1: Bee Sting: Review from notes 2: Foreign Body Swallowing: not Inhaled case

1: You are an HMO and a 9-year-old girl was brought by a school nurse. She was stung by a bee and developed swollen lips along with SOB. On examination, she has tachycardia and her BP is 60/40. You are about to see the nurse on duty in the hospital and you will meet the mother later on.

Task o Give the nurse instructions regarding

management o Explain childs condition to the mother and

answer her questions 2014 RCH Anaphylaxis Guidelines: http://www.rch.org.au/clinicalguide/guideline_index/Anaphylaxis/

RCH Guidelines o Vasopressor and bronchodilator therapy:

adrenaline 10mcg/kg; o Adrenaline 0.01 ml/kg 1:1000 IM or 0.01 mg/kg

1:10,000. Repeat dose in 5 minutes if needed o Oxygen by mask o IV volume expander: 0.9% NSS 20ml/kg then

give repeat boluses of 10-20 ml/kg until BP restored

o Bronchodilator therapy with salbutamol continuous nebulized (0.5%) or IV 5mcg/kg per min for 1 hour, then 1 mcg/kg per minute thereafter

o Relief of upper airway obstruction: mild to moderate edema may respond to inhalation of nebulized adrenaline 1% adrenaline (1ml per dose diluted to 4 ml) or 5 ml of nebulised 1:1000 solution

o Anaphylaxis biphasic and may deteriorate again over the next few hours; all patients with anaphylaxis should be observed for at least 12 hours (4 hours 2014 guidleines??)

o Consider refer for Allergen testing

o Discharge pack: self-injectable adrenaline epi pen, medi-alert bracelet

Immediate Resuscitation DR-ABC o Can you please check the patients level of

consciousness? o What is her GCS? o Can you see a bee sting in the skin? o Can you please take it out with the help of a

forcep? o Can you please check her airway? Is it patent?

Any secretions? Can you please auscultate the lungs for air entry?

o I would like you to put her on oxygen around 6-8 liters/minute via a mask.

o Can you please give her IM adrenaline in a concentration of 1:1000 IM 0.01ml/kg or 0.1 ml/kg 1:10,000 IV.

Can you check the blood pressure? o If the response is not good, could you kindly

repeat it in the same concentration every 5-10 minutes.

o Can you please put in 2 IV cannula.

Please start her on normal saline 0.9% bolus 20ml/Kg and repeat until shock is cleared and then 300-500 ml normal saline depending upon the childs stature.

Can you please give Nebulised adrenaline if upper airway obstruction. (Nebulised adrenaline is not recommended as first-line therapy, but may be a useful adjunct to IM adrenaline if upper airway obstruction is present).

If airway oedema is not responding to parenteral and nebulised adrenaline, early intubation is indicated.

o Determination of ETT tube: o Diameter ETT tube: Age of child/4 + 4 o Length of ETT tube: Age of child/2 + 12

Can you please tell me if the child has any wheezing or if she is still SOB?

Can you please start her on nebulized salbutamol.

Can you please give her 1mg/kg of hydrocortisone IV.

Would you kindly give her cimetidine or other antihistamine that might be available.

RCH Admission Criteria:

All children with anaphylaxis should be observed at least 4 hours. Admission should be considered if any of the following circumstances apply:

o Greater than one dose of adrenaline (including nebulized adrenaline) required.

o A fluid bolus required o Inadequate response to treatment o The child lives a long distance from medical

services Explanation to Mom

Let me reassure you that your child is stable at the moment. She is better with the emergency measures we have done. It is quite understandable that you are very anxious to know what happened to her. Basically, what she had is a condition called an anaphylactic reaction to the bee sting. It is a kind of an allergic reaction that can happen after insect bite, certain foods, as well as intake of certain medications. It is a serious condition as there is a risk of choking or circulatory compromise. Therefore, we need to keep her in the hospital for the next 12-24 hours ??. There is a chance of rebound reaction within the 1st 6-12 hours. I will call in the pediatric registrar to come and take a look at her for further assessment. They will assess her condition and they will do further testing later on that might include skin prick testing or RAST. With these tests we will determine if she is allergic to other substances as well.

Can you please tell me if she has any known allergies already? Any history of eczema, asthma, hay fever or drug allergy? Hows her general health? Does she have family history of similar allergies? Was she stung before?

Before going home, I will ask the nurse to explain to you what to do in case of another bee sting, but let me explain the components of the anaphylaxis action plan. This includes the use of a special kit. Basically, it contains an

epipen (an injection of adrenaline) that needs to be given IM in case of anaphylaxis. It also contains a ventolin puffer, a tablet of antihistamine, and steroids. During another attack, you need to observe her for certain signs such as wheeze, hoarseness of voice, loss of consciousness, vomiting/diarrhea, and swollen blue lips with or without swelling all over the body. In case she develops these symptoms you will use this injection and give it on the thigh over the clothes. You can repeat it every 5-10 minutes. Make her lie flat on the ground, elevate the legs, call family for help, but most importantly, call 000 for an ambulance. Please provide these injections to the school along with written instructions. Avoid places where she is likely to have a bee sting. Avoid wearing colorful clothes. Avoid using perfumes, places especially gardens.

Once she is discharged, please come for followup with the immunologist for venom immunotherapy.

Reading material.

Local reactions o Local ice application, elevation, analgesics and

antihistamines o Removal of bee sting: scrape off skin with

fingernail (dont squeeze) o Care at home: washing skin, calamine lotion to

help with itching, ice packs, elevation, antishistamine (phenergan or zyrtec), strong steroid creams applied early and regularly onto skin that was bitten;

o See doctor if: reactions in other parts of the body such as hives, or breathing problems; child has a lot of pain where they were bitten which does not settle down within a few hours; swelling or itching gets worse after 24 hours

o Medications should be carried with the child at all times.

2: You are an HMO in ED. A 3-year-old girl brought to you by mom. She says that girl swallowed bulletin board pin about half an hour ago. The child is fine at the moment. She has been examined by another doctor and she is asymptomatic.

Task: o Talk to the mother about the management. o History:

o Can you please describe how it happened? o Did you or anyone else see her at the time? o What type of pin is it? o Can you show me? Did she have anything to

drink afterwards? o Any vomiting? Cough? Bleeding? Any abdominal

pain? Is it the first time for this to happen? o At the moment, your child doesnt have any symptoms.

All examination is normal so we need to find out where the pin is lodged. So I would like to order xrays of the neck, chest and abdomen. As you can see on the x-ray that the pin has crossed the pylorus, which is one of the narrowest parts of the stomach, so there is a very high chance it will pass out spontaneously. You can take her home but keep an eye on her. Watch out for symptoms like fever, tummy pain, vomiting or blood in stools. These symptoms indicate that the pin might be causing damage to the bowel wall. Unless you want to, there is no need to check the stools for the pin. We will not be doing follow up xrays unless she develops symptoms. Please understand that it is very important to supervise your child at all times to prevent this from happening again. I will give you written material regarding safety at home for kids.

o For food bolus: allow to drink fizzy drinks then do back tap

o For lead (eg. button battery): if passing to stomach then do not do anything about it but if it stays, then take it out and do followup xrays

RCH - Foreign Bodies Inhaled o The signs and symptoms of a foreign body in the upper

airway or bronchial tree will vary depending upon the site of impaction.

o Sudden and catastrophic event. o Coughing, choking and possibly vomiting. o If obstruction is total - rapidly progresses to

unconsciousness and cardiorespiratory arrest. o May be present in a child with a cardiorespiratory arrest

in whom it is impossible to ventilate.

If Obstruction Is Total: o Open the airway and under direct vision (preferably using

a laryngoscope) check in the mouth for a foreign body - if present remove it with magills forceps.

o Place child prone with the head down. o Apply 5 blows with the open hand to the interscapular

area. o Turn child face up. o Apply 5 chest thrusts using the same technique as for

chest compression during CPR. o Check in the mouth to see if foreign body has appeared. o Apply 5 lateral chest thrusts. o If unsuccessful repeat interscapular blows, central chest

compressions and lateral chest thrusts.

FOREIGN BODY

Radio-opaque

(pins, batteries,

buttons, coins) or

unknown

Radiolucent

(glass/plastic)

Xray (neck, chest

and abdomen)

Stomach and

beyond Esophagus

(ENT surgeon)

Asymptomatic

(Observe at

home)

Symptomatic

(drooling, chest

pain, intolerant to

food)

o Positive pressure "ventilation" can be tried in an attempt to force the foreign body into the left or right main bronchus.

o A surgical airway may be tried if the obstruction is in or above the larynx and it is impossible to remove it through the mouth.

If Obstruction Is Partial: o DO NOT perform the above manoeuvres. o Place child upright in the position they feel most

comfortable. o Arrange for urgent removal of foreign body in the

operating theatre.

Impaction Lower Than The Main Bronchus: o Children between the ages of 6 months and 4 years are

at greatest risk. o There may have been an episode of choking, coughing or

wheezing while eating or playing but many episodes are unwitnessed.

o Symptoms may include persistent wheeze, cough, fever or dyspneoa not otherwise explained. Recurrent or persistent pneumonia may be the presenting feature.

o The child may be asymptomatic after the initial event.

Examination o Asymmetrical chest movement o Tracheal deviation o Chest signs such as wheeze or decreased breath

sounds. o The respiratory examination may be completely normal.

Radiology: o Request inspiratory and expiratory chest films. Look for:

an opaque foreign body, segmental or lobar collapse, localised emphysema in expiration (ball valve obstruction)

o The CXR may be normal.

Mx: o DO NOT perform the above manoeuvres. o Place child upright in the position they feel most

comfortable. o Arrange for urgent removal of foreign body in the

operating theatre. o Prevention: o No child less than 15 months old should be offered foods

such as popcorn, hard lollies, raw carrot or apples. Children under the age of 4 years should not be offered peanuts.

o Encourage the child to sit quietly while eating and offer food one piece at a time.

o Avoid toys with small parts for children under the age of 3 years.