NICE indications for CT scan following traumatic head injury in children

NICE has proposed indications for CT scan following traumatic head injury in children in 2014. The indications are given below:

Any of:
• Suspicion of non-accidental injury
• Post-traumatic seizure
• Glasgow Coma Score (GCS) <14 on arrival at emergency department (<15 for <1 year of age)
• GCS <15 two hours after injury
• Suspected open or depressed skull fracture
• Evidence of basal skull fracture
• Focal neurological deficit
• Presence of bruise or swelling >5 cm in
diameter in children aged <1 year

More than one of:

The Common Cold In Pediatric Practice

The common cold is a viral infection with prominent symptoms of rhinorrhea and nasal obstruction, absent or mild fever and lacking systemic manifestations.

Etiology
The viruses primarily involved with colds are rhinoviruses and less commonly coronaviruses. Other viruses that cause common cold symptoms as part of broader clinical syndromes include respiratory syncytial virus and less commonly influenza viruses, parainfluenza viruses and adenoviruses.

Pathophysiology
Viral infection of the nasal epithelium causes an acute inflammatory response with mucosal infiltration by inflammatory cells and release of inflammatory cytokines. The inflammatory response is partly responsible for many of the symptoms.

Clinical FeaturesCommon cold symptoms typically develop 1 to 3 days after viral infection and include nasal obstruction, rhinorrhea, sore or scratchy throat and occasional non productive cough. Colds usually persist about 1 week although 10% lasts 2 weeks. there is often a change in color or consistency of nasal secretions, which is not indicative of sinusitis or bacterial superinfection.

Examination of the nasal mucosa may reveal swollen, erythematous nasal turbinates.

Management Of Status Epilepticus In Children

Definition Of Status Epilepticus
Status Epilepticus is defined as ongoing seizure activity for greater than 20 minutes or repetitive seizures without return of consciousness for greater than30 minutes.

Any child presenting with status epilepticus is at a risk of irreversible brain injury and needs immediate management:

Initial Stabilization

1. The first priority of treatment is to ensure an adequate airway and to assess the cardiovascular status i.e look for ABC = airway, breathing and circulation.

2. Maintain an IV access.

3. Oxygen is administered and pulse oximetery observed.

4. ECG monitoring is done.

5. If violent muscle activity impairs ventilation, muscle paralysis and sedation should be instituted.

6. Immediate laboratory tests that need to be done include:

• Blood glucose
• Basic metabolic panel (sodium, calcium, magnesium)
• Antiepileptic drug levels
• Toxicology screening

Basic Laboratory Tests For Fever In Children

Fever is one of the most common presenting symptom in pediatric practice and has a number of different causes. Sometimes the concerned physician needs to do some basic laboratory workup apart from a detailed history and physical examination to reach the definitive diagnosis and determine the cause of fever.

Laboratory Workup

1. CBC with differential
Often over utilized in well appearing febrile children. High WBC is a risk factor for bacteremia in a highly febrile child. Low WBC count is not a reliable predictor of one specific disease as it may be seen in viral infections, overwhelming infections ( including meningitis) and in immune deficiency states.

The differential helps in identifying acute or chronic infections. In acute bacterial infections there is increased neutrophil count .

2. Lumbar PunctureAlthough not done in all children with fever it is a gold standard for diagnosis of meningitis and must be performed whenever history and physical examination are pointing towards the risk of having meningitis.

3. Blood Culture
It has a little value to assess for occult bacteremia (bacteremia unexpected on clinical grounds). Most of these episodes are benign and resolve without treatment. Children who develop serious deep infections often present for medical care before positive test for blood culture. Multiple (3 or 4) blood cultures are warranted when certain diseases e.g osteomyelitis, endocarditis are suspected, to increase their yield. Blood cultures should be obtained through central lines if present.

4. Urinalysis
It is a useful test in female children without other evidence of infectious foci; it has significantly lesser yield in male children but should be considered in uncircumcised boys during infancy if fever is not self limited. Urine nitrities, leukocyte esterase , Gram stains and direct cell visualization add to the immediate diagnostic value of urinalysis.

Understanding Some Common Symptoms Seen In Infants

Some of the common symptoms seen in infants ( young children upto one year of age) are summarized as below:

1. Crying
Parents commonly report problems about a crying baby, in the first 3 months of life. In most of the cases no cause is found. Crying peaks at 6–8 weeks old (~3h/day, worse in the evenings) and subsides by 4 months. Cries of hunger and thirst are indistinguishable.
Sometimes a crying baby makes a disturbed parent angry and if mother has been suffering from postpartum depression it can worsen it. Sometimes it is OK to leave a baby crying if it is in the
child’s best interests. A baby who is abused due to excessive crying would rather have been left alone.
The following measures can be done for a crying baby:
• Don’t make parents feel inadequate; Explain them the normal crying and sleeping pattern of babies appropriate for the age. Parents can take turn in looking after the baby.
• Help parents recognize when their baby is tired and hungry and to apply a consistent approach to care.
• Vocal (singing), vestibular (rocking, going for a drive) or tactile stimulation (hugs) may help. Encourage help from friends/family. Simplify daily living.
• If not coping, admit to a parenting center or hospital.

Management Of Diabetic Ketoacidosis

Therapy for patients with diabetic ketoacidosis DKA involves careful replacement of fluid deficits, correction of acidosis and hyperglycemia via insulin administration, correction of electrolyte imbalances and monitoring for complications of treatment.

1. Dehydration
A patient with severe DKA is assumed to be approximately 10% dehydrated. An initial IV fluid bolus of a glucose-free isotonic solution ( normal saline, lactated Ringer’s solution) at 10-20 ml/kg should be given to restore intravascular volume and renal perfusion. The remaining fluid deficit after the initial bolus should be added to maintenance fluid requirements, and the total should be replaced slowly over 36 to 48 hrs. To avoid rapid shifts in serum osmolality, 0.9% sodium chloride can be used as the replacement fluid for the initial 4 to 6 hrs followed by 0.45% sodium chloride.

2. Hyperglycemia
Fast-acting soluble insulin should be administered as a continuous IV infusion (0.1U/kg/hr). Serum glucose concentration should decrease at a rate no faster than 100 mg/dl/hr. When serum glucose concentration decreases to less than 250-300 mg/dl, glucose should be added to IV fluids.

3. Acidosis
Insulin therapy lowers glucagon and diminishes its activity on liver, decreases the production of free fatty acids and protein catabolism, and enhances glucose usage in target tissues. theses processes correct acidosis. Bicarbonate therapy should be avoided unless there is severe acidosis ( pH < 7.0).

4. Electrolyte ImbalancesRegardless of the serum potassium concentration at presentation, total body potassium depletion is likely. When adequate urin output is shown potassium should be added to the IV fluids. Potassium replacement should be given as 50% KCl and 50% KPO4 at a concentration of 20-40 mEq/L.

5. Monitoring
A flow sheet should be used to record and monitor fluid balance and laboratory measurements. Serum glucose measurements should be repeated every hour during therapy and electrolyte concentrations should be repeated every 2 to 3 hours. Calcium, phosphate and magnesium concentrations should be measured initially and then every 4 to 6 hours during therapy.