicated for children less than 1 year old
Steroid creams do not work. For severe cases, a single dose of oral prednisolone may be
considered
Indications for Specialist Referral:

associated bruising or systemic features (need to exclude urticarial vasculitis or chronic

urticaria as a manifestation of another disease process)
Severe life-threatening allergy e.g. peanut or latex allergy
Poor response to antihistamines
Angioedema involving the airways
Chronic urticaria (>6 weeks)

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.

Signs and symptoms

Symptoms of hives include:

Raised round wheals that look like mosquito bites.

The wheals are red on the outside and white in the middle.
They are normally very itchy.
A single wheal often lasts around 24 hours.
The wheals appear in batches or clusters.
One batch fades away as a new batch appears.
The rash may last for days or weeks.

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.

Symptoms of anaphylactic shock include:

Swelling of the tongue and throat.

Breathing difficulties.
Choking.
 Collapse.

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.

The following can cause histamine release and hives:

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.

Treatment for severe or frequent hives may include:

Checking that the rash isn't caused by an underlying disorder.

Avoiding known triggers in your child.
Medications, such as antihistamines and corticosteroids, to reduce the immune system
response to the triggers.
Avoiding things that make the rash worse - such as sunshine, heat and hot showers.
Applying cool compresses (a face washer/ cloth nappy/ clean tea towel soaked in cool water)
may also help relieve the itching and stinging.
Antihistamines are often prescribed for your child to provide relief from itching. These can be
very useful if taken at bedtime.

Key points to remember

Hives is a skin rash characterised by reddened and raised round wheals.

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.

Von Willebrand Disease (vWD)

See also: Haemophilia

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.

There are three main phenotypes of vWD.

vWF problem Typical bleeding picture

Type 1 Reduced levels of vWF Typically associated with mild
(common) bleeding
Type 2 Abnormal structure and Variable bleeding pattern
(uncommon) function of vWF, several
variants
Type 3 (rare) Near absence of vWF Patients may behave like those
with moderate to severe
haemophilia

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 site and extent of bleeding.

Assess type and severity of vWD, if known. Refer to RCH Emergency Department alert system for
individual treatment plan.

Management

Antifibrinolytics (Tranexamic Acid)

 Often helpful for mucosal bleeding (most common form of bleeding) - mouth, epistaxis,
menorrhagia.
May be given alone or as adjunct therapy to DDAVP/factor concentrate.
Dose of tranexamic acid (500mg tabs) 25mg/kg/dose (max:1.5g/dose) tds orally for 5-7 days

Weight (kg) Tranexamic acid

< 20 250 mg tds
20 – 30 500 mg tds
30 – 40 750 mg tds
> 40 1 g tds

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).

Von Willebrand Factor/FVIII Plasma Concentrate (Biostate )

A human plasma-derived product, available from blood bank

May be required in Type 1 vWD if severe bleeding or unresponsive to DDAVP
Used to treat bleeding in patients with Type 2 and Type 3 vWD.
Each reconstituted vial of BiostateTM contains 50 IU/ml FVIII and 100 IU/ml von Willebrand
factor
Note that recombinant FVIII products do not contain von Willebrand factor

Recommended dosage (note dosage according to Factor VIII units):

Type of bleeding Dose of Biostate

Oral mucosa/epistaxis/menorrhagia 25 FVIII units/kg
GI/GU bleed 40 FVIII units/kg
Joint/Muscle 40 FVIII units/kg
CNS bleed 60 FVIII units/kg
Trauma or surgery 60 FVIII units/kg
Weight Management
1. Introduction
2. Definition of terms
 3. Background
4. Assessment
5. Addressing the Issue of Obesity
6. Management
7. Follow up Review/Referral
8. Resources

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.

Overweight: Overweight is defined as a BMI greater than the 85th percentile.

Obesity: Obesity is defined as a BMI greater than the 95th percentile.

3. Background

56% of Australian adults are overweight; 18% are obese

18% Australian children are overweight; 5% are obese
From 1985-95 the prevalence of overweight in children doubled and obesity tripled
Consequences of childhood overweight

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

Aetiology of childhood overweight

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.

Risk factors include:

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.

Environment Physical inactivity, increase in sedentary behaviour (espescially screen

based activities), increased consumption of high fat foods and sugar sweetened drinks,
children’s food advertising.

Other risk factors for obesity: early infant feeding, parental obesity, parental
encouragement of children to eat, lower socioeconomic status.

Underlying medical conditions: (v rare) secondary obesity may occur due to

hypothyroidism, hypercortisolism, growth hormone deficiency and hypothalamic damage

Drugs: steroids, antipsychotic drugs (risperidone) and some antiepileptic medications.

4. Assessment

The Body Mass Index (BMI) is recommended as a practical measure of overweight and
obesity in children

Rapid changes in BMI can occur in normal growth

BMI varies with age and sex
BMI rises in the first year of life, then falls during the preschool year, before rising again into
adolescence (adiposity rebound)

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. (Age: 2 - 20)

GIRLS (download) BMI> 85th percentile suggests overweight

BOYS (download) BMI >95th percentile suggests obesity

BMI for Age percentile charts recommended for use in Australia are developed by the CDC in the US

5. Addressing the Issue of Obesity

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

1. Do no harm! approach with respect but address the issue!

2. Assess child and parent’s perceptions of the issue - do they even see it as a concern? - do
they have differing awareness/concerns?
3. Highlight the issue of weight in the context of health show the growth chart to the family and
explain what the healthiest weight for their child would be; explain they are still growing in
height, so probably do not need to actually lose weight they need to grow into their weight
4. Ask what they think they could do and possibly suggest some behaviour change ideas ( see
below)
5. Organise follow up - the options are local GP, paediatrician or RCH Weight management
Clinic.

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’

Some behaviour change ideas you can discuss with families

Physical activity any increas in activity is an improvement!

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!

Nutrition and don’t forget drinks!

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

Parent Fact Sheet (Children’s Hospital, Westmead)

6. Management

Management of obesity is complex and ongoing.

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

Wound dressings - acute traumatic wounds

See also: Lacerations guideline

Burns guideline

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.

Objectives of wound dressing

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

Elicit a careful history of injury i.e.:

mechanism of injury; associated blood loss; risk of contamination; deeper structure damage;
tetanus status;
consider Non accidental Iinjury;
underlying chronic illness or disability.

Fully examine the injured part in particular checking for

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

Request special investigations where appropriate

xray for radiopaque foreign body or underlying fracture

ultrasound is useful for puncture wounds with a radiolucent foreign body such as thorn or
splinter.

Consider referral for plastic or general surgical opinion either in ED or as outpatient

Management

Anaesthesia - see Analgesia and sedation guideline

Cleansing - see Laceration guideline
Wound closure - see Laceration guideline
Dressing: in general keep dressings as simple as possible

Dressing Choices

Dressing types Examples Advantages Disadvantages Indications Co

Semi-permeable – thin, OpSite, Some moisture Exudate may Superficial Hig
adhesive, transparent Tegaderm evaporation, pool, may be wounds.As a wo
polyurethrane film Reduces pain. traumatic to secondary
Barrier to external remove. dressing.
contamination.
Allows inspection.
Non adherent Moist Jelonet, Reduces Does not absorb Burns.Wounds All
(Tulle Gras Dressing) – Unitulle adhesion to exudate.Requires healing by
Gauze impregnated Bactigras, wound.Moist secondary secondary
with paraffin or similar. Sofra- environment aids dressing May intention
May be impregnated Tulle healing. induce allergy or
with antiseptics or delay healing
antibiotics when
impregnated
Non adherent Dry Thin Melolin, Low wound Not suitable in Wounds with Dr
perforated plastic film Melolite, adherence.May high exudate Can moderate ca
coating attached to Tricose absorb light dry out and stick exudate de
absorbent pad exudate. to wound. May
require
secondary
dressing
Fixation SheetPorous Fixomull, Can be used Dressing needs Wounds with Inf
polyester fabric with Hypafix, directly on wound washing with mild exudate, all
adhesive backing Mefix site. Conforms to soap and water not needing ad
body contours, pat-dried twice frequent review
good pain relief daily.Requires
and controls application of oil
oedema, Remains prior to removal –
permeable ideally soaked in
allowing exudate oil and wrapped
to escape and be in cling film
washed and dried overnight.
off
wound.Dressing
changes can be
left for 5-7 days.
Calcium Kaltostat Forms gel on May require Moderately or Dr
AlginateNatural wound and hence secondary highly exudative ha
polysaccharide from moist dressing.Not wounds.Need
seaweed environment. recommended in for haemostasis
Reduces pain. anaerobic
Can pack infections.Gel
cavities.Absorbent can be confused
in exudative with slough or
 wounds.Promotes pus in wound.
haemostasis. Low
allergenic.
Foam PolyMem Moist, highly Set size of foam Wounds with Dr
DressingsPolyurethane absorbent and may be limited by mild to moderate wo
foam dressing with protective wound size exudate. tha
adhesive layer rev
incorporated
Hydrocolloid Duoderm Retains moisture, Avoid on high Burns Dr
DressingsPolyurethane painless removal. exudate wounds (small)Abrasions wo
film coated with
adhesive mass
Paper adhesive Micropore Non allergenic. Non absorbent Small wounds Ex
tapesAdhesive tape Provides wound wo
may be applied directly support
to healing laceration

Decision TreeTypes of wounds and dressing options

Wound Type Dressing options Review times

Dry necrotic wound Moisture retention eg 3-4 days
hydrocolloid, semi permeable
Slough – covered wounds Moisture retention and fluid 3-4 days
absorption eg hydrocolloid,
alginate
Infected wound Avoid semi occlusive 1-2 days
dressings. Consider alginate
or hydrocolloid if high
exudate
Graze, abrasions – clean Film, tulle, fixation sheet or 2 days
dry
Graze, abrasions – soiled Dry or tulle 2 days
Puncture wounds or bites Open or dry 2 days
Laceration - Open or dry, consider paper 3-7days see
suturedLacerations tape support after suture
removal
Burn-minor Burns Film, medicated tulle, fixation 4-5 days visual
 sheet review leave
dressing on if
healing see
Burn-major or requiring Plastic wrap prior to surgical Inpatient review
admission eg special review, medicated tulle
areasBurns
Chronic wounds eg ulcers, Hydrocolloid, alginate, foam 5 days
PEG sites etc