PAEDIATRIC EMERGENCIES DR.S SEN Specialist Registrar Paediatrics North Western Deanery
PAEDIATRIC EMERGENCIES <ul><li>1. COMA </li></ul><ul><li>2. SHOCK (Septicaemia, anaphylaxis) </li></ul><ul><li>2. UPPER AN...
PAEDIATRIC EMERGENCIES <ul><li>4. INFECTIONS </li></ul><ul><ul><li>Meningitis  </li></ul></ul><ul><ul><li>Encephalitis </l...
PAEDIATRIC EMERGENCIES <ul><li>6. RENAL  </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Haematuria </li></u...
PAEDIATRIC EMERGENCIES <ul><li>8. PAINS </li></ul><ul><ul><li>Limping child  </li></ul></ul><ul><ul><li>Chest pain </li></...
EMERGENCIES  IN BABIES <ul><li>Excessive crying </li></ul><ul><li>Not feeding </li></ul><ul><li>Cyanosis </li></ul><ul><li...
COMA <ul><li>STATE OF UNRESPONSIVENESS DUE TO DIFFUSE LESIONS OF HEMISPHERES / BRAIN STEMS   </li></ul><ul><li>Structural ...
COMA: ASSESSMENT AND DIAGNOSIS <ul><li>Rapid History and General Examination </li></ul><ul><li>Skin (trauma, petechiae, bl...
CHILDREN’S COMA SCORE (15) <ul><li>Eyes : 4 spont. open </li></ul><ul><li>3 verbal command </li></ul><ul><li>2 pain </li><...
MANAGEMENT OF COMA   <ul><li>Always emergency - get Registrar/Consultant </li></ul><ul><li>Airways - check, suction, venti...
INVESTIGATIONS IN COMA <ul><li>FBC, U+E, LFT, BC, Blood gases, Glucose,  </li></ul><ul><li>NH3, toxic screen, lactate, ami...
TREATMENT OF COMA <ul><li>Treat Shock - Restore and control BP  </li></ul><ul><li>Treat The Treatable </li></ul><ul><ul><l...
SHOCK   <ul><li>Failure of circulation of oxygen to tissues </li></ul><ul><li>resulting in lactic acidosis, cellular dysfu...
1. HYPOVOLAEMIC SHOCK <ul><li>Haemorrhagic loss: </li></ul><ul><ul><li>trauma, gastrointestinal bleed, coagulopathy </li><...
2. SEPTIC (DISTRIBUTIVE) SHOCK <ul><li>MALDISTRIBUTION OF BLOOD WITHIN ORGANS DUE TO ABNORMAL PERIPHERAL FUNCTION </li></u...
<ul><li>REDUCED VASCULAR SIZE AND LIMITED BLOOD FLOW  DUE TO INTRINSIC OR EXTRINSIC FACTORS </li></ul><ul><li>Pericardial ...
4.CARDIOGENIC SHOCK <ul><li>PRIMARY HEART PROBLEM WITH INADEQUATE CARDIAC OUTPUT AND INADEQUATE TISSUE PERFUSION  </li></u...
ASSESSMENT OF SHOCK <ul><li>Full history  and physical examination </li></ul><ul><li>Classic signs: </li></ul><ul><li>tach...
EARLY AND LATE SHOCK <ul><li>tachycardia    bradycardia, dysrhytmia </li></ul><ul><li>tachypnoea     severe tachypnoea a...
GENERAL MANAGEMENT OF SHOCK <ul><li>MONITOR: HR, BP, BP (CVP), O2 sat., fluid balance </li></ul><ul><li>AIRWAY, BREATHING,...
SPECIFIC MANAGEMENT OF SHOCK <ul><li>Hypovolaemia: rapid volume replacement </li></ul><ul><li>Septic shock: antibiotics an...
RESPIRATORY FAILURES Upper Airway Obstruction Asthma (see BPA guideline)
ASTHMA ASSESSMENT
ASTHMA TREATMENT <ul><li>NEBULISERS (use oxygen): </li></ul><ul><ul><li>Salbutamol: 5mg </li></ul></ul><ul><ul><li>Atroven...
SYMPTOMS OF CROUP <ul><li>Babies and toddlers (rarely school children)  </li></ul><ul><li>Coughing (barking) </li></ul><ul...
CROUP - ASSESSMENT <ul><li>Mild croup: stridor only when crying / agitated </li></ul><ul><ul><li>no hypoxia and comfortabl...
CROUP - MANAGEMENT <ul><li>Mild croup : comfortable, stridor only when crying  </li></ul><ul><li>No treatment, reassure an...
CROUP - CRITERIA FOR ADMISSION <ul><li>Stridor at rest </li></ul><ul><li>Transport or phone difficulties </li></ul><ul><li...
EPIGLOTTITIS <ul><li>Toxic child, fever, drooling, can't swallow, can't talk, no cough.  </li></ul><ul><li>Advice to GP an...
EPIGLOTTITIS - MANAGEMENT <ul><li>Treatment before intubation: none . Adrenaline is not helpful and may irritate glottis. ...
MENINGOCOCCUS INFECTION  CLINICAL SIGNS  <ul><li>Suspect in any child with sudden onset of  </li></ul><ul><ul><li>fever wi...
MENINGOCOCCAL INFECTION MANAGEMENT <ul><li>Patients with meningococcal infection should be rapidly assessed in resuscitati...
MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION  Relatively Well Child   <ul><li>Insert 2 iv lines and collect blood for i...
MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Unstable Child   <ul><li>Inform CDC, Anaesthetist and PICU </li></ul><ul><...
MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION:   Early selection for transfer to PICU   <ul><li>Refractory hypotension </li...
CHILDREN’S COMA SCORE (15) <ul><li>Eyes : 4 spont. open </li></ul><ul><li>3 verbal command </li></ul><ul><li>2 pain </li><...
STATUS EPILEPTICUS - MANAGEMENT   <ul><li>Monitor vital signs (watch apnoea and hypotension) </li></ul><ul><li>Give O2 100...
DRUGS IN STATUS EPILEPTICUS <ul><li>MIDAZOLAM (im, oral, nasal, rectal) </li></ul><ul><ul><li>iv 50-100-200 ugm/kg/dose (1...
COMPARISON OF DRUGS FOR STATUS
FURTHER DRUGS IN STATUS <ul><li>PHENYTOIN (cardiac monitor: HR and BP) </li></ul><ul><ul><li>20 mg/kg iv in normal saline ...
NON- FEBRILE  CONVULSION <ul><li>The younger the child, the more likely is an underlying disorder (lower threshold for inv...
NON- FEBRILE  CONVULSION:  INVESTIGATIONS  <ul><li>Blood for glucose, FBC, Na+K+Ca+P+Mg, </li></ul><ul><li>Toxicology, pH ...
JITTERY OR FITTING BABY?
FITTING BABIES: MANAGEMENT <ul><li>Urgent treatment is indicated because repeated seizures may result in brain injury: hyp...
FEBRILE FIT - ASSESSMENT <ul><li>Accurate history of event  </li></ul><ul><ul><li>Any preceding illness, including fever <...
SIMPLE FEBRILE CONVULSIONS <ul><li>At age of 6 months-5 years  </li></ul><ul><li>Generalized </li></ul><ul><li>Loss of con...
FEBRILE FIT- INVESTIGATIONS  <ul><li>>  1 year old </li></ul><ul><ul><li>If recovered from fit, can rely on clinical REVIE...
FEBRILE FIT  -  TREATMENT <ul><li>FEVER: take off clothes, give paracetamol, use fan </li></ul><ul><li>FITS: rectal Diazep...
DKA - SYMPTOMS <ul><li>high blood glucose >16mmol/l  </li></ul><ul><li>significant dehydration >5% </li></ul><ul><li>acido...
CLINICAL ASSESSMENT  OF HYDRATION <ul><li>Deficit should not be overestimated with traditional 5,10,15%! (Mismanagement mi...
 
DKA - INITIAL INVESTIGATIONS <ul><li>Blood:  glucose (BM stix is usually lower),  </li></ul><ul><ul><ul><li>FBC, culture, ...
DKA - IMMEDIATE MONITORING <ul><li>vital signs: RR, HR, BP. temp  </li></ul><ul><li>body weight (estimate on 50th centile,...
DKA - IMMEDIATE MANAGEMENT <ul><li>ESTABLISH IV ACCESS: </li></ul><ul><ul><li>give initially 10-20ml/kg plasma or 4.5% alb...
DKA REHYDRATION What do you want to give? <ul><li>Albumin 4.5% for the start  if BP is low  (10-20 ml/ kg) </li></ul><ul><...
DKA - REHYDRATION How much do you want to give? <ul><li>Estimate the degree of dehydration on the clinical signs </li></ul...
DKA - VOLUME OF REHYDRATION
DURATION OF REHYDRATION <ul><li>Depending on osmolality:  </li></ul><ul><li>over 24 hrs if normosmolality (280 mosm) </li>...
DKA - INSULIN TREATMENT <ul><li>Aim : slow reduction of hyperglycaemia (2.5mmol/hr) and maintainance of normoglycaemia (4-...
 
<ul><li>THANK YOU </li></ul>
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Paediatric Emergencies

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Paediatric Emergencies

  1. 1. PAEDIATRIC EMERGENCIES DR.S SEN Specialist Registrar Paediatrics North Western Deanery
  2. 2. PAEDIATRIC EMERGENCIES <ul><li>1. COMA </li></ul><ul><li>2. SHOCK (Septicaemia, anaphylaxis) </li></ul><ul><li>2. UPPER AND LOWER AIRWAY OBSTRUCTION </li></ul><ul><ul><li>Croup and Epiglottitis, Foreign Body </li></ul></ul><ul><ul><li>Asthma, Bronchiolitis, Chest infection </li></ul></ul><ul><li>3. CARDIAC EMERGENCIES </li></ul><ul><ul><li>Heart Failure </li></ul></ul><ul><ul><li>Supraventricular Tachycardia </li></ul></ul>
  3. 3. PAEDIATRIC EMERGENCIES <ul><li>4. INFECTIONS </li></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Encephalitis </li></ul></ul><ul><ul><li>Kawasaki </li></ul></ul><ul><ul><li>HUS </li></ul></ul><ul><ul><li>Pertussis </li></ul></ul><ul><ul><li>Endocarditis </li></ul></ul><ul><li>5. SEIZURES </li></ul><ul><ul><li>Status epilepticus </li></ul></ul><ul><ul><li>Febrile fits </li></ul></ul><ul><ul><li>Hypsarrhythmia </li></ul></ul><ul><ul><li>Non febrile fits </li></ul></ul><ul><ul><li>Increased intracranial pressure </li></ul></ul>
  4. 4. PAEDIATRIC EMERGENCIES <ul><li>6. RENAL </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Haematuria </li></ul></ul><ul><ul><li>UTI </li></ul></ul><ul><ul><li>Nephrosis </li></ul></ul><ul><ul><li>HUS </li></ul></ul><ul><li>7. SKIN </li></ul><ul><ul><li>Rash, Erythema </li></ul></ul><ul><ul><li>Purpura, Petechia </li></ul></ul><ul><ul><li>Peeling </li></ul></ul><ul><ul><li>Vesicles, Pustula </li></ul></ul><ul><ul><li>Cellulitis </li></ul></ul><ul><ul><li>NAI </li></ul></ul>
  5. 5. PAEDIATRIC EMERGENCIES <ul><li>8. PAINS </li></ul><ul><ul><li>Limping child </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Backache </li></ul></ul><ul><ul><li>Sickle Cell </li></ul></ul><ul><li>9. ENVIRONMENTAL </li></ul><ul><li>Burns, smoke inhalation </li></ul><ul><li>Drowning </li></ul><ul><li>Poisoning </li></ul><ul><li>Hypothermia, heat stress </li></ul><ul><li>Anaphylaxis </li></ul><ul><li>Head injury and RTA </li></ul><ul><li>NAI and SA </li></ul>
  6. 6. EMERGENCIES IN BABIES <ul><li>Excessive crying </li></ul><ul><li>Not feeding </li></ul><ul><li>Cyanosis </li></ul><ul><li>Apnoea </li></ul><ul><li>Jaundice </li></ul><ul><li>Fitting </li></ul><ul><li>Diarrhoea </li></ul><ul><li>Vomiting </li></ul><ul><li>Fever </li></ul><ul><li>Bleeding </li></ul>
  7. 7. COMA <ul><li>STATE OF UNRESPONSIVENESS DUE TO DIFFUSE LESIONS OF HEMISPHERES / BRAIN STEMS </li></ul><ul><li>Structural lesions </li></ul><ul><ul><li>bleeding, tumour, abscess, hydrocephalus </li></ul></ul><ul><li>Non-structural lesions (95%) </li></ul><ul><ul><li>seizures, drugs / poisons </li></ul></ul><ul><ul><li>infection (meningitis, encephalitis, HUS) </li></ul></ul><ul><ul><li>metabolic (hypoglycaemia, DKA, Reye) </li></ul></ul><ul><ul><li>renal failure, hepatic coma </li></ul></ul><ul><ul><li>endocrine (Addison) </li></ul></ul>
  8. 8. COMA: ASSESSMENT AND DIAGNOSIS <ul><li>Rapid History and General Examination </li></ul><ul><li>Skin (trauma, petechiae, bleeding) </li></ul><ul><li>Sutures in infant and neck stiffness, systemic, AF </li></ul><ul><li>CNS examination </li></ul><ul><li>GCS, Gag R, Blinking </li></ul><ul><li>Pupils, Reaction, EOM Palsy, Fundi, Dolls Eye </li></ul><ul><li>Motor- Posture, Tone, Symmetry/Lateralizing signs </li></ul><ul><li>Reflexes- DTR, Plantars </li></ul><ul><li>Pain, Grimace, Flexion, Extension, None </li></ul><ul><li>Assess level of Central Dysfunction </li></ul>
  9. 9. CHILDREN’S COMA SCORE (15) <ul><li>Eyes : 4 spont. open </li></ul><ul><li>3 verbal command </li></ul><ul><li>2 pain </li></ul><ul><li>1 no response </li></ul><ul><li>Motor :6 obeys verbal </li></ul><ul><li>5 localizes pain </li></ul><ul><li>4 withdraws from pain </li></ul><ul><li>3 abn. flexion to pain </li></ul><ul><li>2 extends to pain(decer) </li></ul><ul><li>1 no response </li></ul><ul><li>Best verbal response : </li></ul><ul><li>5 orientated </li></ul><ul><ul><li>smiles, follows </li></ul></ul><ul><li>4 disorientated </li></ul><ul><ul><li>consolable crying </li></ul></ul><ul><ul><li>inapropriate interaction </li></ul></ul><ul><li>3 inappropriate words </li></ul><ul><ul><li>sometimes consolable </li></ul></ul><ul><ul><li>moaning </li></ul></ul><ul><li>2 incomprehensible sounds </li></ul><ul><ul><li>inconsolable, irritable </li></ul></ul><ul><li>1 no response </li></ul>
  10. 10. MANAGEMENT OF COMA <ul><li>Always emergency - get Registrar/Consultant </li></ul><ul><li>Airways - check, suction, ventilation if needed </li></ul><ul><li>Breathing - ensure adequacy: RR, BS,saturation </li></ul><ul><ul><li>Give high flow oxygen, if breathing </li></ul></ul><ul><ul><li>Ventilate with bag and mask </li></ul></ul><ul><ul><li>Intubate with Anaesthetist, if </li></ul></ul><ul><ul><ul><li>breathing inadequate / GCS 8 / herniation syndromes </li></ul></ul></ul><ul><li>Circulation - monitor BP, CRT, PR </li></ul><ul><ul><li>iv access: 2 venous and arterial lines </li></ul></ul>
  11. 11. INVESTIGATIONS IN COMA <ul><li>FBC, U+E, LFT, BC, Blood gases, Glucose, </li></ul><ul><li>NH3, toxic screen, lactate, aminoacids, ammonia, </li></ul><ul><li>Virus studies, PCR </li></ul><ul><li>Chest X-ray, EEG </li></ul><ul><li>CT scan (has limited value), </li></ul><ul><li>LP only with neurosurgical support </li></ul>
  12. 12. TREATMENT OF COMA <ul><li>Treat Shock - Restore and control BP </li></ul><ul><li>Treat The Treatable </li></ul><ul><ul><li>Maintain BS with 10% dextrose 5mls/kg PRN </li></ul></ul><ul><ul><li>Restricted fluid (document type & rate) </li></ul></ul><ul><ul><li>Mannitol, if increased intracranial pressure </li></ul></ul><ul><ul><li>Consider Cefotaxime, Acyclovir, Erythromycin </li></ul></ul><ul><ul><li>Consider Flumazenil, Naloxone, Anticonvulsant </li></ul></ul><ul><li>May require transfer to PICU </li></ul>
  13. 13. SHOCK <ul><li>Failure of circulation of oxygen to tissues </li></ul><ul><li>resulting in lactic acidosis, cellular dysfunction </li></ul><ul><li>and cell death </li></ul><ul><li>1. Hypovolaemic shock due to loss of blood or fluid </li></ul><ul><li>2. Distributive (septic) shock: maldistribution of blood </li></ul><ul><li>3. Obstructive shock: reduced vascular size </li></ul><ul><li>4. Cardiogenic shock: primary heart problem </li></ul>
  14. 14. 1. HYPOVOLAEMIC SHOCK <ul><li>Haemorrhagic loss: </li></ul><ul><ul><li>trauma, gastrointestinal bleed, coagulopathy </li></ul></ul><ul><li>Fluid and electrolytes : </li></ul><ul><ul><li>gastroenteritis, diabetic ketoacidosis, polyuric states, mineralocorticoid deficiency </li></ul></ul><ul><li>Plasma/ protein loss: </li></ul><ul><ul><li>burns, peritonitis, bowel obstruction/ necrosis </li></ul></ul>
  15. 15. 2. SEPTIC (DISTRIBUTIVE) SHOCK <ul><li>MALDISTRIBUTION OF BLOOD WITHIN ORGANS DUE TO ABNORMAL PERIPHERAL FUNCTION </li></ul><ul><li>Sepsis: Gram negative bacteria, Meningococcus </li></ul><ul><li>Neurogenic shock </li></ul><ul><li>Drugs: antihypertensives, barbiturates </li></ul><ul><li>Anaphylaxis </li></ul>
  16. 16. <ul><li>REDUCED VASCULAR SIZE AND LIMITED BLOOD FLOW DUE TO INTRINSIC OR EXTRINSIC FACTORS </li></ul><ul><li>Pericardial tamponade </li></ul><ul><li>Tension pneumothorax </li></ul><ul><li>Pulmonary embolism </li></ul>3.OBSTRUCTIVE SHOCK
  17. 17. 4.CARDIOGENIC SHOCK <ul><li>PRIMARY HEART PROBLEM WITH INADEQUATE CARDIAC OUTPUT AND INADEQUATE TISSUE PERFUSION </li></ul><ul><li>SVT, bradycardia, ventricular tachycardia </li></ul><ul><li>Myocarditis </li></ul><ul><li>Hypoplastic left heart </li></ul><ul><li>Left sided outflow obstruction </li></ul><ul><li>Critical aorta stenosis and coarctation of aortae </li></ul>
  18. 18. ASSESSMENT OF SHOCK <ul><li>Full history and physical examination </li></ul><ul><li>Classic signs: </li></ul><ul><li>tachycardia, tachypnoea, </li></ul><ul><li>oliguria (anuria), </li></ul><ul><li>weak pulse, mottled extremities, </li></ul><ul><li>hypotension </li></ul><ul><li>Children can compensate for hypoperfusion states </li></ul><ul><li>Hypotension is a late sign of decompensated shock </li></ul>
  19. 19. EARLY AND LATE SHOCK <ul><li>tachycardia  bradycardia, dysrhytmia </li></ul><ul><li>tachypnoea  severe tachypnoea and gasping </li></ul><ul><li>low pulse pressure  hypotension </li></ul><ul><li>cool extremities, decreased CR  absent peripheral pulses </li></ul><ul><li>dry mucosa  mild oliguria  severe oliguria  anuria </li></ul><ul><li>restlessness / agitation  unconsciousness </li></ul>
  20. 20. GENERAL MANAGEMENT OF SHOCK <ul><li>MONITOR: HR, BP, BP (CVP), O2 sat., fluid balance </li></ul><ul><li>AIRWAY, BREATHING, CIRCULATION </li></ul><ul><ul><li>Reverse hypoxia and acidosis </li></ul></ul><ul><ul><li>Control bleeding with direct pressure </li></ul></ul><ul><ul><li>Obtain intravenous (arterial) access </li></ul></ul><ul><li>INVESTIGATIONS: </li></ul><ul><ul><li>FBC, U+E+osm, LFT (fibr, glu), BG, BC, clotting, BG </li></ul></ul><ul><ul><li>MSU, X-ray, ECG, Brain scan </li></ul></ul><ul><li>TRANSFER TO ITU: </li></ul><ul><ul><li>no response to Dopamine 2-20ugm/kg/min </li></ul></ul><ul><ul><li>signs of organ failure </li></ul></ul>
  21. 21. SPECIFIC MANAGEMENT OF SHOCK <ul><li>Hypovolaemia: rapid volume replacement </li></ul><ul><li>Septic shock: antibiotics and inotropes </li></ul><ul><li>Cardiogenic shock: minimal volume support </li></ul><ul><ul><li>Inotropes (Dopamin, Dobutamine), if low BP+high HR </li></ul></ul><ul><ul><li>Chronotropes (Isoproterenol or Epinephrine), </li></ul></ul><ul><ul><ul><li>if low BP + bradycardia or normal heart rate </li></ul></ul></ul><ul><li>Obstructive shock: drainage </li></ul><ul><li>Anaphylaxis: oxygen, adrenalin, hydrocortisone </li></ul>
  22. 22. RESPIRATORY FAILURES Upper Airway Obstruction Asthma (see BPA guideline)
  23. 23. ASTHMA ASSESSMENT
  24. 24. ASTHMA TREATMENT <ul><li>NEBULISERS (use oxygen): </li></ul><ul><ul><li>Salbutamol: 5mg </li></ul></ul><ul><ul><li>Atrovent 250 ugm </li></ul></ul><ul><li>STEROIDS: </li></ul><ul><ul><li>prednisolone 2mg/kg/day (max 40) </li></ul></ul><ul><ul><li>hydrocortisone: 4mg/kg 6 hourly </li></ul></ul><ul><li>AMINOPHYLLINE (with paediatricians): </li></ul><ul><ul><li>loading dose: 5mg/kg </li></ul></ul><ul><ul><li>maint. 1mg/kg/hour (max 20mg/kg/day) </li></ul></ul>
  25. 25. SYMPTOMS OF CROUP <ul><li>Babies and toddlers (rarely school children) </li></ul><ul><li>Coughing (barking) </li></ul><ul><li>Mild fever </li></ul><ul><li>Inspiratory stridor (=croup) </li></ul><ul><li>Intercostal, suprasternal or subcostal recession </li></ul><ul><li>Use of accessory muscle use </li></ul><ul><li>Differentialdiagnosis of viral or spasmodic croup: </li></ul><ul><li>(Get a second opinion from ENT Consultant) </li></ul><ul><li>epigolottitis, bacterial tracheitis, laryngeal foreign body, retropharyngeal abscess, infectious mononucleosis, angioneurotic oedema, diphtheria </li></ul>
  26. 26. CROUP - ASSESSMENT <ul><li>Mild croup: stridor only when crying / agitated </li></ul><ul><ul><li>no hypoxia and comfortable </li></ul></ul><ul><li>Moderate croup: stridor at rest </li></ul><ul><ul><li>recession and tachypnoea, but no hypoxia </li></ul></ul><ul><li>Severe croup: STRIDOR all the time </li></ul><ul><ul><li>recession and tachypnoea, tachycardia </li></ul></ul><ul><ul><li>decreased breath sounds </li></ul></ul><ul><ul><li>HYPOXIA- MONITOR SATURATION </li></ul></ul><ul><li>NO INVESTIGATIONS, PLEASE </li></ul>
  27. 27. CROUP - MANAGEMENT <ul><li>Mild croup : comfortable, stridor only when crying </li></ul><ul><li>No treatment, reassure and discharge with advice to return </li></ul><ul><li>Moderate  severe croup : </li></ul><ul><li>STRIDOR AT REST, recession and tachypnoea  </li></ul><ul><li>HYPOXIA, stridor, tachycardia, decreased breath sounds </li></ul><ul><li>Keep calm and nurse in warm room, in upright position </li></ul><ul><li>Oxygen if oxygen saturations <92% </li></ul><ul><li>Budesonide (Pulmicort) 2mg nebulised </li></ul><ul><li>Dexamethasone (single dose) 0.6mg/kg </li></ul><ul><li>Adrenaline (1:1000) 0.5mls nebulised with 5mls saline repeat 0.5mls/kg (max. dose 5mls) </li></ul>
  28. 28. CROUP - CRITERIA FOR ADMISSION <ul><li>Stridor at rest </li></ul><ul><li>Transport or phone difficulties </li></ul><ul><li>Great distance from hospital </li></ul><ul><li>Concerns over degree of supervision of the child </li></ul><ul><li>Parental anxiety </li></ul><ul><li>Timing of presentation </li></ul><ul><li>Recent onset and course felt to be progressive. </li></ul><ul><li>NO IMPROVEMENT FOR 4 HOURS AFTER NEDULISED ADRENALINE (ICU admission, if remains hypoxic with deteriorating respiratory distress after 2 doses) </li></ul>
  29. 29. EPIGLOTTITIS <ul><li>Toxic child, fever, drooling, can't swallow, can't talk, no cough. </li></ul><ul><li>Advice to GP and ambulance staff: any child with severe stridor should be transported sitting on parent's lap with mask oxygen. Paediatrician and Intensivist should be waiting to receive the child. Inform ENT Consultant. </li></ul><ul><li>Admission is automatic. This is a very serious condition. </li></ul><ul><li>Monitoring of vital signs frequently (<4 hourly) </li></ul><ul><li>No investigations (except urine Haemophilus ag) </li></ul>
  30. 30. EPIGLOTTITIS - MANAGEMENT <ul><li>Treatment before intubation: none . Adrenaline is not helpful and may irritate glottis. Steroids is of no use. </li></ul><ul><li>5-10% of children may be managed without intubation : </li></ul><ul><li>if they arrive in the morning </li></ul><ul><li>if they can still just talk and swallow </li></ul><ul><li>if the physician is experienced </li></ul><ul><li>there is facility for close observation on ICU </li></ul><ul><li>Indication for intubation : the child is getting tired out despite adrenaline or with falling saturation. </li></ul><ul><li>In ICU: bloods and iv 50 mg/kg Cefotaxime </li></ul>
  31. 31. MENINGOCOCCUS INFECTION CLINICAL SIGNS <ul><li>Suspect in any child with sudden onset of </li></ul><ul><ul><li>fever with headache, </li></ul></ul><ul><ul><li>vomiting, </li></ul></ul><ul><ul><li>stiff neck or pain in neck, </li></ul></ul><ul><ul><li>petechial rash ( non blanching) </li></ul></ul><ul><li>Other features include photophobia, drowsiness or confusion and signs of meningism </li></ul><ul><li>A rapidly evolving red macular rash may precede the typical petechial rash </li></ul>
  32. 32. MENINGOCOCCAL INFECTION MANAGEMENT <ul><li>Patients with meningococcal infection should be rapidly assessed in resuscitation room </li></ul><ul><li>Monitor HR, BP, O2 saturation, respiratory rate </li></ul><ul><li>Act on A.B.C. of resuscitation if required </li></ul><ul><li>Further management depends on general condition </li></ul>
  33. 33. MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Relatively Well Child <ul><li>Insert 2 iv lines and collect blood for investigations (clotting screen, venous gas, PCR, serum) </li></ul><ul><li>Immediately start iv Ceftriaxone 80 mg/kg (repeat dose in 12 hours, cont. 7 days) </li></ul><ul><li>Assess Glasgow Meningococcal Scoring </li></ul><ul><li>Inform CDC within 2 hrs of arrival of the patient </li></ul><ul><li>Admit for 48 hrs </li></ul>
  34. 34. MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Unstable Child <ul><li>Inform CDC, Anaesthetist and PICU </li></ul><ul><li>Give oxygen via face mask (6 litres), intubate </li></ul><ul><li>Site 2 iv lines and collect blood samples, do CXR </li></ul><ul><li>Start iv Ceftriaxone 80mg /kg immediately </li></ul><ul><li>Treat shock vigorously, use 4.5% HAS 20mls/kg over 10-30 mins (up to 60-80mls/kg may be required) </li></ul><ul><li>Give Dopamine 2.5ug-5ug/kg/min, if impaired perfusion has not responded to initial measures </li></ul><ul><li>Glasgow Meningococcal Score and temperature hourly </li></ul>
  35. 35. MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION: Early selection for transfer to PICU <ul><li>Refractory hypotension </li></ul><ul><li>Deteriorating sensorium / coma </li></ul><ul><li>Meningococcal score of 8 or more (30 % mortality) </li></ul><ul><li>Rapid clinical progress of rash within 12 hrs (extensive/ necrotic skin lesion) </li></ul><ul><li>Metabolic acidosis pH < 7.3 </li></ul>
  36. 36. CHILDREN’S COMA SCORE (15) <ul><li>Eyes : 4 spont. open </li></ul><ul><li>3 verbal command </li></ul><ul><li>2 pain </li></ul><ul><li>1 no response </li></ul><ul><li>Motor :6 obeys verbal </li></ul><ul><li>5 localizes pain </li></ul><ul><li>4 withdraws from pain </li></ul><ul><li>3 abn. flexion to pain </li></ul><ul><li>2 extends to pain(decer) </li></ul><ul><li>1 no response </li></ul><ul><li>Best verbal response : </li></ul><ul><li>5 orientated </li></ul><ul><ul><li>smiles, follows </li></ul></ul><ul><li>4 disorientated </li></ul><ul><ul><li>consolable crying </li></ul></ul><ul><ul><li>inapropriate interaction </li></ul></ul><ul><li>3 inappropriate words </li></ul><ul><ul><li>sometimes consolable </li></ul></ul><ul><ul><li>moaning </li></ul></ul><ul><li>2 incomprehensible sounds </li></ul><ul><ul><li>inconsolable, irritable </li></ul></ul><ul><li>1 no response </li></ul>
  37. 37. STATUS EPILEPTICUS - MANAGEMENT <ul><li>Monitor vital signs (watch apnoea and hypotension) </li></ul><ul><li>Give O2 100% by mask </li></ul><ul><li>If not breathing: bag + mask / ventilate if required </li></ul><ul><li>Investigations: </li></ul><ul><ul><li>BMstix, U & E, Ca, BG, FBC, C+S, toxic screen </li></ul></ul><ul><li>Always admission </li></ul><ul><li>Use minimum doses to control seizures </li></ul>
  38. 38. DRUGS IN STATUS EPILEPTICUS <ul><li>MIDAZOLAM (im, oral, nasal, rectal) </li></ul><ul><ul><li>iv 50-100-200 ugm/kg/dose (12-18yrs 300ugm/kg) </li></ul></ul><ul><li>LORAZEPAM (im, oral, rectal) </li></ul><ul><ul><li>iv 50-100 ugm/kg/dose (12-18yrs 4mg) </li></ul></ul><ul><li>DIAZEPAM (oral, rectal, iv) </li></ul><ul><ul><li>PR: < 3 yrs 5 mg, > 3 yrs 10 mg </li></ul></ul><ul><ul><li>iv bolus 200 - 400 ugm/kg slowly, repeat in 10 mins </li></ul></ul><ul><ul><li>(12-18 yrs 10-20 mg) </li></ul></ul>
  39. 39. COMPARISON OF DRUGS FOR STATUS
  40. 40. FURTHER DRUGS IN STATUS <ul><li>PHENYTOIN (cardiac monitor: HR and BP) </li></ul><ul><ul><li>20 mg/kg iv in normal saline over 10-20 mins </li></ul></ul><ul><ul><li>may repeat 20 mg/kg (do not use in febrile status) </li></ul></ul><ul><li>PHENOBARBITONE (in febrile status) </li></ul><ul><ul><li>15-20 mg/kg iv over 10 mins </li></ul></ul><ul><ul><li>(10-20 mg/kg iv may be repeated) </li></ul></ul><ul><li>PARALDEHYDE (im abscess, iv CSF peak 20-60 mins) </li></ul><ul><ul><li>rectal 0.4 ml/kg + equal volume of arachnis oil </li></ul></ul>
  41. 41. NON- FEBRILE CONVULSION <ul><li>The younger the child, the more likely is an underlying disorder (lower threshold for investigation < 1 yr) </li></ul><ul><ul><li>intracranial space occupying lesions </li></ul></ul><ul><ul><li>hypertensive encephalopathy </li></ul></ul><ul><ul><li>metabolic disturbance (hypoglycaemia, hypocalcaemia) </li></ul></ul><ul><ul><li>inborn errors of metabolism </li></ul></ul><ul><ul><li>congenital and inherited disorders (TS) </li></ul></ul><ul><li>History (prenatal and natal) and examination </li></ul><ul><li>Monitoring (pulse oximetry) </li></ul>
  42. 42. NON- FEBRILE CONVULSION: INVESTIGATIONS <ul><li>Blood for glucose, FBC, Na+K+Ca+P+Mg, </li></ul><ul><li>Toxicology, pH </li></ul><ul><li>Septic screen, incl.CXR </li></ul><ul><li>Babies:TORCH, PCV / Clotting screen, urine metabolic screen, reducing substances </li></ul><ul><li>MRI /CT / Brain US </li></ul><ul><li>EEG 2-3 weeks after fit, except suspected infantile spasms </li></ul>
  43. 43. JITTERY OR FITTING BABY?
  44. 44. FITTING BABIES: MANAGEMENT <ul><li>Urgent treatment is indicated because repeated seizures may result in brain injury: hypoventilation and apnoea, hypercapnia and hypoxemia leading to IVH </li></ul><ul><li>Intubation </li></ul><ul><li>Glucose if hypoglycemia is present: 2 ml/kg (200 mg/kg) 10% dextrose iv and maintainance on 8 mg/kg/min PRN </li></ul><ul><li>Phenobarbital iv loading dose of 20 mg/kg in 10 minutes </li></ul><ul><li>Phenytoin iv loading dose of 20 mg/kg (monitoring) </li></ul>
  45. 45. FEBRILE FIT - ASSESSMENT <ul><li>Accurate history of event </li></ul><ul><ul><li>Any preceding illness, including fever </li></ul></ul><ul><ul><li>Funny turns, rigors, jerking with fever? </li></ul></ul><ul><ul><li>Breath-holding attacks? </li></ul></ul><ul><li>Careful examination </li></ul><ul><ul><li>presence of fever? </li></ul></ul><ul><ul><li>evidence of URTI, otitis or tonsillitis, MENINGITIS, GE, septic arthritis, UTI? </li></ul></ul>
  46. 46. SIMPLE FEBRILE CONVULSIONS <ul><li>At age of 6 months-5 years </li></ul><ul><li>Generalized </li></ul><ul><li>Loss of consciousness </li></ul><ul><li>No focal features </li></ul><ul><li>No serious perinatal problems, previous illness or head injuries </li></ul><ul><li>Short lasting (< 20 minutes) </li></ul>
  47. 47. FEBRILE FIT- INVESTIGATIONS <ul><li>> 1 year old </li></ul><ul><ul><li>If recovered from fit, can rely on clinical REVIEW </li></ul></ul><ul><ul><li>If obvious source of infection, investigate as appropriate </li></ul></ul><ul><ul><li>If no obvious source, do MSU and continue REVIEW </li></ul></ul><ul><ul><li>If child is getting worse, do LP </li></ul></ul><ul><li>< 1 year old: </li></ul><ul><ul><li>Much lower threshold for full investigations, including LP, blood cultures, CXR, MSU </li></ul></ul><ul><ul><li>If the child is ill, especially one with signs of meningitis start iv antibiotics immediately (cultures) </li></ul></ul>
  48. 48. FEBRILE FIT - TREATMENT <ul><li>FEVER: take off clothes, give paracetamol, use fan </li></ul><ul><li>FITS: rectal Diazepam 2.5 mg < 1 year and 5 mg > 1 year </li></ul><ul><li>INFECTION: antibiotics if not for viral URTI </li></ul><ul><li>ADVICE TO PARENTS (fact sheet) </li></ul><ul><li>PROLONGED FIT: </li></ul><ul><li>Diazepam IV 0.25 - 0.3 mg/kg. (250 - 300 mcg/kg) slowly </li></ul><ul><li>Phenobarbitone (after 15 mins) IV 10 mg/kg slowly </li></ul><ul><li>Phenytoin IV (cardiac monitor!) 10 mg/Kg slowly </li></ul><ul><li>Paraldehyde PR 0.4 ml/kg + equal volume of araechis oil </li></ul><ul><li>IM 1 ml/yr (maximum 10 ml)10 mins </li></ul>
  49. 49. DKA - SYMPTOMS <ul><li>high blood glucose >16mmol/l </li></ul><ul><li>significant dehydration >5% </li></ul><ul><li>acidotic pH < 7.3 and bicarbonate < 15 </li></ul><ul><li>heavy ketonuria </li></ul><ul><li>impaired level of consciousness </li></ul>
  50. 50. CLINICAL ASSESSMENT OF HYDRATION <ul><li>Deficit should not be overestimated with traditional 5,10,15%! (Mismanagement might start here!) </li></ul><ul><li>Alert: mild 3% dehydration (only oral rehydration) </li></ul><ul><li>Thirsty, lethargic : moderate 6% dehydration (iv rehydr.) </li></ul><ul><li>Drowsy or comatose child with low or unrecordable blood pressure has severe 10% dehydration, requiring immediately 20ml/kg 4.5% plasma (given in 15-60 mins, depending on BP) </li></ul>
  51. 52. DKA - INITIAL INVESTIGATIONS <ul><li>Blood: glucose (BM stix is usually lower), </li></ul><ul><ul><ul><li>FBC, culture, pH and bicarbonate </li></ul></ul></ul><ul><ul><ul><li>U+ E+ osm. </li></ul></ul></ul><ul><li>Urine: glucose and ketones, C+ S </li></ul><ul><li>Arterial or capillary blood gases if venous pH<7.0 </li></ul><ul><li>CXR </li></ul><ul><li>Calculate osmolality: 2(Na+K) + glu + urea </li></ul>
  52. 53. DKA - IMMEDIATE MONITORING <ul><li>vital signs: RR, HR, BP. temp </li></ul><ul><li>body weight (estimate on 50th centile, last clinic weight) </li></ul><ul><li>blood glucose hourly until acidosis resolved </li></ul><ul><li>U+E 6 hourly, urine ketones and glucose 2-4 hourly </li></ul><ul><li>fluid flow-chart (input, output, ongoing losses (aspirate) </li></ul><ul><li>oxygen saturation </li></ul><ul><li>neurological observation to detect cerebral oedema </li></ul>
  53. 54. DKA - IMMEDIATE MANAGEMENT <ul><li>ESTABLISH IV ACCESS: </li></ul><ul><ul><li>give initially 10-20ml/kg plasma or 4.5% albumin </li></ul></ul><ul><ul><li>over one hour or within 15-30 mins to restore BP </li></ul></ul><ul><ul><li>give normal 0.9% saline until BG is >15 mmol/l </li></ul></ul><ul><li>PASS NGT AND/OR BLADDER CATHETER </li></ul><ul><ul><li>if the child is unconscious, </li></ul></ul><ul><ul><li>not passing urine, vomiting or </li></ul></ul><ul><ul><li>presenting with abdominal distension </li></ul></ul><ul><li>CONSIDER IV ANTIBIOTICS </li></ul>
  54. 55. DKA REHYDRATION What do you want to give? <ul><li>Albumin 4.5% for the start if BP is low (10-20 ml/ kg) </li></ul><ul><li>Normal, isotonic 0.9% saline without potassium until blood glucose >15mmol/l </li></ul><ul><li>4% dextrose / 0.18% saline with 20 mmol /500ml potassium, when blood glucose <15 mmol/lif serum potassium is <6 mmol/l and urine output is present </li></ul><ul><li>Bicarbonate supplementation rarely if ph < 7.1 </li></ul><ul><li>give half of the calculated dose (1/3 x wt x BE) </li></ul>
  55. 56. DKA - REHYDRATION How much do you want to give? <ul><li>Estimate the degree of dehydration on the clinical signs </li></ul><ul><li>Calculate expected weight on 50th centile </li></ul><ul><li>Calculate total loss and required volume of total rehydration: deficit + added daily maintenance </li></ul><ul><li>Maximum fluid is limited to 4.0 litre / m2 / 24hrs </li></ul><ul><li>Mild dehydration: oral 30ml/kg deficit + daily maint. </li></ul><ul><li>Moderate: iv 60 ml/kg fluid deficit + daily maint. </li></ul><ul><li>Severe dehydration: 20ml/kg plasma in 15-30-60 mins, followed by iv 100ml/kg deficit + daily maint. </li></ul>
  56. 57. DKA - VOLUME OF REHYDRATION
  57. 58. DURATION OF REHYDRATION <ul><li>Depending on osmolality: </li></ul><ul><li>over 24 hrs if normosmolality (280 mosm) </li></ul><ul><li>over 36 hrs if hyperosmolality > 340 </li></ul><ul><li>over 48 hrs if hyperosmolality > 400 </li></ul><ul><li>Reassess fluid requirement 4 hourly and add any accumulated negative balance (urine loss, vomiting, gastric aspirate etc) </li></ul><ul><li>Treat cerebral oedema immediately </li></ul><ul><li>with reduction of rate of fluid administration and </li></ul><ul><li>with iv mannitol 0.25 -1.0gm/kg/dose over 30 mins </li></ul>
  58. 59. DKA - INSULIN TREATMENT <ul><li>Aim : slow reduction of hyperglycaemia (2.5mmol/hr) and maintainance of normoglycaemia (4-8 mmol/l) </li></ul><ul><li>Initial dose of intravenous insulin infusion: </li></ul><ul><li>0.1unit / kg / hr of soluble Humulin S or Actrapid (use 50 units/50 ml saline) NEVER GIVE SC STAT DOSE! </li></ul><ul><li>Reduce iv insulin infusion to 0.05 unit/kg/hr, when blood glucose falls to 10-15 mmol /l </li></ul><ul><li>Increase to 0.15unit/kg/hr if acidosis persists (pH < 7.0) </li></ul><ul><li>Replace iv sliding scale with sc insulin asap </li></ul>
  59. 61. <ul><li>THANK YOU </li></ul>
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