1: Bee Sting: Review from notes

2: Foreign Body Swallowing: not Inhaled case

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

Task
o Give the nurse instructions regarding
management
o Explain childs condition to the mother and
answer her questions

2014 RCH Anaphylaxis Guidelines:

http://www.rch.org.au/clinicalguide/guideline_index/Anaphylaxis/
RCH Guidelines
o Vasopressor and bronchodilator therapy:
adrenaline 10mcg/kg;
o Adrenaline 0.01 ml/kg 1:1000 IM or 0.01 mg/kg
1:10,000. Repeat dose in 5 minutes if needed
o Oxygen by mask
o IV volume expander: 0.9% NSS 20ml/kg then
give repeat boluses of 10-20 ml/kg until BP
restored
o Bronchodilator therapy with salbutamol
continuous nebulized (0.5%) or IV 5mcg/kg per
min for 1 hour, then 1 mcg/kg per minute
thereafter
o Relief of upper airway obstruction: mild to
moderate edema may respond to inhalation of
nebulized adrenaline 1% adrenaline (1ml per
dose diluted to 4 ml) or 5 ml of nebulised 1:1000
solution
o Anaphylaxis biphasic and may deteriorate again
over the next few hours; all patients with
anaphylaxis should be observed for at least 12
hours (4 hours 2014 guidleines??)
o Consider refer for Allergen testing

o Discharge pack: self-injectable adrenaline epi

pen, medi-alert bracelet
Immediate Resuscitation DR-ABC
o Can you please check the patients level of
consciousness?
o What is her GCS?
o Can you see a bee sting in the skin?
o Can you please take it out with the help of a
forcep?
o Can you please check her airway? Is it patent?
Any secretions? Can you please auscultate the
lungs for air entry?
o I would like you to put her on oxygen around 6-8
liters/minute via a mask.
o Can you please give her IM adrenaline in a
concentration of 1:1000 IM 0.01ml/kg or 0.1
ml/kg 1:10,000 IV.
Can you check the blood pressure?
o If the response is not good, could you kindly
repeat it in the same concentration every 5-10
minutes.
o Can you please put in 2 IV cannula.
Please start her on normal saline 0.9% bolus 20ml/Kg
and repeat until shock is cleared and then 300-500 ml
normal saline depending upon the childs stature.
Can you please give Nebulised adrenaline if upper airway
obstruction. (Nebulised adrenaline is not recommended
as first-line therapy, but may be a useful adjunct to IM
adrenaline if upper airway obstruction is present).
If airway oedema is not responding to parenteral and
nebulised adrenaline, early intubation is indicated.
o Determination of ETT tube:
o Diameter ETT tube: Age of child/4 + 4
o Length of ETT tube: Age of child/2 + 12
Can you please tell me if the child has any wheezing or if
she is still SOB?
Can you please start her on nebulized salbutamol.
Can you please give her 1mg/kg of hydrocortisone IV.

Would you kindly give her cimetidine or other

antihistamine that might be available.
RCH Admission Criteria:
All children with anaphylaxis should be observed at least
4 hours. Admission should be considered if any of the
following circumstances apply:
o Greater than one dose of adrenaline (including
nebulized adrenaline) required.
o A fluid bolus required
o Inadequate response to treatment
o The child lives a long distance from medical
services
Explanation to Mom
Let me reassure you that your child is stable at the
moment. She is better with the emergency measures we
have done. It is quite understandable that you are very
anxious to know what happened to her. Basically, what
she had is a condition called an anaphylactic reaction to
the bee sting. It is a kind of an allergic reaction that can
happen after insect bite, certain foods, as well as intake
of certain medications. It is a serious condition as there is
a risk of choking or circulatory compromise. Therefore,
we need to keep her in the hospital for the next 12-24
hours ??. There is a chance of rebound reaction within
the 1st 6-12 hours. I will call in the pediatric registrar to
come and take a look at her for further assessment. They
will assess her condition and they will do further testing
later on that might include skin prick testing or RAST.
With these tests we will determine if she is allergic to
other substances as well.
Can you please tell me if she has any known allergies
already? Any history of eczema, asthma, hay fever or
drug allergy? Hows her general health? Does she have
family history of similar allergies? Was she stung before?
Before going home, I will ask the nurse to explain to you
what to do in case of another bee sting, but let me explain
the components of the anaphylaxis action plan. This
includes the use of a special kit. Basically, it contains an

epipen (an injection of adrenaline) that needs to be given

IM in case of anaphylaxis. It also contains a ventolin
puffer, a tablet of antihistamine, and steroids. During
another attack, you need to observe her for certain signs
such as wheeze, hoarseness of voice, loss of
consciousness, vomiting/diarrhea, and swollen blue lips
with or without swelling all over the body. In case she
develops these symptoms you will use this injection and
give it on the thigh over the clothes. You can repeat it
every 5-10 minutes. Make her lie flat on the ground,
elevate the legs, call family for help, but most importantly,
call 000 for an ambulance. Please provide these
injections to the school along with written instructions.
Avoid places where she is likely to have a bee sting.
Avoid wearing colorful clothes. Avoid using perfumes,
places especially gardens.
Once she is discharged, please come for followup with
the immunologist for venom immunotherapy.
Reading material.
Local reactions
o Local ice application, elevation, analgesics and
antihistamines
o Removal of bee sting: scrape off skin with
fingernail (dont squeeze)
o Care at home: washing skin, calamine lotion to
help with itching, ice packs, elevation,
antishistamine (phenergan or zyrtec), strong
steroid creams applied early and regularly onto
skin that was bitten;
o See doctor if: reactions in other parts of the body
such as hives, or breathing problems; child has a
lot of pain where they were bitten which does not
settle down within a few hours; swelling or itching
gets worse after 24 hours
o Medications should be carried with the child at all
times.

2:
You are an HMO in ED. A 3-year-old girl brought to you by mom. She
says that girl swallowed bulletin board pin about half an hour ago. The
child is fine at the moment. She has been examined by another doctor
and she is asymptomatic.
Task:
o Talk to the mother about the management.
o History:
o Can you please describe how it happened?
o Did you or anyone else see her at the time?
o What type of pin is it?
o Can you show me? Did she have anything to
drink afterwards?
o Any vomiting? Cough? Bleeding? Any abdominal
pain? Is it the first time for this to happen?
o At the moment, your child doesnt have any symptoms.
All examination is normal so we need to find out where
the pin is lodged. So I would like to order xrays of the
neck, chest and abdomen. As you can see on the x-ray
that the pin has crossed the pylorus, which is one of the
narrowest parts of the stomach, so there is a very high
chance it will pass out spontaneously. You can take her
home but keep an eye on her. Watch out for symptoms
like fever, tummy pain, vomiting or blood in stools. These
symptoms indicate that the pin might be causing damage
to the bowel wall. Unless you want to, there is no need to
check the stools for the pin. We will not be doing follow
up xrays unless she develops symptoms. Please
understand that it is very important to supervise your child
at all times to prevent this from happening again. I will
give you written material regarding safety at home for
kids.
o For food bolus: allow to drink fizzy drinks then do back
tap
o For lead (eg. button battery): if passing to stomach then
do not do anything about it but if it stays, then take it out
and do followup xrays

FOREIGN BODY

Radio-opaque
(pins, batteries,
buttons, coins) or
unknown
Xray (neck, chest
and abdomen)
Stomach and
beyond

Radiolucent
(glass/plastic)
Asymptomatic
(Observe at
home)

Symptomatic
(drooling, chest
pain, intolerant to
food)

Esophagus
(ENT surgeon)

RCH - Foreign Bodies Inhaled

o The signs and symptoms of a foreign body in the upper
airway or bronchial tree will vary depending upon the site
of impaction.
o Sudden and catastrophic event.
o Coughing, choking and possibly vomiting.
o If obstruction is total - rapidly progresses to
unconsciousness and cardiorespiratory arrest.
o May be present in a child with a cardiorespiratory arrest
in whom it is impossible to ventilate.
If Obstruction Is Total:
o Open the airway and under direct vision (preferably using
a laryngoscope) check in the mouth for a foreign body - if
present remove it with magills forceps.
o Place child prone with the head down.
o Apply 5 blows with the open hand to the interscapular
area.
o Turn child face up.
o Apply 5 chest thrusts using the same technique as for
chest compression during CPR.
o Check in the mouth to see if foreign body has appeared.
o Apply 5 lateral chest thrusts.
o If unsuccessful repeat interscapular blows, central chest
compressions and lateral chest thrusts.

o Positive pressure "ventilation" can be tried in an attempt

to force the foreign body into the left or right main
bronchus.
o A surgical airway may be tried if the obstruction is in or
above the larynx and it is impossible to remove it through
the mouth.
If Obstruction Is Partial:
o DO NOT perform the above manoeuvres.
o Place child upright in the position they feel most
comfortable.
o Arrange for urgent removal of foreign body in the
operating theatre.
Impaction Lower Than The Main Bronchus:
o Children between the ages of 6 months and 4 years are
at greatest risk.
o There may have been an episode of choking, coughing or
wheezing while eating or playing but many episodes are
unwitnessed.
o Symptoms may include persistent wheeze, cough, fever
or dyspneoa not otherwise explained. Recurrent or
persistent pneumonia may be the presenting feature.
o The child may be asymptomatic after the initial event.
Examination
o Asymmetrical chest movement
o Tracheal deviation
o Chest signs such as wheeze or decreased breath
sounds.
o The respiratory examination may be completely normal.
Radiology:
o Request inspiratory and expiratory chest films. Look for:
an opaque foreign body, segmental or lobar collapse,
localised emphysema in expiration (ball valve obstruction)
o The CXR may be normal.

Mx:
o DO NOT perform the above manoeuvres.
o Place child upright in the position they feel most
comfortable.
o Arrange for urgent removal of foreign body in the
operating theatre.
o Prevention:
o No child less than 15 months old should be offered foods
such as popcorn, hard lollies, raw carrot or apples.
Children under the age of 4 years should not be offered
peanuts.
o Encourage the child to sit quietly while eating and offer
food one piece at a time.
o Avoid toys with small parts for children under the age of 3
years.