PAEDIATRIC EMERGENCIES DR.S SEN Specialist Registrar Paediatrics North Western Deanery

PAEDIATRIC EMERGENCIES

• 1. COMA

• 2. SHOCK (Septicaemia, anaphylaxis)

• 2. UPPER AND LOWER AIRWAY OBSTRUCTION

• • Croup and Epiglottitis, Foreign Body

• • Asthma, Bronchiolitis, Chest infection

• 3. CARDIAC EMERGENCIES

• • Heart Failure

• • Supraventricular Tachycardia

PAEDIATRIC EMERGENCIES

• 4. INFECTIONS

• • Meningitis

• • Encephalitis

• • Kawasaki

• • HUS

• • Pertussis

• • Endocarditis

• 5. SEIZURES

• • Status epilepticus

• • Febrile fits

• • Hypsarrhythmia

• • Non febrile fits

• • Increased intracranial pressure

PAEDIATRIC EMERGENCIES

• 6. RENAL

• • Hypertension

• • Haematuria

• • UTI

• • Nephrosis

• • HUS

• 7. SKIN

• • Rash, Erythema

• • Purpura, Petechia

• • Peeling

• • Vesicles, Pustula

• • Cellulitis

• • NAI

PAEDIATRIC EMERGENCIES

• 8. PAINS

• • Limping child

• • Chest pain

• • Abdominal pain

• • Headache

• • Backache

• • Sickle Cell

• 9. ENVIRONMENTAL

• Burns, smoke inhalation

• Drowning

• Poisoning

• Hypothermia, heat stress

• Anaphylaxis

• Head injury and RTA

• NAI and SA

EMERGENCIES IN BABIES

• Excessive crying

• Not feeding

• Cyanosis

• Apnoea

• Jaundice

• Fitting

• Diarrhoea

• Vomiting

• Fever

• Bleeding

COMA

• STATE OF UNRESPONSIVENESS DUE TO DIFFUSE LESIONS OF HEMISPHERES / BRAIN STEMS

• Structural lesions

• • bleeding, tumour, abscess, hydrocephalus

• Non-structural lesions (95%)

• • seizures, drugs / poisons

• • infection (meningitis, encephalitis, HUS)

• • metabolic (hypoglycaemia, DKA, Reye)

• • renal failure, hepatic coma

• • endocrine (Addison)

COMA: ASSESSMENT AND DIAGNOSIS

• Rapid History and General Examination

• Skin (trauma, petechiae, bleeding)

• Sutures in infant and neck stiffness, systemic, AF

• CNS examination

• GCS, Gag R, Blinking

• Pupils, Reaction, EOM Palsy, Fundi, Dolls Eye

• Motor- Posture, Tone, Symmetry/Lateralizing signs

• Reflexes- DTR, Plantars

• Pain, Grimace, Flexion, Extension, None

• Assess level of Central Dysfunction

CHILDRENS COMA SCORE (15)

• Eyes : 4 spont. open

• 3 verbal command

• 2 pain

• 1 no response

• Motor :6 obeys verbal

• 5 localizes pain

• 4 withdraws from pain

• 3 abn. flexion to pain

• 2 extends to pain(decer)

• 1 no response

• Best verbal response :

• 5 orientated

• • smiles, follows

• 4 disorientated

• • consolable crying

• • inapropriate interaction

• 3 inappropriate words

• • sometimes consolable

• • moaning

• 2 incomprehensible sounds

• • inconsolable, irritable

• 1 no response

MANAGEMENT OF COMA

• Always emergency - get Registrar/Consultant

• Airways - check, suction, ventilation if needed

• Breathing - ensure adequacy: RR, BS,saturation

• • Give high flow oxygen, if breathing

• • Ventilate with bag and mask

• • Intubate with Anaesthetist, if

• • • breathing inadequate / GCS 8 / herniation syndromes

• Circulation - monitor BP, CRT, PR

• • iv access: 2 venous and arterial lines

INVESTIGATIONS IN COMA

• FBC, U+E, LFT, BC, Blood gases, Glucose,

• NH3, toxic screen, lactate, aminoacids, ammonia,

• Virus studies, PCR

• Chest X-ray, EEG

• CT scan (has limited value),

• LP only with neurosurgical support

TREATMENT OF COMA

• Treat Shock - Restore and control BP

• Treat The Treatable

• • Maintain BS with 10% dextrose 5mls/kg PRN

• • Restricted fluid (document type & rate)

• • Mannitol, if increased intracranial pressure

• • Consider Cefotaxime, Acyclovir, Erythromycin

• • Consider Flumazenil, Naloxone, Anticonvulsant

• May require transfer to PICU

SHOCK

• Failure of circulation of oxygen to tissues

• resulting in lactic acidosis, cellular dysfunction

• and cell death

• 1. Hypovolaemic shock due to loss of blood or fluid

• 2. Distributive (septic) shock: maldistribution of blood

• 3. Obstructive shock: reduced vascular size

• 4. Cardiogenic shock: primary heart problem

1. HYPOVOLAEMIC SHOCK

• Haemorrhagic loss:

• • trauma, gastrointestinal bleed, coagulopathy

• Fluid and electrolytes :

• • gastroenteritis, diabetic ketoacidosis, polyuric states, mineralocorticoid deficiency

• Plasma/ protein loss:

• • burns, peritonitis, bowel obstruction/ necrosis

2. SEPTIC (DISTRIBUTIVE) SHOCK

• MALDISTRIBUTION OF BLOOD WITHIN ORGANS DUE TO ABNORMAL PERIPHERAL FUNCTION

• Sepsis: Gram negative bacteria, Meningococcus

• Neurogenic shock

• Drugs: antihypertensives, barbiturates

• Anaphylaxis

• REDUCED VASCULAR SIZE AND LIMITED BLOOD FLOW DUE TO INTRINSIC OR EXTRINSIC FACTORS

• Pericardial tamponade

• Tension pneumothorax

• Pulmonary embolism

3.OBSTRUCTIVE SHOCK

4.CARDIOGENIC SHOCK

• PRIMARY HEART PROBLEM WITH INADEQUATE CARDIAC OUTPUT AND INADEQUATE TISSUE PERFUSION

• SVT, bradycardia, ventricular tachycardia

• Myocarditis

• Hypoplastic left heart

• Left sided outflow obstruction

• Critical aorta stenosis and coarctation of aortae

ASSESSMENT OF SHOCK

• Full history and physical examination

• Classic signs:

• tachycardia, tachypnoea,

• oliguria (anuria),

• weak pulse, mottled extremities,

• hypotension

• Children can compensate for hypoperfusion states

• Hypotension is a late sign of decompensated shock

EARLY AND LATE SHOCK

• tachycardia bradycardia, dysrhytmia

• tachypnoea severe tachypnoea and gasping

• low pulse pressure hypotension

• cool extremities, decreased CR absent peripheral pulses

• dry mucosa mild oliguria severe oliguria anuria

• restlessness / agitation unconsciousness

GENERAL MANAGEMENT OF SHOCK

• MONITOR: HR, BP, BP (CVP), O2 sat., fluid balance

• AIRWAY, BREATHING, CIRCULATION

• • Reverse hypoxia and acidosis

• • Control bleeding with direct pressure

• • Obtain intravenous (arterial) access

• INVESTIGATIONS:

• • FBC, U+E+osm, LFT (fibr, glu), BG, BC, clotting, BG

• • MSU, X-ray, ECG, Brain scan

• TRANSFER TO ITU:

• • no response to Dopamine 2-20ugm/kg/min

• • signs of organ failure

SPECIFIC MANAGEMENT OF SHOCK

• Hypovolaemia: rapid volume replacement

• Septic shock: antibiotics and inotropes

• Cardiogenic shock: minimal volume support

• • Inotropes (Dopamin, Dobutamine), if low BP+high HR

• • Chronotropes (Isoproterenol or Epinephrine),

• • • if low BP + bradycardia or normal heart rate

• Obstructive shock: drainage

• Anaphylaxis: oxygen, adrenalin, hydrocortisone

RESPIRATORY FAILURES Upper Airway Obstruction Asthma (see BPA guideline)

ASTHMA ASSESSMENT

ASTHMA TREATMENT

• NEBULISERS (use oxygen):

• • Salbutamol: 5mg

• • Atrovent 250 ugm

• STEROIDS:

• • prednisolone 2mg/kg/day (max 40)

• • hydrocortisone: 4mg/kg 6 hourly

• AMINOPHYLLINE (with paediatricians):

• • loading dose: 5mg/kg

• • maint. 1mg/kg/hour (max 20mg/kg/day)

SYMPTOMS OF CROUP

• Babies and toddlers (rarely school children)

• Coughing (barking)

• Mild fever

• Inspiratory stridor (=croup)

• Intercostal, suprasternal or subcostal recession

• Use of accessory muscle use

• Differentialdiagnosis of viral or spasmodic croup:

• (Get a second opinion from ENT Consultant)

• epigolottitis, bacterial tracheitis, laryngeal foreign body, retropharyngeal abscess, infectious mononucleosis, angioneurotic oedema, diphtheria

CROUP - ASSESSMENT

• Mild croup: stridor only when crying / agitated

• • no hypoxia and comfortable

• Moderate croup: stridor at rest

• • recession and tachypnoea, but no hypoxia

• Severe croup: STRIDOR all the time

• • recession and tachypnoea, tachycardia

• • decreased breath sounds

• • HYPOXIA- MONITOR SATURATION

• NO INVESTIGATIONS, PLEASE

CROUP - MANAGEMENT

• Mild croup : comfortable, stridor only when crying

• No treatment, reassure and discharge with advice to return

• Moderate severe croup :

• STRIDOR AT REST, recession and tachypnoea

• HYPOXIA, stridor, tachycardia, decreased breath sounds

• Keep calm and nurse in warm room, in upright position

• Oxygen if oxygen saturations