Pediatric Emergencies                   By         M.H.Farjoo M.D. , Ph.D. Shahid Beheshti University of Medical Science
Pain and Sedation   Topical anesthetics for wound repair is: 2% lidocaine,    epinephrine, and 2% tetracaine (LET).   It...
Pain and Sedation   Midazolam (0.05-0.075 mg/kg IV/PO/PR) is a    relatively fast acting drug commonly used in    emergen...
Pain and Sedation   Ketamine, 3-4 mg/kg IM, or 1-2 mg/kg IV, is used for children    of any age and is used in:        b...
Pain and Sedation   Ketamine may elevate ICP & IOP, induce    emesis, and occasionally precipitate    laryngospasm.   ke...
Pain and Sedation   For individuals requiring imaging studies such    as CT scan or MRI these drugs may be used:        ...
Pain and Sedation   Sedative agents should only be used by those with    appropriate training and familiarity with the ag...
Pain and Sedation   Outpatient analgesia includes an NSAID such    as ibuprofen., 4-10 mg/kg every 6-8 hours.   This dru...
Drug and Fluid Administration   All parenterally and orally administered agents    should be given strictly on a per-kilo...
Drug and Fluid Administration   Deaths due to acute hypertonic cerebral edema    has occured with as little as 40 mg/kg 5...
Endotracheal Tube   the endotracheal route is a good conduit for delivery    of drugs such as    epinephrine, atropine, l...
Endotracheal Tube   So insert a nasogastric tube or a size 5F    umbilical catheter past the tip of the ET tube.   direc...
Dehydration   For severely dehydrated patients:        provide supplemental oxygen        attach pulse oximeter and car...
Dehydration   Administer an isotonic fluid bolus of 20 mL/kg   Repeat boluses of 20 mL/kg until physical    signs (heart...
Daily maintenance requirements for fluids and electrolytes.                                                     Sodium    ...
Oral Rehydration Therapy   Vomiting does not contraindicate the use of ORT.   Unless shock, altered mental status, or se...
Shock   Apply supplemental oxygen and Initiate volume    resuscitation.   Start with 20 cc/kg of isotonic saline adminis...
Shock   If inotropic agents are used, the intravascular    volume must be adequate.   Start with epinephrine at 0.1-1.0 ...
Bronchiolitis   If wheezing is present, nebulized epinephrine or    albuterol (0.15 mg/kg of 0.5% solution or 0.03 mL/kg ...
Asthma   Provide supplemental oxygen therapy, and attach    pulse oximeter.   Inhaled β2-agonists are the first-line age...
Asthma   In severe asthma epinephrine (SC, 0.01 mg/kg    up to 0.3-0.5 mg) or IV terbutaline (10 μg/kg    over 10 minutes...
Asthma   Ipratropium bromide is used as an adjuvant    therapy to β-agonist therapy.   It decreases ED treatment time an...
Gastroenteritis   ORS is indicated in mild to moderate dehydration and    IV fluids for severe dehydration.   Breast-fee...
Gastroenteritis   Antibiotic therapy is not indicated for a majority of    gastroenteritis infections, as most are self-l...
Child Abuse   Consider child abuse if:        injuries seem incompatible with the given history        injuries have no...
Child Abuse   If the child is verbal, a separate history should    be obtained from the child and the caretaker    when e...
Child Abuse   Any child who presents with a change in    mental status or seizures must raise    concern for intracranial...
Child Abuse   Intentionally-inflicted injuries frequently differ    significantly from the unintentional injuries.   Tod...
Child Abuse   In children physical manifestations of neglect    may be uncovered during the examination.   These include...
Child Abuse   Unintentional injuries tend to occur in a distal and/or    lateral anatomic distribution   these areas hav...
Child Abuse   Unintentional injuries also tend to be    unilateral.   It is rare to sustain symmetrical bruises from    ...
Child Abuse   Some intentionally-inflicted bilateral injuries include:        finger tip grab marks on both arms       ...
Child Abuse   In patients of any age, “patterned” injuries    should raise suspicion for intentionality.   Patterned inj...
Chest radiograph of the same child shows healingrib fractures bilaterally
Thank you  Any question?
Pediatric emergencies 8 khordad 1389
Pediatric emergencies 8 khordad 1389
Pediatric emergencies 8 khordad 1389
Pediatric emergencies 8 khordad 1389
Pediatric emergencies 8 khordad 1389
Pediatric emergencies 8 khordad 1389
Pediatric emergencies 8 khordad 1389
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Pediatric emergencies 8 khordad 1389

  1. 1. Pediatric Emergencies By M.H.Farjoo M.D. , Ph.D. Shahid Beheshti University of Medical Science
  2. 2. Pain and Sedation Topical anesthetics for wound repair is: 2% lidocaine, epinephrine, and 2% tetracaine (LET). It is easily applied and is safe. The onset of action is approximately 30 min.; thus it should be applied early. Any anesthetic containing epinephrine (such as LET) should be avoided on end-arterial structures, such as the ears, nose, digits, or penis.M.H.Farjoo MD, Ph.D
  3. 3. Pain and Sedation Midazolam (0.05-0.075 mg/kg IV/PO/PR) is a relatively fast acting drug commonly used in emergency department sedation. It is used in conjunction with morphine (0.1 mg/kg) or fentanyl (1-1.5 μg/kg). Some children will have a paradoxical excitation to midazolam and will experience agitation. this unpleasant reaction may be reversed with flumazenil.M.H.Farjoo MD, Ph.D
  4. 4. Pain and Sedation Ketamine, 3-4 mg/kg IM, or 1-2 mg/kg IV, is used for children of any age and is used in:  burn debridement  foreign body removal  deep wound care  abscess incision and drainage  sexual abuse evaluation  lumbar puncture  orthopedic reductions. atropine (0.01 mg/kg) may be added to ketamine to avoid hypersalivation.M.H.Farjoo MD, Ph.D
  5. 5. Pain and Sedation Ketamine may elevate ICP & IOP, induce emesis, and occasionally precipitate laryngospasm. ketamine in older children may cause an adverse behavioral reaction upon emergence from sedationM.H.Farjoo MD, Ph.D
  6. 6. Pain and Sedation For individuals requiring imaging studies such as CT scan or MRI these drugs may be used:  pentobarbital, 5 mg/kg IM  midazolam, 0.5 mg/kg orally (maximum dose, 20 mg)  methohexital, 1 mg/kg IVM.H.Farjoo MD, Ph.D
  7. 7. Pain and Sedation Sedative agents should only be used by those with appropriate training and familiarity with the agents used. Proper precautions should be taken such as:  constant vital sign and pulse oximetry monitoring  End-tidal CO2 monitoring to assess the adequacy of a patients ventilation.  Rescue airway equipment and reversal agents (naloxone, 0.01-0.1 mg/kg IV, and flumazenil, 0.01 mg/kg IV) should be readily available.M.H.Farjoo MD, Ph.D
  8. 8. Pain and Sedation Outpatient analgesia includes an NSAID such as ibuprofen., 4-10 mg/kg every 6-8 hours. This drug can also be used in combination with oral narcotic agents for treatment of severe pain. Acetaminophen, 10-15 mg/kg every 4-6 hours, can also be used for treatment of mild pain on an outpatient basisM.H.Farjoo MD, Ph.D
  9. 9. Drug and Fluid Administration All parenterally and orally administered agents should be given strictly on a per-kilogram basis Over dosing and over hydration are dangerous errors in emergency pediatrics. Under dosing is also frequent, especially in infants and small children. Initial treatment of dehydration should include isotonic fluids (normal saline or lactated Ringers).M.H.Farjoo MD, Ph.D
  10. 10. Drug and Fluid Administration Deaths due to acute hypertonic cerebral edema has occured with as little as 40 mg/kg 5% dextrose. Physicians and nurses should meticulously review drug and fluid orders to ensure that they are age and weight correctedM.H.Farjoo MD, Ph.D
  11. 11. Endotracheal Tube the endotracheal route is a good conduit for delivery of drugs such as epinephrine, atropine, lidocaine, naloxone, and diazepam. when administered through the endotracheal tube, higher doses of epinephrine up to 10 times the IV dose, must be used. It is better to deliver the drug into the highly vascular trachea and proximal tracheobronchial tree instead of the endotracheal tube.M.H.Farjoo MD, Ph.D
  12. 12. Endotracheal Tube So insert a nasogastric tube or a size 5F umbilical catheter past the tip of the ET tube. directly instill the drugs through the tube. endotracheal drugs are more effective if aerosolized. So dilute the drug with normal saline to a maximum volume of 0.5-1.0 mL/kg, and inject rapidly to achieve an aerosolized form.M.H.Farjoo MD, Ph.D
  13. 13. Dehydration For severely dehydrated patients:  provide supplemental oxygen  attach pulse oximeter and cardiac monitor  establish IV or intraosseous access with one or two secure catheters. For a severely dehydrated infant or young child, rapidly infuse a balanced isotonic solution (e.g., normal saline or lactated Ringers). Infants and children have limited glycogen stores and are prone to hypoglycemia when stressed. rapid blood glucose analysis should be performed, and glucose should be replaced if less than 60 mg/dLM.H.Farjoo MD, Ph.D
  14. 14. Dehydration Administer an isotonic fluid bolus of 20 mL/kg Repeat boluses of 20 mL/kg until physical signs (heart rate, skin temperature, and capillary refill) indicate improved perfusion. If vital signs have not normalized after 60 mL/kg of isotonic fluid,consider administration of albumin or packed red blood cells, 10-20 mL/kg.M.H.Farjoo MD, Ph.D
  15. 15. Daily maintenance requirements for fluids and electrolytes. Sodium Potassium Weight Water Requirement* Requirement Requirement+1-10 kg 100 mL/kg11-20 kg 50 mL/kg + 1000 mL 3 mEq/kg 2 mEq/kg>20 kg 20 mL/kg + 1500 mL*Assume that the child is normothermic. Fever significantly increases insensible water losses.+Do not exceed 0.25 mEq/kg/h intravenously. Use oral route when possible. Add KCI tointravenous infusion after urination.
  16. 16. Oral Rehydration Therapy Vomiting does not contraindicate the use of ORT. Unless shock, altered mental status, or severe weakness is present, ORT may be used as part of early emergency treatment. oral ondansetron (dose 2-8 mg based on weight) reduces vomiting and facilitate successful ORT. The composition of ORT as set by the WHO includes 90 mEq/L of sodium, 20 mEq/L potassium, 30 mEq/L of citrate, and 1-2% glucoseM.H.Farjoo MD, Ph.D
  17. 17. Shock Apply supplemental oxygen and Initiate volume resuscitation. Start with 20 cc/kg of isotonic saline administered as rapidly as access will allow. The bolus may be repeated up to two times if no clinical response. If there is no response after 60 cc/kg, consider colloid or packed red blood cell transfusion or administration of an inotropic agent.M.H.Farjoo MD, Ph.D
  18. 18. Shock If inotropic agents are used, the intravascular volume must be adequate. Start with epinephrine at 0.1-1.0 μg/kg/min or dopamine 10-20 μg/kg/min Add a second inotropic agent if cardiovascular response does not occur.M.H.Farjoo MD, Ph.D
  19. 19. Bronchiolitis If wheezing is present, nebulized epinephrine or albuterol (0.15 mg/kg of 0.5% solution or 0.03 mL/kg by mask; maximum 2.5 mg) can be considered. If bronchodilator therapy produces improvement, continue it. The use of steroids in bronchiolitis is controversial as well. Some clinicians believe that early treatment with steroids might shorten the duration of illness.M.H.Farjoo MD, Ph.D
  20. 20. Asthma Provide supplemental oxygen therapy, and attach pulse oximeter. Inhaled β2-agonists are the first-line agents for acute asthma. Albuterol is typically the agent used (0.15 mg/kg; maximum 5 mg). Both metered dose inhaler and nebulizer have been shown to be equally efficacious. Nebulizer is the method of choice in young children who may have difficulty with proper inhaler use.M.H.Farjoo MD, Ph.D
  21. 21. Asthma In severe asthma epinephrine (SC, 0.01 mg/kg up to 0.3-0.5 mg) or IV terbutaline (10 μg/kg over 10 minutes) may be considered. Glucocorticoids are indicated for all children with acute asthma. The dose of prednisone is 2 mg/kg, (maximum of 80 mg). Oral and IV routes are equivalent.M.H.Farjoo MD, Ph.D
  22. 22. Asthma Ipratropium bromide is used as an adjuvant therapy to β-agonist therapy. It decreases ED treatment time and improve pulmonary function tests. Magnesium may improve pulmonary function and reduce hospitalizations Dosage is 75 mg/kg (maximum of 2.5 g) over 20 minutes. Close monitoring for hypotension is indicated.M.H.Farjoo MD, Ph.D
  23. 23. Gastroenteritis ORS is indicated in mild to moderate dehydration and IV fluids for severe dehydration. Breast-feeding infants should continue to breast feed while taking oral rehydration Antiemetic and antidiarrheal drugs occasionally worsen symptoms in children with gastroenteritis. Promethazine is contraindicated in children younger than 2 yearsM.H.Farjoo MD, Ph.D
  24. 24. Gastroenteritis Antibiotic therapy is not indicated for a majority of gastroenteritis infections, as most are self-limited. The empiric use of antibiotic therapy can be considered for obvious symptoms of bacterial dysentery. TMP-SMZ (TMP, 8-12 mg/kg/d, and SMZ, 30-60 mg/kg/d, in divided doses every 12 hours) can be given empirically until culture results are availableM.H.Farjoo MD, Ph.D
  25. 25. Child Abuse Consider child abuse if:  injuries seem incompatible with the given history  injuries have no logical explanation ED staff must maintain a high index of suspicion to identify the 10% of abused children. To encourage disclosure, examiners must obtain the history in a nonaccusatory manner.M.H.Farjoo MD, Ph.D
  26. 26. Child Abuse If the child is verbal, a separate history should be obtained from the child and the caretaker when each is alone. You should explain that you are concerned about the child’s safety without blaming any specific person. You may need to call in another person to help with the evaluation (child protective services or a social worker).M.H.Farjoo MD, Ph.D
  27. 27. Child Abuse Any child who presents with a change in mental status or seizures must raise concern for intracranial injury from abuse. The most common form of head injury is due to “shaken baby syndrome,” the forcible shaking of an infant resultes in subdural hematomas, retinal hemorrhages, and diffuse brain injury.M.H.Farjoo MD, Ph.D
  28. 28. Child Abuse Intentionally-inflicted injuries frequently differ significantly from the unintentional injuries. Toddlers universally display unintentional bruises or cuts to the forehead from frequent collisions with furniture or the floor. Perpetrators of abuse may purposely injure victims in areas that are usually covered by clothing. Hence, patients must be completely disrobed to identify possible injuries.M.H.Farjoo MD, Ph.D
  29. 29. Child Abuse In children physical manifestations of neglect may be uncovered during the examination. These include  failure to grow and/or reach developmental milestones  dehydration, malnutrition  late-stage bedsores  inappropriate clothing  improper administration of medicationsM.H.Farjoo MD, Ph.D
  30. 30. Child Abuse Unintentional injuries tend to occur in a distal and/or lateral anatomic distribution these areas have greater exposure and are more likely to be injured while running into objects. Distal and lateral body parts (e.g., outstretched arms, knees, and shins) generally provide protection when you fall. Therefore, central injuries to the face, neck, breasts, and abdomen should raise suspicion for intentional trauma.M.H.Farjoo MD, Ph.D
  31. 31. Child Abuse Unintentional injuries also tend to be unilateral. It is rare to sustain symmetrical bruises from an unintentional mechanism. It is always important to consider the history in context of the injury.M.H.Farjoo MD, Ph.D
  32. 32. Child Abuse Some intentionally-inflicted bilateral injuries include:  finger tip grab marks on both arms  bruises on the medial aspect of upper arms from having them pinned down by the perpetrator’s knees  inner thigh bruises from forced sexual assault. Any injury to the genital or rectal area should raise suspicion for sexual assault and abuse.M.H.Farjoo MD, Ph.D
  33. 33. Child Abuse In patients of any age, “patterned” injuries should raise suspicion for intentionality. Patterned injuries reflect the shape of objects used to inflict intentional injuries. They usually have sharper edges and are more geometric than the typical unintentional injury.M.H.Farjoo MD, Ph.D
  34. 34. Chest radiograph of the same child shows healingrib fractures bilaterally
  35. 35. Thank you Any question?
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