Emergencies in peadiatrics Krzysztof Narębski Toruń

Problems to discuss Child assessment Neonatal resuscitation Shock Septicaemia Status epilepticus / febrile seizures Dyspnoea Anaphylaxis Inhaled foreign body 2

Child assessment Basic / Advanced Live Support Primary assessment ABCD scale or AVPU scale Resuscitation Etiologic treatment 3

„SICK CHILD”, „SEPTIC” A - Arousal, Alertness, Activity, Apathy B - Breathing difficulties C - poor Colour (pale) and Circulation (Cold peripheries) D - Decreased fluids intake (fewer than half a normal intake) and Decreased urine output (fewer than 4 wet nappies a day) 4

Level of awareness, Coma A - Alert V - responds to Voice P - responds to Pain U - Unresponsive 5

Neonatal Resuscitation at birth 6

NR first 30 sec = routine care !!! 7

NR breathing and chest compressions 8

Neonatal resuscitation Adrenaline iv 10 – 30 mcg / kg (0.01 – 0.03 mg / kg) Amp. 0,1 % (1 : 1000), 1 ml 1 ml - 1 mg = 1000 mcg Dilution 10 x >> 1 ml - 0.1 mg = 100 mcg >> give 0.1 – 0.3 ml / kg (= 10 – 30 mcg)

Apgar score : good 8 – 10 points, intermediated 4 - 7, bad 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 Muscle tone None Some flexion Flexed legs & arms Activity Breathing Weak, irregular Strong cry Respiration 10

Shock Definition : inadequate circulation to meet the tissues’ demands Etiology : - Hypovolemia !!! viral gastroenteritis - Maldistribution of fluid : Sepsis Anaphylaxis

Signs of shock Early (compensated shock) tachypnoea and tachycardia sunken eyes and fontanelle mottled, pale, cold skin decreased skin turgor decreased capillary refill (> 2 sec) decreased urinary output (< 1 ml/kg/h) 12

Signs of shock Late (decompensated shock) confusion / depressed cerebral state bradycardia hypotension blue peripheries absent urine output 13

Hydratation 14

Decreased skin turgor 15

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Hypovolemia - treatment Fluids resuscitation : 1. 0.9 % saline iv - 20 ml / kg - in 10 – 20 min, - repeat if necessary !!! (Ringer if urine output present) 2. Blood if trauma 17

Figure 6.8 Initial fluid resuscitation in shock. Downloaded from: StudentConsult (on 26 February 2012 12:39 PM) © 2005 Elsevier

Fluids intake at different ages 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 calculations Infant 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 19

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Septicaemia - meningococcal purpura Poor state + fever + rash that does not blanch when pressed under a glass 21

Septicaemia - meningococcal purpura 22

Septicaemia - clinical features History : - fever - poor feeding - irritability, lethargy Examination : - tachycardia, tachypnoea, hypotension shock, multi organ failure purpuric rash ABCD / AVPU scale Vaccination 23

Septicaemia - treatment Antibiotic immediately iv Hospital (Intensive Care Unit) Treatment of shock 24

Seizures Definition : Uncontrolled electrical activity in the brain, which may produce a physical convulsion. 25

Status epilepticus / febrile seizures Status epilepticus - definition : - seizure lasting 30 min or - successive frequent seizures with unconsciousness Febrile seizures - definition : - seizure accompanied by a fever in absence of intracranial infection

Seizures - etiology Febrile seizures – any infections & fever Also : Metabolic (hypoglycemia, hypoCa, hypoMg, hypo or hypernatraemia) Meningitis and encephalitis Cerebral trauma or tumor Toxins (poison, metabolic disorders) Epilepsy and others 27

Seizures - treatment Febrile seizures – antipyretics !!! - Diazepam 0.5 mg / kg pr Seizures or status epilepticus : Phenobarbital iv 10 – 20 mg / kg Phenytoin iv 20 mg / kg Repeat if no response in 5 min !!! Give oxygen !!! >> PICU If hypoglycemia < 3 mmol/L Give 10 % glucose iv 2 ml / kg 28

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Dyspnoea - Croup The degree of subcostal, intercostal and sternal recession is a more useful indicator of severity of upper airways obstruction than the respiratory rate.

Dyspnoea - Croup Features : viral, 6 months to 6 years, harsh, loud stridor, coryza, mild fever Treatment Inhalation of fresh air Steroids : prednisolon oral, im, iv or inhaled budesonid Nebulised adrenaline with oxygen 31

Dyspnoea – Asthma fit Treatment - Oxygen !!! History of allergy or asthma Symptoms and signs : - too breathless to eat or talk - use of accessory muscles - distended chest - wheeze or silent chest - cyanosis and alter level of consciousness Treatment - Oxygen !!! - Bronchodilators (B2-agonist) - Steroids iv, oral or inhaled 32

Anaphylaxis Definition : Severe, whole – body reaction to an allergen, after being previously exposed to this allergen (sensitization to it). This reaction happen very quickly. 33

Anaphylaxis History of allergy / anaphylaxis Food or insect sting venom allergy Symptoms immediately : - airways : swelling, hoarseness, stridor - breathing : tachypnea, wheeze, cyanosis, SpO2< 92 % - circulation : pale, clammy, hypotension, drowsy, coma 34

Anaphylaxis - treatment Adrenaline / epinephrine 1 : 1000 im < 6 years - 150 mcg (0.15 ml) 6 – 12 years - 300 mcg (0.3 ml) > 12 years - 500 mcg (0.5 ml) Hydrocortison im or iv 35

Inhaled foreign body 36

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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Thank you 42