Management of Emergencies in Children

Pediatric Critical Care Division,Child Health Department Sanglah Hospital, Faculty of Medicine University of Udayana

Introduction

providers must recognize these differences in order to provide the best possible care for an ill or injured child.

providers must recognize these differences in order to provide the best possible care for an ill or injured child.

• Children's bodies respond to significant injury and shock differently than adults.

• These differences may be subtle and difficult to recognize.

A child’s anatomy differs in four significant ways from an adult’s. They are:• Smaller airways

• Less blood volume • Bigger heads• Vulnerable internal organs

• Large tongue in relation to a small oropharynx

• Diameter of the trachea is smaller

• Trachea is not rigid and will collapse easily

• Back of the head is rounder and requires careful positioning to keep airway open

smaller airway smaller airway

• Relatively smaller blood volume

• Approximately 70 cc of blood for every 1kg (2 lbs) of body weight

• A 20 lb child has about 700cc of blood—about the volume of a medium sized soda cup

smaller airway smaller airway

less blood volume

less blood volume

• Head size is proportionally larger

• Prominent occiput and a relatively straight cervical spine

• Neck and associated support structures aren’t well developed

• Infants and small children are prone to falling because they are top heavy

less blood volume

less blood volume

bigger heads bigger heads

smaller airway smaller airway

• Internal organs are not well protected

• Soft bones and cartilage and lack of fat in the rib cage make internal organs susceptible to significant internal injuries

• Injury can occur with very little mechanism or obvious signs

bigger heads bigger heads

internal organs internal organs

less blood volume

less blood volume

smaller airway smaller airway

Infant: 1 to 12 months• Active extremity movement• Tracks object with eyes• Obstruction of the nose may cause

respiratory distress• Separation anxiety later in this

period• Provide sensory comfort such as a

warm stethoscope• Explain procedures in very simple

terms

Toddler: 1 to 3 years• Approach slowly & limit physical

contact• Most have stranger anxiety• Sit down or squat next to and use a

quiet voice• Not good at describing or localizing

pain• Use play and distraction objects• Have caregiver hold• Ask only yes/no questions• Get history from parent

Preschool Age: 3 to 5 years• Explain procedures in simple terms• Use games or distractions• Set limits on behaviors• Praise good behavior• Offer a stuffed animal or toy to hold• Do not allow to handle equipment

School Age: 6 to 12 years• Speak directly to the child• Be careful not to offer too much

information• Explain procedures immediately before

carrying them out• Don’t negotiate unless the child really

has a choice• Keep conversation with child to a

minimum

Adolescent: 12 to 15 years• Explain what you are doing and why• Show respect• Get history from patient if possible• Respect independence; address

directly• Allow parents to be involved in

examination if patient wishes• Consider asking questions about sexual

activity, drug/alcohol use privately

CNSRespiratoryCardiovascularGastrointestinalEndocrineEtc

The PAT

Appe

aran

ceW

ork of Breathing

Circulation to Skin

Respiratory distress

N

N

N

Cardiopulmonary failure

/

Shock

N

N

Primary CNS dysfunction/

metabolic abnormality

N

NN

N

N

AirwayBreathingCirculationDisabilityExposure

A state in which there is inadequate A state in which there is inadequate

tissue perfusion to meet metabolic tissue perfusion to meet metabolic

demandsdemands

It is not LOW BLOOD PRESSURE !!!It is HYPOPERFUSION…..

COMPENSATED

blood flow is normal or increased and may be maldistributed; vital organ function is maintained

UNCOMPENSATED

microvascular perfusion is compromised; significant reductions in effective circulating volume

IRREVERSIBLE

inadequate perfusion of vital organs; irreparable damage; death cannot be prevented

Hypovolemic or

Hemorrhagic

Cardiogenic

Obstructive

Distributive

Neurological: fluctuating mental status,

sunken fontanel

Cardio-pulmonary: tachypnea, tachycardia

Skin and extremities: cool, pallor, mottling,

cyanosis, poor cap refill, weak pulses

Renal: scant, concentrated urine

Always begin with Always begin with ABCsABCs

AirwayAirway: : must be patent, adequately oxygenated and ventilated

BreathingBreathing: always provide suplemental : always provide suplemental

oxygen oxygen

CirculationCirculation: vascular access, volume : vascular access, volume

expansionexpansion

Mainstay of therapy is fluid

Fluid challenge

Fluid loading

Fluid replacement

Fluid maintenance

Isotonic crystalloid is always a good choice

20 to 50 cc/kg rapidly if cardiac function is

normal

Degree of dehydration often

underestimated

Reassess perfusion, urine output, vital

signs

Treat underlying cause

Correct acidosis

Inotropic and vasoactive drugs: select to

optimized desire effect

The impaired ability of the

respiratory system to maintain

adequate oxygen and carbon

dioxide homeostasis

Two main categories:

Ventilation Oxygenation

Removal of waste CO2

Transfer of O2 from air in blood

Acute hypoxemic (Type I):

pneumoni

Ventilatory (Type II): asthma

Specific treatment vary according to

the underlying cause

Corrected hypoxemia

Reduced load on the respiratory

muscle

Optimized ventilatory pump capacity

Administration of supplemental oxygen Acute hypoxaemic or mixed respiratory

failure Simple mask, nasal cannulae, Venturi mask,

mask with rebreathing bag, oxygen tents Physiological effects of oxygen therapy Oxygen toxicity

Control of secretion Hydration

Control of secretion Mucolytic agents Chest physiotherapy Tracheal intubation and tracheostomy Respiratory stimulants

Control of infection Treatment of airways obstruction

-stimulants, ipratropium bromide, steroids

Control of lung water Optimizing ventilatory pump

capacity Malnutrition, catabolism, immobility,

metabolic disturbance Mechanical ventilatory support

Seizure : transient, involuntary alteration of

consciousness, behavior, motor activity,

sensation, and/or autonomic function

caused by an excessive rate and

hypersynchrony of discharges from a group

of cerebral neurons

Convulsion : seizure with prominent

alterations of motor activity

BREATHING

CIRCULATION

Ensure airway patency Jaw thrust, suctioning of the

oropharynx, use of adjunctive airways

(oral or nasopharyngeal) Considered intubation : hypoxia,

hypoventilation, GCS < 8 Supplemental oxygen provided and

respiration assisted as needed

BREATHING

CIRCULATION

Established intravena access or intraosseous

Hypotension or dehydration isotonoic fluid resuscitation

Hypoglycemia dextrose intravenously

Electrolyte abnormalities replaced appropirately

Diazepam 5-10 mg per rectal, max 2x, interval 5 mnt 0-10 minPrehospital

Diazepam 0.25-0.5 mg/kg iv/io, max dose 20 mg,rate 5mg/min

10-20 minHospital/ED ABC

Midazolam 0,2 mg/kg iv bolus

OR

OR

Lorazepam 0,5-1 mg/kg iv, rate < 2mg/min

Phenytoin 15-20 mg/kg iv, max 30 mg/kg,rate 20 min/50 ml NS

Phenobarbitone 20 mg/kg iv, max 1000 mg,rate >5-10 min (100mg/min)

Refracter

Midazolam 0.2-0.5 mg/kg iv bolus,followed by infusion 0.05-4 ,cg/kg/min

Pentotal 10-15 mg/kg iv then 2-5 mg/kg q 5 min to stop seizure, followed by infusion 1-3 mg/kg/hr

Tiopental 5 mg/kg iv then 1-2 mg/kg q 5 min to stop seizure, followed by infusion 3-5 mg/kg/hr

Propofol 2-5 mg/kg iv, followed byInfusion 25-65 mcg/kg/min

ICU/ED

ICU/ED

Additional 5-10 mg/kg iv

Additional 5-10 mg/kg iv

20-30 min

30-60 min

Statler KD. Status epilepticus. 2007Komisi Resusitasi Pediatrik. Konvulsi. 2006