Emergencies in peadiatrics Krzysztof Narębski Toruń

Problems to discuss 1) Child assessment 2) Neonatal resuscitation 3) Shock 4) Septicaemia 5) Status epilepticus / febrile seizures 6) Dyspnoea 7) Anaphylaxis 8) Inhaled foreign body

Child assessment Basic / Advanced Live Support 1) Primary assessment - ABCD scale or - AVPU scale 2) Resuscitation 3) Etiologic treatment

„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)

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

Neonatal Resuscitation at birth

NR first 30 sec = routine care !!!

NR breathing and chest compressions

Neonatal resuscitation Adrenaline iv 10 – 30 mcg / kg Adrenaline iv 10 – 30 mcg / kg (0.01 – 0.03 mg / 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 mg = 100 mcg >> give 0.1 – 0.3 ml / kg (= 10 – 30 mcg)

Apgar score : good 8 – 10 points, intermediated 4 - 7, bad Score of 0Score of 1Score of 2Acronym Skin colorBlue / pale all over Body pink, Blue extremities All pinkAppearance Pulse rateAbsent< 100 /min> 100 /minPulse Reflex irritability No respond to stimuli GrimaceCryGrimace Muscle tone NoneSome flexionFlexed legs & arms Activity BreathingAbsentWeak, irregularStrong cryRespiration

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

Signs of shock Early (compensated 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)

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

Hydratation

Decreased skin turgor

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

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

Fluids intake at different ages Body weightFluids requirement / 24 hours Volume / kg per hour First 10 kg100 ml / kg4 ml / kg Second 10 kg50 ml / kg2 ml / kg Subsequent kg20 ml / kg1 ml / kg Examples of calculations Infant 7 kg700 ml29 ml / h Child 18 kg = 1400 ml = 56 ml/h Child 42 kg = 1940 ml = 78 ml/h

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

Septicaemia - meningococcal purpura

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

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

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

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

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

Seizures - treatment Febrile seizures – antipyretics !!! Febrile seizures – antipyretics !!! - Diazepam 0.5 mg / kg pr Seizures or status epilepticus : 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 If hypoglycemia < 3 mmol/L Give 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. Dyspnoea - Croup

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

Dyspnoea – Asthma fit History of allergy or asthma History of allergy or asthma Symptoms and signs : 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 !!! Treatment - Oxygen !!! - Bronchodilators (B2-agonist) - Steroids iv, oral or inhaled

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

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

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

Inhaled 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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