Textbook of Paediatric Emergency Medicine

4th Edition - April 4, 2023
Editors: Peter Cameron, Gary J. Browne, Biswadev Mitra, Stuart Dalziel, Simon Craig
Language: English
Paperback ISBN:
9 7 8 - 0 - 7 0 2 0 - 8 5 3 5 - 2
eBook ISBN:
9 7 8 - 0 - 7 0 2 0 - 8 5 3 6 - 9

This leading text is essential reading for all those working in the paediatric emergency medicine setting who require concise, highly practical guidance that incorporates the la… Read more

Textbook of Paediatric Emergency Medicine

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This leading text is essential reading for all those working in the paediatric emergency medicine setting who require concise, highly practical guidance that incorporates the latest best practice and evidence-based guidelines.

The Textbook of Paediatric Emergency Medicine provides clear, concise and comprehensive information to support clinicians in what can be a challenging area to provide care. It not only covers diagnosis and management of all common presentations, but it also includes practical tips on communicating with both patients and their families.

As a companion book to Cameron’s Textbook of Adult Emergency Medicine, this volume is specifically tailored to the educational needs of emergency medicine trainees, but is also expected to benefit others working in the emergency setting including paramedics and emergency nurse specialists.

Title of Book
Instructions for online access
Cover image
Title page
Table of Contents
Copyright
Preface
Contributors
Section 1. Approach to the paediatric patient
1.1. Approach to the paediatric patient
Introduction
Who sees paediatric emergencies?
Prehospital care
First aid response
General Practitioner
Emergency Department Care
1.2. Common chronic paediatric conditions
Introduction
Cerebral palsy
Introduction
Complications seen in the emergency department
Respiratory complications
Neurological complications
Gastrointestinal complications
Musculoskeletal complications
Common medications used in cerebral palsy
Baclofen
Dantrolene sodium
Botulinum toxin
Spina bifida
Introduction
Types of spina bifida:
Occulta
Meningocoele
Myelomeningocoele
Implications for emergency department management
Cystic fibrosis
General
Aetiology
Diagnosis
Management
Management principles
Respiratory
History and examination
Investigations
Management
Gastrointestinal
Intestinal obstruction syndromes
Endocrine
The ex-premature infant
Introduction
Complications of prematurity
Chronic neonatal lung disease
Autism spectrum disorder
Overview
Characteristics of autism spectrum disorder
Autism spectrum disorder in the emergency department
Section 2. Resuscitation
2.1. Paediatric cardiopulmonary arrest
Epidemiology
Aetiology
Preventing in-hospital cardiac arrest
Outcome
Differences compared with adults
Development of resuscitation guidelines
Ethical considerations in paediatric resuscitation
Presence of family
Termination of paediatric resuscitation
Non-initiation of resuscitative efforts
Nonaccidental injury
Organ donation
Death certificates, notification to the coroner and other legal issues
Child death: follow-up of family
2.2. Paediatric basic life support
Introduction
Paediatric versus adult basic life support
Aetiology of arrests
Anatomy and physiology
Preparation and equipment
Basic life support sequence
Check for danger (D)
Assess responsiveness (R)
Send for help (S)
Open and maintain the airway (A)
Breathing (B)
Circulation (C)
Precautions and complications with cardiopulmonary resuscitation
Foreign body airway obstruction
FBAO management: conscious patient with effective cough
FBAO management: conscious patient with ineffective cough
FBAO management: unconscious patient
2.3. Paediatric advanced life support
Introduction
Definition of advanced life support
Diagnosing cardiac arrest
Oxygen, ventilation and advanced airway support
Oxygen
Nasal prongs/nasal catheters
High-flow nasal cannula
Oxygen masks
Ventilation
Rates and ratios of external cardiac compression and ventilation in advanced life support
Advanced airway support
Endotracheal intubation
Endotracheal tube size (Table 2.3.1)
Laryngeal mask airway
Management of the difficult airway
Causes of a difficult airway
Monitoring
Vital signs
Oximetry
Expired CO2 detection
Electrocardiograph
Vascular access
Peripheral venous cannulation
Intraosseous access
Central venous cannulation
Endotracheal route
Other techniques
Fluid therapy
Resuscitation drugs
Cardiac arrest/ Arrhythmias/Dysrhythmias
Management of pulseless arrhythmias
Nonshockable arrhythmias
Shockable arrhythmias
Management of pulsatile dysrhythmias
Bradycardias
Tachycardias (Fig. 2.3.2)
Ventricular tachycardia with a pulse
Supraventricular tachycardia
Post-resuscitation management (Box 2.3.1)
Oxygenation and ventilation
Haemodynamic monitoring
Targeted temperature management
Glucose control
2.4. Paediatric resuscitation in specific circumstances
Teamwork in critical care management
Rapid sequence induction in critical situations
Resuscitation of children with congenital cardiac disease
Anaphylaxis
Asthma
Drowning
Traumatic cardiac arrest
Toxicological emergencies
Intravenous lipid emulsion
Envenomation
Snake envenomation (see Chapter 24.1)
Marine envenomation: Box jellyfish
2.5. Shock
Introduction
Diagnosis and assessment
Airway
Breathing
Circulation
Heart rate
Blood pressure
Capillary refill
Initial management
Circulation
Further management
Hypovolaemia
Septic shock
Acute severe allergic reaction (anaphylaxis)
Duct-dependent congenital heart disease
Heart failure
Neurogenic shock
2.6. Sepsis recognition and initial management
Background
Definition
Aetiology
Pathophysiology
Diagnosis
Initial emergency management (Fig. 2.6.1)6
Monitoring
General supportive measures
Intravenous access
Initial blood tests
Initial treatment
Therapeutic targets
Disposition
Section 3. Analgesia and sedation
3.1. Analgesia
Introduction
Assessment of pain
Management
Nonpharmacological methods
Pharmacological methods
Oral analgesic agents
Intranasal or inhaled options
Local anaesthetic agents
Regional anaesthetic techniques
Environment
Psychological
Cognitive–behavioural
Physical
Breast-feeding
General
Fascia iliaca compartment block (with or without ultrasound guidance)
Femoral nerve block (with ultrasound guidance)
3.2. Paediatric procedural sedation within the emergency department
Introduction
The goal of procedural sedation
Preprocedure
Governance
Patient selection and risk assessment
Fasting
Consent
Equipment and personnel
Rapport building
Intraprocedure
Postprocedure
Nonpharmacological methods
Environment
Distraction techniques
Physical
Focused therapies
Selection of agents by procedure and age
Pharmacological methods
Nitrous oxide
Ketamine
Propofol
Ketofol
Other agents
Balanced sedation
Section 4. Neonatal emergencies
4.1. The normal neonate
Definition and introduction
Immediately after birth
The neonatal history
The neonatal examination
Common reasons for healthy neonates to present to the emergency department
Feeding problems
Crying (see Chapter 4.2, The crying infant)
Vomiting and spilling
Preventative advice
Conclusion
4.2. The crying infant
Introduction
Recurrent crying
Colic
Management
Gastrooesophageal reflux
General advice
Acute crying
Assessment
Examination
Investigations
Disposition
4.3. Neonatal dermatology
Skin in the neonatal period
Neonatal erythroderma (Fig. 4.3.1)
Potential causes of erythroderma
Investigations in erythroderma
Management of the erythrodermic neonate
Red scaly rashes
Infantile seborrheic dermatitis/eczema
Psoriasis
Ichthyosis
Neonatal lupus erythematosus (Fig. 4.3.2)
Zinc deficiency/acrodermatitis enteropathica
Langerhans cell histiocytosis (see Chapter 15.1, Dermatology)
Tinea corporis
Congenital syphilis
Vesicles and blisters
Herpes simplex
Varicella
Staphylococcus aureus
Miliaria
Epidermolysis bullosa
Management in the emergency department
Autoimmune blistering disease
Pustular lesions
Infection
Neutropenia
Erythema toxicum neonatorum (toxic erythema of the newborn)
Transient neonatal pustular dermatosis
Acropustulosis of infancy
Eosinophilic pustular folliculitis (scalp)
Milia and sebaceous gland hyperplasia
Birthmarks
Congenital melanocytic naevi
Small (<0.5 cm) and medium (0.5–7 cm) congenital melanocytic naevi
Large (7–15 cm) and giant (>15 cm) congenital melanocytic naevi
Epidermal naevi
Inflammatory verrucous epidermal naevus
Sebaceous naevus
Incontinentia pigmenti
Pigmentary mosaicism
Café au lait macules
Cutis aplasia
Blue/purple lesions
Blueberry muffin syndrome (Fig. 4.3.5)
Vascular lesions in the neonatal period
Cutis marmorata
Harlequin colour change
Salmon patch (naevus simplex, stork mark, angel’s kiss)
Vascular anomalies
4.4. Acute neonatal emergencies
The neonatal period
Neonatal resuscitation (see Chapter 4.5, Neonatal resuscitation)
Assessment of the neonate
The collapsed neonate
Sepsis
Antibiotics
Viruses
Cardiac emergencies
Congenital heart disease
Arrhythmia (see Chapter 5.10, Cardiac arrhythmias)
Endocrine disorders
The neonate with vomiting
Intestinal obstruction
Small bowel atresia
Malrotation and midgut volvulus
Meconium ileus
Hirschsprung disease
Hypertrophic pyloric stenosis
The neonate with seizures
The neonate with breathing difficulty
Lung parenchymal pathology
Airway obstruction
Laryngomalacia
Nonpulmonary disease
The neonate with jaundice
4.5. Neonatal resuscitation
Introduction
Epidemiology
Aetiology and pathophysiology
Preparation
Assessment at birth
Breathing
Positive pressure ventilation
Heart rate
Compression technique
Colour
Muscle tone and reflex irritability
Medications
Vascular access
Adrenaline
Naloxone
Glucose
Volume expansion
Bicarbonate
Specific resuscitation situations
Premature neonate
Meconium aspiration
Congenital heart disease
Postresuscitation stabilisation
Controversies
Respiratory function monitoring during resuscitation
Next steps to improve outcome when resources are limited
Ethics of resuscitation
Prognosis
Section 5. Cardiology
5.1. Cardiovascular assessment and murmurs
Introduction
History
Physical examination
Chest X-ray
Electrocardiography
Atrial enlargement
Ventricular enlargement
The child with an asymptomatic murmur
Pathological murmurs
Disposition
5.2. Chest pain
Introduction
Immediate approach
General approach
History
Cardiac causes
Noncardiac causes
Anxiety
Physical examination
Investigations
Chest pain following COVID-19 mRNA vaccine
Conclusion
5.3. Syncope
Introduction
Aetiology
Typical presentations
Vasovagal syncope
Breath-holding spells and reflex anoxic seizures
Cardiac syncope
Hypovolaemic states
Seizures
Hyperventilation and conversion syncope
Clinical
History
Examination
Investigations within the emergency department
Further investigations of syncope
Management of syncope within the emergency department
Conclusion
5.4. Cyanotic heart disease and tetralogy of Fallot spells
Introduction
Cyanotic congenital heart disease
Differential diagnosis
Increased capillary oxygen extraction (peripheral cyanosis)
Clinical features2–6
Investigations
Management2–6
Disposition
Tetralogy spells
Introduction3–6,9–12
Investigations3–6
Laboratory
Electrocardiograph
Chest x-ray
Echocardiography
Treatment3–6,9–12
Disposition
5.5. Heart failure
Definition
Causes of congestive heart failure
Clinical manifestations and investigations
Presentation1–3
General features1–3
Staging5–10
Assessment
Investigations1–3
Routine
Specialised
Referral
Management1–3,11–15
Acute management
Diuretics
Angiotensin-converting enzyme inhibitors
β-blockers
Digoxin
Levosimendan
5.6. Congenital heart disease
Introduction
Incidence
Pathophysiology
Undiagnosed congenital heart disease
Findings that may indicate congenital heart disease
Diagnostic approach
Common presentations and initial management
Neonate/infant
Older child
Complications/residua of congenital heart disease and its treatment
Early
Late
Congenital heart disease and intercurrent illness
Dehydration, including gastroenteritis
Respiratory disease
5.7. Acute rheumatic fever
Introduction
Epidemiology
Pathophysiology
Diagnosis of acute rheumatic fever
Clinical manifestations (history and examination)
Investigations
Laboratory evidence of group A β-haemolytic streptococcal infection
Acute phase reactants
Electrocardiogram
Echocardiogram
Differential diagnosis
Treatment
Acute management
Symptomatic treatment of arthritis
Treatment of carditis and control of heart failure
Management of chorea
Prevention and prophylaxis
Prognosis
5.8. Infective endocarditis
Introduction
Epidemiology
Pathophysiology
Microbiology
History and presenting clinical features
Examination
Modified duke criteria8
Major criteria
Positive blood cultures for infective endocarditis
Evidence of endocardial involvement
Minor criteria
Investigations
Laboratory
Imaging
Differential diagnosis
Treatment
Medical
Surgical
Prognosis
Prevention
5.9. Kawasaki disease
Introduction
Pathophysiology
Clinical features
Cardinal diagnostic features of Kawasaki disease
Other features of Kawasaki disease
Incomplete Kawasaki disease
Differential diagnosis
Complications
Investigations
Treatment
Refractory Kawasaki disease
Prognosis
5.10. Cardiac arrhythmias
Introduction
Normal conduction system
The cardiac action potential
Vaughan Williams antiarrhythmia drug classification
Pathogenesis of arrhythmias
Bradyarrhythmias
Tachyarrhythmias
Reentry
Enhanced automaticity
After depolarisations
General principles for arrhythmia management
Bradyarrhythmias
Sinus bradycardia
Sinus node dysfunction
Management
Conduction disturbances: atrioventricular block
Clinical features
Management
Bundle branch block
Tachyarrhythmias
Wide complex tachyarrhythmia
Narrow complex tachyarrhythmia
Wolff-Parkinson-White syndrome
Atrial flutter
Atrial fibrillation
Ventricular fibrillation
Role of ‘molecular autopsy’ in sudden unexplained cardiac death in the young
Section 6. Respiratory
6.1. Stridor and noisy breathing
Introduction
Initial assessment
History
Examination
Common causes of acute stridor in children
Common causes of chronic stridor in children
Larynx
Subglottis
Trachea
6.2. Upper respiratory tract infections
Introduction
Nasopharyngitis
Introduction
History
Examination
Investigations
Treatment
Stomatitis
Introduction
History
Examination
Investigation
Treatment
Pharyngitis/tonsillitis
Introduction
History
Examination
Investigations
Treatment
6.3. Inhaled foreign body
Introduction
Upper airway foreign bodies
History
Examination
Investigations
Treatment
Total obstruction
Partial obstruction
Lower airway foreign body
History
Examination
Investigations
Treatment
Prevention
6.4. Croup
Introduction
Presentation
History
Examination
Investigations
Differential diagnosis
Treatment and disposition
Mild or moderate croup
Severe croup
Prognosis
Prevention
6.5. Acute asthma
Introduction
Diagnosis of asthma
Infrequent intermittent asthma
Frequent intermittent asthma
Persistent asthma
Risk factors for mortality
Clinical assessment
Examination
Investigations
Differential diagnosis
Treatment: mild/moderate
Treatment: severe
Treatment: life threatening
Discharge from hospital
Discharge pack
Prognosis
Prevention
Future directions/research
6.6. Pertussis
Introduction
Pathophysiology
Epidemiology
History
Stage 1: Catarrhal (1–2 weeks)
Stage 2: Paroxysmal (2–6 weeks, can be longer)
Stage 3: Convalescent (1–2 weeks)
Examination
Investigations
Differential diagnosis
Complications
Treatment
Chemoprophylaxis of contacts
Prevention
Current immunisation schedule
Prognosis
6.7. Community-acquired pneumonia
Introduction
Definition
Aetiology
Clinical findings
Investigations
Management
Complications
Prevention
Conclusion
6.8. Bronchiolitis
Introduction
Epidemiology
Pathophysiology
Clinical assessment
History
Examination
Assessment
Differential diagnosis
Investigations
Treatment
Drug therapy
Prognosis
Prevention
Section 7. Gastroenterology and hepatology
7.1. Abdominal pain
Introduction
Pathophysiology
Assessment
History
Neonates and infants
Preschool
School age
Adolescents
Examination
Investigations
Pathology
Imaging
Management
Disposition
Acute Appendicitis
Introduction
Clinical features
Differential diagnoses
Investigations
Ultrasound
Computed tomography scan
Magnetic resonance imaging
Active observation
Management
Meckel diverticulum
Introduction
Clinical features
Differential diagnoses
Investigations
Management
Chronic Abdominal Pain
Introduction
Assessment
Diagnosis
Management
7.2. Vomiting
Introduction
Definitions
Clinical evaluation
History
Presenting complaint and past history
ABC: fluids in and out
Examination
General observation
Hydration status
Cardiovascular and respiratory status
Abdominal examination
Neurological examination
Differential diagnoses
Surgical causes of bilious vomiting
Intestinal atresia
Anorectal anomalies
Meconium ileus
Hirschsprung disease
Malrotation with volvulus
Irreducible inguinal hernia (see also Chapter 7.11)
Intussusception (see also Chapter 7.10)
Inflammatory
Meckel diverticulum
Adhesions
Investigations
Bedside tests
Formal investigations
Investigations specific to bilious vomiting
Management
Fluids
Antiemetic medication
Antibiotics
Analgesia
Consultation
Surgical-specific management
Transfer
Complications
Bilious vomiting
Conclusion
Differential diagnostic possibilities
General approach
Surgical review
7.3. Gastrointestinal bleeding
Introduction
Definitions
Aetiology
History
Examination
Investigations
Laboratory testing
Stool testing
Imaging
Endoscopy
Capsule endoscopy
Primary medical management
Fluid resuscitation and blood transfusion
Nasogastric aspiration and lavage
Treatment of acute UGIB
Pharmacological treatment (Table 7.3.4)
Variceal bleeding
Disposition
7.4. Gastrooesophageal reflux
Introduction
Pathophysiology
History
Examination
Differential diagnosis
Complications
Failure to thrive
Respiratory
Oesophagitis
Investigations
Treatment
Simple measures
Pharmacological
Surgical
Follow-up
7.5. Pyloric stenosis
Introduction
Epidemiology
Clinical presentation
Examination findings
Imaging studies
Differential diagnosis
Management
Complications
7.6. Ingested foreign bodies
Introduction
History
Examination
Investigations
Treatment
Coins
Button (disc) batteries
Magnets
Other metallic foreign bodies
Nonmetallic foreign bodies
Disposition
Prevention
7.7. Acute liver failure
Introduction
Definitions
Pathophysiology
Hepatic encephalopathy
Aetiology
Infectious hepatitis
Immune dysregulation
Autoimmune hepatitis (AIH)
Gestational alloimmune liver disease
Hemophagocytic lymphohistiocytosis
Inherited metabolic disease
Drug- and toxin-induced liver injury
Paracetamol
Anticonvulsants
Aspirin and Reye syndrome
Mushrooms
Structural anomalies
Idiopathic PALF (iPALF)
Presentation
History
Examination
Investigations
Management
Prognosis
7.8. Diarrhoea
Introduction
Clinical evaluation
History
Presenting complaint and past history
ABC – fluids in and out
Examination
General observation and examination
Cardiovascular and respiratory status
Abdominal examination
Neurological examination
Differential diagnoses
Investigations
Common investigations:
Urine:
Stool:
Blood:
Less common investigations
Blood:
Imaging:
Management
Fluids
Dietary modification
Antibiotics and Probiotics
Consultation
Conclusion
Differential diagnostic possibilities
General approach
7.9. Acute hepatitis
Introduction
Aetiology
History
Examination
Investigations
Viral hepatitis
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis E
Viral hepatitis due to other viruses
Drug- and toxin-induced liver injury
Chronic liver disease presenting as acute hepatitis
Autoimmune hepatitis
Wilson disease
Other causes of chronic liver disease presenting in childhood
7.10. Intussusception
Introduction
Aetiology
Epidemiology
Clinical
Investigations
Abdominal X-ray
Ultrasound
Management
Outcome
7.11. Herniae
Introduction
Types of herniae
Inguinal
Femoral
Umbilical and paraumbilical herniae
Epigastric herniae
Complications
Treatment
7.12. Gastroenteritis
Introduction
Aetiology
History
Examination
Assessment of dehydration
Laboratory investigations in the assessment of dehydration
Differential diagnosis
Investigations
Treatment
Mildly dehydrated
Appropriate oral fluids
Method of giving oral fluids
Indications for re-presentation
Refeeding
Moderately dehydrated
Intravenous rehydration
Rapid intravenous rehydration
Severely dehydrated
Other treatments
Disposition
Prognosis
7.13. Constipation
Introduction
Definitions
What is normal?
Neonates
Infants
Toddlers
Types of constipation
Assessment
History
Functional constipation
Common withholding postures
Examination
Investigations
Management
Discharge recommendations
Basics
Medications
Behaviour modification
Dietary changes
Rectal medication for disimpaction
Inpatient disimpaction
7.14. Inflammatory bowel disease
Introduction
New diagnoses
Presentation
Examination
Investigations in the emergency department
Differential diagnosis
Diagnosis/management
Known inflammatory bowel disease patients
Crohn disease
Perianal disease
Ulcerative colitis
Toxic megacolon
Common treatments and their complications
Section 8. Neurology
8.1. Cerebrospinal fluid shunt complications
Introduction
Cerebral spinal fluid shunts
Complication rate
Clinical presentation
Causes of shunt complications
Shunt occlusion/obstruction/blockage
Infection
Early postoperative complications
Migration and penetration of shunts
Disconnection
Fracture
Investigation
Palpation
Pump bulb test
Computed tomography
Lumbar puncture
‘Shunt series’ radiographs
Ultrasound
Magnetic resonance imaging
Management
8.2. Raised intracranial pressure
Introduction
Basic science
Normal physiology
Pathophysiology
Clinical features
Important points to consider
Symptomatology based on age
A Central herniation syndrome
B Lateral mass herniation syndrome
C Cerebellar tonsillar herniation syndrome
Some specific signs
Herniation syndromes
Causes
Idiopathic intracranial hypertension
Increased cerebrospinal fluid (hydrocephalus)
Space-occupying lesion
Decreased or fixed intracranial volume
Investigation
Imaging
Manometry
Management of ICP
8.3. Seizures and nonepileptic events
Introduction
General comments
Classification of seizures
Febrile seizures
Presentation to emergency department
Presentation following a possible seizure
History
Examination
Differential diagnosis and specific seizure syndromes
Infancy
Seizure types
Familial (and nonfamilial) infantile epilepsy
West syndrome (infantile spasms)
Dravet syndrome
Nonepileptic events of infancy
Childhood
Seizure types
Nonepileptic events
Adolescence
Seizure types
Nonepileptic events
Hypnogogic jerks
Rage attacks
Presentation of a seizure
Convulsive status epilepticus
Drug therapy
First line
Second line
Third line
Investigations
Blood tests
Neuroimaging
EEG
ECG
Disposition
8.4. Acute weakness
Introduction
Presentation
Trauma masquerading as weakness
Primary survey approach
General inspection
ABC
DEFG
History
Examination
Investigations
Laboratory
Imaging
Specific conditions causing acute weakness
Conditions of the central nervous system
Stroke
Brain tumours
Seizures and todd paralysis
Hemiplegic migraine
Spinal cord lesions
Transverse myelitis
Spinal cord trauma
Spinal cord space-occupying lesions
Tumours
Arteriovenous malformations
Epidural abscess
Tethered cord/diastematomyelia
Lower motor neuron lesions
Poliomyelitis and other enteroviral infections
Guillain-Barré syndrome
Bell palsy
Toxic neuropathies
Anticholinesterases
Lead and other heavy metals
Chemotherapeutic agents
Hereditary neuropathy
Conditions of the Neuromuscular Junction
Botulism
Myasthenia gravis
Tick paralysis
Neurotoxic envenomations
Muscular disorders
Infectious myositis
Juvenile dermatomyositis
Metabolic/endocrine myopathies
Somatisation disorders/conversion disorder
8.5. Acute ataxia
Introduction
Pathophysiology
Cerebellum
Cerebral hemispheres and vermis
Cerebellar peduncles and connections
Differential diagnosis
Acute cerebellar ataxia
Acute cerebellitis
Poisoning
Anticonvulsants
Benzodiazepines
Alcohols
Essential oils
Cough suppressants
Substances of abuse
Tumours
Trauma
Infections
Vascular conditions
Other neurological conditions
Metabolic disorders
Chronic ataxia
Hereditary ataxias/spinocerebellar degenerative
Congenital malformations
Clinical evaluation of the patient
History
Examination
Investigations
Management
Prognosis
Disposition
8.6. Headache
Introduction
Incidence
Pathophysiology
Clinical assessment
History
Site
Nature
Onset of the headache
Progression
Pyrexia
Behavioural change and avoidance behaviour
Sleep disturbance
Postural symptoms
Neurological deficit
Family history (especially of migraine)
Analgesic use
Examination
Investigation
Blood tests
Imaging
Lumbar puncture
Other investigations
Management
Disposition
Migraine
Essentials
Pathophysiology
Clinical features
Investigation
Treatment
Disposition
Conclusion
8.7. Central nervous system infections: meningitis and encephalitis
Introduction
Meningitis
Classification
Aetiology
Bacteria
Viruses
Fungi
Clinical findings
Investigations
Examination of the cerebrospinal fluid
Other investigations
Management
Antibiotics
Steroids
Fluids
Prevention
Chemoprophylaxis
Complications
Age <2 months
Age ≥2 months
Viral meningitis
Brain abscess
Encephalitis
Aetiology
Aciclovir
Clinical findings
Investigations
Management
Complications
Conclusion
Section 9. Infectious diseases
9.1. Infectious diseases
Fever
Defining and measuring temperature
Fever: to treat or not to treat?
Practical approach to the febrile child
Fever with localising signs
Fever without focus
Pyrexia of unknown origin
Empiric antibiotic therapy
Antimicrobial resistance
Common infectious exanthems
What specimens, when should they be ordered and what tests?
Collection of microbiological specimens
Blood cultures
Cerebrospinal fluid
Urine
Stool specimens
Throat swab
Nasopharyngeal aspirate
Nasal swab
Infection control in the emergency department
Needlestick injury
The child presenting with a (community) needlestick injury
Hospital staff exposure to blood-borne viruses
Immunisation
Immunisation of staff
Opportunistic immunisation
9.2. SARS-CoV-2
Introduction
Incubation and transmission
Epidemiology
History and examination
Investigations
Diagnosis
Differential diagnosis
Complications
Treatment
Prognosis
Prophylaxis: management of contacts
Current immunisation strategies
Section 10. Endocrinology and metabolic
10.1. Inborn errors of metabolism
Introduction
Physiology and pathogenesis
Clinical features
Investigation
Management
Correction of altered homeostasis
Reduction of toxic compound production
Removal/enhancement of excretion of toxic compounds
Chronic presentations
Extended newborn screening
Conclusion
10.2. Hypoglycaemia in the nondiabetic child
Introduction
The hypoglycaemia screen
Causes of hypoglycaemia
Endocrine causes
Metabolic causes
Pharmacological and toxic causes
Treatment of hypoglycaemia
10.3. Diabetic emergencies in children
Introduction
The child with suspected diabetes
The child with diabetic ketoacidosis
Initial management
Bedside:
Laboratory:
Rehydration
Reverse ketosis, correct acidosis and hyperglycaemia
Monitor and treat complications
Potassium
Cerebral oedema
Hypoglycaemia
Hyperchloraemic metabolic acidosis
Sepsis
Abdominal pain
Persisting acidosis
Identify and treat any precipitating event
The child with hypoglycaemia
The child with an insulin pump
The child with diabetes and intercurrent illness
The child with diabetes and surgery
10.4. Thyroid emergencies
Thyrotoxicosis
Symptoms
Signs
Neonatal thyrotoxicosis
Hypothyroidism
Congenital hypothyroidism
Hashimoto thyroiditis
10.5. Adrenal emergencies
Adrenal crisis
Introduction
Clinical presentation
History
Examination
Investigations
Differential diagnosis
Treatment
Fluid management
Replacement of corticosteroid
Hypoglycaemia
Hyperkalaemia
Disposition
Prevention
Cushing syndrome
Introduction
Presenting symptoms
Diagnostic testing
Treatment
10.6. Disorders of fluids, electrolytes and acid–base
Introduction
Physiology
Clinical assessment of hydration
Haemorrhagic shock
Fluid deficit
Oedema
Investigations
Treatment
Replacement of circulating volume
How much fluid?
How to administer fluid in shock
Investigation and management of fluids in different conditions
Dehydration
Sepsis and meningococcal disease
Haemorrhagic shock
Head injury
Burns
Diabetic ketoacidosis
Gastrointestinal loss
Renal loss
Insensible loss
Hypernatraemia and hypernatraemic dehydration
Diabetes insipidus
Hyponatraemia and hyponatraemic dehydration
Syndrome of inappropriate antidiuretic hormone secretion
Potassium disorders
Hyperkalaemia
Hypokalaemia
Maintenance fluids
Acid–base disorders
Metabolic acidosis
Metabolic alkalosis
Pyloric stenosis
Section 11. Haematology and oncology
11.1. The use of blood products in children
Introduction
Use of blood products in resuscitation1–4
Packed red blood cells1
Indications
Recommended initial dose of packed red blood cell transfusion
Adverse reactions
Platelets
Indications
General
Immune thrombocytopenia
Chemotherapy-induced thrombocytopenia7
Administration
Adverse reactions and other problems
Fresh frozen plasma
Administration
Cryoprecipitate
Clotting factor concentrates
Albumin
Indications
Administration
Adverse effects and risks
Normal human immunoglobulin
Hyperimmune immunoglobulins
Risks of blood component use2
Infections8
Transfusion-related acute lung injury
Transfusion-mediated immunomodulation
Transfusion-associated graft-versus-host disease
Other transfusion-related adverse reactions
11.2. Anaemia
Introduction
Production defect
Increased RBC turnover
Acute management
Neonatal anaemia
Physiological
Immune related
Neonatal infection
Haemoglobinopathies and enzymopathies
Blood loss
Anaemias of childhood
Iron deficiency
Stages
Causes
Adverse effects
Diagnosis
Treatment
Haemolytic anaemias
Acquired haemolytic anaemias
Autoimmune haemolytic anaemia
Nonimmune haemolytic anaemia
Erythrocyte fragmentation syndromes
Thrombotic thrombocytopenic purpura
Hereditary haemolytic anaemia
Glucose-6-phosphatase dehydrogenase deficiency
Hereditary spherocytosis
Haemoglobinopathies
Thalassaemias
Heterozygous β-thalassaemia
Homozygous β-thalassaemia
α-Thalassaemia
Sickle cell disease
Sickle cell trait
11.3. Disorders of coagulation
Vitamin K deficiency bleeding
Introduction
Clinical presentation
Investigations
Treatment
Haemophilia
Introduction
Clinical presentation
Investigations
Treatment
von Willebrand disease
Introduction
Clinical presentation
Investigations
Treatment
11.4. Platelet disorders
Introduction
Immune thrombocytopaenia
Introduction
Clinical presentation
Diagnosis
Management
Current treatments
Medical emergencies
Chronic immune thrombocytopaenia
11.5. Vasculitis
Introduction
Clinical presentation
Small-vessel vasculitis
IgA vasculitis (formerly Henoch-Schönlein purpura)
Anticytoplasmic-antibody-associated vasculitis
Granulomatosis with polyangiitis
Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss)
Medium-Vessel Vasculitis
Kawasaki disease
Polyarthritis nodosa
Clinical presentation
Investigation and treatment
Large-vessel vasculitis
Takayasu disease
Clinical presentation
Secondary vasculitis and vasculitis mimics
11.6. Acute leukaemia
Introduction
Classification
Clinical presentation
Differential diagnosis
Investigations
Prognosis
Complications
Hyperleukocytosis
Tumour lysis syndrome
Superior vena cava and superior mediastinal syndrome
Spinal cord compression
Management
11.7. Febrile neutropaenia
Introduction
Presentation
Investigations
Treatment
Low-risk children
11.8. Emergencies in paediatric oncology
Introduction
Fever and infection
Initial assessment
Gastrointestinal emergencies
Gastrointestinal bleeding
Gastrointestinal obstruction
Pancreatitis
Perforation
Infection and inflammation
Neutropaenic enterocolitis (typhlitis)
Perirectal abscess
Gastrointestinal complications of stem cell transplantation
Sinusoidal obstruction syndrome
Blood product use in oncology
Irradiation of blood products
Platelet transfusion
Blood transfusion
Cardiothoracic emergencies
Superior vena cava syndrome and superior mediastinal syndrome
Pneumonia
Pleural and pericardial effusions
Metabolic emergencies
Tumour lysis syndrome
Hyperleucocytosis
Sodium abnormalities
Hypercalcaemia
Genitourinary emergencies
Urinary tract obstruction
Other renal complications
Neurological emergencies
Seizures
Acute alterations in consciousness
Brain and spinal cord tumours in children
Brain tumours
Supratentorial brain tumours
Spinal cord compression
Conclusion
Section 12. Renal
12.1. Acute kidney injury
Introduction
Pathophysiology
Clinical presentation
Treatment
Acute presentation of chronic renal failure
Acute kidney injury in the renal transplant recipient
12.2. Haematuria
Introduction
Isolated microscopic haematuria
History
Examination
Investigations
Disposition
12.3. Hypertension
Introduction
History
Examination
Emergency department management
Severe hypertension
12.4. Urinary tract infection in preschool children
Introduction
History and examination
Diagnosis
Treatment
Age <3 months
Age 3 months to 3 years old
Age >3 years old
Antibiotic choice6,7
Parenteral treatment (IV/IM)
Oral treatment
Management after discharge from emergency department or observation wards
Prognosis
Prevention
12.5. Haemolytic uraemic syndrome
Introduction
Incidence
Pathophysiology
Pneumococcal-associated haemolytic uraemic syndrome
Complement-mediated haemolytic uraemic syndrome
History
Examination
Investigation
Coagulation tests (prothrombin time, partial thromboplastin time) are normal
Differential diagnosis
Management
Complications
Prevention
12.6. Idiopathic nephrotic syndrome
Introduction
Pathophysiology of proteinuria
Nephron and glomerular filtration barrier
Renal handling of albumin
Mechanisms of proteinuria
Definition of nephrotic syndrome
Classification of paediatric nephrotic syndrome
Epidemiology
Response to corticosteroids
Minimal change disease
Terminology of minimal change disease
Pathogenesis of minimal change disease
Primary (idiopathic) focal segmental glomerulosclerosis
Terminology of focal segmental glomerulosclerosis
Pathogenesis of primary focal segmental glomerulosclerosis
Clinical features of idiopathic nephrotic syndrome
Oedema
Other features
Investigations
Urine analysis
Blood tests
Imaging
Differential diagnosis
Complications of idiopathic nephrotic syndrome
Hypovolaemia
Infection
Thrombosis
Management of initial nephrotic phase
Immunisation
Corticosteroid medication
Management of proteinuria
Prophylactic antibiotics
Patient with frequent relapses of nephrotic syndrome or persistent nephrotic syndrome
Prognosis
12.7. Immunoglobulin A vasculitis
A note on nomenclature
Introduction
Epidemiology
Pathogenesis
Signs and symptoms
Investigations
Differential diagnosis
Acute haemorrhagic oedema of infancy
Treatment
Prevention
Preventing persistent kidney disease in patients with newly diagnosed IgA nephritis
Follow-up
Prognosis
Section 13. Trauma in children
13.1. Introduction to paediatric trauma
Prevalence
Prevention
Systematic paediatric trauma care
Primary survey
Catastrophic external haemorrhage control
A Airway and cervical spine control
B Breathing and oxygen delivery
C Circulation and haemorrhage control
D Disability
E Exposure and environment
Radiology during the primary survey
Early analgesia
Ongoing monitoring
Psychological support of child and family members
Secondary survey
Tertiary survey
Definitive care, disposition
Rehabilitation
13.2. Paediatric Neurotrauma
Introduction
Epidemiology
Pathophysiology
Classification
History
Examination
Glasgow Coma Scale
Investigations
Laboratory
Radiological
Skull X-rays
Computed tomography scan
Magnetic resonance imaging
Management
Mild traumatic brain injury
Moderate and severe traumatic brain injury
Airway control, oxygenation and ventilation
Circulation
Hypertonic saline
Mannitol
Positioning
Intracranial pressure monitoring
Antibiotics
Steroids
Thermoregulation: prophylactic hypothermia and prevention of hyperthermia
Decompressive craniectomy
Biomarkers
Disposition
13.3. Spinal injury
Introduction
Developmental anatomy and physiology
Initial assessment
Spinal immobilisation
Cervical spine injuries
Mechanisms of injury
Flexion
Extension
Rotation
Vertical compression
Clinical assessment
Radiographic images
Flexion and extension
Computerised tomography
Magnetic resonance imaging
Radiographic evaluation
Cervical spine clearance guidelines
Atlantoaxial rotatory subluxation
Thoracic and lumbar spine injuries
Mechanism of injury
Clinical assessment
Radiographic evaluation
Management
Spinal cord injury
Spinal cord injury syndromes
Clinical assessment
Radiographic evaluation
Treatment
Spinal cord injury without radiographic abnormality
13.4. Thoracic injuries in childhood
Introduction
Initial approach in the emergency department
Chest wall injury
Rib fractures
Pulmonary injury
Contusion
Pneumothorax
Tension pneumothorax
Pulmonary lacerations
Haemothorax1,14,16
Tracheobronchial injuries
Mediastinal injury
Aortic transection
Cardiac injuries
Commotio cordis
Penetrating cardiac trauma
Diaphragmatic injury
Oesophageal injury
Emergency department thoracotomy
13.5. Abdominal trauma
Important characteristics of paediatric patients with abdominal trauma
Anatomy
Physiology
Lethal trauma triad and thermoregulation
Physiological reserve
Weight-based dosing of medications and blood products
Mechanism of injury
Handlebar injuries
Seatbelt injuries
Assessment and management
History
Physical exam
Vital signs
Inspection
Palpation
Percussion and auscultation
Investigations
Laboratory testing
Focused assessment with sonography for trauma
Computed tomography
Initial management
Take-home message
13.6. Burns
Introduction
Pathophysiology
Classification
Superficial
Partial thickness
Superficial partial thickness
Deep partial thickness
Full thickness
History
Examination
Primary survey
Evaluation of burn area
Investigations
Management
Prehospital
Emergency department
Fluid resuscitation
Management of burns
Major burns
Minor burns
Superficial burns
Small superficial burns
Superficial facial burns
Partial-thickness/small full-thickness burns
Tetanus prone burns
Electrical burns
Introduction
Clinical effects
Skin
Cardiac
Muscular
Neurological
Renal
Other
Management
Specific issues
Burns
Fluids
Myoglobinuria
Compartment injury
Disposition
Admission
Discharge
Chemical burns
Treatment
13.7. Children in a disaster response
Introduction
Mass-casualty events
Types of disasters
Natural
Human-generated
Gradual onset/hybrid
What disasters affect children?
What are children’s vulnerabilities in disasters that affect disaster planning?
Disaster planning and response
Response
Care for the carers
Training and testing disaster plans
Conclusion
13.8. Wound Management
Introduction
Anatomy of the skin
Pathophysiology of wound healing
Wound infection
Classification of wounds
Evaluation of the patient with a laceration
History
Examination
Investigation
Treatment of wounds
Wound anaesthesia
Wound preparation and cleansing
Antibiotic prophylaxis
Wound closure
Sutures
Needles
Suturing techniques
Staples
Tissue adhesives
Skin tapes
Post-wound-closure care
Dressing and suture removal
Immobilisation and drains
Treatment of selected injuries
Abrasions
Eyelid lacerations
Lip lacerations
Tongue lacerations
Fingertip amputation
Nailbed lacerations
Subungual haematoma
Puncture wounds to the foot
Bites
Animal bites
Human bites
Section 14. Orthopaedics and rheumatology
14.1. Orthopaedics and rheumatology
Introduction
The child with acute musculoskeletal pain or dysfunction
General approach
Assessment
History
Body proportions
Physiology of developing bone
Joints and ligaments
Exposure to mechanisms
Immunology
Psychology
Healing
Examination
Investigations
Pathology
Radiology
Plain radiographs
Ultrasound
Bone scintigraphy
Magnetic resonance imaging
Generalised or multifocal bone/joint pain
Introduction
History
Examination
Investigations
Specific conditions
Infection
Postinfectious (immune-mediated)
Inflammatory/vasculitic
Neoplastic
Haematological
Neoplastic presentations
Bone tumours
Other important subacute paediatric musculoskeletal presentations
Traction apophysitis
Torticollis
Vertebrospinal inflammation
Conclusion
14.2. The child with a limp
Introduction
History
Trauma
Infection (point focus)
Postinfective
Inflammatory
Primary bone disorders
Neoplastic
Haematological
Physical
Psychological and idiopathic pain syndromes
Abdominal
Spine
Examination
Investigation
Clinical decision-making in a child with a limp
Relative immune deficit
Injury mechanism
Joint disease
Specific conditions
Transient synovitis
History
Clinical examination
Differential diagnosis
Management
Prognosis
Septic arthritis and osteomyelitis
Introduction
Presentation
Microbiology
Management
Prognosis
Prevention
Most common (80% of most isolates)
Other organisms
Perthes disease
Pathophysiology
Emergency department presentations
Slipped upper femoral epiphysis
Epidemiology and pathophysiology
Clinical presentation
Differential diagnosis
Treatment
Complications
14.3. Fractures and dislocations
Fracture patterns in childhood
Initial assessment and management
Upper limb and shoulder girdle injuries
Clavicular fractures
Fractures
Presentation features
Assessment
Refer
Shoulder dislocation
Proximal humerus
Midshaft humeral fractures
Injuries to the elbow region
Supracondylar fracture
Management of supracondylar fractures
Intercondylar (T-condylar) fracture
Lateral condyle
Medial epicondylar avulsion
Pulled elbow (radial head subluxation)
Reduction of radial head subluxation
Elbow dislocation
Proximal radial and ulnar fractures
Olecranon fractures
Radial neck fractures
Monteggia fracture-dislocation
Midshaft radial and ulnar fractures
Distal radial and ulnar fractures
Distal radial epiphyseal fractures
Carpal injuries: the scaphoid
Metacarpal fractures
Phalangeal fractures
Thumb fractures
Fingertip injuries
Lower limb and pelvis injuries
Pelvic fractures
Hip dislocation
Femoral fractures
Injuries about the knee
Distal femoral physeal separation
Tibial spine injury
Avulsion of tibial tubercle
Patellar dislocation
Patellar fractures
Lower leg fractures
Ankle fractures
Tillaux fracture
Triplane fracture
Inversion injuries
Conclusions
Future directions
14.4. Risk management in acute paediatric orthopaedics
Introduction
Nonidentification or delayed identification of paediatric fractures
Low-risk fractures
Adverse events in acute paediatric orthopaedics
Section 15. Dermatology
15.1. Dermatology
Introduction
Erythroderma and skin failure
Vesiculobullous eruptions
Infections
Inflammatory
Immune mediated
Photosensitive dermatoses
Drug induced
Pustular eruptions
Infectious
Inflammatory
Drug induced
Papular eruptions (widespread)
Infectious
Inflammatory
Infectious
Tumours
Inflammatory
Red scaly (papulosquamous) eruptions
Inflammatory
Infectious
Red blanching (erythematous) eruptions
Infectious
Inflammatory
Vascular
Drug
Petechiae and purpura
Infectious
Inflammatory
Haematological
Trauma
Tumours
Malformations
Hyperpigmentation (widespread)
Hyperpigmentation (localised)
Hypopigmentation
Anogenital rashes
Inflammatory
Infectious
Hair and scalp
Itchy
Hair loss
Nails
Painful
Discoloration
Management
Vesiculobullous rashes
Varicella (chickenpox)
Management
Zoster
Management
Hand, foot and mouth disease
Herpes simplex infection
Management
Eczema herpeticum
Management
Impetigo (School sores)
Management
Staphylococcal scalded skin syndrome
Management
Erythema multiforme
Management
Reactive infectious mucocutaneous eruption
Stevens-Johnson syndrome/toxic epidermal necrolysis
Management
Dermatitis herpetiformis
Management
Other immune-mediated blistering disorders
Isolated blisters
Chronic erosions or ulcers
Management
Prevention
Sunburn and photosensitivity
Primary photosensitivity disorders
Polymorphous light eruption
Juvenile spring eruption
Hydroa vacciniforme
Solar urticaria
Porphyrias and other inherited disorders with photosensitivity
Erythropoietic protoporphyria
Congenital erythropoietic porphyria
Familial porphyria cutanea tarda
Photosensitivity and bullous reactions to drugs
Management
Photosensitivity reactions to plants
Management
Plant contact dermatitis
Id reactions
Pustular rashes
Acne
Management
Acne and depression
Acne fulminans
Management
Acne with Gram-negative folliculitis
Early onset acne
Atypical acneiform rashes
Folliculitis
Acute generalised exanthematous pustulosis
Pustular psoriasis
Papular (raised) rashes
Scabies
Management
Papular acrodermatitis of childhood
Management
Papular urticaria
Management
Molluscum
Management
Adnexal tumours: pilomatricoma
Keratosis pilaris
Management
Granuloma annulare
Langerhans cell histiocytosis
Management
Juvenile xanthogranulomas
Xanthomas
Angiofibromas in tuberosclerosis
Red scaly (papulosquamous) rashes
Psoriasis
Management
Tinea corporis
Management
Pityriasis rosea
Management
Secondary syphilis
Seborrhoeic dermatitis
Management
Lichen striatus
Eczematous rashes
Atopic eczema: general issues
Atopic eczema: general management principles:
Atopic eczema: dietary principles
Atopic eczema: use of topical corticosteroid preparations
Systemic effects of topical steroid use
Local effects of topical steroid use
Atopic eczema: acute flare
Atopic eczema: admission to hospital
Atopic eczema: generalised infantile
Atopic eczema: facial
Atopic eczema: perioral eczema versus juvenile rosacea
Perioral eczema
Juvenile rosacea
Atopic eczema: periorbital
Atopic eczema: molluscum
Atopic eczema: discoid
Atopic eczema: juvenile plantar dermatosis
Atopic eczema with systemic associations
Irritant contact dermatitis
Allergic contact dermatitis
Generalised dry skin: ichthyosis
Generalised dry skin: ectodermal dysplasias
Red blanching rashes (erythematous)
Fever and exanthem
Scarlet fever
Toxic shock syndrome
Kawasaki disease
Erythema infectiosum
Roseola infantum
Enteroviruses
Infectious mononucleosis
Measles
Rubella
Unilateral laterothoracic exanthem
Management
Urticaria
Serum sickness
Management (see urticaria)
Lupus erythematosus
Neonatal lupus erythematosus (see Chapter 4.3, Neonatal dermaology) Juvenile dermatomyositis
Juvenile idiopathic arthritis
Erythema nodosum
Management
Necrobiosis lipoidica
Palmoplantar hidradenitis
Pernio (chilblains)
Spider naevi
Other erythematous rashes
Purpuric rashes
Fever and petechiae
Fever and petechiae in an unwell child (including meningococcal sepsis)
Fever and petechiae in a well child
Meningococcal sepsis and other septicaemia
Vasculitis and IgA vasculitis (Henoch-Schönlein purpura)
Thrombocytopenic purpura
Leukaemia
Coagulation disorders
Child abuse
Artefactual purpura
Papular-purpuric gloves-and-socks syndrome
Dusky purple nodules on hands and feet
Chronic pigmented purpura
Other causes of childhood purpura
Vascular tumours: haemangiomas and haemangioma variants
Haemangiomas of infancy
Association with stridor
Eye involvement
Involvement of facial structures
Ulceration
Macular facial lesions
Sudden onset of swelling and bruising in a large vascular lesion
Multiple haemangiomas (diffuse neonatal haemangiomatosis)
Cardiac failure with a hepatic mass
Management
Congenital haemangioma
Kaposiform haemangioendothelioma/tufted angioma
Pyogenic granuloma
Management
Vascular malformations
Neonatal vascular malformations
Facial nevus simplex (small pink/red stains on the eyelids/central forehead)
Facial capillary malformations (port-wine stain)
High-flow lesions
Symptoms of vascular malformations
Pain, swelling
Bleeding, coagulopathy
Chest pain or shortness of breath
Intestinal bleeding, anaemia
Bladder or bowel dysfunction in older children
Leg length discrepancy
Multiple telangiectatic vessels
Fabry disease
Management of vascular malformations
Hyperpigmentation
Diffuse hyperpigmentation
Localised macular hyperpigmentation: including café au lait macules
Neurofibromatosis
McCune-Albright syndrome
Incontinentia pigmenti
Peutz-Jeghers syndrome
Segmental pigmentary disorder (including linear and whorled hyperpigmentation and hypopigmentation of Ito)
Mastocytosis
Presentations with dermal (blue/grey) pigmentation
Postinflammatory hyperpigmentation
Dermal melanocytosis (Mongolian spot)
Naevus of Ota
Localised raised hyperpigmentation
Congenital pigmented naevi
Management
Acquired pigmented naevi
Dysplastic naevi
Halo naevi
Spitz naevi
Hypopigmentation
Pityriasis versicolor
Pityriasis alba
Vitiligo
Postinflammatory hypopigmentation
Linear and whorled hypopigmentation (‘hypomelanosis of Ito’)
Tuberous sclerosis
Generalised hypopigmentation
Skin texture
Lax skin
Firm or thickened skin
Mouth disorders
Primary herpetic gingivostomatitis
Herpangina
Transient lingual papillitis
Angular cheilitis
Geographic tongue
Recurrent mouth ulcers
Anogenital rashes
Irritant napkin dermatitis
Management
Candida napkin dermatitis
Anogenital psoriasis
Perianal streptococcal dermatitis
Management
Staphylococcal-mediated anogenital rashes
Herpes simplex virus
Varicella
Threadworms
Lichen sclerosus
Vulval itch/vulvitis in prepubertal girls
Zinc and other nutritional deficiencies
Malabsorption
Langerhans cell histiocytosis
Constipation
Anogenital papules and lumps
Anogenital warts
Molluscum
Congenital syphilis
Immunodeficiency states
Hair problems
Head lice
Tinea capitis
Kerion (inflammatory ringworm)
Alopecia areata
Management
Traumatic alopecia
Management
Diffuse hair loss
Hypertrichosis
Hirsutism
Nail problems
Paronychia
Acute paronychia (inflammation of the nail fold)
Chronic paronychia
Management
Nail psoriasis
Ingrown toenail
Tinea unguium (onychomycosis)
Itch without rash
Collection of specimens
Bacterial swabs (Gram stain and culture)
Swabs for herpes simplex virus or varicella-zoster virus
Swabs for polymerase chain reaction (for pertussis, varicella-zoster virus, herpes simplex virus, Mycobacterium ulcerans, etc.)
Swabs for Chlamydia trachomatis
Skin scrapings for fungal/dermatophyte culture
Section 16. Ophthalmology
16.1. Ophthalmological emergencies
Introduction
History
Examination
Reduced pupil light response
The red eye in paediatrics
The red eyelid
Preseptal versus orbital cellulitis
Blepharitis
Hordeolum (stye)
Chalazion (meibomian cyst)
Dacryocystitis
Dacryoadenitis
The red eye
Conjunctivitis
Neonatal conjunctivitis
Conjunctivitis in older children
Allergic conjunctivitis
Keratitis
Recurrent corneal erosion
Uveitis
Episcleritis and scleritis
16.2. Congenital, developmental and neoplastic conditions of the eye
Deficits in visual acuity
Strabismus
Paediatric cataracts
Congenital nasolacrimal duct obstruction
Infantile glaucoma
Ocular tumours
Retinoblastoma
Rhabdomyosarcoma
Neuroblastoma
16.3. Ocular trauma
Introduction
Time-critical ocular trauma
Retrobulbar haemorrhage
Chemical eye injury
Open globe injury
Globe trauma
Subconjunctival haemorrhage
Conjunctival lacerations
Corneal abrasion
Corneal foreign bodies
Corneal lacerations
Hyphaema
Eyelid trauma
Ecchymosis
Orbital trauma
Thermal burns
Traumatic iritis
Nonaccidental injury
Section 17. ENT and dental
17.1. The ear
Otitis externa
Introduction
History
Examination
Investigations
Treatment
Prevention
Complications
Acute otitis media
Introduction
History
Examination
Investigations
Treatment
Complications
Prevention
Discharging otitis media: chronic suppurative otitis media
Introduction
History
Examination
Investigations
Treatment
Complications
Otitis media with effusion
Introduction
History
Examination
Investigations
Treatment
Complications
Mastoiditis
Introduction
History
Examination
Investigations
Treatment
Complications
Trauma
Introduction
History and examination
Investigation
Treatment
Complications
17.2. The nose
Rhinitis and sinusitis
Introduction
History
Examination
Investigations
Treatment
Complications
Prevention
Epistaxis
Introduction
History
Examination
Investigations
Treatment
Complications
Nasal trauma
Introduction
History and examination
Investigations
Treatment
Complications
Epistaxis
Nasal trauma
17.3. The mouth and throat
Stomatitis
Introduction
History
Examination
Investigations
Differential diagnosis
Treatment
Complications
Pharyngitis/tonsillitis
Introduction
History
Examination
Investigations
Treatment
Complications
Peritonsillar abscess
Introduction
History and examination
Investigations
Treatment
Complications
Posttonsillectomy haemorrhage
Introduction
History
Examination
Investigations
Treatment
Complications
Oral/dental trauma
Introduction
History
Examination
Investigations
Treatment
Luxation
Avulsion
Intrusion
Root fractures
Hard tissue injuries
Soft tissue injuries
Prevention
Oral/dental infection
Introduction
History
Examination
Investigations
Treatment
Prevention
Other dental issues
Spontaneous oral haemorrhage
Pharyngitis/tonsillitis
Tonsillectomy
Oral/dental trauma
Oral/dental infection
17.4. Retropharyngeal abscess
Introduction
History
Examination
Investigation
Treatment
17.5. Foreign bodies of the nose and throat plus caustic ingestions
Nasal foreign bodies
Introduction
History
Examination
Investigations
Treatment
Complications
Aural foreign bodies
Introduction
History
Examination
Investigation
Treatment
Complications
Caustic ingestion
Introduction
History
Examination
Investigations
Treatment
Complications
Prevention
Section 18. Obstetrics and gynaecology
18.1. Paediatric gynaecology
Infant and prepubescent gynaecology
Vaginal discharge
Introduction
History
Examination
Investigations
Management
Vaginal bleeding
Introduction
Hormonal causes
Nonhormonal causes
Nonvaginal causes of bleeding
History
Examination
Investigations
Management
Adolescent gynaecology
Vaginal discharge and sexually transmitted infections
Introduction
History
Examination
Investigations
Management
Disposition
Abnormal vaginal bleeding
Introduction
Examination
Investigations
Management
Disposition
Pelvic pain
Introduction
History
Examination
Investigations
Management
Disposition
18.2. Emergency contraception
Introduction
Clinical assessment
Available medicines
Medication interactions
Medicine contraindications
Medicine adverse effects
Medicine outcomes
Copper intrauterine devices
Section 19. Male genitalia
19.1. Male genitalia
The acute scrotum
Introduction
Torsion of a testicular or epididymal appendage
Torsion of the testis
Epididymo-orchitis
Idiopathic scrotal oedema
Henoch-Schönlein purpura
Testicular tumours
Irreducible inguinal hernia
Rupture of the testis
Acute hydrocele
Acute problems of the penis and foreskin
Introduction
Adhesions
Smegma
Phimosis of the foreskin
Balanitis
Paraphimosis
Meatal stenosis
Priapism
Section 20. Adolescent medicine in the emergency department
20.1. Adolescent medicine in the emergency department
Introduction
Adolescent health problems in the emergency department
Support in times of crisis
Kids Helpline (www.kidshelp.com.au)
Lifeline (www.lifeline.org.au)
Beyond Blue (www.beyondblue.org.au)
Resources focusing on young people’s health and well-being
Headspace (www.headspace.org.au)
Reach Out (www.au.reachout.com)
Alcohol and substance use
Australian Alcohol and Drug Foundation (www.adf.org.au)
Family Drug Support Australia (www.fds.org.au)
Legal Information
Youth Law Australia (www.yla.org.au)
The approach to the adolescent in the emergency department
Establishing rapport
Seeing adolescents alone
Psychosocial screening
Using the HEEADSSS framework
H Home
E Education (or employment)
E Eating and exercise
A Activities
D Drugs
S Sexuality and Gender
S Suicide
S Safety
Confidentiality
The mature minor principle
Physical examination
Linking adolescents with community follow-up
Conclusion
Facilities for managing aggressive, intoxicated or distressed adolescents
Opportunistic health screening
20.2. Eating disorders and anorexia
Introduction
Anorexia nervosa
History
Examination
Investigations
Weight profile
Restriction and diet history
Associated behaviours with eating
Exercise
Body dysmorphic concerns
Complications
Differential diagnosis
Management
Goals of management in the emergency department
Consider medical admission for patients with4,5,8,9:
Feeding
Refeeding syndrome
Prognosis
Bulimia nervosa
Section 21. Psychlatric
21.1. Paediatric psychiatric emergencies
Introduction
General approach
Assessment
History
Collateral history
Examination
Investigations
Synthesis of assessment
Common paediatric psychiatric presentations
The acutely disturbed child
Suicidal attempts and intentional self-harm
Introduction
Assessment
Engagement
Medical evaluation
Preliminary suicide evaluation including psychosocial history
Mental health assessment
Hazards during assessment
Management
Maintaining safety in the emergency department
Medical care
Safety planning
Arranging follow-up after the attempt
Suicidal patients: important considerations
Anxiety disorders
Psychosis
Psychosis and other psychiatric disorders
Nonpsychotic hallucinations
Psychosis and hallucinations induced by an underlying medical condition
Treatment
Other psychiatric presentations
Acute dystonic reactions
Night terrors
History
Management
Excessive use of electronic screens
21.2. Acute behavioural disturbance in children and young people
Introduction
Arousal
Behaviour
Containment
Cognitive processes
The principles of psychiatric triage
Purpose of triage
Pre triage
The hierarchy of needs
Management
Behaviours that usually calm the patient and deescalate aggression
Practice
Avoid
The four main themes
Safety plan and risk management
Time is risk
Managing the ABCC including restraint and acute sedation
Sedating the young brain
Tracking the seven stages of sedation
Five tips on sedating young people
Treating comorbid medical disorder
Mental state signs of organic dysfunction
Treating comorbid psychiatric disorder
Differential diagnosis: psychiatric
Identify patient’s threat to themself
Managing a threat to themself
Identify medical risks
Manage specific medical risks
Three tips for monitoring young people
Transfer is a potential escalation of risk
The special problem of the autistic spectrum disorders
Conclusion
Controversies in the immediate term
Controversies in the medium term
Controversies in the long-term
Section 22. Crisis intervention
22.1. Sexual assault
Introduction
Definitions
Attitudes/myths surrounding child sexual assault
Epidemiology of child sexual assault
Child sexual assault and emergency medicine
Recognition of child sexual assault
Signs and symptoms
Nonspecific
Specific
Genitoanal injury
Sexually transmitted infections
Diagnostic considerations
Role of the emergency physician
Documentation
Mandatory reporting legislation
Long-term effects
22.2. Child at risk
Introduction
Definition
Physical abuse
Presentation
History
Physical examination
Bruising of the skin
Laceration and abrasion of the skin
Burns or scalds
Fractures
Eye injuries
Ear injuries
Head injuries
Intraabdominal injury
Sentinel injuries
Investigations
Emotional abuse
History and examination
Neglect
History and examination
Treatment
Medical child abuse
The community response to the child at risk
Responsibilities to report
What to do as the medical practitioner, in suspected cases
Legal responsibilities
Role of child protection agency
Section 23. Poisoning
23.1. General approach to poisoning
Introduction and epidemiology
Diagnosis
Risk assessment
Investigations
Resuscitation
Decontamination
Antidotes
Enhanced elimination
Supportive care
Consultation and disposition
23.2. Specific poisons
Common poisons
Paracetamol
Nonsteroidal antiinflammatory drugs
Benzodiazepines
Opioids
Anticholinergics and antihistamines
Corrosive ingestions
Rare and dangerous poisons
Salicylates
β-Blockers
Calcium-channel blockers
Digoxin
Clonidine
Iron
Warfarin and rodenticides
Oral hypoglycaemics
Tricyclic antidepressants
Toxic alcohols
Psychostimulants
Essential oils
Organophosphates and carbamates
House fires
Section 24. Envenomation
24.1. Envenomation
Introduction
Snakebite
Introduction
History
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
Future directions
Scorpion stings
Introduction
History
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
Spiderbite
Introduction
History
Australian funnel web spiders
Widow spiders including Australian redback spiders
Banana spiders
Recluse or fiddleback spiders
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
Tick bite paralysis
Introduction
History
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
Jellyfish stings
Introduction
Box jellyfish
Irukandji syndrome
Portuguese man-of-war
History
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
Venomous fish stings
Introduction
History
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
Venomous marine molluscs
Introduction
History
Examination
Investigations
Differential diagnosis
Treatment
Prognosis
Prevention
24.2. Drowning
Introduction
Definition
Epidemiology
Aetiology
Pathophysiology
History
Examination
Investigations
Differential diagnosis
Treatment
Disposition
Prognosis
Prevention
24.3. Heat-induced illness
Introduction
Causes of heat-related illness
Clinical syndromes
The neonate/infant
Heat syncope
Heat cramps
Heat exhaustion
Heat stroke
Other heat-related syndromes
Investigations
Management
Heat syncope and heat cramps
Heat exhaustion
Heat stroke
Malignant hyperthermia
Serotonin syndrome, neuroleptic malignant syndrome and anticholinergic syndrome
Prognosis and disposition
24.4. Cold injuries
Introduction
Normal thermal physiology: A review
Hypothermia
Perfusing rhythm present
Perfusing rhythm not present
History
Examination
Diagnosis
Treatment
Prehospital treatment
Treatment in the emergency department
Neonatal resuscitation
Complications
Disposition
Localised cold injuries
Frostbite
Clinical features and diagnosis
Treatment
Disposition
Hypothermia not due to environmental causes
24.5. Anaphylaxis and food reactions
Introduction
Pathophysiology
Aetiology
Clinical features
Investigations
Treatment
Adrenaline
Airway and breathing
Circulation
Supplemental treatment
Duration of treatment
Admission/observation
Diagnosis
Types of anaphylaxis
Common
Less common
Uncommon
Recurrent anaphylaxis
Differential diagnosis
Prevention
Future directions and research
Section 25. Administration in EMS
25.1. Managing the death of a child in the emergency department: Bereavement issues
Introduction
Clinical
Operational
Legal and forensic
Ethical
Spiritual and emotional
Follow-up care for family
Follow-up care for team
The resuscitation process
Talking to parents and families
Laying out of the child
Viewing the body: quiet suite
The grief response
Support of the family
Cultural implications
Legal issues
Organ and tissue donation and collection
Debriefing and support for emergency department staff
Collaboration with paediatric palliative care services
The concept of a good death
Conclusion
Section 26. Transport and retrieval
26.1. Paediatric emergency retrieval
Paediatric retrieval
What is different about children?
Paediatric emergency referrals
Paediatric referral and retrieval: roles and expectations
The referrer
The coordinator/administrator
The paediatric retrieval specialist
The paediatric emergency transport team
Paediatric retrieval staff
Paediatric retrieval equipment
Airway
Difficult airway
Breathing
Circulation
Monitoring
Ultrasound
Anaesthetic agents
Muscle relaxants
Cardiovascular medications
Sedation and antidote
Antibiotics
Antiepileptics
Asthma treatment
Other
Criteria for transport
Degrees of urgency
Time-critical retrieval
General conditions requiring urgent referral
Definitions
Transport platforms
Road ambulance
Rotary wing aircraft
Fixed-wing aircraft
Weather
While waiting
Stabilisation
Communication and retrieval leadership
Framework for communications during paediatric retrieval
Interface with adult retrieval
Parents
Paediatric retrieval and end-of-life situations
Quality
Conclusion
26.2. Sick child in a rural hospital
Introduction
Challenges in the rural setting
Income
Housing
Education
Culture
The illnesses
Birth history
Trauma
Infection and diet
The health services
Caring for the critically ill child
Decisions to consider when child presents with an emergency
Coordination of a resuscitation team prior to the child’s arrival
Potential problems in the stabilisation of the child
What can be done to assist care in remote environments?
Personnel
Education
Content of training
Consultation support
Transport
Management protocols
Hospital facilities
Relations between rural and urban hospitals
Section 27. Teaching paediatric emergency medicine
27.1. Web-based resources
Accessing web-based resources
Needs of paediatric emergency medicine staff
Educational tools available online
Social media
Pitfalls of online content
Links
Conflict of interest
27.2. Teaching paediatric emergency medicine
Introduction
Desirable attitudes in paediatric emergency medicine
Humility
Caring
Empathy and compassion
Nonjudgemental approach
Honesty and integrity
Advocacy and healthy paternalism
Self-monitoring and awareness of cognitive errors
Skill set for paediatric emergency medicine
Effective communication
Skillful clinical examination
Mastering procedural skills
Learning to teach
Self-preservation
Putting knowledge into perspective
Helping others acquire knowledge, skills and attitudes
Engagement
Feedback
Learning resources
People
Books
Other media
Distance learning and virtual environments
Simulation
Pandemic challenges
Conclusion
Section 28. Paediatric research in the emergency department
28.1. Research in children in the emergency department
Introduction
Research science
Research question
Literature review
Types of studies
The ethics of medical research
Key principles
Ethics of research involving children
Ethics review process
The practice and governance of research
Research documents
Research protocol
Case report forms
Patient information statement and consent form
Study document file
The research team
Databases and analysis
Reporting guidelines
Key regulatory documents
International Conference on Harmonisation of Good Clinical Practice guidelines (ICH-GCP)12
National- and state-based regulations
Project registration
Privacy and confidentiality
Implementation research
Multicentre research
Funding research
Section 29. Common procedures
29.1. Estimating the weight of infants and children
Background
Age-based tools to estimate body weight
Best guess formula
Length- and body-habitus–based tools
Tips
29.2. Basic airway management techniques
Background
Oropharyngeal and nasopharyngeal airways
Indications
Contraindications
Nasopharyngeal airway
Oropharyngeal airway
Equipment
Preparation
Nasopharyngeal airway
Oropharyngeal airway
Positioning
Procedure
Nasopharyngeal airway
Oropharyngeal airway
Complications
Tips
Laryngeal mask airway
Indications for laryngeal mask airway
Equipment
Preparation
Positioning
Procedure
Complications
Tips
Bag–valve-mask and flow-inflating mask ventilation
Indications
Contraindications
Relative contraindication
Bag–valve-mask equipment
Preparation
Positioning
Procedure
Complications
Tips
Flow-inflating bag
Equipment
Preparation
Procedure
29.3. Noninvasive ventilation
Noninvasive continuous positive pressure ventilation
Indications
Contraindications
Relative contraindications
Humidified high-flow nasal prong oxygenation
Equipment
Procedure
Complications
Tips
T-piece ventilation device
Equipment
Procedure
Complications
Tips
Continuous positive airway pressure/biphasic positive airway pressure
Equipment
Contraindications
Relative contraindications
Procedure
Complications
Tips
29.4. Endotracheal intubation
Background
Indications
Contraindications
Equipment
Preparation
Laryngoscope
Endotracheal tube
Positioning
Procedure
Complications
Tips
Confirmation of intubation
Background
Indications
Contraindications
Equipment
Preparation and positioning
Procedure
Digital capnography
End-tidal colorimetric capnometer
Complications
Tips
29.5. The surgical airway
Background
Indications
Contraindications
Needle cricothyroidotomy
Equipment
Preparation
Procedure
Complications
Tips
Surgical cricothyroidotomy
Equipment
Optional
Preparation
Procedure
Guidewire or Seldinger technique
Preparation and procedure
Complications
Tips
29.6. Chest procedures
Introduction
Needle thoracostomy
Background
Indications
Contraindications
Equipment
Preparation
Procedure
Complications
Tips
Tube thoracostomy
Background
Indications
Contraindications
Equipment
Preparation
Procedure
Inserting the tube
Securing the tube
Complications
Tips
Three-sided dressing
Background
Indications
Contraindications
Equipment
Preparation
Procedure
Pericardiocentesis
Background
Indications
Contraindications
Equipment
Emergent procedure
Nonemergent procedure
Indwelling catheter
Standard preparation
Nonemergent procedure
Procedure
Nonemergent procedure
Complications
Tips
29.7. Removing and replacing a tracheostomy tube
Background
Indications for emergent replacement
Contraindications
Equipment
Preparation
Procedure
Removing an old tracheostomy tube
Replacing the tracheostomy tube
Option 1. Using a new tracheostomy tube
Option 2. Using an endotracheal tube
Option 3. Using a suction catheter as a guide
Option 4. Endotracheal intubation and other rescue measures
Securing the tracheostomy tube
Complications
Tips
29.8. Central and peripheral intravenous lines
Background
Indications
Contraindications
Peripheral venous catheter placement
Equipment
Preparation
Procedure
Complications
Local complications
Systemic complications
Tips
Central venous line placement
Equipment
Preparation
Procedure
Complications
Tips
29.9. Intraosseous access
Background
Indications
Cardiopulmonary arrest
Contraindications
Relative contraindications
Equipment
Preparation
Identification of the entry site
Positioning the child
Selecting the correct side
Procedure
Complications
The EZ-IO intraosseous vascular access system
Tips
29.10. Umbilical vessel cannulation
Background
Indications
Contraindications
Equipment
Preparation
Procedure
Umbilical vein catheterisation
Umbilical artery catheterisation
Complications
Tips
29.11. Defibrillation
Background
Current technology for defibrillators
Pads versus paddles
Asynchronous versus synchronous
Indications for defibrillation (asynchronous)
Indications for synchronous cardioversion
Contraindications
Equipment
Standard preparation
Standard procedure
COACHED
Automated external defibrillators procedure
Complications
Tips
29.12. Transurethral catheterisation and suprapubic bladder aspiration
Background
Indications
Indications for transurethral catheterisation
Indications for suprapubic bladder aspiration
Contraindications
Urethral catheterisation
Suprapubic aspiration
Transurethral catheterisation
Equipment
Preparation
Procedure
Complications
Tips
Suprapubic aspiration
Equipment
Preparation
Procedure
Complications
Tips
29.13. Lumbar puncture
Background
Indications
Contraindications
Equipment
Preparation and positioning
Lateral decubitus position
Sitting position
Procedure
Complications
Local
Central nervous system/systemic
Tips
29.14. Reduction of paediatric inguinal hernias
Introduction
Preparation
Procedure
Inguinal hernias in girls
Complications
29.15. Paraphimosis reduction
Introduction
Indications
Contraindications
Procedures
Noninvasive methods
Invasive methods
The Dundee technique
Postreduction management
Contraindications to attempted reduction
Complications
Tips
29.16. Gastrostomies and other enteral feeding devices: trouble shooting in the emergency department
Background
Anatomy of a percutaneous endoscopic gastrostomy tube
Percutaneous endoscopic gastrostomy insertion method
Complications
Percutaneous endoscopic gastrostomy displacement
Buried bumper
Gastrocolocutaneous fistula
Peristomal leak
Peristomal infection
Mechanical problems: blockage
Jejunal feeding devices
Granulation tissue
Section 30. Ultrasound
30.1. Ultrasound
30.2. Diagnostic ultrasound in paediatric emergency medicine
Introduction
Haemodynamic assessment with ultrasound
Lung ultrasound
Musculoskeletal
Abdominal ultrasound
Neurological
30.3. Ultrasound guidance for procedures
Ultrasound guidance for procedures
Vascular access
Peripheral venous access
Central venous access
Suprapubic aspiration
Nerve blocks
Foreign body identification and removal
Joint aspiration
Neonatal lumbar puncture
Confirmation of nasogastric tube position
Fracture reduction
30.4. Incorporating ultrasound into paediatric resuscitation
Introduction
Undifferentiated severe respiratory distress
Intubation
Cardiac arrest
Shock
Assessment of fluid status and the response to fluid therapy
Serial evaluations at the bedside
Conclusion
Index

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Peter Cameron

Gary J. Browne

Biswadev Mitra

Stuart Dalziel

Simon Craig