I would attend to the child immediately ensuring that the most experienced paedatric anaesthetist was also in attendance.
I would assess the child as per APLS principles starting with the airway, listening for stertor and stridor and characterising this as inspiratory, expiratory or biphasic.
At the same time, I would be asessing the effort of breathing looking at the respiratory rate, use of accessory muscles and for subcostal and sternal recession or evidence that the child is beggining to tire. Throughout, I would ensure that I avoided distressing the child.
If there was evidence of impending airway compromise, I would at this point agree a shared airway plan with the anaestehtist to secure the airway as per DAS guidelines. If I had time, I would transfer the child to theatre. Airway plan would involve attempted oro-tracheal intubation a maximum of 4 attempts followed by railroading an endotracheal tube over a rigid hopkins rod and then surgical tracheostomy.
If/once the child was stable, then I would proceed to a focused history and examination. I would want to ask about:
- Onset, duration and progression of the symptoms as well as exacerbating and relieving factors.
- History of coryzal symptoms, fever, cough, foreign body or trauma.
- Problems with feeding or abnormal cry.
- Past medical and peri-natal history including history of intubation and review the 'red book' looking at immunisations, screening and grow charts.
- I would also want to know about the drug and family history as well as social situation.
I would then proceed to examination starting with a general inspection and looking for any syndromic features. I would perform a complete ear nose, throat and neck examination and if tolerated, flexible nasoendoscopy. This would allow me to make either a confident or a working diagnosis.
Further investigations may involve a (lateral and AP) soft tissue neck and chest radiograph or a CT scan of the neck and chest.
I would attend to the child immediately in conjunction with my paediatric colleagues.
I would begin with assessment as per APLS principles for the management of a septic child. I would start by listening to the airway, asessing the effort of breathing and ensuring that the child is haemodynamically stable and adequately resucitated.
If the child was in shock I would give high-flow oxygen, gain intravenous or intraosseous access and take blood for blood gas and laboratory tests including full blood count (FBC), urea and electrolytes (U&Es), renal and liver function, C-reactive protein (CRP), blood culture, cross-match and coagulation studies.
I would begin resucitation with 20 mL/kg rapid bolus of Hartmann's/crystalloid, reassessing the child after each fluid bolus until there is improvement and start broad-spectrum intravenous antibiotics in the form of co-amoxiclav 30mg/kg (or ceftriaxone 50 mg/kg).
If/once the child was stable, I would proceed to a focused history and examination. I would ask about:
- Onset, duration and progression of the symptoms as well as exacerbating and relieving factors.
- Associated otological symptoms of tinnitus, vertigo, otalgia and otorrhea.
- History of coryzal symptoms, fever, headache, photophobia, confusion and rash.
- Past medical and peri-natal history including history of ear problems and surgery and review the 'red book' looking at immunisation status, screening and grow charts.
- I would also want to know about the drug and family history as well as social situation and when the child last ate and drank.
I would then proceed to examination starting with a general inspection looking for any syndromic features. I would examine both ears looking for post-auricular erythema and swelling and otoscopic evidence of acute otitis media or perforation with discharge which I would swab. I would make a gross neurological assessment including the facial nerve. I would also look for signs of meningism including a rash.
Initial management of a patient with acute mastoiditis would involve analgesia, intravenous fluid resuscitation and antibiotics in the form of co-amoxiclav (30mg/kg) and considering a CT scan.
I would attend to the child immediately in conjunction with my paediatric and opthalmology colleagues.
I would begin with assessment as per APLS principles for the management of a septic child. I would start by listening to the airway, asessing the effort of breathing and ensuring that the child is haemodynamically stable and adequately resucitated.
If the child was in shock I would give high-flow oxygen, gain intravenous or intraosseous access and take blood for blood gas and laboratory tests including full blood count (FBC), urea and electrolytes (U&Es), renal and liver function, C-reactive protein (CRP), blood culture, cross-match and coagulation studies.
I would begin resucitation with 20 mL/kg rapid bolus of Hartmann's/crystalloid, reassessing the child after each fluid bolus until there is improvement and start broad-spectrum intravenous antibiotics in the form of co-amoxiclav 30mg/kg (or ceftriaxone 50 mg/kg).
If/once the child was stable, I would proceed to a focused history and examination. I would ask about:
- Onset, duration and progression of the symptoms as well as exacerbating and relieving factors.
- Associated visual symptoms including diplopia, decreased vision and pain on eye movement.
- History of coryzal symptoms, fever, headache, photophobia, confusion and rash.
- Past medical and peri-natal history including history of sinonasal problems and surgery and review the 'red book' looking at immunisation status, screening and grow charts.
- I would also want to know about the drug and family history as well as social situation and when the child last ate and drank.
I would then proceed to examination starting with a general inspection looking for any syndromic features.
I would assess visual acuity and colour vision and perform a cranial nerve examination. I would make a gross neurological assessment looking for signs of meningism including a rash. I would attempt flexible nasoendoscopy if tolerated.
Initial management of a patient with periorbital cellulitis would involve analgesia, intravenous fluid resuscitation and antibiotics in the form of co-amoxiclav (30mg/kg) and considering a CT scan.
I would attend to the patient immediately in conjunction with the remainder of the trauma team as per ATLS principles.
I would begin with a primary survery listening to the airway, asessing the effort of breathing and ensuring that the patient is haemodynamically stable and adequately resucitated.
If there was evidence of impending airway compromise, I would at this point agree a shared airway plan with the anaesthetist to secure the airway. This would depend on the specific injury but may involve attempted oro-tracheal intubation followed by emergency surgical tracheostomy.
¶ If/once the patient was stable, I would proceed to a focused history and examination. I would ask about:
- Associated otological symptoms of tinnitus, vertigo, otalgia and otorrhea.
- History of coryzal symptoms, fever, headache, photophobia, confusion and rash.
- Past medical and peri-natal history including history of ear problems and surgery and review the 'red book' looking at immunisation status, screening and grow charts.
- I would also want to know about the drug and family history as well as social situation and when the child last ate and drank.
I would then proceed to examination starting with a general inspection looking for any syndromic features. I would examine both ears looking for post-auricular erythema and swelling and otoscopic evidence of acute otitis media or perforation with discharge which I would swab. I would make a gross neurological assessment including the facial nerve. I would also look for signs of meningism including a rash.
Initial management of a patient with acute mastoiditis would involve analgesia, intravenous fluid resuscitation and antibiotics in the form of co-amoxiclav (30mg/kg) and considering a CT scan.