PEDIATRIC EMERGENCIES                

Cardiopulmonary resuscitation

  The physician must know early signs of distress before activation of the emergency medical system. These signs include:

1- Respiratory distress: tachypnea, retraction, nasal flaring, cyanosis, stridor or wheezes.

2- Poor perfusion: capillary refill time >3 seconds, cool and mottled skin, tachycardia and decrease urine output.

3- Blood pressure: hypotension.

4- Mental status changes: confusion and coma. 

Basic life support (BLS)

I- Determine responsiveness: the level of responsiveness is determined by gently shaking, tapping or shouting at the patient. If no response but the patient is breathing or struggling to breathe, call for assistance.

II- Airway opening: establishment and maintenance of a patent airway and support of adequate ventilation are the most important components of BLS. This is usually accomplished by the head tilt-chin lift maneuver by using one hand to tilt the head and extending the neck while the index finger of the rescuer’s other hand lifts the mandible outward by lifting on the chin (Fig. 18-1). If neck injury is suspected, head tilt should be avoided and the airway opened by a jaw thrust (Fig.18-2) while the cervical spine is completely immobilized. If the child is conscious and demonstrates spontaneous but labored respiratory efforts, the child should be transported to an advanced life support facility as rapidly as possible.

 

 

 

 
 
 

 

Fig. 18-1 Head tilt maneuver                Fig. 18-2 Jaw thrust-spin stabilization maneuver

 

III- Breathing establishment:  after the airway is opened, the rescuer must determine if the

child is breathing. The rescuer looks for a rise and fall of the chest and abdomen, listens for exhaled air, and feels for exhaled airflow at the mouth.

1- If there is chest rise and exhaled air is felt, the patient is ventilated.

2- If the chest rises, but without exhalation, the patient is not ventilated and rescue breathing should be provided while patient airway is maintained by a chin lift or jaw thrust. The rescue breathing at a rate of 20 breath/minute is maintained by one of 3 methods:

 

 

 

   a- By mouth - to- mouth (Fig. 18-3).

   b- By mouth to mask ventilation.

   c- Bag-valve mask ventilation with l00% O2.

                            

 

 

Fig. 18-3 Rescue breathing in a child

3- If the child received the correct volume of air for each breath, the chest will rise. 

4- If the chest does not rise, either the airway is obstructed or more breath volume and pressure is needed, reposition of the head and try ventilation again.

5- If unsuccessful, there is airway obstruction. So, you must clear the airways.

  Airway obstruction is suspected when there is any combination of ineffective cough, nasal flaring, tachypnea, retraction, stridor and/ or central cyanosis.

Methods of relieving the airway obstruction:

In infants: by backblows four times and chest thrusts four times (Fig. 18-4).

In older child: by using manual thrust for 6 times (Fig. 18-5).

 

 

 

 

 

 

 

 

 Fig. 18- 4 Back blows and chest thrusts   Fig. 18-5 Abdominal thrusts with victim lying

6- If after these procedures ventilation is not restored, endotracheal intubation (ETI) is indicated. For proper intubation oropharyngeal suctioning, nasogastric suctioning and preoxygenation for 3-4 minutes must be done. Proper intubation is suggested by equal breath sounds and symmetrical chest movements. Monitoring for intubation is done by pulse oximetry for O2  saturation.

IV- Circulation Support

1- Assess brachial or femoral pulse: if absent, start chest compression.

2- Chest compression entails rhythmic compressions of the chest that circulate oxygen containing blood to the vital organs (heart, lungs, and brain) until advanced life support can be provided. Chest compressions must always be accompanied by ventilation (Fig.18-6,18-7).

Table 18-1 Technique of chest compression.

 

Method

Hand position

Sternal depression

No./min

Infant

 

Toddler

Child

Encircle the chest or use 2 fingers

One hand

Two hands

One finger width below the intramammary line

Lower 1/3 of the sternum

Lower 1/3 of the sternum

0.5- 1 inch

 

1- 1.5 inch

1.5 -2 inches

100

 

80-100

80-100

 

 

 

 

 

 

 

 

 

 

Fig. 18-6 Cardiac compression in infants               Fig. 18-7 Chest compression in child

3-  Venous access for administration of fluids and medications:

a- Children < 5 years old: the preferred venous access site is to the largest most accessible veins that does not require the interruption of resuscitation, e.g. femoral vein, median cubital vein or the saphenous vein. If this failed after 90 seconds, try the intraosseous line at the proximal end of the tibia, if this failed try the saphenous vein cut down or the central line.

b- Children > 5 years: try to get peripheral line if failed after 90 seconds, try a central line or cut down.

4- O2 is given immediately.

5- Medications.

a- Epinephrine for cardiac arrest: 0.01 mg/kg of 1/10,000 solution IV or 0.1 ml/kg from the same solution by endotracheal tube or 0.1 mg/Kg /minute by continuous drip and increase gradually to 1mg/Kg/minute.

b- Dopamine: see shock

c- Atropine to increase heart rate in cases of bradycardia (0.02 mg/kg).

d- Sodium bicarbonate is indicated in cases with metabolic acidosis, hyperkalemia; 1mEq/kg followed by 0.5 mEq/kg every ten minutes till correction of acidosis.

Shock

    It is the clinical state of inadequate perfusion due to: massive increase in metabolic demand (­ O2 consumption) and/or decrease metabolic supply (¯ O2 delivery). As circulatory function depends on blood volume, vascular tone and cardiac function, all shock states result from abnormalities in one or more of these factors.

Stages of shock: (table 18-2).

Table 18-2 Stages of shock

Organ system

                                                            Stages of shock

Compensated

Decompensated

Irreversible

 CNS

 Respiration

Metabolism

 

Gut

Kidney

Skin

 

CVS

Not affected

Not affected

Not affected

 

Not affected

¯Urine volume­Sp. gravity

Delayed capillary refill

 

­ Heart rate

Restless, apathetic

­ ventilation

Compensated metabolic

acidemia

¯ Motility

Oliguria

Cool extremities

 

­­  Heart rate

¯ Peripheral pulse

Agitated-confused.

­­ ventilation

Uncompensated metabolic

acidemia

Paralytic ileus. 

Oliguria /anuria.

Mottled cyanotic cold extre- mities.

­­­ Heart rate, ¯ BP, central pulse only.

 

Types of shock

1- Intravascular hypovolemic shock

This may result from decreased intra-vascular volume: e.g. hemorrhage, loss of plasma (e.g. extensive burn), loss of water and electrolytes (e.g. vomiting, diarrhea) or it may result from abnormal vasodilatation (e.g. anaphylaxis, neurogenic shock, drug intoxication, septic shock).

2- Intravascular normo or hypervolemic, (cardiogenic shock):

This may result from: 

a- Failure of myocardial contractility: e.g. myocardial contusion, cardiomyopathy.

b- Impedance to ventricular outflow: e.g. aortic stenosis, coarctation of aorta.

c- Impedance of ventricular filling: e.g. mitral stenosis, cardiac tamponade, constrictive pericarditis.

d- Arrhythmia: e.g. supraventricular tachycardia.

e- Acute valvular diseases e.g. acute mitral regurge or aortic regurge.

 

3- Septic shock 

It may complicate severe sepsis, commonly caused in newborn infants by group B- hemolytic

Streptococcus, E. coli, Listeria, Staph. aureus and herpes simplex, in infants by H. influenzae, Pneumococcus, Staph. aureus, in Children caused by Strept. pneumoniae, N. meningitidis, Staph. aureus and H. influenzae and in immunocompromised by E. coli, Staph. aureus, Pseudomonas and Candida albicans.

Management

1- Monitoring for: heart rate, BP, peripheral perfusion (color, cyanosis, pulse), respiratory rate and pattern, level of consciousness, urine output, blood urea nitrogen measurement, arterial blood gases, serum electrolyte, coagulation profile, ECG, and blood glucose.   

2- Treatment of underlying cause as hemorrhage, dehydration, antibiotics for septic shock.

3- Preload augmentation to restore BP and peripheral perfusion by rapid intravascular volume expansion. Fluids used include 0.9% Nacl, ringer lactate or albumin in 0.9% Nacl. Blood or fresh frozen plasma may be used.

Criteria for satisfactory volume resuscitation include:

  • Decrease in heart rate to normal and stable blood pressure.
  • Improved urine out put to >1 ml/kg/ hour.
  • Improved cutaneous perfusion by skin color and skin turgor.

 

Poisoning

Principles of management of poisoning

1- History: age, type of exposure, product name, route and dose of exposure, the severity of symptoms and signs and body weight.

2- Initial medical care for life support if the patient is shocked, with cardiopulmonary arrest or convulsing.

3- Prevention of absorption by:

a- Emesis: by syrup of ipecac 15-30ml followed by a clear liquid as water. Put the patient on the left side with head down.

N.B. Never use salt as an emetic as this can be fatal

b- Gastric lavage: it is very effective if it is done within one hour post  ingestion.

  • Make sure a suction apparatus is available in case child vomits. Place the child in the left lateral / head down position.
  • Measure the length of tube to be inserted.
  • Pass the tube through the mouth into the stomach.
  • Ensure the tube is in the stomach.
  • Perform lavage with 10mg/kg body weight of warm normal saline (0.9%).
  • The volume of lavage fluid returned should approximate to the amount of fluid given.
  • Lavage should be continued until the recovered lavage solution is clear of particulate matter

Emesis or gastric lavage is contraindicated in cases of:

- Coma,                                 - Poisoning by strong alkalies or acids

- Convulsions,                      -  If there is risk of aspiration. e.g petroleum derivatives

c- Activated  charcoal: almost all drugs and many chemicals are adsorbed by it. It is repeated every 2-6 hours and is stopped when the charcoal black stool appears.

4- Enhancing excretion by:

a- forced diuresis which is used in salicylates poisoning.

b- Hemodialysis: used in cases with salicylates poisoning not responding to other measures or theophylline toxicity.

 

Salicylates poisoning

Toxicity varies with the ingested dose of salicylates

Manifestations of salicylates poisoning

  • Vomiting: begins early after acute ingestion.
  • Throat: mucosal burn.
  • Cardiovascular: tachycardia.
  • Respiratory: hyperpnea, hyperventilation and adult respiratory distress syndrome.
  • Neurological: tinnitus, CNS depression, cerebral edema, seizures and coma.
  • Renal dysfunction: oliguria, and acute renal failure in acute intoxication.
  • Hematological: prolonged bleeding time, platelet dysfunction, leukopenia, eosinophilia, hypoprothrombinemia and hypofibrinogenemia.
  • Endocrinal: hypoglycemia.
  • Acid-base changes: fluid-electrolyte disturbances, metabolic acidosis, respiratory alkalosis or mixed-acid base abnormality may occur.

Monitoring for plasma and urinary pH, arterial blood gases, liver function tests, blood glucose, serum electrolytes and serum salicylates.

Treatment

1- Dehydration and electrolyte losses should be corrected after initiating activated charcoal and emesis.

2- Hemodialysis is indicated in the following cases:

  • Failure of alkalinization of urine.
  • In patients with adult respiratory distress syndrome.
  • Severely ill patients with renal failure, severe central nervous system manifestations, and pulmonary edema.

3- Treatment of cerebral edema and increased intracranial pressure by:

  • Head elevation.
  • Hyperventilation by endotracheal intubation.

 

Iron poisoning

  • Check for clinical features of iron poisoning: nausea, vomiting, abdominal pain and diarrhea.
  • The vomitus and stools are often gray or black.
  • In severe poisoning there may be gastrointestinal haemorrhage, hypotension, drowsiness, convulsions and metabolic acidosis.
  • Gastrointestinal features usually appear in the first 6 hours, and a child who has remained asymptomatic for this time probably does not require antidote treatment.

Treatment

  • Activated charcoal does not bind to iron salts,
  • therefore consider giving a gastric lavage if potentially toxic amounts of iron were taken.

 

Paracetamol poisoning

  • If within 1 hour of ingestion give activated charcoal, if available, or induce vomiting.
  • Antidote is required to prevent liver damage and is more often required for older children who deliberately ingest paracetmol or when parents overdose children by mistake (150 mg/kg or more).
  • If within 8 hours of ingestion give oral methionine or IV acetylcysteine. · If more than 8 hours after ingestion, or the child cannot take oral treatment, give IV acetylcysteine.

lipoid pneumonia.

Scorpion sting

Symptoms are the result of depolarization of nerves and muscles as a consequence of the effects on Na+and K+ ion channels. It may stimulate sympathetic and /or parasympathetic nervous system

 

Clinical picture

  • The severity of the disease is more in younger children.
  • Temperature: hypothermia or hyperthermia.
  • Eyes: lacrimation, mydriasis, blurred vision, nystagmus and temporary blindness.
  • Cardiovascular signs: hypotension, hypertension, arrhythmia or reversible cardiomyopathy.
  • Respiratory system: stridor, wheezes, dyspnea, pulmonary edema and respiratory failure.
  • Neurological features: local pain, hyperthesia, agitation, seizures, coma, intracerebral hemorrhage, hallucination and autonomic nervous system manifestations.
  • Gastrointestinal manifestations: vomiting, dysphagia, gastric dilatation and pancreatitis.
  • Genitourinary: priapism, urgency, polyuria and renal failure.
  • Hematological: coagulopathy and gross bleeding.
  • Endocrinal features: hyperglycemia may be due to inhibition of insulin release.

Management

1- Monitoring for blood pressure, heart rate, temperature, urine volume and blood gases.

2- All cases should receive bed rest and pain relief.

3- Antivenin, 2-5 ml IM.

4- Propranolol for tachycardia, 0.0l-0.l mg/kg/dose IV over ten minutes, maximum dose 1mg /dose.

5- Seizure control: phenytoin (15-20 mg/kg IV) at a rate of 0.5-1.5 mg/kg/ minute in refractory cases.

6- Non-cardiogenic pulmonary edema: mechanical ventilator to maintain PaO2 >50 mm Hg.  Morphia is contraindicated.

7- Hypotension: should be treated by IV fluid. Dopamine 2-5 µg/kg/minute or norepinephrine 0.l-0.2 µg/kg/minute.

8- Hypertension: should be treated by sublingual nifedipine (0.25-0.5 mg/kg) with prazosine    (0.l mg/ kg/ 24 hour divided every 6 hours).

9- Muscle spasm: should be treated by l0 ml of l0% calcium gluconate IV slowly or 5-l0 mg diazepam/4-6 hours for the first 8-l2 hours.

Snake bite

   Snake bite should be considered in any severe pain or swelling of a limb and in any unexplained illness presenting with bleeding or abnormal neurological signs.

Clinical manifestations

General symptoms and signs: include shock, vomiting and headache.

  • Examine the site of the bite for signs such as local necrosis, bleeding or tender local lymph node enlargement.

Specific signs: depend on the venom and its effects. These include:

  • Shock
  • Local swelling that may gradually extend up the bitten limb.
  • Bleeding: from gums, wounds or intracranial.
  • Signs of neurotoxicity: respiratory difficulty or paralysis (ptosis, bulbar palsy limb weakness).
  • Signs of muscle breakdown: muscle pains and black urine.
  • Check haemoglobin, (where possible, blood clotting should be assessed).

Treatment: First Aid for Snake Bites

It is essential to get a victim of a snake bite to a medical facility for emergency treatment as quickly as possible. However, there are some tips that you should also keep in mind:

  • Call 11111
  • Keep the victim calm and still. Movement can cause the venom to move more quickly through the body. Consider making a splint to restrict the movement of the affected area.
  • Remove constricting clothing or jewelry. The area of the bite will likely swell, so it is important to remove these items quickly.
  • Carry or transport the victim by vehicle. This person should not be allowed to walk.
  • If the snake is dead, take it with you for identification. Do not waste time hunting it down, though.

There are also several outdated first aid techniques that are now believed to be unhelpful or even harmful. Do not do any of the following:

  • Do not use a tourniquet.
  • Do not cut into the snake bite.
  • Do not use a cold compress on the bite.
  • Do not give the victim any medications unless directed by a doctor.
  • Do not raise the area of the bite above the victim’s heart.
  • Do not use a pump suction device. While these devices were formerly recommended for pumping out snake venom, it is now believed that they are more likely to do harm than good.

Treatment for Snake Bites

The most important thing to do for a snake bite victim is to get him or her emergency medical help as soon as possible.

  • A nurse will evaluate the victim to decide on a specific course of treatment.
  • In some cases, a bite from a venomous snake is not life-threatening. .The severity depends on the location of the bite and the age and health of the victim.
  • If the bite is not serious, the nurse may simply clean the wound and give the victim a tetanus vaccine.
  • If the situation islife threatening, the doctor may administer an antivenom. This is a substance that is created with snake venom to counter the snake bite symptoms. It is injected into the victim intravenously. The sooner the antivenom is used, the more effective it will be.

 

First aid

- Antivenom is given if available.

- Splint the limb to reduce movement and absorption of venom. If the bite was likely to have come from a snake with neurotoxic venom, apply a firm bandage to affected limb from fingers or toes to proximal of site of bite.

- Clean the wound.

- Avoid cutting the wound or applying tourniquet.

Hospital care

1- Treatment of shock and respiratory arrest: paralysis of respiratory muscles can last for days which may requires intubation and mechanical ventilation.

2- Antivenom if was not given.

- Give polyvalent antivenom if the species is not known.

- The dose for children is the same as for adults.

- Dilute the antivenom in 2-3 volumes of 0.9% saline and give intravenously slowly over 1 hour.

- Monitor closely for anaphylaxis or other serious adverse reactions. If itching /urticarial rash, restlessness, fever, cough or difficult breathing develop, then stop antivenom and give epinephirine 0.01 ml/kg of 1/1000 ' or 0.1 ml/kg of l/10.000 solution subcutaneously or chlorpheniramine 250 micrograms/kg.

- When the child is stable, re-start antivenom infusion slowly.

- More antivenom should be given after 6 hours if there is recurrence of blood incoagulability, or after 1-2 hr if the patient is continuing to bleed or has deteriorating neurotoxic or cardiovascular signs.

- If there is no response to antivenom infusion this should be repeated.

 

 

3-  Other treatment

- Seek surgical opinion if there is severe swelling in a limb, it is pulseless or painful or there is local necrosis.

4- Supportive care

   - Give fluids orally or by nasogastric tube according to daily requirements.

   - Provide adequate pain relief.

   - Evaluate the limb if swollen.

   - Give antitetanus prophylaxis.