Emergencies in peadiatrics Krzysztof Narębski Toruń.
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Transcript of Emergencies in peadiatrics Krzysztof Narębski Toruń.
Emergencies in Emergencies in peadiatricspeadiatrics
KrzysztofNarębski
Toruń
Problems to discussProblems to discuss
1)1) Child assessmentChild assessment
2)2) Neonatal resuscitationNeonatal resuscitation
3)3) ShockShock
4)4) SepticaemiaSepticaemia
5)5) Status epilepticus / febrile seizuresStatus epilepticus / febrile seizures
6)6) DyspnoeaDyspnoea
7)7) AnaphylaxisAnaphylaxis
8)8) Inhaled foreign bodyInhaled foreign body
Child assessmentChild assessmentBasic / Advanced Live Basic / Advanced Live SupportSupport1)1) Primary assessmentPrimary assessment
- ABCDABCD scale scale
oror- AVPU scaleAVPU scale
2)2) ResuscitationResuscitation
3)3) Etiologic treatmentEtiologic treatment
„„SICK CHILD”, SICK CHILD”, „SEPTIC”„SEPTIC”
AA - - AArousal, rousal, AAlertness, lertness, AActivity, ctivity, AApathypathy
BB - - BBreathing difficultiesreathing difficultiesCC - - poor poor CColour (pale) andolour (pale) and
CCirculation (irculation (CCold peripheries)old peripheries)DD - - DDecreased fluids inecreased fluids intaketake (fewer (fewer
than than half ahalf a normal intake) andnormal intake) andDDecreased urine output (fewer ecreased urine output (fewer
than 4 than 4 wet nappies a day)wet nappies a day)
Level of awareness, Level of awareness, ComaComa
AA - - AAlertlertVV - - responds to responds to VVoiceoicePP - - responds to responds to PPainainUU - - UUnresponsivenresponsive
NeonatalResuscitation
at birth
NR first 30 sec = routine care !!!
NR breathing and chest compressions
Neonatal resuscitationNeonatal resuscitation
Adrenaline ivAdrenaline iv 10 – 30 mcg / kg 10 – 30 mcg / kg
(0.01 – 0.03 mg / kg)(0.01 – 0.03 mg / kg)
Amp. 0,1 % (1 : 1000), 1 mlAmp. 0,1 % (1 : 1000), 1 ml
1 ml - 1 mg = 1000 mcg1 ml - 1 mg = 1000 mcg
Dilution 10 xDilution 10 x >>>>
1 ml - 0.1 mg = 100 mcg1 ml - 0.1 mg = 100 mcg
>> >> give 0.1 – 0.3 ml / kg (= 10 – 30 give 0.1 – 0.3 ml / kg (= 10 – 30 mcg)mcg)
Apgar scoreApgar score : good 8 – 10 : good 8 – 10 points, intermediated 4 - 7, points, intermediated 4 - 7, bad 0 - 3bad 0 - 3
Score of 0 Score of 1 Score of 2 Acronym
Skin color
Blue / pale all over
Body pink, Blue extremities
All pink Appearance
Pulse rate
Absent < 100 /min > 100 /min
Pulse
Reflex irritability
No respond to stimuli
Grimace Cry Grimace
Muscle tone
None Some flexion Flexed legs & arms
Activity
Breathing
Absent Weak, irregular
Strong cry
Respiration
ShockShock
DefinitionDefinition : inadequate circulation to : inadequate circulation to meet the tissues’ demandsmeet the tissues’ demands
EtiologyEtiology : :- Hypovolemia !!! viral - Hypovolemia !!! viral
gastroenteritisgastroenteritis
- Maldistribution of fluid :- Maldistribution of fluid :- SepsisSepsis- AnaphylaxisAnaphylaxis
Signs of shockSigns of shock
EarlyEarly (compensated shock) (compensated shock)– tachypnoea and tachycardiatachypnoea and tachycardia– sunken eyes and fontanellesunken eyes and fontanelle– mottled, pale, cold skinmottled, pale, cold skin– decreased skin turgordecreased skin turgor– decreased capillary refill (> 2 sec)decreased capillary refill (> 2 sec)– decreased urinary outputdecreased urinary output
(< 1 ml/kg/h)(< 1 ml/kg/h)
Signs of shockSigns of shock
LateLate (decompensated shock) (decompensated shock)– confusion / depressed cerebral confusion / depressed cerebral
statestate– bradycardiabradycardia– hypotensionhypotension– blue peripheries blue peripheries – absent urine outputabsent urine output
HydratationHydratation
Decreased skin turgorDecreased skin turgor
Hypovolemia - Hypovolemia - treatmenttreatment Fluids resuscitation :Fluids resuscitation :
1. 1. 0.9 % saline iv0.9 % saline iv
- 20 ml / kg- 20 ml / kg
- in 10 – 20 min,- in 10 – 20 min,
- repeat if necessary !!!- repeat if necessary !!!
(Ringer if urine output (Ringer if urine output present)present)
2. Blood if trauma2. Blood if trauma
Figure 6.8 Initial fluid resuscitation in shock.
Downloaded from: StudentConsult (on 26 February 2012 12:39 PM)
© 2005 Elsevier
Fluids intake at different Fluids intake at different agesages
Body weight
Fluids requirement / 24 hours
Volume / kg per hour
First 10 kg 100 ml / kg 4 ml / kg
Second 10 kg
50 ml / kg 2 ml / kg
Subsequent kg
20 ml / kg 1 ml / kg
Examples of calculationsInfant 7 kg 700 ml 29 ml / h
Child 18 kg
1000 + 400 = 1400 ml 40 + 16 = 56 ml/h
Child 42 kg
1000+500+440 = 1940 ml
40+20+18 = 78 ml/h
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SepticaemiaSepticaemia- meningococcal - meningococcal
purpurapurpuraPoor state+ fever+ rashthat does not blanch whenpressedunder a glass
SepticaemiaSepticaemia
- - meningococcal meningococcal purpurapurpura
SepticaemiaSepticaemia-- clinical features clinical features
HistoryHistory : :
- fever- fever
- poor feeding- poor feeding
- irritability, lethargy- irritability, lethargy ExaminationExamination : :
- tachycardia, tachypnoea, - tachycardia, tachypnoea, hypotensionhypotension
- shock, multi organ failureshock, multi organ failure- purpuric rashpurpuric rash
ABCD / AVPU scale
Vaccination
Septicaemia - Septicaemia - treatmenttreatment Antibiotic immediately ivAntibiotic immediately iv Hospital (Intensive Hospital (Intensive CCare are UUnit)nit) Treatment of shockTreatment of shock
SeizuresSeizures
Definition :Definition :
Uncontrolled electrical Uncontrolled electrical activity in the brain, which activity in the brain, which
may produce a physical may produce a physical convulsionconvulsion.
Status epilepticus / Status epilepticus / febrile seizuresfebrile seizures Status epilepticusStatus epilepticus - definition : - definition :
- seizure lasting 30 min or- seizure lasting 30 min or
- successive frequent seizures - successive frequent seizures with with unconsciousnessunconsciousness
Febrile seizuresFebrile seizures - definition : - definition :
- seizure accompanied by a - seizure accompanied by a fever in fever in absence of intracranial absence of intracranial infectioninfection
Seizures - etiologySeizures - etiology
Febrile seizures – any infections & Febrile seizures – any infections & feverfever
AlsoAlso : :– Metabolic (hypoglycemia, hypoCa, Metabolic (hypoglycemia, hypoCa,
hypoMg, hypo or hypernatraemia)hypoMg, hypo or hypernatraemia)– Meningitis and encephalitisMeningitis and encephalitis– Cerebral trauma or tumorCerebral trauma or tumor– Toxins (poison, metabolic disorders)Toxins (poison, metabolic disorders)– Epilepsy and othersEpilepsy and others
Seizures - treatmentSeizures - treatment
Febrile seizures – antipyretics !!!Febrile seizures – antipyretics !!!- Diazepam 0.5 mg- Diazepam 0.5 mg / kg / kg pr pr
Seizures or status epilepticus :Seizures or status epilepticus :- Phenobarbital iv 10 – 20 mg / kgPhenobarbital iv 10 – 20 mg / kg- Phenytoin iv 20 mg / kgPhenytoin iv 20 mg / kg
Repeat if no response in 5 min !!!Repeat if no response in 5 min !!!Give oxygen !!! >> PICUGive oxygen !!! >> PICU
If hypoglycemia < 3 mmol/LIf hypoglycemia < 3 mmol/LGive 10 % glucose iv 2 ml / kgGive 10 % glucose iv 2 ml / kg
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The degree of subcostal, intercostal and sternal recession is a more useful indicator of severity of upper airways
obstruction than the respiratory rate.
DyspnoeaDyspnoea- Croup- Croup
Dyspnoea - CroupDyspnoea - Croup
Features : viral, 6 months to 6 years, Features : viral, 6 months to 6 years, harsh, loud stridor, coryza, mild feverharsh, loud stridor, coryza, mild fever
TreatmentTreatment- Inhalation of fresh airInhalation of fresh air- Steroids :Steroids :
prednisolon oral, im, iv orprednisolon oral, im, iv or
inhaled budesonidinhaled budesonid- Nebulised adrenaline with oxygen Nebulised adrenaline with oxygen
Dyspnoea – Asthma fitDyspnoea – Asthma fit
History of allergy or asthmaHistory of allergy or asthma Symptoms and signs :Symptoms and signs :
- too breathless to eat or talk- too breathless to eat or talk- use of accessory muscles- use of accessory muscles- distended chest- distended chest- wheeze or silent chest- wheeze or silent chest- cyanosis and alter level of - cyanosis and alter level of
consciousnessconsciousness Treatment - Oxygen !!!Treatment - Oxygen !!!
- Bronchodilators (B2-agonist)- Bronchodilators (B2-agonist)- Steroids iv, oral or inhaled- Steroids iv, oral or inhaled
AnaphylaxisAnaphylaxis
Definition :Definition :
Severe, whole – body reaction Severe, whole – body reaction to an allergen, after being to an allergen, after being previously exposed to thpreviously exposed to thisis allergen allergen (sensitization to it).(sensitization to it).
This reaction happen very This reaction happen very quickly.quickly.
AnaphylaxisAnaphylaxis
History of allergy / anaphylaxisHistory of allergy / anaphylaxis Food Food oror insect sting insect sting venom allergy venom allergy Symptoms immediately :Symptoms immediately :
- airways : swelling, hoarseness, - airways : swelling, hoarseness, stridorstridor
- breathing : tachypnea, wheeze, - breathing : tachypnea, wheeze, cyanosis, SpO2< 92 %cyanosis, SpO2< 92 %
- circulation : pale, clammy, - circulation : pale, clammy, hypotension, drowsy, comahypotension, drowsy, coma
Anaphylaxis - Anaphylaxis - treatmenttreatment
Adrenaline / epinephrine 1 : 1000 Adrenaline / epinephrine 1 : 1000 imim
< 6 years < 6 years - 150 mcg - 150 mcg (0.15 ml)(0.15 ml)
6 – 12 years - 300 mcg 6 – 12 years - 300 mcg (0.3 ml)(0.3 ml)
> 12 years > 12 years - 500 mcg - 500 mcg (0.5 ml)(0.5 ml)
Hydrocortison im or ivHydrocortison im or iv
Inhaled foreign bodyInhaled foreign body
In infants, back blows and chest thrusts are recommended to expel an inhaled foreign body. Abdominal thrusts are best avoided
in infants as they may cause intra-abdominal injury.
Abdominal thrusts (Heimlich manoeuvre) in older children to expel an inhaled foreign body. One hand is formed
into a fist and placed against the child's abdomen between umbilicus and xiphisternum.
The other hand is placed over the fist. Both hands are thrust
into abdomen. Repeat several times. The child can be standing, kneeling, sitting
or supine.
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Thank youThank you