S C En  Ped
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  • Simple versus complex features are outlined in the table. This distinction is important because complex (more than 15 minutes, focal, or occurring more than once in 24 hours) seizures show higher rates of CNS infection and of epilepsy than simple febrile seizures.
  • If a child has a simple febrile seizure, no specific studies are indicated. Again, be sure that the patient does not have meningitis. Once you’ve made that decision, approach the child just like you would any other child of this particular age group with a high fever.
  • Pediatric assessment is an integral part of the evaluation of a pediatric patient. It is the assessment that determines initial and subsequent management.
  • The Pediatric Assessment Triangle (PAT) is an observational first impression before touching the patient. What you see and hear as you first encounter the patient can allow you to formulate a visual and auditory first impression. It tells the experienced clinician how to prioritize further assessment. It determines life-threatening emergencies that need immediate attention. Identifies the general category of physiologic abnormality, which formalizes the general impression Establishes severity of illness Determines urgency of interventions The PAT can be completed in seconds and is based on three categories of observations: Appearance (mental status) Work of Breathing Circulation to the Skin
  • Appearance reflects adequacy of ventilation, oxygenation, brain perfusion, body homeostasis, and central nervous system (CNS) function. The “tickles” (TICLS) mnemonic helps to recall observations that give a general impression of appearance. Tone: Is there normal motor movement? Is the infant/child limp and listless, or moving vigorously? Interactiveness: Is the patient alert? Irritable? Lethargic? Does the patient respond appropriately to the environment? Consolability: Is the patient easily comforted/consoled? Is he/she agitated and inconsolable? Look/Gaze: Does the patient fix on a face or object, or is the patient glassy-eyed, with a “nobody-home” stare? Speech/Cry: Is the cry/speech weak, muffled, hoarse? An infant with poor brain perfusion, CNS infection, or brain injury often will have a high - pitched or cephalic cry. Appearance is very dependent on the child’s developmental age.
  • Work of breathing is a quick observational indicator of the adequacy of oxygenation and ventilation. Observe the patient carefully before laying on hands. Listen for audible sounds, and look for signs of increased effort to breathe. Abnormal airway sounds include: Stridor, muffled speech, hoarse voice, and snoring all reflect upper airway obstruction. Grunting is caused by an effort to exhale on a closed glottis to keep alveoli from collapsing, and suggests lower airway disease. Wheezing is caused by lower airway partial obstruction as heard with asthma or bronchiolitis. The position that a patient with increased work of breathing takes is revealing. Tripoding is seen in patients trying to maximize use of accessory muscles to improve ventilation. The “sniffing” position is seen with severe upper airway obstruction as an attempt to line up the axes of the airway to improve air flow. Look carefully for retractions in the intercostal and supraclavicular areas. Nasal flaring and head bobbing are signs of severe respiratory distress.
  • The skin is an organ that has easily seen visual responses to both early and late shock, as well as respiratory failure. Taking time to observe skin color and signs is time well spent! Pallor cannot be ignored. In the trauma patient, it can be a sign of significant occult internal bleeding and need for immediate fluid/blood resuscitation. In the patient with septic or hypovolemic shock, it suggests the need for rapid fluid resuscitation. Children have excellent catecholamine responses to shock, and this can be easily seen as pallor when assessing the PAT. Mottling occurs when the skin starts to lose microvascular integrity. Areas of vasodilatation interspersed with vasoconstriction will give a patchy network of pallor, erythema, and/or cyanosis that is referred to as mottling. This is a pre-morbid condition, and late sign of shock. In small infants, mottling should not be confused with cutis marmorata, or irregular marbled skin often seen in a cool ambient environment. Cyanosis reflects poor tissue oxygenation, and can be seen with respiratory failure or cardiorespiratory compromise.
  • Assess the airway – is it patent? Check for signs of good breathing – chest rise, air entry, good breath sounds. Assess the circulation, pulse, perfusion, refill, blood pressure. As the patient appears cardiovascularly stable, begin the next phase of examination. A bedside glucose would be very appropriate in this somnolent child. Let’s assume that his was normal. You then establish access and draw blood for lab work. What labs would you want? What are some possible etiologies?
  • The management of a simple febrile seizure is relatively straightforward. Make sure that the child does not hurt him/herself during the seizure . Move the child to a low-lying place, making sure that there are soft objects around the side of the head in particular. While you would like to make sure that the child does not bite his tongue during the episode, it is not recommended to put anything in the child’s mouth. There is no evidence for the use of anticonvulsants or antibiotics in this instance.
  • Seizures of long duration can lead to respiratory failure. Do not forget the airway – it is often a major issue in these situations. Positioning of the head and insertion of an airway adjunct, when needed, often helps tremendously. Remember the stepwise progression of medications. Begin with benzodiazepines, followed by phenytoin; this is a reasonable approach. Other anticonvulsants to consider – valproate and phenobarbital Once phenobarbital is initiated, be prepared to support ventilation with BMV and then endotracheal intubation as respiratory failure may ensue.

Transcript

  • 1. EMERGENCIAS MEDICAS Y CONDUCTUALES
  • 2. Crisis epilépticas
    • Alteración súbita y temporal del comportamiento, sensibilidad o movimiento ocasionado por una descarga eléctrica masiva en un grupo de neuronas en el cerebro.
    • Generalmente auto limitada
    • Manifestaciones clínicas diversas
          • Pérdida o no del estado de conciencia
          • Actividad motora anormal
          • Comportamientos anormales
          • Alteración sensibilidad
    • Guías de Pediatría práctica basadas en la evidencia, 2003.
  • 3. CONVULSION
    • Crisis convulsivas recurrentes que no guardan relación con la fiebre ni con lesiones cerebrales agudas
    • Nelson Tratado de Pediatría 17 edición. 2007
  • 4. Crisis epilépticas
    • CONVULSIVAS
    • Contracción muscular excesiva anormal y usualmente bilateral que puede ser sostenida o interrumpida
    • NO CONVULSIVAS
    Nelson Tratado de Pediatría 17 edición. 2007
  • 5. Crisis epilépticas
    • 3-5 % en niños
    • 0.5 a 1 % población
    • 60% se presenta en la infancia
    • 10-20% refractarias a tratamiento
    Nelson Tratado de Pediatría 17 edición. 2007
  • 6. Crisis epilépticas
    • Crisis focales o parciales
    • 47 a 58 % mas frecuentes
    • Crisis generalizadas
    • 30-40%
    Guías de Pediatría práctica basadas en la evidencia, 2003
  • 7.  
  • 8. Nelson Tratado de Pediatría 17 edición. 2007
  • 9. Crisis epilépticas
    • Trauma
    • Infecciones
    • Trastornos metabólicos
    • Intoxicaciones
    • Suspensión de medicamentos
    • Infarto /hemorragia
    • Convulsiones febriles
  • 10. Crisis epilépticas
    • Crisis convulsivas de urgencias
    • 90% casos auto limitadas < 15 minutos
    • Terminan espontáneamente
    • Status epilepticus
    • ¡¡ Recordar ¡¡
    • crisis convulsivas febriles
    • Crisis convulsivas en el recién nacido
    • Crisis epilépticas en consulta externa
  • 11. Status Epilepticus
    • Cualquier convulsión que dure mas de 5-7 minutos
    • Convulsiones que por su duración prolongada aumenta la dificultad de detenerla
    • Las convulsiones prolongadas : mas de 60 minutos se asocian con deterioro neurológico
    • Mortalidad 1- 3 %
    APLS Cuarta edición revisada 2007
  • 12.  
  • 13. Crisis convulsivas febriles
      • Crisis Generalizada en un paciente con fiebre
      • Edad (6 meses a 5 años)
      • Duración (menos de 15 minutos)
      • Sin deficit focal posterior
      • C ausa mas común de desórdenes convulsivos en la infancia.
      • Se clasifican en simples o complejas
  • 14. Crisis Convulsiva Febril Simple vs. Compleja Simple Compleja Duración < 10-15 minutos Examen Neurológico sin focal No recurrencia dentro 24 horas Duración > 10-15 minutos Examen Neurológico con datos de focalización Recurrencia dentro 24 horas
  • 15. Estudios Diagnósticos
    • No hay estudios específicos indicados para una crisis febril simple
    • Debe estar seguro que el examen físico no es compatible con meningitis para realizar o no punción lumbar
    • El manejo es el mismo para un niño con fiebre sin convulsiones.
  • 16. Crisis Recién Nacido
    • 0.15- 0.5 % de todos los recién nacidos
    • Etiología
    • Alteraciones metabólicas
    • Encefalopatía hipóxico isquémica
    • Meningitis, encefalitis
    • Hemorragias intracraneales
    • Anomalías congénitas
    • Enfermedades genéticas
  • 17. Convulsiones Neonatales Características Clínicas TIPO CARACTERISTICAS Clónica focal Contracciones repetitivas y rítmicas de grupos musculares de las extremidades, la cara o el tronco Pueden ser unilaterales o multifocales Pueden aparecer en distintas partes del cuerpo de manera sincrónica o asincrónica No pueden suprimirse sujetando Tónica focal Postura mantenida de una extremidad Postura asimétrica mantenida del tronco Desviación ocular mantenida No puede provocarse por estimulación ni suprimirse sujetando
  • 18. TIPO CARACTERISTICAS Mioclónica Contracciones arrítmicas de grupos musculares de las extremidades, la cara o el tronco De forma característica no son repetitivas o pueden hacerlo con una cadencia lenta Pueden ser generalizados focales o fragmentarios Pueden provocarse por estimulación Tónica generalizada Contracción mantenida y simétrica de las extremidades , el tronco y el cuello Pueden ser en flexión, extensión o mezclar flexión y extensión Pueden provocarse por estimulación Pueden suprimirse sujetando o cambiando de posición
  • 19. TIPO CARACTERISTICAS Signos oculares Movimientos oculares aleatorios y erráticos o nistagmus Se diferencia de la desviación tónica de los ojos Movimientos orobucolinguales Succión, masticación, protrusión lingual Pueden provocarse por estimulación Movimientos de progresión Movimientos de natación o remo con los brazos Movimientos de pedaleo con las piernas Pueden provocarse por estimulación Pueden suprimirse sujetando o cambiando de posición
  • 20. Cadena de supervivencia en pediatría Prevención RCP inmediata Acceso SMU Manejo Avanzado Niveles de Intervención
  • 21. B. L. S. >P.E.E.P. > A.V.A.P. > A.P.L.S. Actuar Reanimación Evaluar Pre-Reanimación Re-evaluar Post-Reanimación
  • 22. EVALUACION PEDIATRICA
  • 23.
    • Apariencia
    Triángulo de Evaluación Pediátrica Respiración Circulación
  • 24. Apariencia
    • T ono
    • I nteracción
    • C onsolabilidad
    • M irada
    • H abla/Llora
  • 25. Trabajo Respiratorio
    • Sonidos anormales de Vía Aérea
    • Posición anormal Retracciones
    • Aleteo Nasal
    • Cabeza en movimiento
  • 26. Circulación de la Piel
    • Palidez
    • Marmórea
    • Cianosis
  • 27. Prioridades de Manejo
    • A: Vía aérea
    • Inclinación cabeza/elevación del mentón
    • Succión
    • Cánula oro /nasofaríngea
    • Oxígeno si lo requiere
    • B: Ventilación
    • Bolsa-<mascarilla
    • C: Acceso vascular
  • 28. Manejo
    • Cuidado de soporte en caso de recurrencia
      • Mover al paciente a un lugar seguro.
      • No poner nada en la boca.
    • Anticonvulsivantes
  • 29. Puntos clave
    • Crisis. Convulsiva, pueden desencadenar falla respiratoria!
    • NUNCA OLVIDAR VIA AEREA.
      • Los aditamentos para vía aérea pueden ser necesarios.
    • MEDICAMENTOS
  • 30. DUDAS…???
  • 31.