Emergency care in children
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Transcript of Emergency care in children
Emergency care in children
Pavlyshyn Halyna Andriyivna
Ternopil state medical university
Learning Objectives
1. Essentials of pediatric intensive care of seizures
2. Essentials of pediatric intensive care respiratory disease
3. Essentials of pediatric intensive care of anaphylaxis
Definition of Child Care
Children requiring emergency care have unique and special needs.
This is especially so for those with serious and life-threatening emergencies.
It is an illness or injury that may threaten a child’s life
Learning Objectives
Essentials of pediatric
intensive care of seizures
Convulsions or seizures
are when a person's body shakes rapidly and uncontrollably.
During convulsions, the person's
muscles contract and relax
repeatedly.
• are the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain.
Seizure ClassificationsGeneralized Partial
Complex Simple
Involves BOTH hemispheres of the brain
May have aura No impaired consciousness
Always involves loss of consciousness
Involves motor* or autonomic# symptoms with altered level of consciousness
Can involve motor,* autonomic# or somatosensory+ symptoms
Types: Tonic or clonic movements or combination (grand mal) Absence (petit mal) Myoclonic Atonic (e.g., drop attacks) Infantile spasms
May generalize May generalize
Types of symptoms:1) Motor* - head/eye deviation, jerking, stiffening2) Autonomic# - pupils dilatation, drooling, pallor, change in heart rate or respiratory rate3) Somatosensory+ - smells, alteration of perception
A Seizure Is:
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Simple Febrile Seizure (SFS) Unprovoked Seizures (UnS) Status Epilepticus (SE)
Seizure activity cannot be interrupted with verbal or physical stimulation
Seizure activity cannot be interrupted with verbal or physical stimulation
Febrile Seizure are the most common seizure
disorder in childhood, affecting 2 - 5% of children between
the ages of 6 months and 5 years
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Febrile Seizure is a seizure accompanied by a fever
Caused by the increase in the body temperature greater than 100.4F or 38C
Threshold of temperature which may trigger seizures is unique to each individual
Can occur within the first 24 hours of an illness Can be the first sign of illness in 25 - 50% of
patients 9
Febrile Seizures Are benign condition
Repetitive non-purposeful movements Staring Lip-smacking Falling down without cause Stiffening of any or all extremities Rhythmic shaking of any or all extremities May be either simple or complex type seizure
Seizure accompanied by fever (before, during or after) WITHOUT ANY
Central nervous system infection Metabolic disturbance
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Febrile Seizure: ED Assessment
Baseline assessment
Vital signs (including temperature) Assess A, B, C, D’s Begin passive cooling measures Remove clothing/coverings
Damp towels Consider giving antipyretic if not previously administered
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Oxygen, oral airway. Suction.
Avoid hypoxia!
Consider bag-valve mask ventilation. Consider intubation
IV/IO access. Treat hypotension, but NOT hypertension
Disability
AA
BB
CC
Assess A, B, C, D’s airway, breathing, circulation,
neurological status = Disability
DD
First Unprovoked Seizure:
Partial seizure Generalized onset, tonic-clonic seizure Tonic seizure
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Remember: this is a seizure that occurs without an immediate precipitating event
(fever, trauma or infection).
Remember: this is a seizure that occurs without an immediate precipitating event
(fever, trauma or infection).
First Unprovoked Seizure: Diagnostic Testing
Laboratory tests are based on individual clinical circumstances and may include: CBC with differential Blood glucose Electrolytes Calcium, magnesium, phosphorous Urine drug/toxicology screen EEG MRI, CT Scan
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Lumbar puncture is only indicated if there are other symptoms that suggest
a diagnosis of meningitis.
Lumbar puncture is only indicated if there are other symptoms that suggest
a diagnosis of meningitis.
Status Epilepticus
Seizures that persist without interruption for more than 5 minutes
Two or more sequential seizures without full recovery of consciousness between seizures
This is a life threatening emergency that requires immediate treatment.
This is a life threatening emergency that requires immediate treatment.
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Family education should include instruction to protect the child during the
Seizure
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Instruct parent/caregivers to prevent injury during a seizure :
Position child while seizing in a side-lying position
Protect head from injury Loosen tight clothing about the neck Prevent injury from falls Reassure child during event Do not place anything
in the child’s mouth
1. Protect from potentiallyharmful objects.2. Cushion head.
3. Turn on side and keepairway clear4. Observe & time events
5. NOTHING in the mouth6. Don’t grab, don’t hold down 7. Speak softly & calmly8. Protect from hazards
First Aid: Seizure
Anticonvulsants
Rapid acting
Plus Long acting
Anticonvulsants - Rapid acting Benzodiazepines
Lorazepam 0.1 mg/kg i.v. over 1-2 min Diazepam 0.2 mg/kg i.v. over 1-2 min
In children, rectal diazepam gel - Diastat – the only FDA approved product for non-medical
professional administration
Anticonvulsants - Long acting
Phenytoin 20 mg/kg i.v. over 20 min
Onset 10-30 min May cause hypotension, dysrhythmia
Phenobarbital 20 mg/kg i.v. over 10 - 15 min Onset 15-30 min May cause hypotension, respiratory depression
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Learning Objectives
Essentials of pediatric intensive care respiratory disease
Learning Objectives
Respiratory illnesses that occur in children and necessitate intensive care can be divided intoupper and lower respiratory obstruction.
Upper airway obstructionAcute causes (infective) of
upper airway obstruction
Croup Epiglottitis Bacterial tracheitis Foreign bodyDiphtheria Acute tonsillitis Infectious mononucleosis Retropharyngeal abscess Trauma
Upper airway obstruction‘Congenital’ (non-acute) causes of
upper airway obstruction Choanal atresia or stenosis Laryngomalacia Laryngeal webs, stenosis, cleft, cyst Tracheomalacia Vascular ring Bronchomalacia Sub-glottic stenosis Laryngeal papillomata Intra-thoracic tumours
• Larynx is located on level the 3-4th (neck) vertebrae; •Vocal and mucous membranes are rich blood vessels and lymphatic tissue, prone to inflammation, swelling, due to babies suffering from laryngitis (viral croup), airway obstruction, inspiratory dyspnea;
Upper respiratory tract in children
•The larynx of a child is funnel-shaped, cartilage soft;
Upper respiratory tract in children
• The most narrow point is a mucous membrane on level the cartilage larynx until the age of 8-10 years
Normal Laryngomalacia
Upper respiratory tract in children
Croup
Croup
is the most common acute upper airway obstruction
is seen predominately in children between
6 months and 3 years of age Etiology - the primary etiologic agents are parainfluenza influenza viruses,respiratory syncytial virusadenovirus
CroupLaryngitis,
laryngotracheitis
Inflammation involving the vocal
cords and structures inferior to the cords;Is manifested by "barking" cough, inspiratory stridor (a high-pitched
sound produced by an obstruction of the trachea or larynx that can be heard during inspiration and/or expiration),
some degree of respiratory distress.
Croup Syndromes
Signs and Symptoms
“Barky” cough, Inspiratory stridor Hoarseness Nasal drainage, coryza (catarrh). Low-grade fever Intercostal, suprasternal, infrasternal
retractions. RR - slightly increased A frontal X-ray of the neck shows a
characteristic narrowing of the trachea, called the STEEPLE sign
The steeple sign on X-ray of a child with croup
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Symptoms are characteristically worse at night.
Agitation and crying greatly aggravate the symptoms and signs.
The child may prefer to sit up in bed or be held upright.
Hoarse voice, coryza, a slightly increased respiratory rate.
Hypoxia and low oxygen saturation
The child who is hypoxic, cyanotic, pale or obtunded needs immediate airway management.
Croup
Croup score Mild croup, 0–3; moderate croup, 4–6;
severe croup, 7–10
Score 0 1 2Breath sounds Normal Harsh, wheeze Delayed
Stridor None InspiratoryInspiratory and
expiratory
Cough None Hoarse cry Bark
Recession/flaring
NoneFlaring,
suprasternal recession
Flaring, suprasternal,
intercostal recession
Cyanosis None In air In oxygen 40%
A scoring system for croup is useful in assessing severity
TreatmentCroup Syndrome
includes humidification of respiratory gases, oxygen, steroids and nebulized epinephrine;
The treatment of croup includes nebulized racemic epinephrine, systemic or nebulized corticosteriods, fluids, rest and comforting measures.
Epinephrine is a short-acting bronchodilator. It also decreases congestion in the airway, thus reducing tissue edema.
Treatmentcroup syndrome
Nebulized epinephrine is used for children with hypoxia who have some degree of respiratory distress.
Corticosteroids, which may be systemic or nebulized, are indicated for mild to severe croup.
The anti-inflammatory
action of these medications reduces airway edema.
Treatmentcroup syndrome
Epiglottitis
Epiglottitis is bacterial infection of the epiglottis and supraglottic structures
H. influenzae type b (Hib)
Acute Epiglottitis
Stridor inspiratory Sore throat, painful swallowing Drooling, Hoarse, muffled voice High fever Dysphagia Suprasternal, substernal
retractions Position of head and neck - to sit
leaning forwards, mouth open and with tongue and jaw protruding in order to open the airway.
On X-ray - the thumb-print sign is a finding that suggests the diagnosis of epiglottitis
Diagnosis
Croup Gradual onset Late night seal-bark cough Low-grade fever Inspiratory stridor Hoarse voice Other signs and symptoms depending on degree of
distress
Epiglottitis Sudden onset Muffled cough (not a prominent
finding) High fever Inspiratory stridor Dysphagia Sore throat Drooling (sometimes noted) Tripod position (facilitates air
movement)
Acute Epiglottitis
Establishing an airway by nasotracheal intubation or by tracheostomy is indicated in patients with epiglottitis, regardless of the degree of apparent respiratory distress, because as many as 6% of children with epiglottitis without an artificial airway die, compared with <1% of those with an artificial airway.
Children with acute epiglottitis are
intubated for 2-3 days + antibiotics therapy.
Foreign body aspiration
A foreign body above the vocal cords can cause complete obstruction of the upper airway, stridor, a change or loss of voice;
Small objects - seeds, nuts, toy parts, buttons, pebbles Sudden onset of cough Choking or gagging or wheezing Stridor, high pitched wheezing Cyanosis
An aspirated foreign body (coin)
Foreign body aspirationPartial
Blockagecoughingaccessory
muscle usenasal flaringwheezing
Complete BlockageComplete Blockage- no soundno sound- no cryno cry- stridorstridor- cyanosiscyanosis- loss of loss of
consciousnessconsciousness
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Foreign bodies
Atelectasis of right apex Note the coil and the
endotracheal tube just above it
Explaining the difficulties in placing the tube
• Bronchoscope under sedation may be necessary to remove object or surgery.
The peculiarities of the bronchi in children
In young children the bronchi are relatively wide,
The right bronchus is a straight continuation of the trachea,
The muscle and elastic fibers are undeveloped, The bronchi are well blood supplied, The lobules and segmental bronchus are
narrow.
Anatomy and physiology Several anatomical and physiological features of
the respiratory system in infants (age <1 yr) and young children make them susceptible to airway obstruction.
The upper and lower airways are small, prone to occlusion by secretions and susceptible to oedema and swelling.
A small decrease in the radius of the airway results
in a marked increase in resistance to airflow and the work of breathing (Poiseuille's law);
The support components of the airway are less developed and more compliant than in the adult.
Bronchiolitis – acute inflammation in the mucosa of small bronchi
and bronchioles, predominantly in young children with the concomitant obstruction of respiratory ways
Dry cough, nonproductive Dyspnea (breathlessness) Noisy breathing Moaning breathing with prolonged expiration Retractions Ban-box sound - on percussion Bronchial breathing with prolonged
expiration, wheezing, diffuse crackles;
Clinical case 6 months patient
Complaints: Increased body temperature to 38 °C Irritability Dry cough Dyspnea (breathlessness)
Anamnesis morbi (present history)
Acute onset Disease has begun from cough, sneezing, high
temperature up to 38 °C, then has appeared noisy breathing, cough, which have increased gradually;
He became ill in 36 hours after contact with an ill mother;
Treatment started at home (antibiotic by mouth, mucolitic, decongestant);
Condition of patient remained the same, and he was admitted to the hospital;
Anamnesis vitae (past history)
Infant was born from 1st pregnancy, 1st
delivery Birth weight was 3100 g Neonatal period – without complication Breastfeeding In age of 2 month he had acute viral
infection Vaccination: BCG, DPT+IPV+Hib (1st
and 2nd)
Physical examination at hospitalization:• General condition was moderate due to dyspnea syndrom; • Skin was pale with perioral cyanosis and acrocyanosis
Nasal breathing was impaired because of nasal congestion
Cough was nonproductive, moderate retractions, moaning breathing with prolonged expiration were present
Physical examination at hospitalization:
On percussion – ban-box sound, On auscultation – harsh breathing with prolonged
expiration, numerous moist diffuse rales and crepitation
RR - 68 per min HR - 148 beats per min
Video
Laboratory data
CBC (complete blood count) Er – 3,68 х1012/l, Hb – 92 g/l, Le – 5,4х109/l,
eosinophyls – 1%, bands – 2%, polymorphonuclear cells – 39%, lymphocytes – 56%, monocytes – 2%, ESR - 2 mm per h
Rapid immuno-chromatographic test for determination of RSV - positive
X-ray chest
Clinical diagnosis:
RS-infection:
Acute bronchiolitis. RI II degree.
DIAGNOSTIC CRITERIA OF ACUTE BRONCHIOLITIS
1. Deterioration of the general patient's condition with the symptoms of rhinitis, nasopharyngitis, the catarrhal symptoms.
2. The body temperature in most cases is normal. 3. The pronounced respiratory failure, the expiratory
dyspnea, the cyanosis of nasolabial triangle. 4. The symptoms of the bronchial obstruction
(enlargement of anterioposterior chest size, the horizontal positions of the ribs, the prolapse of the diaphragm).
5. Percussion: tympanic percussion sounds.
DIAGNOSTIC CRITERIA OF ACUTE BRONCHIOLITIS
6. Auscultation: bronchial breath sounds, the extended expiration, the moist small bubbling rales, the wheezes in expiration.
7. In chest X-ray, the lung pattern is enhanced, the transparence of the lungs increases due to the obturation emphysema, the bronchial pattern is also enhanced.
What is Asthma?
Disease of chronic inflammatory disorder of the airways
Characterized by: Airway inflammation Airflow obstruction Airway
hyperresponsiveness
DEFINITION Asthma is a disorder defined by its clinical,
physiological and pathological characteristics
The predominant feature of the clinical history is episodic shortness of breath,
particularly at night, often accompanied by cough.
Wheezing defined on auscultation of the chest is the most common physical
finding.
DEFINITION Asthma is a disorder defined by its clinical,
physiological and pathological characteristics
The main physiological feature of asthma is episodic airway obstruction.
The dominant pathological feature is airway inflammation (limits airflow from
bronchospasm, mucosal edema, mucus plugs)
recurring episodes of wheezing breasthlessness chest tightness cough particularly at night or in the early morning.
Asthma causes
Wheezing
Wheezes are musical adventitious lung sounds
Diagnosis of asthma
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Cough Episodic wheezing, recurrent wheeze Shortness of breath, episodic breathlessness Chest tightness, hyperinflated chest, Use of accessory muscles and intercostals
recession
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Peak expiratory flow (PEF)
Measurements of lung function
The Peak Flow Meter
The Peak Flow The Peak Flow MeterMeter
Acute severe asthmatic episode (status asthmaticus)
Correction of significant hypoxemia with supplemental
oxygen: In severe cases, alveolar hypoventilation requires
mechanically assisted ventilation. Use repeated or continuous administration of an inhaled
beta2-agonist (Albuterol, Ventolin) Early administration of systemic corticosteroids (oral
prednisone or IV methylprednisolone) is suggested in children with absent effect from inhaled beta2-agonists.
Bronchodilator, beta2-agonists (Sympathomimetics)
Short acting beta agonists – SABAAlbuterol, Ventolin, Salbutamol, Proventil,Terbutaline,
Long-acting – Sereven, Foradil, Formoterol, Salmeterol
Learning Objectives
Essentials of pediatric
intensive care of Anaphylaxis
Case
A child with bee sting came to ED
He has Facial Edema, wheezing
Anaphylaxis is a severe, systemic allergic reaction
multisystem involvement, including the skin, airway, vascular system, and GI
Severe cases may result in complete obstruction of the airway, cardiovascular collapse, and death
Etiology
Pharmacologic agents Antibiotics (especially parenteral
penicillins and other ß-lactams), aspirin and nonsteroidal anti-inflammatory
drugs intravenous (IV) contrast agents are the
most frequent medications associated with life-threatening anaphylaxis.
Stinging insects
ants, bees, hornets, wasps, and yellow jackets.
Foods
Peanuts, seafood, and wheat are the foods most frequently associated with life-threatening anaphylaxis.
Paraesthesia, flushing, facial swellingGeneralised itching – hands and feet
Shock
Cardiac arrest
Cardiac anaphylaxis
Clinical Signs
Symptoms Peripheral vasodilation
vascular permeablility (edema)
Bronchospasm Cardiac arrhythmias Smooth muscle contractions
Laryngeal Angioedema
Signs and Symptoms Serious upper airway (laryngeal) edema, lower
airway edema (asthma), or both may develop, causing stridor and wheezing.
Bronchospasm and laryngospasm (wheezing and breathing difficulty)
Rhinitis
Cardiovascular collapse - rapid weak pulse together with fall in blood pressure
Gastrointestinal signs and symptoms of anaphylaxis include abdominal pain, vomiting, and diarrhea
Guidelines for ED Treatment
Suspicion of severe anaphylaxis ABC
1e line : Adrenaline + Fluid resuscitation: crystalloïds or saline 0.9%, adult 500 ml to1000 ml, children 20ml/Kg
Jasmeet S. Resuscitation 2008;77:157-169.
A U T H O R S ’ C O N C L U S I O N S Implications for practice
We found no relevant evidence for adrenaline use in the treatment of anaphylaxis. We are, therefore, unable to make any new recommendations based on the findings of this review. Guidelines on the management of anaphylaxis need to be more explicit about the basis of their recommendations regarding the use of adrenaline.
Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock (Review)Sheikh A, Shehata YA, Brown SGA, Simons FERThis is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 10http://www.thecochranelibrary.com
Adrenaline I.M
Adrenaline IM: dilution 1/1000
- Adult : 500 microgramms (0,5ml)- Child > 12 years: 500 microgrammes
(0,5ml)- Child 6 to 12 years: 300 microgrammes
(0,3ml)- Child < 6 years: 150 microgrammes
(0,15ml)
Jasmeet S. Resuscitation 2008;77:157-169.
An EpiPen
Self-injected epinephrine
Self-injected epinephrine
Self-injected epinephrine
Adrenaline I.V Intravenous adrenaline has been associated with fatal
cardiac arrythmias and myocardial infarction, these cases have been associated with too rapid injection, undiluted doses, or excessive doses (Fischer, 1995; Pumphrey, 2000; Brown, 2001; Montanaro and Bardana, 2002).
To minimise these adverse effects, the use of intravenous adrenaline is now recommended at a dilution of 1:10,000 (Project Team of the Resuscitation council, UK, 2005).
Second line treatment
Histamine antagonists
Dexchlorpheniramine=against itching Corticosteroids
Hydrocortisone - Methylprednisolone=prevent recurrent anaphylaxis
Jasmeet S. Resuscitation 2008;77:157-169.
A U T H O R S ’ C O N C L U S I O N S Implications for practice
We found no relevant evidence for the use of glucocorticoids in the treatment of an acute episode of anaphylaxis. We are, therefore, unable to make any new recommendations based on the findings of this review. While we do not necessarily suggest that anaphylaxis guidelines no longer recommend glucocorticoids, these guidelines need to be more explicit about the basis of their recommendations regarding the use of these agents (Alrasbi M, Sheikh A. Comparison of international guidelines for the emergency medical management of anaphylaxis. Allergy 2007; 62:838–41.).
Glucocorticoids for the treatment of anaphylaxis (Review)Choo KJL, Simons FER, Sheikh A
This This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 10http://www.thecochranelibrary.com
Management of Anaphylactic Shock
Position:Oxygen. Epinephrine.Antihistamines. H2 blockers. Inhaled b-adrenergic agents.
Management of the Anaphylactic shock
Position: in a position of comfort. If hypotension is present, elevate the legs until replacement fluids and vasopressors restore the blood pressure
Oxygen. Administer oxygen at high flow rates. Epinephrine. Administer epinephrine to all patients with clinical
signs of shock, airway swelling, or definite breathing difficulty. Antihistamines. Administer antihistamines slowly IV or IM. Inhaled b-adrenergic agents. Provide inhaled albuterol if
bronchospasm is a major feature. If hypotension is present administer parenteral epinephrine before inhaled albuterol to prevent a possible further decrease in blood pressure.
Corticosteroids. Infuse high-dose IV corticosteroids slowly or administer IM after severe attacks. The beneficial effects are delayed at least 4 to 6 hours
Thank You