Emergency cases


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  • In children, most cardiorespiratory arrests are secondary to hypoxia caused by respiratory pathology, including birth asphyxia, inhalation of foreign body, bronchiolitis and asthma. Respiratory arrest also occurs secondary to neurological dysfunction caused by such events as a convulsion or poisoning Whatever the cause, by the time of cardiac arrest the child has had a period of respiratory insufficiency, which will have caused hypoxia and respiratory acidosis combination of hypoxia and acidosis causes cell damage and death (particularly in more sensitive organs such as the brain, liver and kidney), before myocardial damage is severe enough to cause cardiac arrest The outcome of cardiac arrest in children is poor. Of those who survive, many are left with permanent neurological deficits. The worst outcome is in children who have had an out-of-hospital arrest and arrive at hospital apnoeic and pulseless
  • Primary assessment and resuscitation involve management of the vital ABC functions and assessment of disability (CNS function). This assessment and stabilisation occurs before any illness-specific diagnostic assessment or treatment takes place. Once the patient’s vital functions are supported, secondary assessment and emergency treatment begins. Illness-specific pathophysiology is sought and emergency treatments are instituted. During the secondary assessment vital signs should be checked frequently to detect any change in the child’s condition. If there is deterioration then primary assessment and resuscitation should be repeatedThe final phase of the structured approach is to stabilise the child, focussing on achieving homoeostasis and system control and leading onto transfer to a definitive care environment, which will often be the paediatric intensive care unit
  • Assess and treat ABC firstABC problems may cause agitation, restlessness & depressed consciousnessNeurological problems may cause respiratory irregularities, (eg hyperventilation, Cheynes-Stokes breathing, slow & sighing respiration, apnoea) bradycardia and hypertension (Cushing’s triad).
  • For a full AVPU assessment, a response to pain must be undertaken (unless there is a response to voice). Discuss assessing pain – methods of producing a painful stimulus, and what response might be seen: motor, verbal, eyes. This can be used to introduce the fuller assessment with GCS or CCS.
  • Emergency cases

    1. 1.  Most Cases of cardiac arrest in children are preceded by respiratory failure  Most common form in children  Heart stops due to ischemia or hypoxia secondary to another condition  Arrest rhythm is usually bardycardia progressing to asystole  Hypoxia initially present  Out com depends on prevention or prompt resuscitation
    3. 3. Primary survey Resuscitation Secondary survey Emergency treatment Continuing stabilization and definitive care
    4. 4.  An 18 month old girl is brought into the A&E department by paramedics having been found lying face down in the neighbours outdoor swimming pool. Her mother states that she had been missing for 5 minutes. Basic life support has been carried out on the pool side and during transportation to hospital
    5. 5.  Initial Impression  The child is pulseless and apnoeic. She is very cold to touch
    6. 6. Cardiac Arrest ABC Check the pulse Attach monitor/defibrillator Shockable Ventricular Fibrillation (VF) Ventricular Tachycardia (VT) NON Shockable Asystole / Pulseless Electrical Activity (PEA)
    7. 7. Ventricular Fibrillation (VF) No Pulse: Shockable
    8. 8. During CPR Attempt /Verify Tracheal intubation Intraosseous /Vascular access Check Electrodes/Paddles position and contact Give Adrenaline every 3 minutes Consider antiarrhythmics Consider giving Bicarbonate Correct reversible causes ( 4H/4T) Hypoxia Tension Pneumothorax Hypovolaemia Tamponade Hyper/hypokalaemia Toxic/therapeutic Hypothermia Thromboemboli
    9. 9. Adrenaline  IV / IO 10 mcg /kg 0.1 ml/kg of 1:10 000 solution  ET 100 mcg/kg 0.1ml/kg of 1:1 000 solution  May be repeated every 3 minutes
    10. 10.  Intubate to prevent aspiration  Gastric drainage to remove swallowed water  Measure core temperature and treat hypothermia  Full trauma assessment for other injuries
    11. 11.  Blood glucose  Arterial blood gases and lactate  Urea, electrolytes and coagulation status  Blood and sputum cultures  Chest x–ray  Lateral cervical spine x-ray or CT scan
    12. 12.  Hypothermia may be protective, continue to resuscitate until expert advice obtained  Active core rewarming vital  Do not give initial medications until core > 30o C  Give initial defibrillating shocks but do not repeat until core >30o C  Volume expansion may be needed
    13. 13. External rewarming  Remove wet clothing  Wrap warmly  Radiant heat  Warm air system  Direct heat Core rewarming  IV fluids to 39oC  Ventilator gases to 42oC  Gastric/bladder/ peritoneal/pleural lavage at 42o C  Endovascular warming  Extra-corporeal rewarming with by-pass
    14. 14.  Airway  Oral tracheal intubation   Breathing  Bag and mask with added O2   Bag and ETT with added O2   Circulation  VF protocol   General Therapy  Uninterrupted BLS   Specific Therapy  Resus until T>32, active rewarming 
    15. 15.  Diagnosis  Cardio-respiratory arrest, ventricular fibrillation, hypothermia secondary to drowning
    16. 16. Intensive Care Pre-Hospital Surgery Rapid ResponseEmergency Medicine Medical Center
    17. 17.  History   A 3 year old girl was eating a sandwich when she suddenly started coughing, and then stopped breathing. Her mother picked her up and slapped her back but couldn't dislodge the food. She called an ambulance. On arrival a paramedic performed abdominal thrusts and dislodged piece of bread. Basic life support was started.  Initial Impression  Apnoeic and pulseless
    18. 18.  Clinical Course}  The child remains in asystole until satisfactory ventilation is achieved, initial drugs have been given and one cycle of the asystole protocol has been completed. She then develops sinus tachycardia on the monitor but there is no pulse
    19. 19.  She has PEA secondary to a tension pneumothorax. This responds to chest decompression. Guide weight 14kg
    20. 20. PEA no palpable pulses
    21. 21. PROTOCOL FOR ASYSTOLE AND PEA 2min CPR High flow O2, IV/IO access ROSC Oxygen should be titrated (spO2 94%-98%) Therapeutic hypothermia Blood glucose control Parental presence Drugs used in CPR Adrenaline; induce vasoconstriction, increase coronary perfusion Amiodarone; is a membrane –stabilising anti-arrhythmic drug, used in treatment of shockable rhythms Atropine; is effective in increasing HR when bradycardia is caused by excessive vagal tone Sodium bicarbonate; the routine use of it is not recommended. Calcium; administration of calcium during cardiac arrest has been associated with increased mortality Magnesium; is indicated with documented hypomagnesaemia or with polymorphic VT Assess rhythm Continues CPR Post cardiac arrest treatment If signs of life check rhythm if perfusable rhythm, check pulse. Adrenaline immediately and then every 4minutes 1omcg/kg IV or IO Consider 4Hs and 4Ts
    22. 22. Proximal Humerus Proximal Humerus Proximal Tibia Proximal Tibia Distal Tibia Distal Tibia Distal FemurDistal Femur Intraosseous access sites for the pediatric patient Site is most suitable for patients 5 years of age and older Site is suitable most for patients 5 years of age and older
    23. 23.  Airway  Establish airway patency   Oral tracheal intubation  Breathing  Bag and mask with added O2  Bag with TT with added O2  Circulation  IV/IO access  Asystole protocol   PEA protocol  General Therapy  Uninterrupted BLS  Specific Therapy  Needle Thoracocentesis
    24. 24.  History  A 10 month old girl is brought into the Emergency Department with a 12 hour history of vomiting and diarrhoea  Initial Impression Respiratory rate 36, pulse 130, capillary refill 4 seconds. Appears pale and hypotonic.
    25. 25.  Clinical  The child continues to have vomiting and profuse watery diarrhoea. Blood pressure is 90 systolic. Following 20 ml/kg of normal saline the pulse rate comes down to 115 per minute and the child appears more alert. The child is started on maintenance fluids but an hour later when she is about to go to the ward and following further vomiting and profuse diarrhoea she again has a pulse rate of 140 and is pale and lethargic. A further fluid bolus corrects this. The serum sodium taken on insertion of the IV cannula is reported as 132 mmol/l
    26. 26.  Airway  Establish airway patency  Breathing  Oxygen via face mask  Circulation  IV access  Fluid bolus x 2  General Therapy  Calculation of maintenance fluids and electrolytes  Diagnosis  Gastroenteritis
    27. 27.  History  A five day old infant is brought to A&E by his parents. He was born at full term and was born by a normal delivery. Initially he was well, but over the last 24 hours he has become increasingly lethargic and has not fed for 8 hours
    28. 28.  High flow oxygen should be administered and airway breathing and circulation assessed. IV access is only possible via the intraosseous route. Blood sugar should be checked. The infant worsens after the first bolus of fluid and femoral pulses are still absent. 
    29. 29.  Initial Impression  He is pale and drowsy but responding to pain. Respiratory rate is 75bpm, heart rate 195bpm and pulses are difficult to feel. Capillary refill time is seven seconds centrally.  Additional History and Observations  Mum was well through the delivery. There are no risk factors for infection.
    30. 30.  Cyanosis, not correcting with oxygen therapy  Tachycardia out of proportion to respiratory difficulty  Raised jugular venous pressure  Gallop rhythm, murmur  Enlarged heart on CXR  Enlarged liver  Absent femoral
    31. 31.  Neonates with ,duct-dependent pulmonary circulation (e.g., critical pulmonary stenosis, pulmonary atresia, tricuspid atresia)  Neonates with duct-dependent systemic circulation (eg transposition of great arteries, .aortic stenosis, /Artesia,left hypoplastic heart, coractation of aorta) .
    32. 32.  Give an intravenous infusion of Prostin (e.g. for PGE2):  Initial dose of 5 nanograms/kg/min (may be increased. to 20 nanograms/kg/min in 5-nanograms/kg /min increments until side, effects develop  Suggested preparation of PGE2 : Add 1ampule(500mcg) to 50 ml = 0.6ML/ h x weight kg needed to infuse 0.1 mcg/kg/min
    33. 33.  This is a duct dependant lesion and requires treatment with an IV infusion of alprostadil. This condition can be difficult to differentiate from sepsis in the neonate so if the candidate gives IV antibiotics this should be accepted as good practice. Guide weight 4kg
    34. 34.  Airway  Airway opening manoeuvres   Breathing  High flow oxygen   Plan for intubation   Circulation  IV access   1 x fluid bolus   Specific Therapy  IV alprostadil   Contact Cardiac centre    Diagnosis  Shock secondary to coarctation of the aorta
    35. 35.  History  A four year old boy is brought to A&E by his parents He has been unwell for twenty-four hours with right-sided abdominal pain, and over the last few hours he has had some bile stained vomiting. His father tried to wake him and give him a drink, but was unable to rouse him.  Initial Impression  Unrousable. Pale child. Shallow breathing. Cold, mottled peripheries
    36. 36.  Additional History and Observations   Respiratory rate 45 bpm, barely fogging the mask. Capillary refill time is 7 seconds and heart rate 170 bpm. The abdomen is rigid on palpation.   Clinical Course  The child becomes bradycardic and apnoeic while IV access is sought. Bag and Mask ventilation is started, and if compressions are not started the child develops PEA. The child improves after two boluses of fluid. A surgical opinion should be sought. Guide weight 16kg. 
    37. 37.  while IV access is sought. Bag and Mask ventilation is started, and if compressions are not started the child develops PEA. The child improves after two boluses of fluid. A surgical opinion should be sought. Guide weight 16kg.
    38. 38.  Airway  Establish airway patency  Breathing  High flow oxygen  Attempt bag-mask ventilation with O2   Circulation  Chest compression   IV access   Bradycardia protocol   Fluid bolus x 2   Specific Therapy  IV Antibiotics   Surgical opinion    Diagnosis  Septic shock secondary to perforated appendix 
    39. 39. Diagnosis  Septic shock secondary to perforated appendix
    40. 40.  History  A 3 year old boy is carried into Accident & Emergency in his fathers arms. He is pale, limp and having difficulty breathing. The father says he has been unwell and coughing for 3 days.   Initial Impression  Respiratory rate is 60 with marked intercostal recession and a tracheal tug. Pulse 150. He is thin, pale and only responsive to painful stimulation.  Additional History and Observations  His temperature is 36oC. SaO2 is 76% in 100% O2 by face mask. Capillary perfusion is 6 sec. BP 60/? and thready
    41. 41.  Clinical Course  The child is peripherally shut down and needs a bolus of fluids and IV antibiotics. Despite high flow O2 saturation remains poor as he is exhausted and needs elective intubation. If this is not carried out bradycardia develops prior to asystole.. There is then gradual improvement. Guide weight 14 kg. 
    42. 42.  systemic inflammatory response syndrome(SIRS)  the presence of at least two of the following four criteria, one of which must be abnormal temperature or leukocyte count:  core [oral or rectal]temperature of>38.5C or <36C  Tachycardia, in the absence of external stimulus , chronic drugs, or painful stimuli, or otherwise unexplained persistent elevated period or for children< 1 year old : bradycardia , in absence of vagal stimulus , B-blocker drugs, or congenital heart depression over a 0.5-h time period  Tachypnea for an acute process not related to underlying neuromuscular disease.  Leukocyte count elevated or depressed for age [ not secondary to chemotherapy-induced leucopenia] or >10% immature
    44. 44.  Heart Rate; Tachycardia – bradycardia  Skin colour: Pallor, mottling secondary to endogenous epinephrine  Mental Status :Agitation, restlessness, reduced conscious level, coma
    45. 45.  Airway  Establish airway patency   Breathing  High flow O2 via face mask   Electively intubate & ventilate with 100% O2   Circulation  IV access   Fluid bolus   Specific Therapy  IV antibiotics    Diagnosis  Severe bilateral pneumonia (probably streptococcus pneumoniae)
    46. 46.  Diagnosis  Severe bilateral pneumonia (probably streptococcus pneumoniae)
    47. 47.  History  A five-year-old boy is brought into the A&E department with vomiting and fever. The parents describe these symptoms as having developed during the morning and he now doesn’t want to walk at all.   Initial Impression  Respiratory rate 25/min, SaO2 98%, heart rate 95/min, capillary refill 2s, temperature 40.7ºC. Initially responds to voice
    48. 48.  Additional History and Observations   He had been complaining of headache. His blood pressure is 120/95 and he has good pulses. He has small, poorly reactive pupils. Exposure reveals some petechia on his abdomen and lower limbs.
    49. 49.  Clinical Course  His conscious level deteriorates. He requires airway control, assessment of conscious level and posture, management of raised intra-cranial pressure and i.v. antibiotics. An anaesthetic colleague may help with intubation. Guide weight 18kg. 
    50. 50. Conscious Level Posture Pupillary Signs
    51. 51.  Alert A  Responds to Voice V  Responds only to Pain P  Unresponsive U
    52. 52.  . He requires airway control, assessment of conscious level and posture, management of raised intra- cranial pressure and i.v. antibiotics. An anaesthetic colleague may help with intubation. Guide weight 18kg.
    53. 53.  Treatment of disability in shock  The priority in patients with a mixed picture of shock and meningitis is  brain perfusion is dependent on adequate cardiac output.  If signs of raised ICP persist tracheal intubation and mechanical ventilation should be initiated urgently.  Monitor CO2 levels by capnography and blood gases, and keep in a normal range  Insert a urinary catheter early, and monitor urine output.  Nurse the child with 20° head elevation and midline position.   Lumbar puncture must be avoided as its performance may cause death through coning of the brainstem through the foramen magnum.
    54. 54.  Airway  Establish airway patency   Insert oropharyngeal airway   Breathing  High flow O2   Orotracheal intubation & ventilate with O2   Circulation  IV access   Disability  Head in-line and raised 20º   Mannitol   Specific Therapy  IV cefotaxime / ceftriaxone   IV dexamethasone  
    55. 55.  Diagnosis  Acute meningitis – raised intra-cranial pressure