Global Pediatric Advanced Life Support: Improving Child Survival in Limited-Resource Settings Mark...

Global Pediatric Global Pediatric Advanced Life Advanced Life

Support: Support: Improving Improving Child Survival in Child Survival in Limited-Resource Limited-Resource

SettingsSettingsMark Ralston, MD MPHMark Ralston, MD MPH

Dept Pediatrics, Naval Hospital Oak Dept Pediatrics, Naval Hospital Oak Harbor, WAHarbor, WA

Assistant Prof Pediatrics, USUHSAssistant Prof Pediatrics, USUHS

Global Under-Five Global Under-Five MortalityMortality Occurrence: 99% occurs in LR Occurrence: 99% occurs in LR

settingssettings66

Sub-Saharan Africa: 49%Sub-Saharan Africa: 49%

South Asia: 33%South Asia: 33%

Other: 17%Other: 17% Leading single causes (deaths/year):Leading single causes (deaths/year):5656

Pneumonia: 1.396 million (18% Pneumonia: 1.396 million (18% total) total) Diarrhea: 0.801 million Diarrhea: 0.801 million (11% total)(11% total)

Total: 7.6 million (2010)Total: 7.6 million (2010) Infectious cause:Infectious cause:5656 64% total 64% total

““Deaths occur outside the vision of Deaths occur outside the vision of health services, mainly in the health services, mainly in the home, with the majority home, with the majority occurring in the poorest occurring in the poorest households in the poorest households in the poorest communities.”communities.”

Edward (Kim) Mulholland, MDEdward (Kim) Mulholland, MD

London School of Hygiene and Tropical London School of Hygiene and Tropical MedicineMedicine

Menzies School of Health Research, Darwin Menzies School of Health Research, Darwin AustraliaAustralia

United Nations Millennium United Nations Millennium Development Goal 4Development Goal 4

UN MDG 4 = UN MDG 4 = 2/3 reduction in 2/3 reduction in U5M by 2015 U5M by 2015 (from 13 million (from 13 million annual deaths in annual deaths in 1990)1990)55

2015 Goal = 4.3 2015 Goal = 4.3 million annual million annual deathsdeaths

Combination Approach Combination Approach for U5M Reduction for U5M Reduction

Prevention:Prevention: eg, eg, breastfeeding until 6 breastfeeding until 6 mos, clean mos, clean water/hygiene, water/hygiene, vaccines, vaccines, micronutrients (zinc, micronutrients (zinc, Vitamin A), Vitamin A), complementary feedingcomplementary feeding

Treatment Treatment (weak link (weak link in LR settings is in LR settings is emergency & critical emergency & critical care)care)8,10,158,10,15

Global causes of childhood deaths in 201056

Pediatric Advanced Life Pediatric Advanced Life Support in LR SettingsSupport in LR Settings

Definition: emergency Definition: emergency management beyond CPR/AED in management beyond CPR/AED in children beyond newborn periodchildren beyond newborn period

Achievements: some gains in Achievements: some gains in management of severe infection & management of severe infection & shockshock

Reality: often ALS is incomplete Reality: often ALS is incomplete (where nearly all global pediatric (where nearly all global pediatric deaths occur!)deaths occur!)

Limited Access to Limited Access to ResourcesResources

PRE-HOSPITALPRE-HOSPITAL HOSPITALHOSPITAL

PreventionPrevention Emergency care Emergency care centerscenters

Disease surveillanceDisease surveillance Triage systemsTriage systems

Referral servicesReferral services Ancillary servicesAncillary services

EMS modelsEMS models Infrastructure for Infrastructure for critical carecritical care

Transport servicesTransport services ICUICU

Trained healthcare Trained healthcare providersproviders

Trained healthcare Trained healthcare providersproviders

EquipmentEquipment EquipmentEquipment

Disposable materialsDisposable materials Disposable materialsDisposable materialsReferences: 3,4,8-23

Reported Limited Reported Limited Resources for Children in Resources for Children in

Low-Income SettingsLow-Income Settings Oxygen or Oxygen or

equipment equipment to detect to detect hypoxemia hypoxemia are often are often unavailable unavailable to critically to critically ill childrenill children2424


Low-Income SettingsLow-Income Settings Guinea-Bissau:Guinea-Bissau: 16% acutely ill 16% acutely ill

children die enroute to or while waiting children die enroute to or while waiting for carefor care2525

Kenya:Kenya: insufficient basic items to treat insufficient basic items to treat critical illness are unavailable at district critical illness are unavailable at district hospitalshospitals1919

Uganda:Uganda: 1/3 U5M (pneumonia) occurs 1/3 U5M (pneumonia) occurs at home;at home;26 26 1/3 children needing referral 1/3 children needing referral for hospital care receive referral after 2 for hospital care receive referral after 2 wkswks2727


Low-Income SettingsLow-Income Settings Tanzania:Tanzania: ~50% children referred to ~50% children referred to

hospital take hospital take >> 2 days to arrive 2 days to arrive88 India:India: effective transport system is effective transport system is

non-existentnon-existent1111

Mongolia:Mongolia: no infrastructure exists to no infrastructure exists to implement available sepsis guidelinesimplement available sepsis guidelines33

Brazil:Brazil: no services for shock is no services for shock is frequentfrequent3030

Table 1: Table 1: Levels of Pediatric ALS Levels of Pediatric ALS CapabilityCapabilityResourceResource Level 1Level 1 Level 2Level 2 Level 3Level 3

Continuum of Continuum of CareCare

Pre-hospitalPre-hospital Pre-hospital/Pre-hospital/HospitalHospital

Hospital Hospital

FacilityFacility

SystemSystem

PersonnelPersonnel

LaboratoryLaboratory

RadiologyRadiologyEquipment/Equipment/DisposablesDisposables

MonitoringMonitoring

Medications/Medications/FluidsFluids

ManagementManagement

Note: see hardcopy Table 1 for full details; higher level capability exists but is uncommon16

Modifying ALS Guidelines Modifying ALS Guidelines to to

Reflect Different Disease Reflect Different Disease SpectrumSpectrum Sepsis:Sepsis:

Severe infection Severe infection (malaria)/Shock:(malaria)/Shock: bolus-fluid bolus-fluid resuscitation (NS/Albumin) in resuscitation (NS/Albumin) in children associated with children associated with increased 48 hour mortalityincreased 48 hour mortality3838

Dengue Shock:Dengue Shock: early aggressive early aggressive fluid resuscitation with judicious fluid resuscitation with judicious fluid removal & early colloid may fluid removal & early colloid may be preferred in childrenbe preferred in children39-4239-42


Reflect Different Disease Reflect Different Disease SpectrumSpectrum Severe Acute MalnutritionSevere Acute Malnutrition

Infection:Infection: children have more children have more critical presentation, different critical presentation, different causative organisms, higher causative organisms, higher mortalitymortality2,43-482,43-48

Shock:Shock: aggressive fluid aggressive fluid resuscitation may have adverse resuscitation may have adverse effectseffects16,4916,49


Reflect Different Disease Reflect Different Disease SpectrumSpectrum Micronutrient DeficienciesMicronutrient Deficiencies

Vitamin A Deficiency:Vitamin A Deficiency: mortality mortality risk due to diarrhea, measles & risk due to diarrhea, measles & malaria in children is increased by malaria in children is increased by 20-24%20-24%5050

Zinc Deficiency:Zinc Deficiency: mortality risk mortality risk due to diarrhea, pneumonia & due to diarrhea, pneumonia & malaria in children is increased by malaria in children is increased by 13-21%13-21%5151


Reflect Different Disease Reflect Different Disease SpectrumSpectrum MeaslesMeasles

Pneumonia & diarrhea are common co-Pneumonia & diarrhea are common co-morbidities in critically ill childrenmorbidities in critically ill children5252

Children suffer higher mortality riskChildren suffer higher mortality risk22

HIVHIV Children have different causative Children have different causative

organisms, higher rates antibiotic organisms, higher rates antibiotic resistance/polymicrobial resistance/polymicrobial disease/M&Mdisease/M&M2,53-552,53-55

Impacting U5M with Simple Impacting U5M with Simple Inexpensive ALS Inexpensive ALS

InterventionsInterventionsALS InterventionALS Intervention Cost Cost

perper

TreatmTreatmentent

MortalitMortality y

ReductioReductionn

ETATETAT1313 (Emergency Triage & (Emergency Triage & Treatment)Treatment)

$1.75$1.75 50%50%

Pneumonia OutpatientPneumonia Outpatient5858 $13$13

Pneumonia Oxygen Pneumonia Oxygen SystemSystem22,5722,57 (Oxygen (Oxygen Concentrator/Pulse Oximetry)Concentrator/Pulse Oximetry)

$51$51 35%35%

Pneumonia InpatientPneumonia Inpatient5858 $71$71

Diarrhea ORS+Zinc Diarrhea ORS+Zinc OutpatientOutpatient59-6259-62

$0.30$0.30 ~100%~100%

Diarrhea ORS InpatientDiarrhea ORS Inpatient6363 $75$75

Lack of Infrastructure for Lack of Infrastructure for Pre-hospital Emergency Pre-hospital Emergency

CareCare Insufficient resourcesInsufficient resources Knowledge gaps: occur among lay Knowledge gaps: occur among lay

caretakers for both recognition & caretakers for both recognition & treatment of illnesstreatment of illness6565

Emergencies (10-20% of visits): Emergencies (10-20% of visits): handled by IMCI with “urgent referral handled by IMCI with “urgent referral to hospital” to hospital” 35,66-6835,66-68

Deficient referral processes & Deficient referral processes & inadequate transport servicesinadequate transport services9-9-

12,25,27,29,3312,25,27,29,33

Providing Pre-hospital Providing Pre-hospital Emergency Care by Primary Emergency Care by Primary

Care SystemCare System Expected by local Expected by local

communitycommunity10,3410,34

Shown to be Shown to be cost-effectivecost-effective13,3413,34

Provided Provided effectively by effectively by non-medical non-medical personnelpersonnel3434

Requires basic Requires basic supplies/equipmesupplies/equipment which have nt which have been requestedbeen requested3535

Reduced U5M by Pre-Reduced U5M by Pre-hospital Community Case hospital Community Case

ManagementManagementLocatioLocationn

IllnessIllness U5M U5M ReductionReduction

Age < 1 Age < 1 yearyear

U5M U5M ReductionReduction

Age < 5 Age < 5 yearyear

MexicoMexico77

22

Acute Acute RespiratRespirat

oryory

43%43% 39%39%

MexicoMexico77

22

DiarrheaDiarrhea 36%36% 34%34%

SE SE AsiaAsia7373

AfricaAfrica7373

PneumoPneumoniania

36%36%

95% CI 20-95% CI 20-4848

36%36%

95% CI 20-95% CI 20-49 49

Proposed Solutions for Proposed Solutions for Improved Improved

Pre-hospital Pediatric Pre-hospital Pediatric Emergency CareEmergency Care Define minimum standards for LR Define minimum standards for LR

settingssettings Integrate ALS guidelines within IMCIIntegrate ALS guidelines within IMCI Equip first-level responders for basic Equip first-level responders for basic

stabilization stabilization Determine more specific IMCI referral Determine more specific IMCI referral

criteria for serious conditionscriteria for serious conditions Utilize simple modes of emergency Utilize simple modes of emergency

transporttransport

Poor Quality Hospital Poor Quality Hospital CareCare

Poor quality is Poor quality is widespreadwidespread10,110,1

5,17, 19,30, 31,69,705,17, 19,30, 31,69,70

~50% deaths ~50% deaths of hospitalized of hospitalized children in children in LR settings LR settings occur occur within 24 within 24 hours of hours of admissionadmission

Proposed Solutions for Proposed Solutions for Improved Hospital Improved Hospital

Emergency & Critical CareEmergency & Critical CareNOTE: Strategies to improve overall NOTE: Strategies to improve overall

quality of care at hospital level in low-quality of care at hospital level in low-income countries are in progressincome countries are in progress6969

Update ETAT guidelines (latest Update ETAT guidelines (latest version 2005)version 2005)18,75-7718,75-77

Consider “limited-resource ICU” Consider “limited-resource ICU” offering continued, time-sensitive offering continued, time-sensitive treatment practical to local needs & treatment practical to local needs & limitationslimitations4,784,78

Systematic Approach to Systematic Approach to Patient Patient

Assessment & Categorization Assessment & Categorization of Illnessof Illness

Largely missing from existing Largely missing from existing ALS management in LR ALS management in LR settingssettings8,15,18,308,15,18,30

Improves early recognition of Improves early recognition of critical conditions, treatment critical conditions, treatment & outcomes (eg, pneumonia & outcomes (eg, pneumonia and shock)and shock)4,22,26,30,33,36,43,4,22,26,30,33,36,43, 70,72,79-8170,72,79-81

Existing Pediatric ALS Existing Pediatric ALS CoursesCourses

Mostly originate in full-resource Mostly originate in full-resource settingssettings Exception found in Africa: ETAT plus Exception found in Africa: ETAT plus

Admission Care CourseAdmission Care Course16,18,37,75-77,8216,18,37,75-77,82

Mostly applicable to full-resource Mostly applicable to full-resource settingssettings

Lack universal applicability despite Lack universal applicability despite international acceptanceinternational acceptance18,32,70,75,76,8318,32,70,75,76,83

Effectiveness in improving outcomes Effectiveness in improving outcomes in developing world has not been in developing world has not been shownshown8484

Existing Pediatric ALS Existing Pediatric ALS CoursesCourses

Offer variety of curricula, including:Offer variety of curricula, including: ““ABCDE” approach to patient assessmentABCDE” approach to patient assessment Standardized system of categorizing critical Standardized system of categorizing critical

illnessillness Treatment of specific emergency/trauma Treatment of specific emergency/trauma

conditionsconditions Revised curriculum with evidence-based Revised curriculum with evidence-based

application for LR settings would application for LR settings would expand usefulness worldwideexpand usefulness worldwide

Ideally should be taught from Ideally should be taught from community health level to larger community health level to larger hospitalshospitals

Table 2: Substitute Table 2: Substitute Pediatric ALS Pediatric ALS

Interventions in LR Interventions in LR SettingsSettings Unavailable Resource Unavailable Resource

Substitute ResourceSubstitute Resource

RESPIRATORY DISTRESS & FAILURERESPIRATORY DISTRESS & FAILURE

SHOCKSHOCK

BRADYCARDIA WITH PULSE & POOR BRADYCARDIA WITH PULSE & POOR PERFUSIONPERFUSION

SUPRAVENTRICULAR TACHYCARDIASUPRAVENTRICULAR TACHYCARDIA

VENTRICULAR TACHYCARDIA WITH PULSEVENTRICULAR TACHYCARDIA WITH PULSE

CARDIAC ARRESTCARDIAC ARREST

Note: see hardcopy Table 2 for full details

Empiric ALS GuidelinesEmpiric ALS Guidelines Most existing pediatric ALS Guidelines Most existing pediatric ALS Guidelines

in LR settings are empirical, not in LR settings are empirical, not evidence-basedevidence-based16,24,102,10916,24,102,109

Avoidance of OAvoidance of O22 masks for free-flow O masks for free-flow O22 delivery delivery Use of small fluid bolus then blood in Use of small fluid bolus then blood in

SAM/shockSAM/shock Use of broad-spectrum antibiotics in sepsisUse of broad-spectrum antibiotics in sepsis

Justification for empirical guidelines: Justification for empirical guidelines: pragmatism (eg. Opragmatism (eg. O22 mask consumes mask consumes less Oless O22 than nasal prongs) & lack of than nasal prongs) & lack of evidenceevidence110110

International Evidence-International Evidence-Based Based

ALS Guidelines for LR ALS Guidelines for LR SettingsSettings Evidence-based ALS Guidelines are Evidence-based ALS Guidelines are

needed:needed:MANAGEMENTMANAGEMENT16,32,43,46,49,54,66,95,111,11216,32,43,46,49,54,66,95,111,112

Fluid resuscitation in severe infection/shockFluid resuscitation in severe infection/shock Antibiotic management in sepsisAntibiotic management in sepsis Management of SAM (eg. sepsis, fluid Management of SAM (eg. sepsis, fluid

resuscitation, nutrition)resuscitation, nutrition)TRAININGTRAINING12,33,11312,33,113

Airway skillsAirway skills Implementing OImplementing O22 System System

(concentrators/pulse oximetry)(concentrators/pulse oximetry)

International Pediatric ALS International Pediatric ALS Guidelines: Hypoxemia & Guidelines: Hypoxemia &

Pulse OximetryPulse Oximetry Clinical indicators of hypoxemia:Clinical indicators of hypoxemia:7474

central cyanosis; nasal flaring; central cyanosis; nasal flaring; inability to drink or feed; grunting; inability to drink or feed; grunting; lethargy; consider also severe chest lethargy; consider also severe chest retractions, respiratory rate > retractions, respiratory rate > 70/min, head nodding70/min, head nodding7474

Pulse oximetry:Pulse oximetry:7474 use to detect use to detect hypoxemia & to guide oxygen hypoxemia & to guide oxygen therapytherapy7474

International Pediatric ALS International Pediatric ALS Guidelines:Guidelines:

Oxygen TherapyOxygen Therapy Indications:Indications:7474

SpO2 SpO2 << 90% ( 90% (<< 2500 m above sea 2500 m above sea level) SpO2 level) SpO2 << 87% (> 2500 m 87% (> 2500 m above sea level)above sea level)

Delivery systems:Delivery systems:7474 nasal prongs nasal prongs are preferred in children < 5 y; use are preferred in children < 5 y; use nasal or nasopharyngeal catheters nasal or nasopharyngeal catheters if nasal prongs are unavailableif nasal prongs are unavailable


Antibiotics-Very Severe Antibiotics-Very Severe PneumoniaPneumonia Very severe pneumonia:Very severe pneumonia:7474 cough or cough or

difficult breathing, chest in-drawing, difficult breathing, chest in-drawing, presence of danger signs (lethargy, presence of danger signs (lethargy, unconsciousness, inability to drink or unconsciousness, inability to drink or breastfeed, persistent vomiting, central breastfeed, persistent vomiting, central cyanosis, severe respiratory distress, or cyanosis, severe respiratory distress, or convulsions)convulsions)

Antibiotics:Antibiotics:7474 Ampicillin 50 mg/kg/dose Ampicillin 50 mg/kg/dose or Benzyl Penicillin 50,000 units/kg/dose or Benzyl Penicillin 50,000 units/kg/dose IV/IM every 6 hours + Gentamicin 7.5 IV/IM every 6 hours + Gentamicin 7.5 mg/kg/dose IV/IM every 24 hours for at mg/kg/dose IV/IM every 24 hours for at least 5 days; Ceftriaxone IV/IM if least 5 days; Ceftriaxone IV/IM if treatment failuretreatment failure For children aged 2-59 months


Antibiotics-Severe Antibiotics-Severe PneumoniaPneumonia

Severe pneumonia:Severe pneumonia:7474 cough or cough or difficult breathing, lower chest difficult breathing, lower chest in-drawing, no danger signsin-drawing, no danger signs

Antibiotics:Antibiotics:7474 Amoxicillin 40 Amoxicillin 40 mg/kg/dose orally twice daily for mg/kg/dose orally twice daily for 5 days5 days

For children aged 2-59 months


Antibiotics-Non Severe Antibiotics-Non Severe PneumoniaPneumonia Non-severe pneumonia:Non-severe pneumonia:7474

cough or difficult breathing, fast cough or difficult breathing, fast breathing, no danger signs + no breathing, no danger signs + no wheezewheeze

Antibiotics:Antibiotics:7474 Amoxicillin 40 Amoxicillin 40 mg/kg/dose orally twice daily for mg/kg/dose orally twice daily for 3 days (low HIV prevalence) or 3 days (low HIV prevalence) or for 5 days (high HIV prevalence)for 5 days (high HIV prevalence)

Referral:Referral:7474 recommended if recommended if treatment failuretreatment failureFor children aged 2-59 months


Antibiotics-Non Severe Antibiotics-Non Severe PneumoniaPneumonia

+ Wheeze + Wheeze Antibiotics:Antibiotics:7474

not not recommended recommended as the as the cause is cause is likely virallikely viral

For children aged 2-59 months


Fluid Resuscitation-Acute Fluid Resuscitation-Acute DiarrheaDiarrhea No signs of No signs of

dehydration (fluid dehydration (fluid deficit <5% BW):deficit <5% BW):114114 ORS replacement of ORS replacement of

ongoing losses, ieongoing losses, ie after each loose stool after each loose stool

give 50-100 mL (<2 give 50-100 mL (<2 y) y)

or 100-200 mL (2-10 or 100-200 mL (2-10 y)y)For child without

malnutrition


Fluid Resuscitation-Acute Fluid Resuscitation-Acute DiarrheaDiarrhea Some dehydration Some dehydration

(fluid deficit 5-10% (fluid deficit 5-10% BW):BW):114114

ORS (oral/NG) ORS (oral/NG) 75 mL/kg over 4 75 mL/kg over 4 hours in frequent hours in frequent small amountssmall amounts + replacement of + replacement of

ongoing lossesongoing losses

For child without malnutrition


Fluid Resuscitation-Acute Fluid Resuscitation-Acute DiarrheaDiarrhea Severe dehydration (fluid deficit >10% Severe dehydration (fluid deficit >10%

BW):BW):114114 Isotonic crystalloid —RL or NS (IV) Isotonic crystalloid —RL or NS (IV)

100 mL/kg (30 mL/kg over 1 hour then 100 mL/kg (30 mL/kg over 1 hour then 70 mL/kg over 5 hours (< 12 mo); 30 70 mL/kg over 5 hours (< 12 mo); 30 mL/kg over 0.5 hour then 70 mL/kg mL/kg over 0.5 hour then 70 mL/kg over 2.5 hours (over 2.5 hours (>> 12 mo) 12 mo)

may repeat as needed to restore may repeat as needed to restore normotension (detectable radial pulse)normotension (detectable radial pulse)


Fluid Resuscitation-Acute Fluid Resuscitation-Acute DiarrheaDiarrhea Severe dehydration (fluid deficit >10% Severe dehydration (fluid deficit >10%

BW):BW):114114 if IV therapy unavailable, give ORS if IV therapy unavailable, give ORS

(NG/oral) 120 mL/kg over 6 hours (20 (NG/oral) 120 mL/kg over 6 hours (20 mL/kg/hour)mL/kg/hour)

with improved LOC give ORS with improved LOC give ORS (oral/NG) 75 mL/kg over 4 hours in (oral/NG) 75 mL/kg over 4 hours in frequent small amountsfrequent small amounts

+ replacement of ongoing losses+ replacement of ongoing losses


Antibiotics-Bloody DiarrheaAntibiotics-Bloody Diarrhea Ciprofloxacin 15 mg/kg/dose Ciprofloxacin 15 mg/kg/dose

orally twice daily for 3 daysorally twice daily for 3 days7474

If treatment failure, Ceftriaxone If treatment failure, Ceftriaxone 50-80 mg/kg/dose IV/IM daily for 50-80 mg/kg/dose IV/IM daily for 3 days3 days7474

Follow guidelines according to Follow guidelines according to local sensitivitieslocal sensitivities7474


Zinc Treatment-Acute Zinc Treatment-Acute DiarrheaDiarrhea

Zinc Dosing Zinc Dosing (orally every 24 (orally every 24 hours for 10-14 hours for 10-14 days):days):102,114,115102,114,115 10 mg/dose 10 mg/dose

(< 6 (< 6 months) months)

20 mg/dose 20 mg/dose ( (>> 6 6 months) months)


Septic Shock Septic Shock Pediatric Sepsis Initiative:Pediatric Sepsis Initiative:36,11636,116

0 min:0 min: recognize decreased mental status recognize decreased mental status & perfusion; maintain airway & establish & perfusion; maintain airway & establish vascular access according to PALS vascular access according to PALS GuidelinesGuidelines

5 min:5 min: push 20 mL/kg isotonic saline or push 20 mL/kg isotonic saline or colloid boluses up to & over 60 mL/kg; colloid boluses up to & over 60 mL/kg; correct hypoglycemia & hypocalcemiacorrect hypoglycemia & hypocalcemia

15 min:15 min: observe if fluid-responsive shock; observe if fluid-responsive shock; begin dopamine if fluid-refractory shock begin dopamine if fluid-refractory shock (see further details of Initiative)(see further details of Initiative)


Antibiotics-Acute Bacterial Antibiotics-Acute Bacterial MeningitisMeningitis

Empiric treatment:Empiric treatment:7474 Ceftriaxone 50 mg/kg/dose IV Ceftriaxone 50 mg/kg/dose IV every 12 hours (may substitute every 12 hours (may substitute 100 mg/kg/dose once daily), or 100 mg/kg/dose once daily), or Cefotaxime 50 mg/kg/dose IV Cefotaxime 50 mg/kg/dose IV every 6 hours for 10-14 daysevery 6 hours for 10-14 days


Antibiotics-Acute Bacterial Antibiotics-Acute Bacterial MeningitisMeningitis No known significant resistance No known significant resistance

to Chloramphenicol and beta-to Chloramphenicol and beta-lactam antibiotics:lactam antibiotics:7474 Chloramphenicol 25 mg/kg/dose + Chloramphenicol 25 mg/kg/dose + Ampicillin 50 mg/kg/dose IM/IV Ampicillin 50 mg/kg/dose IM/IV every 6 hours, or Chloramphenicol every 6 hours, or Chloramphenicol 25 mg/kg/dose + Benzyl Penicillin 25 mg/kg/dose + Benzyl Penicillin 100,000 units/kg/dose IM/IV every 6 100,000 units/kg/dose IM/IV every 6 hourshours


Antibiotics-Typhoid FeverAntibiotics-Typhoid Fever Ciprofloxacin 15 mg/kg/dose orally Ciprofloxacin 15 mg/kg/dose orally

twice daily for 7-10 daystwice daily for 7-10 days7474

If treatment failure: Ceftriaxone If treatment failure: Ceftriaxone 80 mg/kg/dose IV every 24 hours 80 mg/kg/dose IV every 24 hours for 5-7 days, or Azithromycin 20 for 5-7 days, or Azithromycin 20 mg/kg/dose every 24 hours for 5-7 mg/kg/dose every 24 hours for 5-7 daysdays7474

Follow guidelines according to Follow guidelines according to local sensitivitieslocal sensitivities7474


Antibiotics-Severe Acute Antibiotics-Severe Acute MalnutritionMalnutrition

Benzyl penicillin 50,000 Benzyl penicillin 50,000 units/kg/dose, or Ampicillin 50 units/kg/dose, or Ampicillin 50 mg/kg/dose, IM/IV every 6 hours mg/kg/dose, IM/IV every 6 hours for 2 days, then Amoxicillin 15 for 2 days, then Amoxicillin 15 mg/kg/dose orally every 8 hours mg/kg/dose orally every 8 hours for 5 days for 5 days

+ Gentamicin 7.5 mg/kg/dose + Gentamicin 7.5 mg/kg/dose IM/IV every 24 hours for 7 daysIM/IV every 24 hours for 7 days7474

For children with complications

Table 3: Table 3: Pediatric ALS for Resp Pediatric ALS for Resp Distress/FailureDistress/Failure

LevLevelel

ALS InterventionALS Intervention UAUAOO

LALAOO

LTLTDD

DCDCBB

1-31-3 Open airwayOpen airway

1-31-3 MedicationsMedications

2-32-3 Pulse OximetryPulse Oximetry

2-32-3 Free-flow oxygenFree-flow oxygen

2-32-3 PPVPPV

33 Airway Surgical Airway Surgical ProceduresProcedures

Note: see hardcopy Table 3 for full details; UAO=upper airway obstruction; LAO= lower airway obstruction; LTD=lung tissue disease; DCB=disordered control breathing

Table 4: Pediatric ALS Table 4: Pediatric ALS for Shockfor Shock

LeveLevell

ALS ALS InterventionIntervention

HYPHYPOO

DISDISTT

CARCARDD

OBSOBSTT

1-31-3 Fluids—ORS/Fluids—ORS/Isotonic Isotonic Crystalloid/BloodCrystalloid/Blood

1-31-3 MedicationsMedications

1-31-3 WarmingWarming

1-31-3 Vagal Vagal maneuversmaneuvers

33 CardioversionCardioversion

33 Surgical Surgical ProceduresProcedures

Note: see hardcopy Table 4 for full details; HYPO=hypovolemic shock; DIST=distributive shock; CARD=cardiogenic shock; OBST=obstructive shock

COMPARISON BY LENGTH OF BROSELOW TAPE WEIGHT TO WHO WEIGHTBOYS 0-59 MONTHS

0

5

10

15

20

25

30

35

40

4548

.551

.954

.957

.560

.763

.566

.568

.571

.6 75 7880

.583

.8 8789

.792

.595

.498

.5 102

105

108

111

115

118

120

123

126

129

132

135

138

141

144

147

150

153

157

LENGTH (CM)

WEIGHT (KG)

WHO Wt Boy Pos 3SD

BT Wt 2011 Ed A

WHO Wt Boy Median

BT Wt 2007 Ed B

WHO Wt Boy Min 3SD

COMPARISON BY LENGTH OF BROSELOW TAPE WEIGHT TO WHO WEIGHTGIRLS 0-59 MONTHS

0

5

10

15

20

25

30

35

4045

48.5

51.9

54.9

57.5

60.7

63.5

66.5

68.5

71.6 75 78

80.5

83.8 87

89.7

92.5

95.4

98.5

102

105

108

111

115

118

120

123

126

129

132

135

138

141

144

147

150

153

157

LENGTH (CM)

WEIGHT (KG)

WHO Wt Girl Pos 3SD

BT Wt 2011 Ed A

WHO Wt Girl Median

BT Wt 2007 Ed B

WHO Wt Girl Min 3SD

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