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HSP
Vasculitis with arthralgia, abdo pain, and or renal involvement. Purpura occurs in all patients. The rash is distinctive. Urinalysis is needed - manage with analgesia. Consider steroids.

A first episode of HSP usually resolves within 4 weeks with the rash being the last symptom to go.
Joint pain usually resolves spontaneously within 72 hours and abdo pain in 24- 48 hours.
Uncomplicated abdominal pain usually resolves spontaneously within 24-48 hours

ITP
Covered on DFTB.

Petechial Rash 
The flow chart on this website is useful for highlighting when to investigate but this one is probably the best.
NICE say give ceftriaxone if:
  petechiae start to spread
  the rash becomes purpuric
  there are signs of bacterial meningitis
  there are signs of meningococcal septicaemia
  the child or young person appears ill to a healthcare professional
A non specific viral illness is the most likely cause of the rash.

References
https://www.rcemlearning.co.uk/foamed/7-pem-rashes/
https://dontforgetthebubbles.com/henoch-schonlein-purpura-steroids-helpful-preventing-nephropathy/
https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/
http://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/emergency-medicine/non-blanching-rash-management-in-children/
https://dontforgetthebubbles.com/itp-idiopathic-thrombocytopenia-purpura/
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A BRUE or an ALTE needs thorough history taking and examination.

It is defined as:

“an episode that is frightening to the observer and that is
characterized by some combination of apnea (central or obstructive), color
change (usually cyanotic or pallid, but occasionally erythematous or plethoric)
marked change in muscle tone (usually marked limpness), choking"

ie Apnoea, Looks Different, Tone different, Exhibits unconsciousness
ALTE? That's so 2015. It's now BRUE (brief,resolved,unexplained)https://t.co/qBS9GRcXW7 #FOAMed via @AmerAcadPeds pic.twitter.com/VlHVpjOxSY
— Lauren Westafer (@LWestafer) April 25, 2016

If this occurs whilst the child is sleeping, it may be apnoea of infancy. The child may also have insomina, hypersomnia etc. History will be key!


Take a careful history. And if there are no high risk features, the child can probably go home.
Learning about high risk features of BRUE and recommended testing during a Sunday AM shift @RushEmergency #FOAMed pic.twitter.com/FhxaMTc7fQ
— Michael Gottlieb (@MGottliebMD) November 11, 2018
References
https://pedemmorsels.com/brue/
http://dontforgetthebubbles.com/brue-is-the-new-black/ 
http://www.stemlynsblog.org/alte-brue/
http://foamcast.org/2016/05/04/episode-49-the-aap-brue-guidelines/
https://www.ncbi.nlm.nih.gov/pubmed/15499062
https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/central-sleep-apnoea-syndrome-csa
http://sleepeducation.org/sleep-disorders-by-category/sleep-breathing-disorders/infant-sleep-apnea/overview-facts
https://www.rcemlearning.co.uk/foamed/pem-and-ex-prems/
https://www.rcemlearning.co.uk/reference/myocarditis/
https://www.rcemlearning.co.uk/modules/causes-and-management-of-myocarditis/
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From a medical point of view, it is worth remembering that especially in toddlers who have a low mass, one pill can kill. Especially:
- Cardiac drugs
- Antidiabetics
- Antidepressents
- Iron, vicks, pepto - bismul (contains salicylates)
One pill killers: Do you know which common drugs are potentially fatal for a small child with ONE pill?https://t.co/OehAgPqmb7#MedEd #toxicology #FOAMed pic.twitter.com/cPdiHUhnXj
— Paediatric FOAMed (@PaediatricFOAM) August 22, 2018

From a mental health point of view - remember to complete all safeguarding paperwork, and encourage talking and communication.


Children’s mental health is a hugely increasing problem of our times. We see it in ED at its worst but remember all parents & carers have to consider their own & their kid’s mental health. Put this poster up in your ED - if it helps 1 family you’ve won #MentalHealthAwarnessWeek pic.twitter.com/boe6ufklSY
— ED Doc (@4hrEmergencyDoc) May 15, 2019
Your thorough HEADSSS assessment will help make sure all important points are covered.

References
https://pemgeek.com/2016/10/27/one-pill-killers/
https://www.nice.org.uk/guidance/cg133/resources/selfharm-in-over-8s-longterm-management-pdf-35109508689349
https://www.nice.org.uk/guidance/cg16/resources/selfharm-in-over-8s-shortterm-management-and-prevention-of-recurrence-pdf-975268985029
https://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh
https://www.rcemlearning.co.uk/curriculum/paeds-acute/pap2/
https://www.rcemlearning.co.uk/modules/paediatric-toxicology-considerations/
https://youngminds.org.uk/find-help/for-parents/parents-guide-to-support-a-z/parents-guide-to-support-self-harm/
https://www.nspcc.org.uk/preventing-abuse/keeping-children-safe/self-harm/
https://www.rcemlearning.co.uk/foamed/the-3cs-of-paediatrics/
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Medium sized artery vasculitis in children under five years old.
Unknown aetiology but possibly infection.
Higher risk in Asians, especially Japenese and Koreans.

Signs
— #hellomynameisDrKirsty (@KirstyChallen) April 21, 2015
or
Symptoms of Kawasaki Disease can be remembered by the mnemonic "CREAM" - http://t.co/4EKqYRMqbP #USMLE #FOAMed pic.twitter.com/zBmzrAXc12
— knowmedge (@knowmedge) January 27, 2014
In the absense of inflammation (high WCC or CRP) Kawasaki is unlikely.
Don't wait for fever >5 days to diagnose it though - it might be incomplete.

https://www.rcemlearning.co.uk/foamed/a-child-with-a-fever/
https://adc.bmj.com/content/99/1/74
https://www.paediatricfoam.com/2017/06/kawasaki-disease-pearls-and-pitfalls/?subscribe=success#blog_subscription-4
http://dontforgetthebubbles.com/kawasaki-disease-beware-the-incomplete/
http://rolobotrambles.com/notjustafever/
https://calgaryguide.ucalgary.ca/wp-content/uploads/image.php?img=2017/05/Kawasaki-Disease.jpg
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