Textbook of Paediatric Emergency Medicine

Peter Cameron; Gary J. Browne; Biswadev Mitra; Stuart Dalziel; Simon Craig

BOOK

Textbook of Paediatric Emergency Medicine

Peter Cameron | Gary J. Browne | Biswadev Mitra | Stuart Dalziel | Simon Craig

(2018)

Additional Information

Book Details

ISBN: 978-0-7020-7304-5
Edition: 3
Language: English
Pages: 688
Subjects: Paediatric medicine
Accident & emergency medicine
First aid & paramedical services
Medical study & revision guides & reference material

Abstract

It is now more than ten years since the publication of the first edition of Textbook of Paediatric Emergency Medicine and interest in this specialty continues to grow at a local and international level. Paediatric emergency medicine can be a challenging and difficult area for doctors. Children cannot always communicate their problems verbally, while parents are anxious and the possibility of a missed diagnosis is ever present. Although the principles in managing paediatric patients are the same as adults there are significant differences in patterns of illness and response. In addition, the therapies available vary widely between adult and paediatric practice.

Textbook of Paediatric Emergency Medicine provides clear, concise and comprehensive coverage of all the major topics that present within paediatric emergency medicine. It offers a consensus approach to diagnosis and treatment, drawing on the latest evidence available. Short chapters with key point boxes allow for the quick and easy retrieval of information, essential when time is short.

This Third Edition captures the major changes in guidelines across the specialty in the assessment and management of paediatric patients, whilst refining established approaches to practice. The text reviews both new technologies and the better application of older techniques which have led to changes in practice. There are significant updates to the sections on resuscitation and trauma, the clinical applications of bedside ultrasound, analgesia and sedation. There is also a new focus on the teaching and research sections.

Section Title	Page	Action	Price
Front Cover	Cover
IFC\r	ES1
Textbook of PAEDIATRIC EMERGENCY MEDICINE	i
Textbook of PAEDIATRIC EMERGENCY MEDICINE	iii
Copyright	iv
Contents	v
Preface to third edition	ix
Preface to second edition	x
Contributors	xi
Acknowledgements	xvii
1 -\rAPPROACH TO THEPAEDIATRIC PATIENT	1
1.1 Approach to the paediatric patient	1
Introduction	1
Who sees paediatric emergencies?	1
Identifying the potentially sick child	1
Children with fever	2
Evolving illness in children	2
The environment	2
Triage	3
Front loading care	3
The paediatric approach	3
Gaining rapport	3
Age appropriate	4
Developmentally appropriate	4
Parental involvement	4
History	4
Critically ill child	4
Parental issues	4
Child-specific issues	4
Examination	5
Age appropriate	5
Gentle, distraction, painful last	5
Improvise	5
Observation	6
Observational variables	6
Observing breathing	6
Confounders	6
Re-evaluate	6
Respiratory examination	6
Abdominal examination	6
ENT last	6
When to investigate	7
The parents	7
Managing the parents	7
Communication issues	7
Management of febrile children	7
Reasonable expectations	8
Decision making	8
When to admit	8
Factors influencing disposition	8
Continuity of care	8
Observation ward	8
Making a diagnosis	8
The role of the GP in paediatric emergency management	9
Introduction	9
Management prior to hospital care	9
Management after hospital care	9
Developmental milestones	10
Growth	10
Immunisation	10
Vital signs	10
REFLECTION ON THE PRACTICE OF PAEDIATRIC EMERGENCY	10
Acknowledgements	11
1.2 Common chronic paediatric conditions	12
2 - Resuscitation\r	19
2.1 Paediatric cardiopulmonary arrest	19
Preventing cardiac arrest	20
Outcome	20
Differences compared to adults	20
Development of resuscitation guidelines	20
Ethics of paediatric resuscitation	20
Termination of resuscitative efforts	21
Non-initiation of resuscitative efforts	22
Non-accidental injury	22
Organ donation	22
Death certificates, notification to the coroner and other legal issues	22
Child death – follow-up of family	22
References	22
2.2 Paediatric basic life support	23
Introduction	23
Paediatric versus adult basiclife support	23
Aetiology of arrests	23
Anatomy and physiology	23
Basic life support techniquesand age	23
Preparation and equipment	23
Basic life support sequence	23
A ‘DRSABC’ approach	23
Duration of basic life support inthe field	26
Precautions and complications	26
Relief of foreign body airwayobstruction	26
Foreign body airway obstructionmanagement: conscious patient witheffective cough	26
Foreign body airway obstruction:consciouspatient with ineffectivecough	26
Foreign body airway obstructionmanagement: unconscious patient	26
2.3 Paediatric advanced life support	27
Introduction	27
Definition of advanced life support	27
Diagnosing cardiac arrest	27
Epidemiology	28
Oxygen, ventilation and advancedairway support	28
Oxygen	28
Nasal prongs/nasal catheters	28
High flow nasal cannula	28
Oxygen masks	28
Head boxes and incubators	28
Ventilation	28
Self-inflating bags	29
T-piece devices	29
Flow-inflating bags	29
Rates and ratios of external cardiaccompression and ventilation inadvanced life support	29
Advanced airway support	29
Tracheal intubation	29
Endotracheal tube size (Table 2.3.1)	30
Depth of tube insertion (see Table 2.3.1)	30
Laryngeal mask airway	30
Management of the difficult airway	30
Causes of a difficult airway	31
Predicting a difficult airway	31
Difficult intubation	31
Endotracheal intubation techniqueoptimisation	31
Failed intubation	31
Emergency surgical airway techniques	32
Monitoring	32
Oximetry	32
Expired CO2 detection	32
Electrocardiograph	32
Vascular access	32
Peripheral venous cannulation	32
Intraosseous access	33
Central venous cannulation	33
Endotracheal route	33
Other techniques	33
Fluid therapy	33
Resuscitation drugs	33
Direct current shock	34
Management of pulselessarrhythmias (Fig. 2.3.1)	35
Asystole/severe pulseless bradycardia	35
Pulseless electrical activity andelectromechanical dissociation	35
Ventricular fibrillation and pulselessventricular tachycardia	35
Management of pulsatiledysrhythmias	36
Bradysrhythmias	36
Tachydysrhythmias (Fig. 2.3.2)	36
Pulsatile ventricular tachycardia	36
Supraventricular tachycardia	36
Wide QRS complex supraventriculartachycardia	37
Post-resuscitation management(Box 2.3.1)	37
Cessation of cardiopulmonaryresuscitation	37
References	37
2.4 Paediatric resuscitation in specificcircumstances	38
Avoiding cardiac arrest duringcritical care management	38
Anaphylaxis	38
Asthma	38
Drowning	39
Traumatic cardiac arrest	39
Toxicological emergencies	39
Intravenous lipid emulsion	39
Drug-induced asystole	39
Envenomation	40
Snake envenomation (see Chapter 22.1,Envenomation)	40
Marine envenomation	40
Box jellyfish (Chironex Fleckeri )	40
References	40
2.5 Shock	40
Introduction	40
Diagnosis and assessment	41
Airway	41
Breathing	41
Circulation	41
Heart rate	41
Blood pressure	41
Capillary refill	41
Effects of circulatory inadequacyincluding neurological status	41
Circulation	42
Further management	42
Hypovolaemia	42
Septic shock	42
Acute severe allergic reaction(anaphylaxis)	42
Duct-dependent congenitalheart disease	43
Heart failure	43
Neurogenic shock	43
Further reading	43
2.6 Sepsis recognition and initial management	43
Introduction	43
Background	44
Definition	44
Aetiology	44
Pathophysiology	45
Diagnosis	45
Initial emergency management(Fig. 2.6.1)	45
Monitoring	45
General supportive measures	45
Intravenous access	45
Initial blood tests	45
Initial treatment	45
Therapeutic targets	45
Disposition	45
References	45
3 -\rNEONATAL EMERGENCIES	47
3.1 The normal neonate	47
Definition and introduction	47
Immediately after birth	47
The neonatal history	47
The neonatal examination	48
Common reasons for healthy neonates to present to the emergency department	48
Feeding problems	48
Crying (see Chapter 3.2, The crying infant)	49
Vomiting and spilling	49
Preventative advice	49
Summary	49
Further reading	49
3.2 The crying infant	50
Introduction	50
Recurrent crying	50
Colic	50
Management	50
Gastro-oesophageal reflux	50
General advice	50
Acute crying	51
Assessment	51
Examination	51
Investigations	51
Disposition	51
References	51
3.3 Neonatal Dermatology	51
SKIN IN THE NEONATAL PERIOD	51
Neonatal erythroderma (Fig. 3.3.1)	52
Potential causes of erythroderma	52
Investigations in erythroderma	52
Management of the erythrodermic neonate	52
Red scaly rashes	53
Infantile seborrheic dermatitis/eczema	53
Psoriasis	53
Ichthyosis	53
Neonatal lupus erythematosus(Fig. 3.3.2)	53
Zinc deficiency/acrodermatitis enteropathica	53
Langerhans cell histiocytosis (see Chapter 12.1, Dermatology)Tinea corporis	53
Congenital syphilis	53
Vesicles and blisters	53
Herpes simplex	53
Varicella	53
Staphylococcus aureus	54
Miliaria	54
Epidermolysis bullosa	54
Autoimmune blistering disease	54
Pustular lesions	55
Infection	55
Neutropenia	55
Neonatal pityrosporum folliculitis(Neonatal cephalic pustulosis)(Fig. 3.3.4)	55
Erythema toxicum neonatorum (toxic erythema of the newborn)	55
Transient neonatal pustular dermatosis	55
Acropustulosis of infancy	55
Eosinophilic pustular folliculitis (scalp)	55
Milia and sebaceous gland hyperplasia	55
Birthmarks	55
Congenital melanocytic naevi	55
Epidermal naevi	55
Incontinentia pigmenti	56
Pigmentary mosaicism	56
Café au lait macules	56
Blue/purple lesions	56
Blueberry muffin syndrome (Fig. 3.3.5)	56
Other important causes	56
Vascular lesions in the neonatal period	56
Cutis marmorata	56
Harlequin colour change	57
Salmon patch (naevus simplex, stork mark, angel’s kiss)	57
Vascular anomalies	57
3.4 Acute neonatal emergencies	57
THE NEONATAL PERIOD	57
Neonatal resuscitation (seeChapter 3.5)	57
Assessment of the neonate	57
The collapsed neonate	58
Sepsis	58
The neonate with vomiting	60
Intestinal obstruction	61
Lung parenchymal pathology	63
Airway obstruction	64
Non-pulmonary disease	64
The neonate with prolonged jaundice	64
3.5 Neonatal resuscitation	66
Introduction	66
Epidemiology	66
Aetiology and pathophysiology	66
Preparation	67
Assessment at birth	67
Ventilation	67
Artificial ventilation	67
Heart rate	68
Compression technique	68
Colour	68
Muscle tone and reflex irritability	68
Medications	68
Vascular access	68
Adrenaline	69
Naloxone	69
Dextrose	69
Volume expansion	69
Bicarbonate	69
Specific resuscitation situations	69
Premature neonate	69
Meconium aspiration	69
Congenital heart disease	69
Post-resuscitation stabilisation	70
Prognosis	70
References	71
Further reading	71
4 - TRAUMA IN CHILDREN\r	73
4.1 Introduction to paediatric trauma	73
Prevalence	73
Prevention	73
Succinct treatment (salvage)	74
Primary survey	74
Paediatric differences	74
Catastrophic external haemorrhage control	74
A. Airway and cervical spine control	75
B. Breathing and high flow oxygen	75
C. Circulation and stop haemorrhage	75
D. Disability	76
E. Exposure and environment	76
Other issues during initial stabilisation	76
Early analgesia	76
Continuous monitoring	76
Psychological support of child and family members	76
Secondary survey	76
Definitive care and disposition	76
Orthopaedic trauma	76
Rehabilitation	77
References	77
4.2 Paediatric neurotrauma	78
Introduction	78
Epidemiology	78
Pathophysiology	78
Classification	79
Mild traumatic brain injury (GCS 14 to 15)	79
Moderate traumatic brain injury (GCS 9 to 13)	79
Severe traumatic brain injury (GCS 8 or less)	79
Assessment	79
History	79
Examination	80
Glasgow Coma Scale	80
Investigations	80
Laboratory	80
Radiological	81
Management	81
Spinal cord injury	84
Supportive care	84
Family considerations	84
Disposition	84
4.3 Spinal injury	86
Introduction	86
Developmental anatomy and physiology	86
Initial assessment	87
Spinal immobilisation	87
Cervical spine injuries	88
Mechanisms of injury	88
Flexion	88
Extension	88
Rotation	88
Vertical compression	88
Clinical assessment	88
Radiographic images	88
Flexion and extension	89
Computerised tomography	89
Magnetic resonance imaging	89
Radiographic evaluation	89
Cervical spine clearance guidelines	89
Atlantoaxial rotary subluxation	90
Thoracic and lumbar spine injuries	90
Mechanism of injury	90
Clinical assessment	90
Radiographic evaluation	90
Management	91
Spinal cord injury	91
Spinal cord injury syndromes	92
Clinical assessment	92
Radiographic evaluation	92
Treatment	92
Spinal cord injury without radiographic abnormality	92
16References	93
4.4 Thoracic injuries in childhood	94
Introduction3–6	94
Initial approach in the emergency department1,7,8	94
Chest wall injury9,10	95
Rib fractures	95
Pulmonary injury11,12	95
Contusion	95
Pneumothorax6,13,14	95
Tension pneumothorax	95
Pulmonary lacerations 7	96
Haemothorax1,13,15	96
Tracheobronchial injuries1,14,15	96
Mediastinal injury1,7,13,15	96
Aortic transection	96
Cardiac injuries16	97
Commotio cordis17,18	97
Penetrating cardiac trauma19	97
Diaphragmatic injury13,15,20	97
Oesophageal injury7	97
Emergency department thoracotomy19,21	97
4.5 Abdominal and pelvic trauma	98
Introduction	98
History	99
Examination	99
Investigations	100
Laboratory	100
Focused assessment by sonography for trauma	100
Plain films	100
Computed tomography scan	100
Formal ultrasound	100
General management	100
Surgical issues	101
Hollow viscus injuries	101
Pancreatic and renal injuries	102
Interventional radiology	102
Penetrating trauma	102
Pelvic fractures	102
Disposition	103
References	103
4.6 Burns	104
Introduction	104
Pathophysiology	104
Classification	104
Superficial	104
Partial thickness	104
Full thickness	105
History	105
Examination	105
Primary survey	105
Evaluation of burn area	105
Investigations	106
Management	106
Pre-hospital	106
Emergency department	106
Fluid resuscitation	106
Management of burns (Box 4.6.1)	107
Major burns	107
Minor burns	107
Superficial burns	107
Electrical burns	107
Introduction	107
Clinical effects	108
Management	108
Specific issues	108
Disposition	108
Chemical burns	108
Treatment	108
Further reading	108
4.7 Children in a disaster response	109
Introduction	109
Children in disaster situations	109
Phases of disaster response	109
4.8 Wound management	110
Introduction	111
Anatomy of the skin	111
Pathophysiology of wound healing	111
Wound infection	111
Classification of wounds	111
Evaluation of the patient with a laceration	111
History	111
Examination	112
Investigation	112
Treatment of wounds	112
Wound anaesthesia	112
Wound preparation and cleansing	113
Antibiotic prophylaxis	113
Wound closure	114
Sutures	114
Needles	114
Suturing techniques	115
Special suturing techniques	116
Correction of dog ears	116
Staples	116
Tissue adhesives	116
Skin tapes	117
Post-wound-closure care	117
Dressing and suture removal	117
Immobilisation and drains	117
Treatment of selected injuries	118
Abrasions	118
Eyelid lacerations	118
Lip lacerations	118
Tongue lacerations	118
Fingertip amputation	118
Nailbed lacerations	119
Subungual haematoma	119
Puncture wounds to the foot	119
Bites	119
Acknowledgement	120
References	120
5 -\rCARDIOVASCULAR	121
5.1 Cardiovascular assessment and murmurs	121
Introduction	121
History	121
Physical examination	122
Chest X-ray	122
Electrocardiography	122
Atrial enlargement	122
Ventricular enlargement	122
The child with an asymptomatic murmur	124
Pathological murmurs	124
Disposition	124
Further reading	124
5.2 Chest pain	125
Introduction	125
Immediate approach	125
General approach (Table 5.2.1)	125
History	125
Physical examination	125
Investigations	126
Summary	126
References	126
5.3 Syncope	126
Introduction	126
Aetiology	127
Typical presentations	127
Vasovagal syncope	127
Breath-holding spells and reflexanoxic seizures	127
Cardiac syncope	127
Hypovolaemic states	127
Seizures	127
Hyperventilation and conversion syncope	127
Clinical	128
History	128
Examination	128
Investigations within theemergency department	128
Further investigations of syncope	129
Management of syncope within the emergency department	129
Summary	129
Further reading	129
5.4 Cyanotic heart disease and tetralogy of Fallot spells	130
Introduction	130
Cyanotic congenital heart disease	130
Clinical features2,3,5,6	130
Investigations	130
Management2–6	131
Disposition	131
TETRALOGY SPELLS	131
Introduction3–6, 9–12	131
Investigations3–6	131
Laboratory	132
ECG	132
Chest X-ray	132
Echocardiography	132
Treatment3–6, 9–12	132
Disposition	132
References	132
Further reading	132
5.5 Heart failure	133
Definition	133
Causes of congestive heart failure	133
Clinical manifestations and investigations	133
Presentation1–3	133
General features1–3	133
Staging4–9	133
Assessment	133
Referral	133
Management1–3, 10–14	134
Acute management	134
Diuretics	134
Angiotensin-converting enzyme inhibitors	134
β-blockers	134
Digoxin	134
Levosimendan	134
References	134
5.6 Congenital heart disease	135
Introduction	135
Incidence	135
Pathophysiology	135
Undiagnosed congenital heart disease	135
Findings that may indicate congenital heart disease	135
Diagnostic approach	135
Common presentations and initial management	135
Neonate/infant	135
Older child	137
Early	138
Late	138
Congenital heart disease and intercurrent illness	138
Dehydration – including gastroenteritis	138
Respiratory disease	138
Further reading	138
5.7 Acute rheumatic fever	139
Introduction	139
Epidemiology	139
Pathophysiology	139
Diagnosis of acute rheumatic fever	139
Clinical manifestations (historyand examination)	139
Investigations	140
Laboratory evidence of group A β-haemolytic streptococcal infection	140
Differential diagnosis	140
Treatment	141
Acute management	141
Symptomatic treatment of arthritis	141
Treatment of carditis and control of heart failure	141
Management of chorea	141
Prevention and prophylaxis	141
Prognosis	141
References	141
5.8 Infective endocarditis	142
Introduction	142
Epidemiology	142
Pathophysiology	142
Microbiology	142
History	142
Examination	142
Modified Duke criteria	143
Major criteria	143
Minor criteria	143
Investigations	143
Laboratory	143
Imaging	143
Differential diagnosis	143
Treatment	143
Medical	143
Surgical	143
Prognosis	143
Prevention	143
11References	144
5.9 Kawasaki disease	144
Introduction	144
Pathophysiology	145
Clinical features	145
Incomplete Kawasaki disease	145
Differential diagnosis	145
Complications	145
Investigations	145
Treatment	146
Refractory Kawasaki disease	146
Prognosis	146
References	147
5.10 Cardiac arrhythmias	147
Introduction	147
Normal conduction system	147
The cardiac action potential	148
Vaughan Williams antiarrhythmia drug classification	148
Pathogenesis of arrhythmias	149
Bradyarrhythmias	149
Tachyarrhythmias	149
General principles for arrhythmia management	150
Bradyarrhythmias	150
Sinus bradycardia	150
Sinus node dysfunction	150
Conduction disturbances: atrioventricularblock	150
Bundle branch block	151
Tachyarrhythmias	151
Wide complex tachyarrhythmia	151
Narrow complex tachyarrhythmia	151
Wolff–Parkinson–White syndrome	152
Atrial flutter	152
Atrial fibrillation	152
Ventricular fibrillation	152
Role of ‘molecular autopsy’ insudden unexplained cardiac death in the young	152
Further reading	153
6 -\rRESPIRATORY	155
6.1 Stridor and noisy breathing \r	155
Introduction	155
Initial assessment	155
History	155
Examination	156
Common causes of acute stridor in children	156
Common causes of chronic stridor in children	156
Larynx	156
Subglottis	157
Trachea	157
References	157
6.2 Upper respiratory tract infections	157
7 - GASTROENTEROLOGY AND HEPATOLOGY	181
7.1 Abdominal pain	181
Introduction	181
Pathophysiology	182
Aetiology	182
Assessment	182
History	182
1. The age of the child	182
2. Whether this is the first episodeor recurrence of abdominal pain	183
3. Whether there are other associated symptoms	183
4. Whether there are any relevant pre-existing conditions	183
5. What are the characteristics ofthe pain?	183
Examination	183
Investigations	183
Pathology	183
Imaging	184
Management	184
Disposition	184
ACUTE APPENDICITIS	184
Introduction	184
Clinical features	184
Differential diagnoses	184
8 - NEUROLOGY	235
8.1 Cerebrospinal fluid shunt complications	235
Introduction	235
Types of shunt	235
Clinical presentation	236
History	236
Examination	236
Shunt evaluation	236
Investigations	237
Aspects of some cerebrospinal fluid shunt complications	237
Early post-operative complications	238
Migration and penetration of shunts	238
Glomerulonephritis	238
Trauma in children with a cerebrospinal fluid shunt	238
References	238
8.2 Raised intracranial pressure	239
Introduction	239
Normal physiology	239
Pathophysiology	239
Measurement of intracranial pressure	239
Particular issues in children	240
Infants	240
Clinical features of raisedintracranial pressure	240
The central herniation syndrome	240
The lateral mass herniation syndrome	240
Cerebellar tonsillar herniation syndrome	240
Other examination findings in raised intracranial pressure	241
Fundi	241
Peripheral neurological signs	241
Investigations	241
Management of raised intracranial pressure	241
Some particular causes of raised intracranial pressure	242
Idiopathic intracranial hypertension (aka pseudotumour cerebri or benign intracranial hypertension)	242
Fever and raised intracranial pressure	242
References	242
8.3 Seizures and non-epileptic events	243
Introduction	243
General comments	243
Classification of seizures	243
Febrile seizures	243
PRESENTATION TOEMERGENCY DEPARTMENT	244
Presentation post a possible seizure	244
History	244
Examination	244
Differential diagnosis and specific seizure syndromes	244
Drug therapy	245
Investigations	246
Disposition	246
Acknowledgements	247
Further reading	247
8.4 Acute weakness	247
Introduction	247
Presentation	247
Trauma masquerading as weakness	247
Primary survey approach	247
General inspection	247
ABC	247
DEFG	248
History	248
Examination	248
Investigations	248
Laboratory	248
Imaging	249
Specific conditions causing acute weakness	249
Guillain–Barré syndromeIntroduction	249
Tick paralysis	250
Botulism	250
Spinal cord lesions	251
Myasthenia gravis	251
Poliomyelitis and other enteroviral infections	252
Bell’s palsy	252
Toxic neuropathies	252
Hereditary neuropathy	253
Muscular disorders	253
Somatisation disorders/malingering	253
Acknowledgement	253
Further reading	253
8.5 Acute ataxia	254
Introduction	254
Pathophysiology	254
Cerebellum	254
Cerebral hemispheres and vermis	254
Cerebellar peduncles and connections	254
Differential diagnosis	255
Acute cerebellar ataxia	255
Poisoning	255
Tumours	256
Trauma	256
Infections	256
Vascular conditions	256
Other neurological conditions	256
Metabolic disorders	256
Chronic ataxia	256
Hereditary ataxias/spinocerebellar degenerative	257
Congenital malformations	257
Clinical evaluation of the patient	257
History	257
Examination	257
Investigations	257
Management	258
References	258
8.6 Headache	259
Introduction	259
Incidence	259
Pathophysiology	259
Clinical assessment	260
History	260
Examination	260
Investigation	261
Management	262
Disposition	262
MIGRAINE	262
Pathophysiology	262
Clinical features	262
Investigation	263
Treatment	263
Disposition	263
Conclusions	263
References	263
8.7 Central nervous system infections: meningitis and encephalitis	264
Introduction	264
Meningitis	264
Classification	264
Aetiology	264
Clinical findings	265
Investigations	265
Management	266
Prevention	266
Complications	266
Brain abscess	267
Encephalitis	267
Aetiology	267
Clinical findings	267
Investigations	267
Management	267
Complications	267
Conclusion	267
References	267
9 -\rINFECTIOUS DISEASES	269
9.1 Infectious diseases	269
Fever	269
Defining and measuring temperature	269
Fever: to treat or not to treat?	269
Practical approach to the febrile child	270
Fever with localising signs	270
Fever without focus	270
Pyrexia of unknown origin	271
Empiric antibiotic therapy	271
Antimicrobial resistance	271
Common infectious exanthems	271
What specimens, when should they be ordered and what tests?	272
Collection of microbiological specimens	272
Blood cultures	272
Cerebrospinal fluid	272
Urine	272
Stool specimens	273
Throat swab	273
Nasopharyngeal aspirate	273
Nasal swab	273
Infection control in the emergency department	273
Needlestick injury	273
The child presenting with a (community) needlestick injury	273
Hospital staff exposure to blood-borne viruses	273
Immunisation	273
Immunisation of staff	273
Opportunistic immunisation	273
References	273
10 - METABOLIC EMERGENCIES	275
10.1 Inborn errors of metabolism	275
Introduction	275
Physiology and pathogenesis	275
Clinical features	275
Investigation	276
Management	277
Reduction of toxic compound production	277
Removal/enhancement of excretion of toxic compounds	278
Chronic presentations	278
Extended newborn screening	278
Conclusion	278
10.2 Hypoglycaemia in the non-diabetic child	279
Introduction	279
The hypoglycaemia screen	279
Causes of hypoglycaemia	279
Endocrine and metabolic causes	279
Pharmacological and toxic causes	279
Treatment of hypoglycaemia	280
References	280
10.3 Diabetic emergencies in children	281
Diagnosis	281
Diabetic ketoacidosis	281
Resuscitation	281
Fluid	281
Insulin	281
Potassium	281
Sodium	282
Acidosis and bicarbonate	282
Phosphate	282
Complications	282
Disposition	282
Hypoglycaemia	282
The child with an insulin pump	282
Long-term management	283
Further reading	283
10.4 Thyroid emergencies	284
Thyrotoxicosis	284
Clinical features	284
Diagnosis	284
Treatment	284
Neonatal thyrotoxicosis	284
Hypothyroidism	284
Congenital hypothyroidism	284
Hashimoto’s thyroiditis	285
Further reading	285
10.5 Adrenal emergencies	285
ADRENAL CRISIS	286
Introduction	286
Clinical presentation	286
History	286
Examination	286
Investigations	286
Differential diagnosis	286
Treatment	286
Fluid management	286
Replacement of corticosteroid	286
Hypoglycaemia	286
Hyperkalaemia	286
Disposition	287
Prevention	287
CUSHING’S SYNDROME	287
Introduction	287
Presenting symptoms	287
Diagnostic testing	287
Treatment	287
Further reading	288
10.6 Disorders of fluids, electrolytes and acid–base	288
Introduction	288
Physiology	288
Clinical assessment	289
Haemorrhagic shock	289
Fluid deficit	289
Oedema	290
Investigations	290
Treatment	290
Replacement of circulating volume	290
How much fluid?	291
How to administer fluid in shock	291
Investigation and management of fluids in different conditions	291
Dehydration	291
Syndrome of inappropriate antidiuretic hormone secretion	292
Pyloric stenosis	292
Sepsis and meningococcal disease	293
Haemorrhagic shock	293
Head injury	293
Burns (Chapter 4.6)	293
Diabetic ketoacidosis (Chapter 10.3)	293
Hyperkalaemia	293
Hypokalaemia	293
Maintenance fluids	293
Acid–base disorders	294
Metabolic acidosis	294
Metabolic alkalosis	295
Acknowledgement	295
References	295
11 - HAEMATOLOGY AND ONCOLOGY	297
11.1 The use of blood products in children	297
Introduction	297
Use of blood products inresuscitation1, 2	298
Packed red blood cells1	298
Recommended initial dose of packed red blood cell transfusion	298
Adverse reactions	298
Platelets	298
Indications	298
12 -\rDERMATOLOGY	327
12.1 Dermatology	327
Introduction	327
Management	327
Vesiculobullous rashes	329
Varicella (chickenpox) (also seeChapter 3.3 Neonatal dermatology)	329
Zoster	329
Hand, foot and mouth disease	330
Herpes simplex infection	330
Eczema herpeticum	330
Impetigo (School sores)	331
Staphylococcal scalded skin syndrome	331
Erythema multiforme	331
Stevens–Johnson syndrome/toxic epidermal necrolysis	332
Dermatitis herpetiformis	332
Other immune-mediated blistering disorders	332
Sunburn and photosensitivity	332
Primary photosensitivity disorders	333
Porphyrias and other inherited disorderswith photosensitivity	333
Photosensitivity and bullous reactions to drugs	333
Photosensitivity reactions to plants	334
Contact dermatitis – plants	334
Contact dermatitis – id reactions	334
Isolated blisters	334
Neonatal vesicles (see Chapter 3.3 Neonatal dermatology)	334
Pustular rashes	334
Acne	334
Acne and depression	335
Acne fulminans	335
Acne with Gram-negative folliculitis	335
Folliculitis	335
Acute generalised exanthematous pustulosis	336
Pustular psoriasis	336
Neonatal pustules (see Chapter 3.3 Neonatal dermatology)Neonatal pityrosporum folliculitis (seeChapter 3.3 Neonatal dermatology)	336
Papular (raised) rashes	336
Scabies	336
Papular acrodermatitis of childhood	337
Papular urticaria	337
Molluscum	337
Adnexal tumours – pilomatricoma	338
Keratosis pilaris	338
Granuloma annulare	338
Langerhans cell histiocytosis	338
Juvenile xanthogranulomas	339
Xanthomas	339
Angiofibromas in tuberosclerosis	339
Red scaly (papulosquamous) rashes	339
Psoriasis	339
Tinea corporis	339
Pityriasis rosea	340
Secondary syphilis	340
Seborrhoeic dermatitis	340
Lichen striatus	341
Eczematous rashes	341
Atopic eczema – general issues	341
Atopic eczema – general management principles	341
Atopic eczema – dietary principles	342
Atopic eczema – use of topicalcorticosteroid preparations	342
Atopic eczema – acute flare	342
Atopic eczema – admission to hospital	342
Atopic eczema – generalised infantile	342
Atopic eczema – facial	342
Atopic eczema – perioral eczema versus juvenile rosacea	343
Atopic eczema – periorbital	343
Atopic eczema – molluscum	343
Atopic eczema – discoid	343
Atopic eczema – juvenile plantar dermatosis	343
Atopic eczema with systemic associations	343
Irritant contact dermatitis	343
Allergic contact dermatitis	343
Generalised dry skin – ichthyosis	344
Generalised dry skin – ectodermal dysplasias	344
Red blanching rashes (erythematous)	344
Fever and exanthem	344
Scarlet fever	344
Toxic shock syndrome	344
Kawasaki disease	344
Erythema infectiosum	345
Roseola infantum	345
Enteroviruses	345
Infectious mononucleosis	345
Measles	345
Rubella	346
Unilateral laterothoracic exanthem	346
Urticaria	346
Serum sickness	347
Lupus erythematosus	347
Neonatal lupus erythematosus (see Chapter 3.3 Neonatal dermatology)	347
Juvenile chronic arthritis	347
Erythema nodosum	348
Necrobiosis lipoidica	348
Palmoplantar hidradenitis	348
Pernio (chilblains)	348
Spider telangiectasia	348
Other erythematous rashes	348
Purpuric rashes	348
Fever and petechiae	348
Fever and petechiae in an unwell child (including meningococcal sepsis)	348
Fever and petechiae in a well child	349
Meningococcal sepsis and other septicaemia	349
Vasculitis and Henoch–Schönlein purpura	349
Thrombocytopenic purpura	349
Leukaemia	349
Coagulation disorders	350
Child abuse	350
Artefactual purpura	350
Papular-purpuric gloves and socks syndrome	350
Dusky purple nodules on hands and feet	350
Chronic pigmented purpura	350
Other causes of childhood purpura	350
Neonatal purpura (see Chapter 3.3 Neonatal dermatology)	350
Vascular tumours – haemangiomas and haemangioma variants	350
Haemangiomas of infancy	350
Rapidly involuting congenital haemangioma	351
Kaposiform haemangioendothelioma/tufted angioma	351
Pyogenic granuloma	352
Vascular malformations	352
Neonatal vascular malformations	352
Facial capillary malformations (‘port wine stain’)	352
High-flow lesions	352
Pain, swelling	352
Bleeding, coagulopathy	352
Chest pain or shortness of breath	352
Intestinal bleeding, anaemia	352
Bladder or bowel dysfunction in older children	352
Leg length discrepancy	352
Multiple telangiectatic vessels	353
Fabry disease	353
Management of vascular malformations	353
Hyperpigmentation	353
Diffuse hyperpigmentation	353
Localised macular hyperpigmentation – including café-au-lait macules	353
Presentations with dermal (blue/grey) pigmentation	354
Localised raised hyperpigmentation	354
Congenital pigmented naevi	354
Acquired pigmented naevi	354
Dysplastic naevi	354
Halo naevi	354
Spitz naevi	355
Hypopigmentation	355
Pityriasis versicolor	355
Pityriasis alba	355
Vitiligo	355
Post-inflammatory hypopigmentation	355
Linear and whorled hypopigmention (‘hypomelanosis of Ito’)	355
Tuberous sclerosis	355
Generalised hypopigmentation	355
Skin texture	355
Lax skin	355
Firm or thickened skin	355
Mouth disorders	355
Primary herpetic gingivostomatitis	356
Herpangina	356
Transient lingual papillitis	356
Angular cheilitis	356
Geographic tongue	356
Recurrent mouth ulcers	356
Anogenital rashes	356
Irritant napkin dermatitis	357
Candida napkin dermatitis	357
Anogenital psoriasis	357
Perianal streptococcal dermatitis	357
Staphylococcal-mediated anogenital rashes	357
Herpes simplex virus	357
Varicella (see p. 327	357
Threadworms	357
Lichen sclerosis	358
Vulval itch/vulvitis in prepubertal girls	358
Zinc and other nutritional deficiencies	358
Malabsorption	358
Langerhans cell histiocytosis	358
Constipation	358
Anogenital papules and lumps	358
Anogenital warts	358
Molluscum	358
Congenital syphilis	358
Immunodeficiency states	358
Hair problems	358
Head lice	358
Tinea capitis	359
Kerion (inflammatory ringworm)	359
Alopecia areata	359
Traumatic alopecia	359
Diffuse hair loss	359
Hypertrichosis	359
Hirsutism	360
Nail problems	360
Paronychia	360
Nail psoriasis	360
Ingrown toenail	360
Tinea unguium (onychomycosis)	360
Itch without rash	360
Collection of specimens	360
References	361
13 - EYES	363
13.1 Ophthalmological emergencies	363
Introduction	363
History	363
Examination	363
The red eye in paediatrics	364
The red eyelid	364
The red eyeball	365
13.2 Congenital, developmental and neoplastic conditions of the eye	367
DEFICITS IN VISUAL ACUITY	367
Strabismus	367
Paediatric cataracts	367
Congenital nasolacrimal duct obstruction	367
Infantile glaucoma	367
Ocular tumours	367
Retinoblastoma	367
Rhabdomyosarcoma	368
Neuroblastoma	368
Further reading	368
13.3 Ocular trauma	368
Introduction	368
Globe trauma	369
Open globe injury (globe rupture and penetrating eye injury)	370
Eyelid trauma	370
Ecchymosis	370
Orbital trauma	370
Further reading	371
14 - ENT AND DENTAL	373
14.1 The ear	373
Otitis externa	373
Introduction	373
History	373
Examination	373
Investigations	373
15 - OBSTETRICS AND GYNAECOLOGY	389
15.1 Paediatric gynaecology	389
Infant and prepubescent gynaecology	389
Vaginal discharge	389
Vaginal bleeding	390
Labial adhesions	391
Distressing vaginal or perineal pain	391
Adolescent gynaecology	391
Vaginal discharge and sexually transmitted infections	391
Abnormal vaginal bleeding	393
Pelvic pain	393
Acknowledgement	394
References	394
15.2 Emergency contraception	395
Introduction	395
Clinical assessment	395
Available medicines	395
Medicine contraindications	396
Medicine adverse effects	396
Medicine outcomes	396
Copper intrauterine devices	396
References	396
16 - RENAL	397
16.1 Acute kidney injury	397
Introduction	397
Pathophysiology	398
Clinical presentation	398
Treatment	398
Acute presentation of chronic renal failure	400
Acute kidney injury in the renal transplant recipient	400
16.2 Haematuria	401
Isolated microscopic haematuria	401
History	402
Examination	402
Investigation	402
Disposition	402
16.3 Hypertension	403
Introduction	403
History	403
Examination	403
Emergency department management	403
Stage 1 hypertension	403
Stage 2 hypertension	403
Further reading	404
16.4 Urinary tract infection in pre-school children	404
Introduction	404
History and examination	404
Diagnosis	405
Treatment	405
Prognosis	406
Prevention	406
11References	406
16.5 Haemolytic uraemic syndrome	407
Introduction	407
Definition of haemolytic uraemic syndrome	407
Classification of haemolytic uraemic syndrome	407
Pathophysiology of haemolytic uraemic syndrome	407
Shiga toxin haemolytic uraemic syndrome	407
Pneumococcal-associated haemolytic uraemic syndrome	408
Complement-mediated haemolytic uraemic syndrome	408
History	408
Examination	408
Investigations	408
Differential diagnosis	408
Treatment	408
Prognosis	409
Complications	409
Prevention	409
Further reading	409
16.6 Idiopathic nephrotic syndrome	410
Introduction	410
Pathophysiology of proteinuria	410
Nephron and glomerular filtration barrier	410
Renal handling of albumin	410
Mechanisms of proteinuria	410
Definition of nephrotic syndrome	411
Peripheral oedema AND marked proteinuria* AND hypoalbuminaemia** AND hyperlipidaemia	411
Classification of paediatric nephrotic syndrome	411
According to cause	411
According to renal histology	412
According to response to corticosteroids	412
Idiopathic nephrotic syndrome: epidemiology	412
Minimal change disease	413
Primary (idiopathic) focal segmental glomerulosclerosis	413
Clinical features of idiopathic nephrotic syndrome	414
Oedema	414
Other features	414
Investigations	414
Urine analysis	414
Blood tests	415
Imaging	415
Differential diagnosis	415
Complications of idiopathic nephrotic syndrome	415
Hypovolaemia	415
Infection	415
Thrombosis	416
Long term due to the nephrotic syndrome or treatment or both	416
Treatment of initial nephrotic phase	416
General measures	416
Immunisation	417
Corticosteroid medication	417
Oedema	417
Proteinuria	417
Infection	417
Patient with frequent relapses of nephrotic syndrome or persistent nephrotic syndrome	417
Prognosis	418
Acknowledgements	418
Further reading	418
16.7 Henoch–Schönlein purpura	418
Introduction	418
Epidemiology	418
Pathogenesis	418
Diagnostic criteria for Henoch–Schönlein purpura	420
Clinical features	420
Rash	420
Arthritis	420
Gastrointestinal	420
Renal	421
Other findings	421
Diagnosis and investigation	421
Initial investigations	421
Radiology	421
Biopsy	421
Differential diagnosis	421
Treatment	422
Symptomatic	422
Complications	422
Prevention	422
Long-term prognosis and follow-up	422
Acknowledgements	422
Further reading	422
17 - PSYCHIATRIC	425
17.1 Paediatric psychiatric emergencies	425
Introduction	425
General approach	425
Assessment	425
History	425
Collateral history	425
Examination	425
Investigations	425
Synthesis of assessment	426
COMMON PAEDIATRIC PSYCHIATRICPRESENTATIONS	426
The acutely disturbed child	426
Suicidal patients	426
Introduction	426
Assessment	426
Hazards during assessment	426
Management following an attempt	427
Suicidal patients: important considerations	427
Psychosis	428
Treatment	428
Other psychiatric presentations	428
Acute dystonic reactions	428
Night terrors	428
Acknowledgement	428
References	429
17.2 The treatment of the behaviourally disturbed adolescent (see Fig. 17.3.4)	429
Introduction	429
The principles of psychiatric triage	429
Purpose	429
Time is risk	429
Pre-triage	430
The hierarchy of needs	430
The ABCC of rapid psychiatric assessment	430
Arousal	430
Behaviour	430
Containment	431
Cognitive processes	431
Managing the ABCC including restraint and acute sedation	431
Sedating the adolescent brain	431
Signs of organic dysfunction	432
Differential diagnosis – medical	432
Differential diagnosis – psychiatric	432
The management of acute risk including medical risk	432
Sentinel nursing observations post intramuscular or intravenous sedation	433
Transfer is a potential escalationof risk	433
Conclusion	433
Further reading	433
17.3 Autism and behavioural disturbance in the pre-adolescent child	434
Introduction	434
Underlying mechanisms in austistic spectrum of disorders/neurodevelopmentaldisorders	434
Approach to assessment	434
Is sedation necessary?	434
Physical examination	434
History	435
Challenges in emergencydepartment presentations	435
Approach to management	435
Management	435
Acute (Fig. 17.3.4)	435
Ongoing management inthe community	436
Conclusion	436
Further reading	437
18 - CRISIS INTERVENTION	439
18.1 Sexual assault	439
Introduction	439
Definitions	439
Attitudes/myths surrounding child sexual assault	439
Epidemiology of child sexual assault	440
Child sexual assault and emergency medicine	440
Recognition of child sexual assault	440
Signs and symptoms	440
Non-specific	440
Specific	440
Genitoanal anatomy	440
Hymen	440
Sexually transmitted infections	440
Diagnostic considerations	440
Role of the emergency physician	441
Documentation	441
Mandatory reporting legislation	441
References	441
18.2 Child at risk	441
Introduction	441
Definition	442
Physical abuse	442
Neglect	443
Medical child abuse	444
The community response to the child at risk	444
Responsibilities to report	444
Legal responsibilities	444
What happens after notification?	444
Actions based on risk assessment	444
Further reading	444
19 - ADMINISTRATION IN EMS	445
19.1 - Managing the death of a child in the emergency department: Bereavement issues	445
The resuscitation process	446
Talking to parents and families	446
Laying out of the child	447
Viewing the body – quiet suite	447
The grief response	447
Support of the family	448
Cultural implications	448
Legal issues	448
Organ and tissue donation and collection	448
Debriefing and support for emergency department staff	449
Collaboration with paediatric palliative care services	449
The concept of a good death	449
Conclusion	449
Acknowledgements	449
References	450
20 - ANALGESIA AND SEDATION	451
20.1 Analgesia\r	451
Introduction	451
Assessment of pain	451
Management	452
Non-pharmacological methods	452
Pharmacological methods	452
Oral analgesic agents	452
Intranasal or inhaled options	454
Methoxyflurane	454
Intranasal fentanyl	454
Nitrous oxide	454
Parenteral analgesics	454
Local anaesthetic agents	454
Regional anaesthetic techniques	456
Chronic pain	456
Discharge analgesia	457
References	457
20.2 Paediatric procedural sedation within the emergency department	459
Introduction	459
The goal of procedural sedation	459
Pre-procedure	459
Governance	459
Patient selection and risk assessment	459
Fasting	459
Consent	459
Equipment and personnel	459
Rapport building	460
Intra-procedure	460
Post-procedure	460
Non-pharmacological methods	461
Selection of agents by procedureand age	461
Pharmacological methods	461
Nitrous oxide	461
Ketamine	462
Propofol	462
Ketafol	462
Other agents	462
Balanced sedation	462
References	464
21 -\rPOISONING	465
21.1 General approach to poisoning\r	465
Introduction and epidemiology	465
Diagnosis	465
Risk assessment	466
Investigations	466
Resuscitation	466
Decontamination	466
Antidotes	467
Enhanced elimination	468
Supportive care	468
Consultation and disposition	468
Further reading	469
21.2 Specific poisons	469
Common poisons	469
Paracetamol	469
Non-steroidal anti-inflammatory drugs	470
Benzodiazepines	470
Opioids	470
Anticholinergics and antihistamines	471
Corrosive ingestions	471
Ethanol	472
Rare and dangerous poisons	472
Salicylates	472
β-Blockers	473
Calcium-channel blockers	473
Digoxin	473
Clonidine	474
Iron	474
Warfarin and rodenticides	474
Oral hypoglycaemics	475
Tricyclic antidepressants	475
Toxic alcohols	475
Psychostimulants	476
Essential oils	476
Organophosphates and carbamates	476
House fires	477
Acknowledgements	477
Further reading	477
22 - ENVIRONMENTAL	479
22.1 Envenomation	479
23 - ULTRASOUND	513
23.1 Ultrasound	513
References	515
23.2 Diagnostic ultrasound in paediatric emergency medicine	516
References	517
24 - COMMON PROCEDURES	525
24.1 - Estimating the weight of infants and children	525
Background	525
Age-based tools to estimate body weight	525
Best guess formula	525
Length- and body-habitus–based tools	525
Tips	525
References	526
24.2 Basic airway management techniques	526
Background	526
OropharYngeal and Nasopharyngeal Airways	526
Indications	526
Contraindications	527
25 - ORTHOPAEDICS AND RHEUMATOLOGY	575
25.1 Orthopaedics and rheumatology	575
Introduction	575
The child with acute musculoskeletal pain or dysfunction	575
General approach	575
Assessment	575
Generalised or multifocal bone/joint pain	577
Introduction	577
History	577
Examination	577
Investigations	577
Specific conditions	578
Macrophage activation syndrome (haemophagocyticlymphohistiocytosis)	578
Urticaria and serum sickness	578
Henoch–Schönlein purpura	578
Rheumatic fever	579
Post-streptococcal and other post-infective immune-mediated reactive arthritides	580
Neoplastic presentations	580
Other important subacute paediatric musculoskeletal presentations	580
Traction apophysitis	580
Torticollis	580
Conclusion	581
Acknowledgement	581
References	581
25.2 C Child with a limp	581
Introduction	581
History	582
Examination	583
Investigation	583
Clinical decision making in a child with a limp	583
Specific conditions	584
Transient synovitis	584
Acknowledgement	589
References	589
26 -\rMALE GENITALIA	603
26.1 Male genitalia\r	603
The acute scrotum	603
Introduction	603
Torsion of a testicular or epididymal appendage	603
Torsion of the testis	603
Epididymo-orchitis	604
Idiopathic scrotal oedema	604
Testicular tumours	604
Irreducible inguinal hernia	604
Rupture of the testis	604
Acute hydrocele	604
Acute problems of the penis and foreskin	604
Introduction	604
Phimosis of the foreskin	604
Balanitis	604
Paraphimosis	605
Priapism	605
References	605
27 -\rTRANSPORT ANDRETRIEVAL	607
27.1 Paediatric emergency retrieval	607
Paediatric retrieval	607
What’s different about children?	607
Paediatric emergency referrals	607
Paediatric referral and retrieval – roles and expectations	608
The referrer	608
The coordinator/administrator	608
The paediatric retrieval specialist	608
The paediatric emergency transport team	608
Paediatric retrieval staff	608
Paediatric retrieval equipment	608
Criteria for transport	609
Degrees of urgency	609
Definitions	610
Transport platforms	610
Road ambulance	610
Rotary wing aircraft	610
Fixed-wing aircraft	610
Weather	610
While waiting	610
Stabilisation	611
Communication and retrieval leadership	611
Framework for communications during paediatric retrieval	611
Interface with adult retrieval	611
Parents	611
Paediatric retrieval and end-of-life situations	612
Quality	612
Summary	612
References	612
Further Reading	612
27.2 Sick child in a rural hospital	613
Introduction	613
Challenges in the rural setting	613
Income	613
Housing	613
Education	613
Culture	613
The illnesses	613
Birth history	613
Trauma	613
Infection and diet	613
The health services	613
Caring for the critically ill child	614
Decisions to consider when child presents with an emergency	614
Coordination of a resuscitation team prior to the child’s arrival	614
Potential problems in the stabilisation of the child	614
What can be done to assist care in remote environments?	614
Personnel	614
Education	614
Content of training	614
Consultation support	614
Transport	615
Management protocols	615
Hospital facilities	615
Relations between rural and urban hospitals	615
Acknowledgement	615
Further reading	615
28 -\rTEACHING PAEDIATRICEMERGENCY MEDICINE	617
28.1 Availing web-based resources\r	617
Accessing web-based resources	617
Needs of paediatric emergency medicine staff	617
Educational tools available online	617
Social media	618
Pitfalls of online content	618
Links	618
References	618
Conflict of interest	618
28.2 Teaching paediatric emergency medicine	619
Introduction	619
Desirable attitudes in paediatric emergency medicine	619
Humility	619
Caring	619
Empathy and compassion	619
Non-judgemental approach	619
Honesty and integrity	619
Advocacy and healthy paternalism	619
Self-monitoring and awareness of cognitive errors	620
Skill set for paedicatric emergency	620
Effective communication	620
Skilful clinical examination	620
Mastering procedural skills	620
Learning to teach	620
Self-preservation	620
Putting knowledge into perspective	621
Learning resources	621
People	621
Books	621
Other media	621
Conclusions	622
Further reading	622
29 -\rPAEDIATRIC RESEARCHIN THE EMERGENCYDEPARTMENT	623
29.1 - Research in children in the emergency department	623
Research science	623
Research question	623
Literature review	624
Types of studies	624
The ethics of medical research	624
Key principles	624
Ethics of research involving children	624
Ethics review process	626
The practice and governance of research	626
Research documents	626
Research protocol	626
Case report forms	626
Patient information statement and consent form	627
Study document file	627
The research team	627
Databases and analysis	627
Reporting guidelines	627
Key regulatory documents	627
International Conference on Harmonisation of Good Clinical Practice guidelines (ICH-GCP) 12	627
National- and state-based regulations	627
Project registration	627
Privacy and confidentiality	627
Implementation research: an emerging research field	627
Multicentre research	628
Funding research	628
References	628
30 - ADOLESCENT MEDICINEIN THE EMERGENCYDEPARTMENT\r	631
30.1 - Adolescent medicine in the emergency department	631
Introduction	631
Adolescent health problems in the emergency department	631
The approach to the adolescent in the emergency department	632
Establishing rapport	632
Seeing adolescents alone	632
Psychosocial screening	632
Using the HEADSSS framework	633
Confidentiality	633
The mature minor principle	633
Physical examination	633
Linking adolescents with community follow-up	633
Summary	633
References	634
30.2 Eating disorders and anorexia	635
Introduction	635
History	635
Examination	635
Investigations	635
Complications	635
Differential diagnosis	636
Management	636
Prognosis	637
References	637
Index	639
A	639
B	640
C	641
D	642
E	643
F	644
G	644
H	645
I	646
J	646
K	646
L	646
M	647
N	647
O	648
P	649
Q	650
R	650
S	650
T	652
U	653
V	653
W	653
X	653
Y	653
Z	653

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