Emergencies in Emergencies in peadiatricspeadiatrics

KrzysztofNarębski

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Problems to discussProblems to discuss

1)1) Child assessmentChild assessment

2)2) Neonatal resuscitationNeonatal resuscitation

3)3) ShockShock

4)4) SepticaemiaSepticaemia

5)5) Status epilepticus / febrile seizuresStatus epilepticus / febrile seizures

6)6) DyspnoeaDyspnoea

7)7) AnaphylaxisAnaphylaxis

8)8) Inhaled foreign bodyInhaled foreign body

Child assessmentChild assessmentBasic / Advanced Live Basic / Advanced Live SupportSupport1)1) Primary assessmentPrimary assessment

- ABCDABCD scale scale

oror- AVPU scaleAVPU scale

2)2) ResuscitationResuscitation

3)3) Etiologic treatmentEtiologic treatment

„„SICK CHILD”, SICK CHILD”, „SEPTIC”„SEPTIC”

AA - - AArousal, rousal, AAlertness, lertness, AActivity, ctivity, AApathypathy

BB - - BBreathing difficultiesreathing difficultiesCC - - poor poor CColour (pale) andolour (pale) and

CCirculation (irculation (CCold peripheries)old peripheries)DD - - DDecreased fluids inecreased fluids intaketake (fewer (fewer

than than half ahalf a normal intake) andnormal intake) andDDecreased urine output (fewer ecreased urine output (fewer

than 4 than 4 wet nappies a day)wet nappies a day)

Level of awareness, Level of awareness, ComaComa

AA - - AAlertlertVV - - responds to responds to VVoiceoicePP - - responds to responds to PPainainUU - - UUnresponsivenresponsive

NeonatalResuscitation

at birth

NR first 30 sec = routine care !!!

NR breathing and chest compressions

Neonatal resuscitationNeonatal resuscitation

Adrenaline ivAdrenaline iv 10 – 30 mcg / kg 10 – 30 mcg / kg

(0.01 – 0.03 mg / kg)(0.01 – 0.03 mg / kg)

Amp. 0,1 % (1 : 1000), 1 mlAmp. 0,1 % (1 : 1000), 1 ml

1 ml - 1 mg = 1000 mcg1 ml - 1 mg = 1000 mcg

Dilution 10 xDilution 10 x >>>>

1 ml - 0.1 mg = 100 mcg1 ml - 0.1 mg = 100 mcg

>> >> give 0.1 – 0.3 ml / kg (= 10 – 30 give 0.1 – 0.3 ml / kg (= 10 – 30 mcg)mcg)

Apgar scoreApgar score : good 8 – 10 : good 8 – 10 points, intermediated 4 - 7, points, intermediated 4 - 7, bad 0 - 3bad 0 - 3

Score of 0 Score of 1 Score of 2 Acronym

Skin color

Blue / pale all over

Body pink, Blue extremities

All pink Appearance

Pulse rate

Absent < 100 /min > 100 /min

Pulse

Reflex irritability

No respond to stimuli

Grimace Cry Grimace

Muscle tone

None Some flexion Flexed legs & arms

Activity

Breathing

Absent Weak, irregular

Strong cry

Respiration

ShockShock

DefinitionDefinition : inadequate circulation to : inadequate circulation to meet the tissues’ demandsmeet the tissues’ demands

EtiologyEtiology : :- Hypovolemia !!! viral - Hypovolemia !!! viral

gastroenteritisgastroenteritis

- Maldistribution of fluid :- Maldistribution of fluid :- SepsisSepsis- AnaphylaxisAnaphylaxis

Signs of shockSigns of shock

EarlyEarly (compensated shock) (compensated shock)– tachypnoea and tachycardiatachypnoea and tachycardia– sunken eyes and fontanellesunken eyes and fontanelle– mottled, pale, cold skinmottled, pale, cold skin– decreased skin turgordecreased skin turgor– decreased capillary refill (> 2 sec)decreased capillary refill (> 2 sec)– decreased urinary outputdecreased urinary output

(< 1 ml/kg/h)(< 1 ml/kg/h)

Signs of shockSigns of shock

LateLate (decompensated shock) (decompensated shock)– confusion / depressed cerebral confusion / depressed cerebral

statestate– bradycardiabradycardia– hypotensionhypotension– blue peripheries blue peripheries – absent urine outputabsent urine output

HydratationHydratation

Decreased skin turgorDecreased skin turgor

Hypovolemia - Hypovolemia - treatmenttreatment Fluids resuscitation :Fluids resuscitation :

1. 1. 0.9 % saline iv0.9 % saline iv

- 20 ml / kg- 20 ml / kg

- in 10 – 20 min,- in 10 – 20 min,

- repeat if necessary !!!- repeat if necessary !!!

(Ringer if urine output (Ringer if urine output present)present)

2. Blood if trauma2. Blood if trauma

Figure 6.8 Initial fluid resuscitation in shock.

Downloaded from: StudentConsult (on 26 February 2012 12:39 PM)

© 2005 Elsevier

Fluids intake at different Fluids intake at different agesages

Body weight

Fluids requirement / 24 hours

Volume / kg per hour

First 10 kg 100 ml / kg 4 ml / kg

Second 10 kg

50 ml / kg 2 ml / kg

Subsequent kg

20 ml / kg 1 ml / kg

Examples of calculationsInfant 7 kg 700 ml 29 ml / h

Child 18 kg

1000 + 400 = 1400 ml 40 + 16 = 56 ml/h

Child 42 kg

1000+500+440 = 1940 ml

40+20+18 = 78 ml/h

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SepticaemiaSepticaemia- meningococcal - meningococcal

purpurapurpuraPoor state+ fever+ rashthat does not blanch whenpressedunder a glass

SepticaemiaSepticaemia

- - meningococcal meningococcal purpurapurpura

SepticaemiaSepticaemia-- clinical features clinical features

HistoryHistory : :

- fever- fever

- poor feeding- poor feeding

- irritability, lethargy- irritability, lethargy ExaminationExamination : :

- tachycardia, tachypnoea, - tachycardia, tachypnoea, hypotensionhypotension

- shock, multi organ failureshock, multi organ failure- purpuric rashpurpuric rash

ABCD / AVPU scale

Vaccination

Septicaemia - Septicaemia - treatmenttreatment Antibiotic immediately ivAntibiotic immediately iv Hospital (Intensive Hospital (Intensive CCare are UUnit)nit) Treatment of shockTreatment of shock

SeizuresSeizures

Definition :Definition :

Uncontrolled electrical Uncontrolled electrical activity in the brain, which activity in the brain, which

may produce a physical may produce a physical convulsionconvulsion.

Status epilepticus / Status epilepticus / febrile seizuresfebrile seizures Status epilepticusStatus epilepticus - definition : - definition :

- seizure lasting 30 min or- seizure lasting 30 min or

- successive frequent seizures - successive frequent seizures with with unconsciousnessunconsciousness

Febrile seizuresFebrile seizures - definition : - definition :

- seizure accompanied by a - seizure accompanied by a fever in fever in absence of intracranial absence of intracranial infectioninfection

Seizures - etiologySeizures - etiology

Febrile seizures – any infections & Febrile seizures – any infections & feverfever

AlsoAlso : :– Metabolic (hypoglycemia, hypoCa, Metabolic (hypoglycemia, hypoCa,

hypoMg, hypo or hypernatraemia)hypoMg, hypo or hypernatraemia)– Meningitis and encephalitisMeningitis and encephalitis– Cerebral trauma or tumorCerebral trauma or tumor– Toxins (poison, metabolic disorders)Toxins (poison, metabolic disorders)– Epilepsy and othersEpilepsy and others

Seizures - treatmentSeizures - treatment

Febrile seizures – antipyretics !!!Febrile seizures – antipyretics !!!- Diazepam 0.5 mg- Diazepam 0.5 mg / kg / kg pr pr

Seizures or status epilepticus :Seizures or status epilepticus :- Phenobarbital iv 10 – 20 mg / kgPhenobarbital iv 10 – 20 mg / kg- Phenytoin iv 20 mg / kgPhenytoin iv 20 mg / kg

Repeat if no response in 5 min !!!Repeat if no response in 5 min !!!Give oxygen !!! >> PICUGive oxygen !!! >> PICU

If hypoglycemia < 3 mmol/LIf hypoglycemia < 3 mmol/LGive 10 % glucose iv 2 ml / kgGive 10 % glucose iv 2 ml / kg

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The degree of subcostal, intercostal and sternal recession is a more useful indicator of severity of upper airways

obstruction than the respiratory rate.

DyspnoeaDyspnoea- Croup- Croup

Dyspnoea - CroupDyspnoea - Croup

Features : viral, 6 months to 6 years, Features : viral, 6 months to 6 years, harsh, loud stridor, coryza, mild feverharsh, loud stridor, coryza, mild fever

TreatmentTreatment- Inhalation of fresh airInhalation of fresh air- Steroids :Steroids :

prednisolon oral, im, iv orprednisolon oral, im, iv or

inhaled budesonidinhaled budesonid- Nebulised adrenaline with oxygen Nebulised adrenaline with oxygen

Dyspnoea – Asthma fitDyspnoea – Asthma fit

History of allergy or asthmaHistory of allergy or asthma Symptoms and signs :Symptoms and signs :

- too breathless to eat or talk- too breathless to eat or talk- use of accessory muscles- use of accessory muscles- distended chest- distended chest- wheeze or silent chest- wheeze or silent chest- cyanosis and alter level of - cyanosis and alter level of

consciousnessconsciousness Treatment - Oxygen !!!Treatment - Oxygen !!!

- Bronchodilators (B2-agonist)- Bronchodilators (B2-agonist)- Steroids iv, oral or inhaled- Steroids iv, oral or inhaled

AnaphylaxisAnaphylaxis

Definition :Definition :

Severe, whole – body reaction Severe, whole – body reaction to an allergen, after being to an allergen, after being previously exposed to thpreviously exposed to thisis allergen allergen (sensitization to it).(sensitization to it).

This reaction happen very This reaction happen very quickly.quickly.

AnaphylaxisAnaphylaxis

History of allergy / anaphylaxisHistory of allergy / anaphylaxis Food Food oror insect sting insect sting venom allergy venom allergy Symptoms immediately :Symptoms immediately :

- airways : swelling, hoarseness, - airways : swelling, hoarseness, stridorstridor

- breathing : tachypnea, wheeze, - breathing : tachypnea, wheeze, cyanosis, SpO2< 92 %cyanosis, SpO2< 92 %

- circulation : pale, clammy, - circulation : pale, clammy, hypotension, drowsy, comahypotension, drowsy, coma

Anaphylaxis - Anaphylaxis - treatmenttreatment

Adrenaline / epinephrine 1 : 1000 Adrenaline / epinephrine 1 : 1000 imim

< 6 years < 6 years - 150 mcg - 150 mcg (0.15 ml)(0.15 ml)

6 – 12 years - 300 mcg 6 – 12 years - 300 mcg (0.3 ml)(0.3 ml)

> 12 years > 12 years - 500 mcg - 500 mcg (0.5 ml)(0.5 ml)

Hydrocortison im or ivHydrocortison im or iv

Inhaled foreign bodyInhaled foreign body

In infants, back blows and chest thrusts are recommended to expel an inhaled foreign body. Abdominal thrusts are best avoided

in infants as they may cause intra-abdominal injury.

Abdominal thrusts (Heimlich manoeuvre) in older children to expel an inhaled foreign body. One hand is formed

into a fist and placed against the child's abdomen between umbilicus and xiphisternum.

The other hand is placed over the fist. Both hands are thrust

into abdomen. Repeat several times. The child can be standing, kneeling, sitting

or supine.

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