Family health diploma Pediatric lecture On importance of to check general danger

signs.

Dr .Shazia Memon Associate Professor

Learning objectives Identify general danger signs.How to check the child for general danger

signs Know the D/D of child with convulsion,

lethargy or coma. To give pre referral treatment.Base line investigations.

A general danger sign is present if:

The child is not able to drink or breast feedThe child vomits every thing The child has had convulsions during current

illnessThe child is lethargic or unconsciousThe child is convulsing now.

Assess For General Danger Sign

Ask:•Is the child not able to drink or feed?•Does the child vomit every thing ?•Has the child has convulsions?

Look:•See if the child is lethargic or unconscious.•See if the child is convulsing now.

CHECK FOR GENERAL DANGER SIGNS

WHEN YOU CHECK FOR GENERAL DANGER SIGNSASK: Is the child not able to drink or breast feed?A child has the sign “not able to drink or breast feed” if he

child is not able to suck or swallow when offered a drink or breast milk.

Causes:CNS infections . Acute gastroentritis with severe dehydration.SepsisThroat abscess

DOES THE CHILD VOMITS EVERY THING?A CHILD WHO IS NOT ABLE TO HOLD ANY

THING DOWN AT ALL HAS THE SIGN ”VOMITS EVERY THING”

CAUSESLethargic/unconscious Acute gastroenteritis with severe dehydrationIntestinal obstructionsepsis

HAS THE CHILD HAD CONVULSIONS ?CONVULSION: Paroxysmal, time limited

change in motor activity and/or behaviour that results from abnormal electrical activity in the brain

CAUSES:

Causes In favour

Meningitis •History of high grade fever•Recurrent history of otitismedia•Neck stiffness•Signs of meningial irritation•Petachial rashes (meningiococal meningitis)•Tense or bulging fontenelle•Abnormal posture•CSF suggestive of

Encephlitis •Reccent history of gastroentritis•Irritibility/behavioural changes•Raised ICP•Csf

T.B meningitis •Hx of contact with t.b patient •Hx of weight loss•Low grade fever•Loss of appetite•Focal neurologicalsigns•Cranial nerve palsy •Labs: CXR ,Sputum AFB, montoux test,

Febrile convulsions •Age 6 months to 5 years•High grade fever•No loss of consciousness•Positive family Hx

Head trauma

Poisoning •Hx of poison ingestion or drug over dose

Hypertensive Encephalopathy •Hx of head ache •Vomiting •Irritibility•Raised blood pressure

Diabetic ketoacidosis •Hx of polydypsia, polyphagia, polyurea•Hx of weight loss•Acidotic breathing•Labs: High blood sugar Urinary ketones

Dr. Shazia Memon Assistant professor

Learning objectives At end of session you become able to: Take relevant history.Know the D/D of child with convulsion or

comaKnow the out-patient management of child

presenting with convulsion /coma and identify the pre referral treatment.

know in-patient management of child presenting with convulsion /coma.

Learning objectives Following Skills you will learn during

practical and clinical session

To Identify general danger signs (practical /clinical)

To Assess the level of consciousness by AVPU scale.

To examine the child for signs of meningeal irritation

To perform the motor system examination .

Why convulsion is selected as general danger sign. CONVULSION: Paroxysmal, time limited

change in motor activity and/or behaviour that results from abnormal electrical activity in the brain.

Convulsion is the presenting complaint in around 30% of children admitted in pediatric emergency

If occur with underlying disease increases the risk of morbidity and mortality.

If uncontrolled will lead to brain damage.

Common causes of convulsions CNS InfectionFebrile convulsionsEpileptic convulsions Metabolic. Hypoglycemia Head injuryIntoxication (drug over dose)Hepatic encephalopathy DKA. AGN ( hypertensive encephalopathy.Most common causes are febrile convulsions

and CNS infections.

Assessment areas Out-patient/

community management.

Patient flow high. Screen the patient for

any severe classification.

Identify the pre-referral treatment.

Give pre-referral treatment.

Inpatient management .

Initially assess the child in triage.

Look for emergency /priority signs.

Give emergency treatment.

Admit the child.

Community or outpatient management History : check for general danger signsAsk for 5 main symptomsFever with general danger or Stiff neck and

enquire about malaria risk. Classify the illness. Identify and give pre-referral treatment.Write down the referral note.Refer the child to inpatient department.

Assess For General Danger Sign

Ask:•Is the child not able to drink or feed?•Does the child vomit every thing ?•Has the child has convulsions?

Look:•See if the child is lethargic or unconscious.•See if the child is convulsing now.

CHECK FOR GENERAL DANGER SIGNS

WHEN YOU CHECK FOR GENERAL DANGER SIGNSASK:Is The Child Not Able To Drink Or Breast Feed?A child has the sign “not able to drink or breast feed” if he

child is not able to suck or swallow when offered a drink or breast milk.

DOES THE CHILD VOMITS EVERY THING?A CHILD WHO IS NOT ABLE TO HOLD ANY THING DOWN

AT ALL HAS THE SIGN ”VOMITS EVERY THING”HAS THE CHILD HAD CONVULSIONS ?History of convulsion during current illness

CLASSIFY THE ILLNESS AS ?

IDENTIFY THE TREATMENT Treat convulsions if present now by giving

diazepam per-rectally.

Complete assessment immediately.

Give first dose of an appropriate antibiotic.

Treat the child to prevent low blood sugar.

Refer URGENTLY to hospital.

PRE-REFERRAL TREATMENT IMPORTANCE.CHARTBOOKLET: TREATMENT GIVEN IN

CLINIC.

Practical session

video demonstration

Facility based management Initially assess the child in triage.

Look for emergency /priority signs.

Give emergency treatment in the triage.

Admit the child.

Facility Based Management

The first step is, to assess referred case in the triage –where we screen the cases to decide to which of the following group(s) a sick child belongs:

Those with emergency signs require immediate emergency treatment .

Those with priority signs should alert you to for immediate assessment and treatment.

Children with no emergency or priority signs are treated as non-urgent cases.

Emergency signs:

Obstructed breathing

Severe respiratory distress.

Central cyanosis.Signs of shockComa ConvulsionsSigns of severe

dehydration

priority signs:Sick child < 2 months Temprature : child very hot Trauma or other urgent surgicalPallorPoisoningPainRespiratory distressLethargic/ irrtibility Severe malnutrition/visible wastingEdema on both feet.Burns.

Assessment of child with convulsion or coma AVPU scale.AlertResponse to vocal commands.Response to pain Un-concouscious .

Stabilize and investigate CBC and MP CSF Blood glucose.Assessment of blood pressureUrine microscopy. Other investigations according to

presentationADMIT THE CHILD & MANAGE

ACCORDINGLY

INPATIENT MANAGEMENT HISTORY FROM LOG BOOK FOR INPATIENTS

DETAIL EXAMINATION & D/D

FOLLOW INVESTIGATIONS

NEED FOR FURTHER INVESTIGATION

MANAGE ACCORDINGLY

Exercise question Salina is 15 months old weighs 8.5 kg with temp

38.5c.The mother said that Salina has been coughing

for 4 days, and not eating well. This is her initial visit.

Mother said that she does not want to breast feed. The health worker gave some water to Salin but she was too weak to lift her head. She was not able to drink. Mother said that she has no vomiting or convulsions. Salina was not lethargic or unconscious and not convulsing now.

Question Classify the illness. What information is missing What pre-referral treatment will you give to

Salina

Key of exercise question Very sever febrile disease Malaria risk Anti biotics Antimalarial Sugar water Oral paracetamol.

Exercise question Kareena, a 4-year-old child has been urgently

referred to you with classification of very severe

febrile disease. Not very low weight and

anaemia. She is from a high malaria risk area.

She is in coma and has no signs of shock. The

child is not severely malnourished and has some

pallor. Her temperature is 39.2ºC.

Exercise question a) List the emergency signs. What emergency

treatment would you give?b) Enlist important points in history and

physical examination.c) What is your differential diagnosis?d) What investigations would you like to do?

key of Exercise question

a. She has coma as emergency sign and high fever as priority sign.

Manage airway, position, check and correct hypoglycaemia.

Key of Exercise question b. H/O skin rash, headache, ear pain.Look for stiff neck, skin rash, discharge from

ear, splenomegaly.c. Meningitis, cerebral malaria, viral

meningoencephalitis.d. LP, smear for MP and RDT, blood glucose,

Hb and complete blood counts.