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Emergency Pediatrics

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mona magdi

on 5 June 2014

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Transcript of Emergency Pediatrics

Emergency Pediatrics
Out of the hospital cardiac arrest
In HOSPItal cardiac arrest
airway
Respiratory failure
- Unknown diagnosis --> prioritize and stabilize
- Structured approach
- Good communication
- A airway
B breathing
C circulation
D disability
E exposure


- Suspect:
1. unconscious
2. No normal breathing
3. No signs of circulation
- Action: 3 S
1. safety
2. stimulate
3. shout for help

What to do?
A: Airway opening
1. Head tilt with a chin lift
--> no cervical spine injury
2. Jaw thrust
B: Breathing
1. Look, Listen and Feel
2. If not breathing NORMALLY:
FIVE rescue breaths
c: CIRCULATION
- Signs of circulation:
1. Any movement
2. Coughing
3. Normal breathing
4. Response to stimulation
- Not longer than 10 seconds
- Carotid -> infant
Brachial -> child
- If in an infant:
1. NO signs of circulation/ no pulse/ slow pulse (<60 bpm)
2. YOU ARE UNSURE ----->
chest compressions
- rate 100-120/min
- depress sternum 1/3 of chest
- over lower 1/2 of sternum
- compression/breath ratio:
1. infant and prepubertal child: 15 : 2
2. postpubertal: 30 : 2
< 1 year
- 2 fingers -> single rescuer
- two thumbs --> 2 rescuers
> 1 year - puberty
Heel of one/ two hands
Airway adjuncts
- Nasopharyngeal/ oral
- underused
- good for bagging when waiting for specialist/ prearrest
- Size:
1. Nasopharyngeal:
tip of nose - tragus of ear
2. Oral:
center of incisors - angle of mandible
O2
- IMMEDIATELY in ALL arrests
- Flow = 15 l/min
- Reservoir
rythm assessment
AFTER achieving an effective ventilation
ASYstole
- MOST common arrest rythm

- usually post hypoxia & acidosis (Respiratory failure)
What to do?
- check the leads
- add the gain
- check for signs of life & pulse (<10 sec)
Pulseless electrical activity
NO pulse + complexes on ECG
- Ventricular fibrillation
- pulseless ventricular tachycardia
- Uncommon in children

- causes:
1. Hypothermia
2. Electrocution injury
3. Heart disease
4. Poisoning with TCA
5. Hyperkalemia
FIVE INITIAL BREATHS --> 15:2
Shockable VS. NON-SHOCKABLE ?
NON SHOCKABLE
- PEA and Asystole

- Adrenaline:
1. as you get an IV access
2.
0.1 ml/kg of 1 in 10 000
3. Repeat Adrenaline every alternate cycle
SHOCKABLE RYTHM
- VF and Pulseless VT

- Defibrillate with
1 ASYNCHRONOUS shock 4 J/Kg

- Adrenaline:
AFTER 3rd shock THEN every alternate cycle

- Amiodarone:

5 mg/kg IV
AFTER 3rd shock THEN after 5th shock
post resuscitation management
- Transfer to PICU
- Regular assessment
- Capnography --> CO2
- Pulse oximetry --> to avoid hperoxia
- Monitor:
1. ECG
2. Bl. pressure
3. Bl. gases
4. Urine output
5. temperature

when to stop resuscitation?
- decision of the most senior

- if resuscitation > 30 mins --> likely not successful

- if hypothermia --> resuscitate until fully warm

- Out-of-hospital arrest --> poor
outcome
recuscitation care plan
- made by:
1. The treating doctor
2. the child
3. the family
4. the multidisciplinary team

- What to do > what NOT to do
ex.:
Do non invasive ventilation
but NOT intubation
Electrocution injury
- Uncommon

- risk of cardiac arrest depends on:
1. duration
2. size of current
3. type (AC / DC)

- Tetany can occur in muscles --> if in diaphragm --> respiratory arrest

- Fluid and blood --> least resistance
skin and bone --> highest resistance

- damage is caused by heat
- compartmental $ (muscles' swelling)
- Massive internal thermal injury --> Myoglobinuria
Treatment
- Disconnect from source

- immobilize cervical spine

- ABCDE

- greater fluid requirement despite small external burn (internal heat injury)
Myoglobinuria
- in major muscle injuries:
ex. electrocution / crush injuries
- TTT:
Forced Alkaline Diuresis
1. Maintain urine output = 2ml/kg/h by loading fluids and giving diuretics (ex. mannitol)
2. IV NaHCO3 --> alkalinization of urine

1. airway obstruction
- occurs at any level:
1. Upper airways --> stridor
2. Lower airways --> expiratory wheezes

- airway resistance is inversely proportional to radius to the power of 4: ++ in babies

- Voices:
1. Poor pharyngeal tone (ex. CP):
- gurgling / bubbling --> secretions
- snoring
2. Grunting:
expiration with partially closed glottis
Causes:
- Stridor:
Croup / larngotracheobronchitis / Epiglotitis (silent stridor + drooling& toxic)

- Wheeze / silent chest:
Asthma

- Prolonged expiratory phase:
tracheobronchomalacia
TTT :
- Call for a senior doctor

- Fully comfort the child (mostly on a parent's knees)

- high flow O2 and measure O2 saturation

- Nebulized adrenaline 5ml of 1:1000 with O2 through a facemask

- intubate (expercienced doctor)

- give oral prednisolone (+ Abs if suspecting infection

- Nasopharyngeal tube (can be enough in poor pharyngeal tone)

chocking
Do NO blind finger sweeps
When a Baby:
if a child:
- same protocol but abdominal thrusts in stead of chest thrusts

- Heimlich manoeuvre:
NEVER in infants (--> injury to internal organs)
3. inadequate airway protection
decreased conscious level:
P on AVPU / 8 on GCS
TTT:
- Immediate intubation:

1. experienced doctor
2. induction of anasthesia and paralysis
3. cricoid pressure& rapid induction --> to prevent gastric contents aspiration
4. chest XRay after intubation (if in rt main bronchus --> right upper lobe collapse)

- Treat the cause

arterial hypoxia/ hypercapnia /
both
N.B.:
- in infections:
indrawing of ribs (recession) indicates poor lung compliance --> decreased efficiency of breathing
apnea
- common in infants and neonates

- DD:
1. Prematurity
2. Bronchiolitis
3. Pertussis
4. Pneumonia
5. Sepsis
6. Severe GERD
7. Fits
8. NAI
9. Vascular ring
TRAUMA AND BREATHING DIFFICULTIES
- a baby's chest is very compliant --> if rib fracture:
1. consider NAI
2. Inevitable lung contusion
3. possible hemothorax/cardiac tamponade/..

- abdominal pain/ distention:
can present with breathing difficulty
Management of acute severe asthma
- Summary of TTT:
- O2 --> saturation 94% - 98%
- Continuous nebulized Salbutamol
- add in nebulized Atrovent
- Hydrocortisone IV
- Salbutamol IV:
* loading dose (2-18 yrs)
15 ug/kg over 10 mins - MAX. 250 ug
* MAX. 5 ug/kg/min after loading dose
- consider MgSO4 IV
AVOID INTUBATION
Unless:
1. Exhausted
2. Hypoxic
- If Intubated :
- induction with Ketamine --> bronchodilator
- manual decompression in expiration --> tells the severity
- permissive hypercapnea:
allow CO2 to rise with pH > 7.2
- slow respiratory rate <20
- consult a respiratory pediatrician
Ventilating children with bronchiolitis
- Ventilate if:
1. Exhausted
2. Apnea
3. Hypoxia with maximum O2
ONCE VENTILATED:
1. Enteral nutrition
2. ventilate for:
- 4 days
OR - till basal crepitations disappear
Children with Pertussis needing PICU
- Same indications
- +++ WBCs
- < 2 months
- prolonged stay in PICU
- may need ECMO
CARDIAC CAUSES OF RESPIratory failure
- Babies' pulmonary vascular bed --> more muscular --> more liable to Pulmonary HTN

- if a cardiac disease --> ++ risk of Pul. HTN

- TTT:
1. O2 --> pulmonary VD
2. silendelafil and inhaled Nitric Oxide

- if no response:
unreactive pul. HTN --> poor prognosis
TTT OF REspiratory failure
Respiratory support
1. AIRWAYS
- Oral / Guedel:
Poorly tolerated in conscious patients

- Nasopharyngeal:
* better
* bleeding from nasal mucosa
2. NON INVASIVE VENTILATION
- Nasal prongs / short tube CPAP

- Good option in:
1. neuromuscular diseases
(ventilation alternative)

2. weaning (post extubation)

- Atelectasis / Collapse:
CPAP / BIPAP (biphasic +ve airway pressure)
3. OSCILLATION
- High frequency breathing

- uses a high mean airway pressure --> no alveolar collapse

- protective to the lungs --> no shearing forces
4. EXTRACORPOREAL MEMBRANE OXYGENATION
- vein-vein ECMO

- a cardiac surgeon inserts the cannulae

- only in specialized ECMO centers

- Used in:
1. Reversible conditions very difficult to ventilate
2. bridge to heart transplantation (cannulate artery and vein)
Child with tachycardia
- a very useful clinical sign

- causes of tachycardia:
1. arrthmia
2. -- CO
3. ventilation
4. central
5. pulmonary HTN
6. drugs
7. poor ventricular function

- start by exclusion:
ex.: pain relivers..

supraventricular tachycardia
- Commonest tachyarrythmia in children

- The younger the child --> the more chance in CV instability

- Characters:
sudden onset
>220 bpm : infant AND >180 bpm : child
rate doesn't slow with a bolus of fluids
-ve P wave (if seen) in leads II, III, AVF
causes of tachyarrythmias
1. Reentrant tachycardia
2. cardiomyopathy
3. post- cardiac surgery
4. drug induced
5. long Q-T $
6. metabolic
7. Poisoning
v. tach
- stable --> consult cardiologist
pulseless --> VF protocol

- ttt electrolyte disturbance:
ex. K, Ca, Mg

- amiodarone can be used with a loading dose ( N.B. it depresses cardiac function)

- anasthesia + DC synchronized cardioversion:
1 J/Kg
then 2 J/Kg
bradycardia
- Slow, irregular rate

- a preterminal sign

- if on vagal stimulant:
Give ATROPINE 20 ug/Kg IV or intraosseous

- Causes:
1. Hypoxia and shock (preteminal)
2. +++ ICP
3. Post cardiac surgery
4. congenital Heart Block
5. myocarditis
EMERGENCY MANAGEMENT OF SEVERE HEART FAILURE
ABCDE
high flow O2
ventilate
diuresis
exclude anemia
INOTROPES
Cardiovascular system
TTT:
ABCDE
Vagal stimulation:
1. Diving reflex
2. carotid massage (one side)
3. valsalva manoeuvre (older children)
- Drug TTT:
IV ADENOSINE --> ECG, QUICKLY, LARGE vein, followed by SALINE FLUSH
- Start with 100 ug/kg
- unsuccessful after 2 mins:
give 200 ug/kg
- unsuccessful after 2 mins:
give 300 ug/kg

MAXIMUM DOSE:
300 ug/kg if < 1 mo AND 500 ug/kg if > 1mo OR 12 mg single dose

CARDIOVERSION:
Under general anasthesia
SYNCHRONIZED DC shock
Start with:
1 j/kg
unsuccessful:
2 j/kg
12-lead ECG monitoring
low co state:
Tachycardia
-- urine output
Poor capillary refill
confusion
LATE SIGNS:
Hypotension
bradycardia
confusion (can be late)
ST depression on ECG
INOTROPES
- neonates have a stable stroke volume --> to ++ CO --> ++ HR

- stimulation of:
B1 --> ++ HR and Contractility
B2 --> bronchodilataion & VD
Alpha --> VC & ++ peripheral resistance

- most of them ++ adenylyl cyclase --> ++
intracellular Ca+

- --- metabolic demands (ex. ttt of pyrexia) : inotropic like effect
1. Adrenaline
2. dopamine
low dose --> B1
High dose --> alpha

most arrythmogenic inotrope
3. dobutamine
mainly --> B1 and B2
High dose --> alpha
(VD if low dose AND VC if high dose)

can be given peripherally

very arrythmogenic
4. Noradrenalin
- mainly --> alpha
large dose --> B
5. MILrinone
prevents break down of adenylyl cyclase

peripheral VD and inotrope

heart relaxes in diastole

termed "inodilator"

long half life = 2.5 h in adults
- mostly work on alpha and B1

- heart doesn't fully relax in diastole

- ++++ metabolic demands of heart
Child in shock
- Types:
cardiogenic
hpovolemic
distributive (anaphylaxis)
dissociative ( anemia/CO poisoning)
Obstructive (tension pneumothorax)
COMMONEST CAUSE:
Bleeding - Septicemia - Gastroentritis
- SEPTIC SHOCK:
COMMONEST SHOCK IN MENINGEOCOCCAL DISEASE
Systemic Inflammatory Response $ occurs
Anaphylaxis
- present with:
resp. distress
CV collapse
TTT:
Remove allergen
ABCDE
high flow O2
ADRENALINE 1:1000 IM
< 6 y = 150ug
6-12 y = 300ug
>12 y = 500 ug
OR 10 ug/kg
IF:
1. Complete obstruction:
- definitive airway
2. Partial obstruction:
nebulized adrenaline 5 ml 1:1000
hydrocortisone
<6 mo = 25 mg
6 mo - 6 y = 50 mg
6 - 12 y = 100 mg
>12 y = 200 mg
wheeze --> nebulized salbutamol
may use: IV Salbutamol 1-5 ug/kg/min
if + shock --> 20 ml/kg fluid bolus +/- adrenaline infusion
Chlorpheniramine IV
<6mo = 250 ug/kg
6 mo - 6 y = 2.5 mg
6 - 12 y = 5 mg
>12 y = 10 mg

epidemioligy
very common but minor

70% are < 5y

HOUSE FIRES:
most fatal burns (smoke inhalation)

2001 --> 23 died
2007 --> 18 died

link with poverty

late infection --> important cause
of morbidity
pathophysiology
- degree of burn:
temperature & duration

- 44 C for 6 hours --> cellular destruction
54 C for 30 sec. --> cellular destruction
Assessment of burn
depth and size of the burn
rule of nine doesn't apply (chart)
depth:
1. superficial:
only epidermis/ painful / no blisters
2. partial thickness:
epidermis + part of dermis/ painful/ blisters
3. full thickness:
epidermis + dermis/ painless
special areas:
- Face / perineal / hands / feet / circumferential
TTT
high flow O2
airway
2 IV cannulas
analgesia
fluids
= % burn * weight/kg * 4
--> over 24 h (give 1/2 in first 8 h)
urinary catheter
--> urine output = 2ml/kg/h
warm child
escharotomies
CO poisoning:
--> 100% or hyperbaric O2
transfer to burn center
10 % patial - / full - thickness
5% full-thickness
special area
circumferential
inhalational burn
chemical / radiation / high voltage burn
chemical burn
alkali is WORSE than acid --> deeper penetration

brush dry powder before irrigation

irrigate with water 20-30 minutes
CHILD WITH SEVERE BURN
tepid water

early intubation

if early-hours-shock --> consider other reason than burn (ex. bleeding)

very high fluids requirement (calculate from time of the burn NOT the arrival)

circumferential burns around chest --> restrict breathing

associated injuries
ASSESS
- breathing problems
- consciousness
- NAI
INDICATion of smoke inhalation:
History

carbonaceous sputum (black)

Soot deposits around mouth/nose/clothes
severe cold
frostbite
- immediate TTT

- rewarm with 40C water till pink in color (advised: 20 mins)

- analgesia (--> v painful)

- avoid dry heat

- cardiac monitoring
systemic hpothermia
- Core temperature < 35 C

- special thermometer

- They Have:
1. arrythmias
2. coagulation problems
3. --- consciousness

- slow rewarming (rapid --> shock)

- only once defibrillation until temperature is above 30 C

- double adrenaline dose between 30 - 35 C

- do not call dead until rewarmed >32 Cand typically >35 C
Convulsing child and picu
non traumatic coma
- mostly will hypoventilate
- 95 % metabolic reason

TRAUMA
Severe head injury
- +++ ICP --> escape of venous blood and CSF --> Monro - Kellie doctrine --> herniation

- signs of herniation:
1. bradycardia
2. HTN
3. enlarging pupils

- Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure -ICP
Maintaining adequate cpp
- Normally:
infants > or = 40 mg Hg
older children > or = 60 mg Hg

- MAP has to be higher than ICP --> GIVE Noradrenaline
Reducing raised icp
keep head central and up (20 - 30 degree)
low to normal CO2 (4.5 kPa)
high serum Na (>140 mmol/l)
high serum osmolality (ex. mannitol)
drain CSF
minimize stimulation
paralysing drugs
complications in ICU
Neurogenic Diabetes insipidus

constipation

pneumonia

bed sores

infection in ventricular drain
Imaging
- Regular head CT to monitor

- normal CT doesn't exclude cervical spine injury (clinically important)

- thoracolumbar XRay

- status epilepticus: generalized convulsions = or > 30 mins / repeating over 30 mins that the child can't regain consciousness in between

- mortality 4% :
(airway obstruction/ aspiration of vomitus/ hypoxia/...)

- complications:
Hyperthermia/ arrythmia / brain damage
Pathophysiology
convulsions --> ++ cerebral metabolic rate
++ BP and HR (--> sympathetic)
++ BP --> Intracranial blood flow --> prolonged fit --> -- BP --> -- intracranial blood flow
++ lactate --> cell death
++ ICP
Ca and Na cellular metabolism --> impaired
TTT:
ABCDE
high flow O2
Follow flow chart
RAPID SEQUENCE INDUCTION:
- anasthetic procedure
- steps:
preoxygenate 100% O2
induction agent:
1. Thiopentone 4mg/kg
2. suxamethonium 2mg/kg
cricoid pressure (close esophagus)
intubate
assess chest movement/ listen to the chest
To PICU for Full monitoring
if he doesn't improve:

--> consider Thiopental coma
Thiopentone coma:
- thiopentone infusion for induction of 1-3 days coma
complications:
- persistent status epilepticus
- hypotension
- chest infection
- renal impairment
alternatives:
- High dose midazolam

- High dose phenobarbitone
IMPORTANT investigations:
- AA --> raised leucine: maple syrup disease
- drug level of anticonvulsants

LIFE THREATENING extremity injuries
1. crush injury abdomen & pelvis



2. partial (>dangerous) and complete amputation


3. massive open long bone fracture

crush INjuries:
- splint the pelvis
- embolize bleeding vessels
- common internal organs' affection

Amputation
- compression over femoral/ brachial artery

- elevation

- specialist center
long bone fracture:
splinting

vascular injury and compartment $

tetanus immunization
gunshots and stabbing
- uncommon
- bullet:
1. follow the path with the least resistance
2. entrance opening: rounded with blackened area
3. exit opening: ragged
- what was penetrated?
Drowning
- 450 000 deaths/year

- commonest cause of accidental deaths

- most deaths are preventable

- cause of death: severe hypoxia

- can occur in small inches of water

- bradycardia and arrythmias are common
Pathophysiology
1. Diving reflex (bradycardia + apnea)

2. --> hypoxia and acidosis --> tachycardia & ++ BP (20 secs - 5 mins)

3. breathing --> fluid inhalation

4. --> laryngeal spasm

5. --> subside --> fluid into lungd

6. alveolitis and pulmonary edema
TTT
- ABCDE (early and
effective life support -->
better outcome

- remove horizontally
(--> no venous pooling)

- immobilize spine

- gastric decompression with a nasogastric tube
Rewarming
Prognostic signs
- consider:

1. Hypothermia (can cause dysarrythmia and coagulation problems)
2. Hypovolemia
3. spinal injury
4.electrolyte imbalance
5. contaminated water --> infection
external
- remove wet clothes

- heated blankets

- warm air

- infrared lamp
CORE
- warm fluids 39 C

- warm ventilator gases 42 C

- warm peritoneal dialysis fluid 42 C

- warm gastric / bladdar lavage with 0.9% saline 42 C
extracorporeal blood warming
- for temperature > 30 C

- with rewarming:
1. vasodilation occurs --> relative hypovolemia --> give bolus fluid
2. ++ metabolic demands of heart --> inotropes may be needed

poor prognosis
- immersion > 10 mins

- no respiratory effort after 40 mins of CPR

- Persistent coma

- pH <7.1 despite TTT

- PO2 < 8 kPa despite TTT
GOOD PROGNOSIS
- Respiratory effort within 3 mins of CPR

- BLS at the scene
N.B.:
Respiratory compromise can occur HOURS AFTER the drowning
Full transcript