What would be your next steps?

1. PEDIATRIC
EMERGENCIES
Dr. Bhupeshwari Patel
Assistant Professor
Dept. Of Trauma & Emergency Medicine
AIIMS Bhopal

2. When you see an injured child
 Common cause of injuries in children.
 50% of second hospital visits for these children result in
death
 Awareness of signs & symptoms of abuse helps identify
cases
Consider Possibility of Child Abuse

3. Pediatric Assessment Triangle
Appearance Work of
Breathing
Circulation to Skin

5. Appearance
 Look at the patient from a slight distance - What do you
see?
• Mental Status
• Color
• Interaction / Movement
• Recognition
STOP

6. Remember
A Quiet Kid is one that
should, SCARE You!!!

7. Respiratory
 AIRWAY: Patent with Precautions
 BREATHING: Respiratory Rate; too fast
v/s too slow, Abnormal Sounds
• A slow or irregular respiratory rate in a child is
an OMINOUS SIGN.
• Watch for the EFFORT NEEDED to BREATHE
 Chest, neck, or abdominal muscle retractions
 Flaring of the nostrils
 Adventitious Sounds -Crackles, Grunts

8. A=Airway: Control C-Spine
 Unconscious kids can’t protect
their airway
• Tongue most common obstruction
• Little airways are easily blocked
• JAW THRUST: Neutral Alignment for
kids includes Pad under the
Shoulders
• May need Oral/Nasal Airway
 Infants in first 30 days of life are
obligate nasal breathers
• May need to suction out
blood/mucus

9. B=Breathing
 All Children get Oxygen & LOTS OF IT
 May need to assist with Bag-Mask
• Good mask seal is the KEY to bagging
• Two people should bag when possible
• Avoid distending the stomach
 Cricoid pressure : not recommended
 Distended stomach = less room for air in lungs
Blue BAD - Oxygen GOOD

15. C=Circulation: Peripheral vs Central
 Pulse
 Color , Temperature
 CAPILLARY REFILL
• < 3 seconds GOOD NEWS
• > 3seconds WATCH OUT

19. Pediatric Trauma Messages
1. A little bleeding is a lot the smaller you are.
2. BP often maintained until very late in hemorrhage by
young patients because of their overactive
vasoconstrictive responses.
Tom Terndrup, MD
Director of Pediatric Emergency Medicine
University Hospital / Syracuse, N.Y.

22. D=Disability: Neuro Evaluation
 Use the AVPU system first
◦ Avoid "lethargic“, "semi-conscious“, etc. because everyone has
different meanings with these terms.
 Use the Pediatric Glasgow Coma Scale
◦ If time and circumstance permit
◦ Age and behavior adjusted
 Traumatic Brain Injuries need adequate oxygen !
• Hyperventilate only if they deteriorate
• Otherwise High Flow O2

23. E=Exposure
 Kids lose heat quickly
 Keep them COVERED UP
 Expose only as you need
 If YOU are COMFORTABLE,
it’s probably TOO COLD for
them

25. S-A-M-P-L-E Hx
 S=Signs and Symptoms
 A=Allergies
 M=Medications currently taken
 P=Pertinent Past/ Present Illnesses
 L=Last Meal
 E=Events/environment related to the
injury

26. Infant Transport by EMS
 “Keep infants in car seats unless treatment of injuries
requires removal (IV, ETT, BVM, control of hemorrhage).
If they survived the crash in an intact car seat, they are
usually better off to stay in it for the ride to the hospital.”
William E. Hauda, II, MD
Pediatric Emergency Medicine Fellow
Attending Emergency Medicine Physician
Fairfax Hospital, Falls Church, VA

27. STATUS EPILEPTICUS

28. INTRODUCTION
• Status epilepticus (SE) is a life threatening emergency
that requires prompt recognition and management.
• Immediate treatment of status epilepticus is crucial to
prevent adverse neurological and systemic
consequences.
• Diagnostic evaluation and seizure control should be
achieved simultaneously to improve outcome.

29. DEFINITIONS
 Status epilepticus (SE): SE is defined as continuous seizure
activity or recurrent seizure activity without regaining of
consciousness lasting for more than 5 min.
 previously cutoff time was 30 min but this has been reduced to
emphasize the risk involved with longer durations.
 Refractory SE: Seizures persist despite the administration of two
appropriate anticonvulsants at acceptable doses, with a minimum
duration of status of 60 minutes.
 Super Refractory SE: SE that continues 24hr or more after onset
of anesthesia.
Nelsons pediatrics south Asian
1st edition.
mishra D et al consensus guideline on management of
childhood CSE IAP vol 51 Dec 2014.

30. Contd…
 Non convulsive SE: Non-Convulsive Status Epilepticus
(NCSE) is a persistent change in the level of consciousness,
behavior , autonomic function, and sensorium from baseline
associated with continuous epileptiform EEG changes, but
without major motor signs.
 Psychogenic non epileptic seizures: Dramatic behavioral
event in conscious individual, typically present in teenagers
with anxiety disorders an family H/O seizures may be
present.

31. ETIOLOGIES
 Etiologically status epilepticus has been classified as:
 Cryptogenic(Idiopathic) : SE In the absence of an acute
precipitating CNS insult or metabolic dysfunction in a patient without a pre-
existing neurologic abnormality.
 Remote symptomatic : SE In a patient with a known history of
a neurologic insult associated with an increased risk of seizures (e.g.,
traumatic brain injury, stroke, static encephalopathy).
 Febrile : SE Provoked solely by fever in a patient without a history of
afebrile seizures

32. Contd…
 Acute symptomatic : SE During an acute illness
involving a known neurologic insult (e.g., meningitis,
traumatic brain injury, hypoxia) or metabolic dysfunction
(e.g., hypoglycemia, hyponatremia, hypocalcemia).
 Progressive encephalopathy : SE In a patient
with a progressive neurologic disease (e.g.,
neurodegeneration, malignancies, neurocutaneous
syndromes).

33. MANAGEMENT OF SE
Management can be broadly divided into two group
(1)Pre hospital management/Home based
 Treatment of SE needs to be initiated as early as
possible since once seizures persist for 5 to 10 minutes,
they are unlikely to stop on their own.
 Rectal diazepam OR buccal midazolam OR intranasal
midazolam can be used on home basis.

34. (2) hospital based management
(a)Initial stabilization,
(b) Seizure termination,
(c) Evaluation and treatment of the underlying cause.
As in any critically ill child it includes adequate airway, breathing
and circulation.
 In all children with seizures and altered sensorium, clearing the
oral secretions and keeping the child in recovery position to
prevent aspiration.
 Airway patency can be maintained by oral airway.(Guedel ’s
airway)

35. Contd…
 All children with ongoing seizures should be
given supplemental oxygen to ameliorate
cerebral hypoxia.
 All children with SE should have their
breathing and SpO2 monitored continuously.
 Continuous monitoring of pulse, blood
pressure and perfusion should be done in all
SE patients.
 If Glasgow coma scale score <8, rapid
sequence intubation should be considered.

36. MANAGEMENT PROTOCOL

37. Management Protocol
Time intervention for emergency department , in-patient setting .
0-5 min
(Stabilizatio
n phase)
1) Stabilize patient (Airway, breathing, circulation, disability-neurological
examination)
2) time seizure from its onset , monitor vital sign
3) Assess oxygenation
4) Initiate ECG monitoring
5) Collect finger stick blood glucose (if hypoglycaemia then correct it)
6) Attempt IV access and collect sample for electrolyte and toxicology
study)
Does seizure continue.. Seizure stop
5-20min
(initial
therapy
phase)
Benzodiazepine is initial therapy of choice ( choose 1 of following)
1) IM (10 mg for >40kg, 5 mg for 13-40 kg single dose) or
2) IV lorazepam(0.1mg/kg/dose max 4 mg/dose, may repeat once) or
3) IV Diazepam(0.15-0.2mg/kg/dose max 10 mg/dose, may repeat once)
If above 3 option not available (IV phenobarbital 15mg/kg/dose, singe dose
or rectal diazepam 0.2-0.5mg/kg/dose max 20 mg/dose single dose or intra
nasal or buccal midazolam)
if patient at base
line , then
symptomatic
medical care

38. Contd..
Does seizure continue.. Seizure stop
20-40 min
(second
therapy
phase)
(There is no evidence based preferred second therapy of
choice) choose one of following and give single dose
IV fosphenytoin(20mgPE/kg, max 1500mg)
IV valproic acid (40mg/kg, max 3000mg)
IV levetracetam(60mg/kg, max 4500mg)
If none of option above are available give IV
phenobarbital 15mg/kg single dose if not given already
if patient at base
line , then
symptomatic
medical care

39. Contd..
Does seizure continue.. Seizure stop
40-60 min
9third therapy
phase)
There is no clear evidence to guide therapy in this
phase
Choice include : repeat second line therapy or
anesthetic dose of either thiopental , midazolam ,
propofol with continuous EEG monitoring.
if patient at base line
, then symptomatic
medical care

40.  Cerebrospinal fluid (CSF) examination: A central nervous
system (CNS) infection is reported in 12.5% of pediatric
convulsive SE.
 A CSF examination should be done, after stabilizing the child
and excluding raised intracranial tension.
 CSF examination should be done if there is any sign of
meningitis.
 In infants younger than 6 months, signs of meningitis may not
be clearly demonstrated and fever also may not be present. In
such a situation, whenever there is a clinical suspicion of a
CNS infection or sepsis, lumbar puncture should be done.
Riviello JJ, et al. Practice Parameter: Diagnostic Assessment of the Child With Status
Epilepticus (an evidence-based review). Report of the Quality Standards Subcommittee of the
American Academy of Neurology and the Practice Committee of the Child Neurology Society.

41. EEG
 Indication of EEG in SE :
 New onset SE
 Refractory SE
 Permanent unexplained loss of consciousness
 suspicion of non-convulsive SE
 Psychogenic non epileptic seizure
 EEG abnormalities have been reported in ~90% children presenting
with SE, though these were done hours to days later.
 EEG should be done to evaluate background activity as soon as
possible after seizure stop , Ideally within 1 to 2 hours.
Riviello JJ, et al. Practice Parameter: Diagnostic Assessment of the Child With
Status Epilepticus (an evidence-based review). Report of the Quality Standards
Subcommittee of the American Academy of Neurology and the Practice
Committee of the Child Neurology Society. Neurology. 2006;67:1542-50.

42. NEUROIMAGING
 Neuroimaging can identify structural causes for SE, especially to
exclude the need for neurosurgical intervention in children with
new-onset SE without a prior history of epilepsy, or in those with
persistent SE despite appropriate treatment.
 Indication of neuroimaging in SE:
 New onset focal deficit
 persistent altered awareness
 H/O trauma
 H/O anti coagulation
 Children with SE, in whom no definitive etiology has been found.
 It should only be done after the child is appropriately stabilized
and the seizure activity controlled.
 Yield of MRI to detect structural lesion in CSE is about 31%.
Yoong M, Madari R, Martinoss R, Clark C, Chong K, Neville B, et al. The
role of magnetic resonance imaging in the follow-up of children with
convulsive status epilepticus. Dev Med Child Neurol. 2012;54:328-33.

43. Take Home Message.
 Pre-hospital management and early stabilization is the
key to a satisfactory outcome of status epilepticus.
 Initial management of status epilepticus consists of a
parenteral benzodiazepine, if IV access not available
buccal ,nasal or per rectal route should be used.
 Pharmacotherapy should not be delayed for any
investigations.

44. Child with Fever, Cough and
Noisy Breathing
⚫ Croup
⚫ Diphtheria
⚫ Pertussis

45. Harshad – a child with fever, cough and noisy
breathing
2 year old Harshad, presents with 1 day history of mild
grade fever and running nose. His mother also says that
his voice has changed and that his cough this time has a
peculiar sound which she has not heard before.
◦ What are the possibilities?
◦ What other information one needs?
45

46. Harshad - Analyzed
Characteristics:
◦ Acute onset
◦ Fever, running nose and cough – infective etiology – likely to be
upper airway
◦ Changed cough character – likely to be involving larynx
 Hence an acute upper airway infection – laryngitis +
46

47.  Other information required:
◦ Is the child playful?
◦ Is the child feeding well?
◦ History of similar complaints in the past?
 His mother says that Harshad is quite playful and has
been eating well. He does not seem to be disturbed by
his loud and almost barking cough. He has not had any
similar episodes in past.
47

48.  O/E: Harshad is active playful 2 year old, well nourished.
His temp is 990F in axilla.
 Ant rhinoscopy reveals rhinitis. His ears and throat are
normal.
 Harshad does have a barking loud cough, and a high
pitched inspiratory noise, particularly after coughing and
crying. But is absent during rest.
 What could the diagnosis be?
48

49. 49
Acute viral croup
How should Harshad’s illness be graded?

50. Grading severity of croup
Mild Moderate Severe
General
Appearance
Happy, Feeds well,
Interested in
surroundings
Fussy but inter-
active. Comforted by
parents.
Restless, agitated.
Altered sensorium.
Stridor Stridor on coughing
and crying. No
stridor at rest.
Stridor at rest
worsening with
agitation
Stridor at rest
worsening with
agitation
Respiratory
Distress
No distress Tachypnoea,
Tachycardia and chest
retractions
Marked Tachycardia,
with chest retractions
Oxygenation > 92% in room air >92% in room air <92% in room air.
Cyanosis.
50

51. 51
Harshad has Mild Croup.
How should one treat Harshad?

52. Croup - Treatment
Mild Moderate Severe
Steroids
Oral/Nebulized/IM
yes Yes Yes
Nebulized
Adrenaline
No No (May be given if
deterioration noted
during observation)
Repeated doses
may be
required.
Oxygen No No As required to
keep SaO2
>92%
ANTIBIOTICS NO
ROLE
NO ROLE NO ROLE
52

53. Harshad has mild croup
 Hence Harshad requires symptomatic
treatment
 Mother may also be advised to give
Humidified air inhalation / bathroom
steaming
 Few authorities may use a single oral
dose of Prednisolone / Dexamethasone to
decrease the parental stress as well as
the risk of return to medical care.
53

54. Parental advice
 Parents to be informed that croup generally gets more
severe at nights.
 To look out for increasing severity manifested by
increasing stridor, increasing breathing difficulty and the
child getting increasingly agitated with refusal of feeds.
 To come back to medical assistance if severity increases.
54

55. 55
Harshad’s mother rings you up in the middle
of the night because his breathing severity
has increased and she is bringing him to
the emergency.
O/E Harshad now has a audible stridor at rest,
He is crying and restless but is consolable by parents.
His HR 120, RR 26, Sats 92% in room air. He has
minimal intercostals retractions, and has good air entry
bilaterally.
 Do we need to run tests on him?
 How should he be treated now?

56. Investigating Croup
 Investigations not required in typical croup.
 Croup is a clinical diagnosis.
 In a child with airway obstruction, neck radiographs or
blood tests cause anxiety which may precipitate
further distress and obstruction.
 X-ray AP view of the soft tissues of neck
◦ if done – reveals a tapered narrowing (steeple sign) of the
subglottic trachea instead of the normal shouldered appearance.
56

57. 57
X-ray AP View of neck showing a classical narrowed
steeple like tracheal air column at larynx with a dilate
hypo pharynx as seen in Croup

58. Harshad now has moderate croup
 Observation for upto 4 hours.
 Steroids:
◦ If not given before, a dose of oral/nebulized/IM steroid has to be given.
◦ If it is > 12h since previous dose, repeat dose of Nebulised steroid can be
given.
 Nebulised Adrenaline:
◦ Used if symptoms are increasing, and repeated if clinically indicated
(0.5ml/kg of 1:1000 dilution to maximum of 5ml). Routinely available
adrenaline is as effective as racemic adrenaline.
 If asymptomatic at the end of 4 hrs, he can be discharged.
58

59. Steroid and Adrenaline Dose
Steroids
 Repeated doses of 2 mg nebulised budesonide 12h x 48hrs
 Oral and intramuscular dexamethasone is equally efficacious
 Oral corticosteroids are preferred for their ease.
◦ Doses:
 Dexamethasone 0.15–0.3 mg/kg
 Prednisolone is 1–2 mg/kg.
Adrenaline
 Adrenaline is used in severe cases and those poorly responsive to
steroids.
 Need for repeated doses should alert for the probable need for
intubation/ PICU care.
59

60. “Why steroids to my child?” Asks Harshad’s
mother.
What advice should one send this child home
with?

61. Steroids in Croup
 The use of steroids has been associated with
◦ A reduced average length of stay in the emergency department.
◦ A significant decrease in the number of adrenaline nebulizations
required.
◦ A reduced need for endotracheal intubation.
◦ If required, the duration of intubation is decreased.
 Current evidence more strong for its efficacy in moderate
to severe croup.
61

62. 62
At the end of 2 hours, Harshad was clearly
unwell. He is now non consolable. His
saturations are 84 – 86% in room air and
requires 2 lts of Oxygen by nasal cannula.
How should one treat Harshad?

63. Harshad has developed signs of severe
croup
 Continue Oxygen as required.
 Admit
 Continue Nebulised adrenaline as frequently as needed
clinically
◦ If adrenaline is required more than 2 hourly, then he has to be shifted
to a place with intensive care facilities.
 Steroids to be continued.
 If airway obstructions/ work of breathing is worsening, then
one has to consider intubation and ventilation. Preferably
use a tube half size smaller then optimal.
 tracheostomy
63

64. Croup – Key points
 Croup is essentially a viral illness.
 No investigations are required in a child with typical croup
 Most children with croup develop a mild illness and do not
require any medical assistance.
 Steroids are extremely useful and indicated in a child with
moderate and severe croup.
 Steroids can be given orally, IM or Nebulised and all routes
are equipotent.
 Adrenaline nebulization is reserved for children with severe
croup.
64

65. ASTHMA IN
CHILDREN

66. Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms
such as wheeze, shortness of breath, chest
tightness and cough that vary over time and in
intensity, together with variable expiratory airflow
limitation.
Definition of asthma
GINA 2017

67. The interplay and interaction between airway
inflammation and the clinical symptoms and
pathophysiology of asthma..

68. In the clinic…..symptoms
Mild Moderate Severe Respiratory
arrest imminent
breathless While walking
Can lie down
While talking
(infant –weaker,
shorter cry :
difficulty in
feeding )
prefer sitting
While at rest
(infant – stops
feeding )
Sits upright
Talks in sentences phrases words
alertness May be agitated Usually agitated Usually agitated Drowsy or
confused

69. Signs…
Mild Moderate Severe Respiratory
arrest imminent
Respiratory rate incresed increased Marked
tachypnea
Use of accessory
muscles :
suprasternal
retractions
Usually not seen Commonly seen Usually seen Paradoxical
thoraco-
abdominal
movement
wheeze Moderate , often
only expiratory
Loud ,
throughout
inhalation and
exhalation
Usually loud,
throughout
Absence of
wheeze
(silent chest )
Pulse/min <100 100-120 >120 bradycardia
Cyanosis absent Usually absent May be
present
present

70. And in hospital….
functional
assessment
Mild Moderate Severe
SaO2% (on room air
)at sea level
>95% ( test not
usually necessary )
91-95% <91%
PaO2( on air)
And /or
Normal > 60 mm hg < 60 mm hg
(possible cyanosis )
PaCO2 < 42 mm hg < 42 mmhg > 42 mm hg
(possible respiratory
failure )
Hypercapnia ( hypoventilation ) develops more rapidly in young children than in adolescents
and adults

71. Red flag signs..
1. Unable to talk or cry
2. Cyanosis
3. Feeble chest movements
4. Absent breath sounds
5. Fatigue or exhausion
6. Agitated
7. Altered sensorium
8. Oxygen saturation <92 %

72. © Global Initiative for Asthma
Acute exacerbation of
Asthma (Status Asthmaticus)

73. © Global Initiative for Asthma
Initial assessment of acute asthma exacerbations in children
≤5 years
Symptoms Mild Severe*
Altered consciousness No Agitated, confused or drowsy
Oximetry on presentation
(SaO2)**
>95% <92%
Speech† Sentences Words
Pulse rate <100 beats/min >200 beats/min (0–3 years)
>180 beats/min (4–5 years)
Central cyanosis Absent Likely to be present
Wheeze intensity Variable Chest may be quiet
*Any of these features indicates a severe exacerbation
**Oximetry before treatment with oxygen or bronchodilator
† Take into account the child’s normal developmental
capability
GINA 2017, Box 6-9

74. © Global Initiative for Asthma
Indications for immediate transfer to hospital for children ≤5
years
GINA 2017, Box 6-10
*Normal respiratory rates (breaths/minute): 0-2 months: <60; 2-12 months: <50; 1-5 yrs: <40
Transfer immediately to hospital if ANY of the following are present:
Features of severe exacerbation at initial or subsequent assessment
▪ Child is unable to speak or drink
▪ Cyanosis
▪ Subcostal retraction
▪ Oxygen saturation <92% when breathing room air
▪ Silent chest on auscultation
Lack of response to initial bronchodilator treatment
▪ Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated
3 times) over 1-2 hours
▪ Persisting tachypnea* despite 3 administrations of inhaled SABA, even if the child
shows other clinical signs of improvement
Unable to be managed at home
▪ Social environment that impairs delivery of acute treatment
▪ Parent/carer unable to manage child at home

75. © Global Initiative for Asthma
Initial management of asthma exacerbations
in children ≤5 years
Therapy Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-
98%
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every 20 min for first
hour, then reassess severity. If symptoms persist or recur, give an additional 2-
3 puffs per hour. Admit to hospital if >10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2mg/kg up to maximum of 20mg for
children <2 years; 30 mg for 2-5 years)
GINA 2017, Box 6-11

76. © Global Initiative for Asthma
Therapy Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-
98%
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every 20 min for first
hour, then reassess severity. If symptoms persist or recur, give an additional 2-3
puffs per hour. Admit to hospital if >10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2mg/kg up to maximum of 20mg for
children <2 years; 30 mg for 2-5 years)
Additional options in the first hour of treatment
Ipratropium bromide For moderate/severe exacerbations, give 2 puffs of ipratropium bromide 80mcg
(or 250mcg by nebulizer) every 20 minutes for one hour only
Magnesium sulfate Consider nebulized isotonic MgSO4 (150mg) 3 doses in first hour for children ≥2
years with severe exacerbation
Initial management of asthma exacerbations
in children ≤5 years
GINA 2017, Box 6-11

77. © Global Initiative for Asthma
GINA 2017, Box 6-8 (2/3)
PRIMARY CARE
Child presents with acute or sub-acute asthma exacerbation
or acute wheezing episode
ASSESS the CHILD
Consider other diagnoses
Risk factors for hospitalization
Severity of exacerbation?
MILD or MODERATE
Breathless, agitated
Pulse rate ≤200 bpm (0-3 yrs) or ≤180 bpm (4-5 yrs)
Oxygen saturation ≥92%
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of:
• Lack of response to salbutamol over 1-2 hrs
• Any signs of severe exacerbation
• Increasing respiratory rate
• Decreasing oxygen saturation
START TREATMENT
Salbutamol 100 mcg two puffs by pMDI + spacer
or 2.5mg by nebulizer
Repeat every 20 min for the first hour if needed
Controlled oxygen (if needed and available):
target saturation 94-98% URGENT
Worsening,
or lack of
improvement
SEVERE OR LIFE THREATENING
any of:
Unable to speak or drink
Central cyanosis
Confusion or drowsiness
Marked subcostal and/or sub-glottic
retractions
Oxygen saturation <92%
Silent chest on auscultation
Pulse rate > 200 bpm (0-3 yrs)
or >180 bpm (4-5 yrs)
TRANSFER TO HIGH LEVEL CARE
(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer
(or 2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 94-
98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.

78. © Global Initiative for Asthma
GINA 2017, Box 6-8 (3/3)
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of:
• Lack of response to salbutamol over 1-2 hrs
• Any signs of severe exacerbation
• Increasing respiratory rate
• Decreasing oxygen saturation
Worsening,
or lack of
improvement
TRANSFER TO HIGH LEVEL CARE
(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer
(or 2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 94-
98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.
Worsening,
or failure to
respond to
10 puffs
salbutamol
over 3-4 hrs
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
Risk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including
inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
Schedule next follow up visit
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up: within 1-7 days
Provide and explain action plan
CONTINUE TREATMENT IF NEEDED
Monitor closely as above
If symptoms recur within 3-4 hrs
• Give extra salbutamol 2-3 puffs per hour
• Give prednisolone 2mg/kg (max. 20mg for
<2 yrs; max. 30mg for 2-5 yrs) orally
IMPROVING
IMPROVING

79. © Global Initiative for Asthma
GINA 2017, Box 4-4 (2/4)
INITIAL ASSESSMENT
A: airway B: breathing C: circulation
Are any of the following present?
Drowsiness, Confusion, Silent chest
Further TRIAGE BY CLINICAL STATUS
according to worst feature
Consult ICU, start SABA and O2,
and prepare patient for intubation
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
NO
YES

80. GINA 2017, Box 4-4 (3/4)
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
In acute care center

81. © Global Initiative for Asthma
GINA 2017, Box 4-4 (4/4)
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as
severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY
MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or
personal best and symptoms improved
MODERATE
Consider for discharge planning
FEV1 or PEF <60% of predicted or
personal best,or lack of clinical response
SEVERE
Continue treatment as above
and reassess frequently

82.  Follow up all patients regularly after an exacerbation, until
symptoms and lung function return to normal
◦ Patients are at increased risk during recovery from an exacerbation
 The opportunity
◦ Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
 At follow-up visit(s), check:
◦ The patient’s understanding of the cause of the flare-up
◦ Modifiable risk factors, e.g. smoking
◦ Adherence with medications, and understanding of their purpose
◦ Inhaler technique skills
◦ Written asthma action plan
Follow-up after an exacerbation
GINA 2017, Box 4-5

83. THANK
YOU

84. Child with Fever, Cough and Rapid &
Difficult Breathing
LRTI
⚫ Bronchiolitis
⚫ Community Acquired Pneumonia
⚫ Nosocomial Pneumonia
⚫ Recurrent Pneumonia
⚫ Empyema
⚫ Bronchiectasis

85. Factors affecting type of illness
 Age of child.
 Frequency of exposure.
 Size of airway.
 Ability to resist invading organism.
 Presence of greater conditions: e.g., malnutrition, CHD, anemia,
or immunodeficiency.
 Presence of respiratory disorders, such as asthma, allergic
rhinitis.
 Season: epidemic appearance of respiratory pathogens occurs in
winter and spring months.

86. Etiology & characteristics:
 Viruses cause the largest number of respiratory infections. Other
organisms that may be involved in primary or secondary invasion
are group A beta- hemolytic streptococcus, homophiles influenza,
& pneumococci.
 Infections are seldom localized to a single anatomic structure, it
tends to spread to available extent as a result of the continuous
nature of the mucous membrane lining the respiratory tract.

87. Clinical signs of LRTI
 Tachypnea (increased RR)
 Hypoxia
 Cyanosis
 Retractions
 Grunting
 Use of accessory muscles of breathing
 Abnormal Auscultatory findings: wheeze,
crepitations/crackles, bronchial breath etc.

88. Signs of Respiratory Distress
Increased Respiratory Effort
 Nasal Flaring : with inspiration, the side of the nostrils flares
outwards
 Retractions
◦ Mild to Moderate– Subcostal, Substernal, Intercostal
◦ Severe – Supraclavicular, Suprasternal and Sternal
◦ Lower chest wall indrawing : with inspiration, the lower chest wall moves in
 Head Bobbing
 Grunting
 See Saw Respiration

89. Other respiratory signs
Abnormal breath sounds-
 Crackles- Sharp Crackling sounds (Lung tissue diseases)
 Bronchial breathing -
 Wheezing- High pitch whistling sound, Expiratory (Lower Airway
Obstruction)
 Grunting- Low pitch sound, Expiratory
(Sign of severe respiratory distress and failure from lung tissue
disease)

90. Child with
Cough, Rapid, Difficult breathing
 Consider Bronchiolitis if:
◦ Age 1mo -1yr
◦ Presence of Upper respiratory catarrh
◦ Progressive increase in respiratory distress
(tachypnea, retractions)
◦ Wheeze + crackles
◦ Clinical and radiological evidence of hyperinflation
90

91. Acute Bronchiolitis
ETIOLOGY:
•Respiratory Syncytial Virus
•Parainfluenza
•Adenovirus
•Mycoplasma
Pathology :
Characterised by Bronchiolar
Obstruction with oedema, mucus and
cellular debris. Partial Obstruction leads
to Air trapping and Over inflation,
Complete Obstruction leads to
Atelectasis

92. Bronchiolitis – Risk factors
 Risk Factors :
• Boys
• Top fed babies
• Overcrowding
• Maternal Smoking
92

93. Bronchiolitis – Risk factors
An increased risk of clinical severity and related hospitalization is
seen in following:
◦ Infants in day care
◦ Exposure to passive smoke
◦ Crowding in the household
◦ Infants younger than 2 – 3 months
◦ Premature birth < 34 – 37 weeks
◦ Congenital heart disease
◦ Chronic Lung disease like CF, Recurrent aspiration, BPD,
Congenital malformations etc
◦ Immunodeficiency
93

94. CLINICAL FEATURES:
•Fever
•Tachypnea
•Increased respiratory effort
•Expiratory phase prolonged
•Wheeze
Diagnosis:
•Basically clinical
•X Ray -Hyperinflation
and infiltrates

95. Bronchiolitis – Indications for hospitalization
 Infants younger than 3 months
 Oxygen saturation < 92%
 RR > 70/min
 ILL appearing child
 Infants with one or more risk factors mentioned before
are likely to have a severe course and merit admission.
95

96. Bronchiolitis - Investigations
 Bronchiolitis is a clinical diagnosis.
 Investigations contribute very little.
 CXR may be indicated in
◦ severe respiratory distress or
◦ in case of a diagnostic uncertainty.
 CXR
◦ often reveals bilateral hyperinflation,
◦ findings like segmental atelectasis may be seen some times
 Blood tests do not contribute.
96

98. Grading bronchiolitis
MILD MODERATE SEVERE
Feeding
Ability
Normal Ability to
feed
Appear short of breath
During feeding
May be reluctant or unable to
feed
Respiratory
Distress
Little or no
respiratory distress
⚫ Moderate distress with
some chest wall retractions
and nasal flaring.
⚫ Brief self limiting apnoeas
⚫ Severe distress with marked
chest wall retractions, nasal
flaring and grunting.
⚫ Can have frequent and
prolonged apnoeas
Saturations Saturations >92%
⚫ Saturations <92%,
⚫ correctable with O2
⚫ Saturations <92%,
⚫ may or may not be
correctable with O2
98

99. Treatment as per Grading of bronchiolitis
Mild Moderate Severe
⚫ No treatment
required.
⚫ Reassure
mother.
⚫ To bring the
baby back if
distress
increases
⚫ Admit
⚫ Humidified oxygen to
maintain sats > 92%
⚫ IV fluids
⚫ Observe for deterioration
⚫ If the child deteriorates treat as
severe
⚫ Admit – ICU care
⚫ O2 to maintain sats >92%
⚫ IV fluids
⚫ Cardio respiratory monitoring
⚫ ABG/CXR
⚫ Assess need for ventilatory
support / ICU care
99

100. 100
VIRAL BRONCHIOLITIS
Mild bronchiolitis
• Normal ability to feed
• Little/no resp. distress
•Not hypoxemic
Moderate bronchiolitis
• Moderate resp. distress
• Mild hypoxemia +/- brief
apnea +/- short of breath
Severe bronchiolitis
• Severe resp. distress +/-
apnoeic episodes +/-
hypoxemic
• Looking tired
• Can’t feed
• Does not need
investigations
• Home treatment
• Admit
• Humidified O2 to maintain
SaO2 above 92%
• IV fluids
• Observe for deterioration
• Admit- ICU care
• O2 to maintain SaO2 above 92%
• IV fluids
• Cardio respiratory monitoring
• ABG, CXR
• Assess need for - ventilatory
support/ ICU care
Improvement
• Decrease O2 [guided by SaO2]
• Re-establish feeding
• Discharge when distress decreased
and feeding well
Deterioration
Treat as severe bronchiolitis

101. Bronchiolitis - DRUGS
Non Controversial
 Oxygen
 IV fluids
Controversial
 Adrenaline nebs
 Hypertonic saline
 Bronchodilators
 Steroids
 Antibiotics
 Antiviral
101

102. Bronchiolitis - Adrenaline
 Very little support from RCTs in moderate/severe
bronchiolitis.
 May be tried in cases with moderate to severe distress and
assess the response. May be continued on as needed basis.
 Adverse effects: tachycardia, irritability and arrhythmias.
 Both L-epinephrine and racemic epinephrine can be used.
 L-epinephrine dose varies between 0.1 to 0.3mg/kg body
weight in 1:1,000 solution (max 3 mg).
102

103. Bronchiolitis - Bronchodilators
 No role for routine use as they do not:
◦ improve oxygen saturation,
◦ affect rate or duration of hospitalization.
 A trial of Nebulized salbutamol can be given in:
◦ older infant (>6 months) with wheeze, with a strong history of atopy,
◦ further therapy continued if there is a objective improvement.
 Ipratropium and combinations of bronchodilators should be
avoided.
103

104. Bronchiolitis –
Hypertonic Saline (3% to 7%)
 Studies have shown inconsistent clinical
results.
 Nebulization is tried in moderate to
severe cases with no to limited benefit.
 Not recommended for office practice.

105. Bronchiolitis - Steroids
 No role as multiple studies have failed to
demonstrate any clear efficacy of
corticosteroids in viral bronchiolitis.
105

106. Bronchiolitis - Antibiotics
 RCTs failed to demonstrate any benefit in
hospitalized infants with bronchiolitis.
 The only role for antibiotics is:
◦ complicated bronchiolitis where a
secondary bacterial infection is suspected.
◦ This is rare, but not easily excluded in a
sick infant with fever, toxicity and
significant opacities on the chest
radiograph.
106

107. Bronchiolitis – Antiviral drugs
 RSV is the most common cause but
specific antiviral therapy of
symptomatic infants has been of
limited value
107

108. Bronchiolitis – Complications
 Respiratory failure
 Apnea
 Pneumothorax
More commonly seen in
◦ Those were born premature
◦ Those with CHD and/or other congenital
anomilies
108

109. Discharge criteria for bronchiolitis
An infant is considered ready for discharge if he or she
had:
• Not received supplemental oxygen for 10 hours.
• Minimal or no chest retractions
• Feeding adequately without the need for IV fluids.
• And consistenly maintained SpO2 >94%.

110. Pneumonia

111. Community Acquired Pneumonia
Definition
 An acute infection of the pulmonary parenchyma in a
previously healthy child, acquired outside of a hospital
setting.
 The patient should not have been hospitalized within 14
days prior to the onset of symptoms or has been
hospitalized less than 4 days prior to onset of symptoms.
111

112. What it excludes
 Child with any immune-deficiency
◦ Severe Malnutrition
◦ Post measles state
 Ventilator associated Pneumonia
 Nosocomial spread
 Recurrent – which one??
112

113. Pneumonia
Prodrome of Upper respiratory tract infection- Rhinitis
and cough
Later developed rapid or difficulty in breathing
Viral Pneumonia-
•Fever (Temp is low )
•Tachypnea
•Increased work of Breathing
•Crackles
•Wheezing
•Severe-cyanosis and respiratory fatigue
Bacterial Pneumonia:
•Sudden High grade Fever with chills
•Drowsiness, restlessness, anxiety
•Tachypnea
•Increased work of Breathing
•Chest pain
•Crackles
•Wheeze
•WBC Count –elevated usually
<20000
•X Ray- Hyperinflation, B/L infiltrates,
peribronchial cuffing
•Definitive diagnosis- shell vial
culture, PCR , Serologic test
•WBC Count- b/w 20000-40000
•X ray – Lobar consolidation
•Definitive Diagnosis- isolation of
organism, PCR

114. Treatment :
•Oxygen
•I/V Antibiotics
•I/V fluids
Treatment:
•Oxygen
•Supportive
therapy
Suspected Bacterial pneumonia
Suspected viral pneumonia

115. Diagnosis Objectives
 Recognition of the signs of pneumonia
 Diagnosis in a community setting
 Diagnosis in a health care setting
 Differential Diagnosis RSV and TB
 Diagnosis in the context of malnutrition, and
considering HIV

116. Sign & Symptoms
 Child can present with
◦ Fever
◦ Cough (may or may not be productive)
◦ Chest pain and/or abdominal pain
◦ Difficulty in breathing (dyspnea) / rapid breathing (tachypnea)
◦ Constitutional symptoms: malaise, lethargy, headache, nausea/vomiting
 Signs that suggest high probability of Pneumonia and
need for antibiotic treatment.
◦ Severe Tachypnea
◦ Respiratory distress
◦ Abnormal breath sounds: crackles, bronchial breath.

117. WHO Definition of Tachypnea
Age Respiratory Rate
(breaths/min)
Indication of severe
infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5 yr > 40 >50
Greater than 5 yr > 20
WHO recommends using these Respiratory rate cutoffs to
diagnose pneumonia at the community level.

118. Diagnosis in Community Setting
SIGNS Classify AS Treatment
•Tachypnea
•Lower chest wall indrawing
•Stridor in a calm child
Severe Pneumonia •Refer urgently to hospital for injectable
antibiotics and oxygen if needed
•Give first dose of appropriate antibiotic
•Tachypnea Non-Severe Pneumonia •Prescribe appropriate antibiotic
•Advise caregiver of other supportive
measure and when to return for a follow-up
visit
•Normal respiratory rate Other respiratory illness •Advise caregiver on other supportive
measures and when to return if symptoms
persist or worsen
From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2006.

119. Diagnosis in a Health Care Setting
• Vital signs that should routinely be taken in an
Emergency Care setting include:
• Respiratory Rate
• Heart Rate
• Temperature
• Oxygen saturation (if available)
• Any child with an increased respiratory rate
should be immediately identified as having
possible pneumonia.

120. Pneumonia Severity Assessment
Non severe pneumonia Severe pneumonia
Infants RR < 70 breaths/min
Mild recession
Taking full feeds
RR > 70 breaths/min
Moderate to severe recession
Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Not feeding
Older Children RR < 50 breaths/min
Mild breathlessness
No vomiting
RR > 50 breaths/min
Severe difficulty in breathing
Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Signs of dehydration

121. Further Testing

122. Chest X-ray
 Confirmation of pneumonia by chest x-ray is not
indicated in children with mild, uncomplicated
lower respiratory tract infections who will be
treated at outpatients.

123. Chest X-ray
Consider if available and:
 Infection is severe
 Diagnosis is otherwise inconclusive
 To exclude other causes of shortness of breath (e.g..
foreign body, heart failure)
 To look for complications of pneumonia unresponsive to
treatment (e.g.. empyema, pleural effusion)
 To exclude pneumonia in an infant less than three
months with fever

124. Right Upper Lobe Pneumonia

125. Right Middle Lobe Pneumonia

126. Laboratory Investigations
 Routine blood work is not required in children with uncomplicated lower
respiratory tract infections who will be treated as outpatients
 Tests to consider if available:
◦ CBC, particularly WBC
◦ TLC, DLC, CRP are not diagnostic but may be useful to monitor the response
to treatment.
◦ Electrolytes, particularly Sodium
◦ Hyponatremia is a common complication in pneumonia patient.
◦ Consider blood cultures, sputum cultures
•Not recommended routinely
•Takes a long time and hence has limited utility
•Sputum cultures / cough swabs have relatively poor reliability
•Invasive methods can not be justified for routine pneumonias.
◦ HIV and TB testing as appropriate

127. Indications for Admission
 All Children with Very Severe Pneumonia need admission
 Infants less than 3 months of age are best treated as
inpatients.
 Other indications
1. Oxygen Saturation <= 92%, cyanosis
2. RR > 70 breaths /min
3. Significant difficulty in breathing
4. Intermittent apnea and/or grunting
5. Not feeding (inability to suck or refusal to feed)
6. Signs of Dehydration
7. Family not able to provide appropriate observation or supervision

128. Criteria for Intensive Care
Transfer to PICU should be considered when:
◦ Failure to maintain an oxygen saturation of >92% in FiO2
of >0.6.
◦ Patient is in shock.
◦ Rising respiratory rate and rising pulse rate with clinical
evidence of severe respiratory distress and exhaustion,
with or without a raised PaCO2.
◦ Recurrent apnea or slow irregular breathing.

129. In-Patient Management
 Antibiotics
 Supportive management: hydration, oxygenation,
nutrition, antipyretics and pain control.
 Monitoring should include:
◦ Respiratory rate
◦ Work of breathing
◦ Temperature
◦ Heart rate
◦ Oxygen saturation (if available)
◦ Findings on auscultation.

130. Supportive therapy
 Oxygen :
◦ as indicated by pulse oxymetry and/ or clinical signs of hypoxia like rapid
breathing as well as retractions
 IV Fluids:
◦ If dehydrated,
◦ Tachypnea severe enough to make the child unable to drink, or impending
respiratory failure.
 Fever management
◦ Important as fever increases oxygen requirement
◦ Paracetamol and sponging are useful in most situations.
 Bronchodilators, where indicated
◦ should be used to decrease the work of breathing.
 Chest Physiotherapy helps in preventing atelectasis.
130

131. 131
Disease Pneumonia
Setting Domicilliary
AGE First Line Second Line Suspected Staphylococcal ds
Upto 3mo Usually Severe, treated as inpatients
3mo- 5yrs of
age
Amoxycillin Co-amoxyclav
OR
Cefuroxime
Amoxycillin+ Cloxacillin (1:2)
OR
Cefuroxime
OR
Co-amoxyclav
5 yrs plus Amoxycillin Co-amoxyclav
OR
Macrolide*
Amoxycillin+ Cloxacillin (1:2)
OR
Cefuroxime
OR
Co-amoxyclav
*routine use for all cases of pneumonia in children over 5 yr age is not advocated for lack of data.

132. Severe Pneumonia
Treat as In-patient
Age First Line Second Line
0-3 mo Inj 3rd Gen Cephalosporins:
Cefotaxime/Ceftriaxone
+
Aminoglycoside (Gent/Amika)
Inj Co-amoxy clav
(if G+ve disease is suspected)
Else
Inj Piperacillin-Tazobactum
OR Cefoperazone-sulbactum
(if resistant G -ve disease is suspected)
3mo-5 years Inj Ampicillin
+ Gentamicin
Inj Co-amoxy clav
OR
Inj 3rd Gen Cephalosporins:
Cefotaxime/Ceftriaxone
5 years + Inj Ampicillin Inj Co-amoxy clavulinic acid
OR
Inj 3rd Gen Cephalosporins:
Cefotaxime/Ceftriaxone
OR
Macrolides
132
*routine use for all cases of pneumonia in children over 5 yr age is not advocated for lack of data.

133. Severe Pneumonia ---- Treat as In-patient
Age Suspected Staphylococcal Ds
First Line Second Line
0-3 mo Inj 3rd Gen Cephalosporins:
Cefotaxime/Ceftriaxone + Cloxacillin
OR
Inj Cefuroxime +/- Aminoglycoside
OR
Inj Co-amoxy clav +/- Aminoglycoside
Vancomycin*/ Teicoplanin
+
Inj 3rd Gen Cephalosporins
3mo-5 years Inj 3rd Gen Cephalosporins:
Cefotaxime/Ceftriaxone + Cloxacillin
OR
Inj Cefuroxime/ Cefazolin
OR
Inj Co-amoxy clav
Vancomycin*/ Teicoplanin
+
Inj 3rd Gen Cephalosporins
5 years + Inj 3rd Gen Cephalosporins:
Cefotaxime/Ceftriaxone + Cloxacillin
OR
Inj Cefuroxime/ Cefazolin
OR
Inj Co-amoxy clav
Vancomycin*/ Teicoplanin
+
Inj 3rd Gen Cephalosporins
133
*Severe staph. infections with septicemic shock or respiratory failure should be started on Vancomycin as the initial therapy to cover
for MRSA. Routine use of Vancomycin carries the risk of poorly treating the larger majority with Methicillin Sensitive Staph aureus.

134. Duration of therapy
 Domiciliary : 5-7 days
 If admitted: Switch to oral after 48-72 hours or earlier if can
accept orally. Total 5-7 days
 If on second line then IV for 7-10days
 If Staph.:
◦ 2 weeks if no complication;
◦ Else 4-6 weeks (complcations like empyema, metastatic
abscesses)
◦ Parental therapy is preffered at least till the fever settles
down or at least seven days, whichever is later.
134

135. THANK YOU…