Pediatric emergencies 8 khordad 1389
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Pediatric emergencies 8 khordad 1389 Presentation Transcript

  • 1. Pediatric Emergencies By M.H.Farjoo M.D. , Ph.D. Shahid Beheshti University of Medical Science
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Chest radiograph of the same child shows healingrib fractures bilaterally
  • 35. Thank you Any question?