ABSTRACT
Which child should be moved to the resuscitation area for urgent management in accident and emergency?
A. A miserable 2 year old with a fever and vomiting temperature of 38.5°C, heart rate of 150, respiratory rate 42, capillary refill time 2-3 seconds who is alert and clinging on to his father and has just been given paracetamol and started on a fluid challenge with oral rehydration salts 5 minutes ago by the triage nurse
B. A quiet 4 year old brought in with an asthma attack who is sitting upright with a respiratory rate of 50, heart rate of 162, capillary refill time of 3 seconds, subcostal recessions and poor air entry on chest auscultation following a salbutamol nebulizer
C. An 8 year old, known diabetic, brought in vomiting with her glucose reader saying HI. She is able to tell you her history and has a heart rate of 120, respiratory rate of 25, capillary refill time of <2 seconds
D. An alert 3 year old who has had a cough and cold for the past 3 days which is keeping him up at night and mum noticed a rash on his neck and face which did not disappear when she pressed a glass tumbler against it. His temperature is 37.8°C, heart rate is 110, respiratory rate is 30, capillary refill time is <2 seconds
E. A 15 year old, known to social services for a family history of domestic abuse, brought in to accident and emergency by her best friend after she admitted to taking 20 paracetamol tablets 4 hours ago. She is alert but does not make eye contact, her heart rate is 98, respiratory rate is 20, capillary refill <2 seconds
A 4-year-old child has been losing weight recently and has been vomiting for the past 24 hours, unable to eat anything. His mother has brought him into accident and emergency out of concern as he seems confused. The triage nurse has taken him to the resuscitation room and asked for your help. On examination he is drowsy, has a heart rate of 150, respiratory rate of 60 and a central capillary refill of 5 seconds. He has subcostal recessions and good air entry bilaterally with no added sounds. He moans when you examine his abdomen but there are no masses. You put in a canula and take bloods. The venous blood gas shows:
pH 7.12 PCO2 2.3 kPa PO2 6.7 kPa HCO3
–15.3 mmol/L BE –8.6 Glucose 32.4 mmol/L
A. Diabetic ketoacidosis, start an insulin infusion B. Diabetic ketoacidosis, give a fluid bolus C. Pneumonia, start IV co-amoxiclav D. Ruptured appendix, give a fluid bolus and book the emergency
operating theatre E. Gastroenteritis with severe dehydration, give a fluid bolus
An 8 year old known asthmatic is brought into accident and emergency by ambulance as a ‘blue call’. He has been unwell with an upper respiratory tract infection for the past 2 days. For the past 24 hours his parents have given him 10 puffs of salbutamol every 4 hours, his last dose being 90 minutes ago. The ambulance staff have given him a nebulizer but he remains agitated with a heart rate of 155, respiratory rate of 44 and sub/intercostal recessions and on auscultation there is little air movement heard bilaterally. Saturations in air are 85 per cent. He is started on ‘back to back’ nebulizers with high flow oxygen. How severe is his asthma exacerbation and what other bedside test would support this?
