Paediatric emergencies - Elsevier...active management of conditions that are life-threatening and...
Transcript of Paediatric emergencies - Elsevier...active management of conditions that are life-threatening and...
There are few situations that provoke greateranxiety than being called to see a child who isseriously ill. This chapter outlines a basic approachto the emergency management of seriously illchildren.
The seriously ill child
The rapid clinical assessment of the seriously illchild will identify if there is potential respiratory,circulatory or neurological failure. This should takeless than 1 minute. Normal vital signs are shown inFigure 6.1 and how a rapid assessment is performed in Figure 6.2. Resuscitation is given immediately ifnecessary, followed by secondary assessment andother emergency treatment.
The seriously ill child may present with shock,respiratory distress, as a drowsy/unconscious orfitting child or with a surgical emergency. Theircauses are listed in Figure 6.4. In children, the key tosuccessful outcome is the early recognition andactive management of conditions that are life-threatening and potentially reversible.
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Regarding the seriously ill child:• prevention of cardiopulmonary arrest is by early
recognition and treatment of respiratorydistress, respiratory or circulatory failure.
Summary
Respiratory rate
Heart rate
Systolic blood pressure
Olderchildren
25 20
Olderchildren
120 80
Infants
9070Young
children
80Older children
11090
Youngchildren
30 25Infants
40 30
Youngchildren
140 95Infants
160 110
100
Vital signs
The seriously ill child 71Cardiopulmonary resuscitation 72
The seriously injured child 76Shock 76
The febrile child 78Septicaemia 80
Coma 80Status epilepticus 83
Anaphylaxis 84Apparent life-threatening events 84
The death of a child 84
Figure 6.1 Variation in the normal range for respiratoryrate, heart rate and systolic blood pressure with age.
Doctors should be able to provide lifesupport for children of all ages, fromnewborn to adolescents.
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Cardiopulmonary resuscitation
In adults, cardiopulmonary arrest is often cardiac in origin, secondary to ischaemic heart disease. Incontrast, children usually have healthy hearts butexperience hypoxia from respiratory or neurolo-gical failure or shock. If this occurs, irrespective of the cause, basic life support must be startedimmediately.
Basic life support (Fig. 6.5)
Advanced life support (Fig. 6.6)
Children who have been resuscitated successfullyshould be transferred to a paediatric high-dependency or intensive care unit.
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The rapid clinical assessment:ABCDEShould take < 1 min
Airway and BreathingLook, listen and feel for:Airway obstruction or respiratory distressWork of breathing (respiratory effort)Respiratory rateStridor, wheezeAuscultation for air entryCyanosis
CirculationFeel and assess:Heart ratePulse volumeCapillary refill time (Fig 6.3)Blood pressure
DisabilityObserve and note:Level of consciousness (Box 6.1)Posture – hypotonia, decorticate, decerebratePupil size and reactivity
Exposure
Secondary assessment
Includes Basic/Advanced life supportConsider:Jaw and neck positioningOxygenSuction and foreign body removalSupporting breathingChest compressionMonitoring pulse oximetry and heart rate
History from:• parents• witnesses• general practitioner• paramedical staff• policeExamination including:• evidence of trauma• rash, e.g. meningococcal• smell, e.g. ketones, alcohol• scars, e.g. underlying congenital heart disease• MedicAlert braceletInvestigations• blood glucose
Other emergency interventions
Resuscitation (if necessary)
Assessment of the seriously ill child
Press on the skin of the sternum or a digit atthe level of the heartApply blanching pressure for 5 secondsMeasure time for blush to returnProlonged capillary refill if >2 seconds
Capillary refill time
Figure 6.3 Capillary refill time. Digital pressure for 5seconds. Normal <2 seconds.
Capillary refill time is affected by bodyexposure in a cold environment.
Figure 6.2 Assessment of the seriously ill child.
Box 6.1 AVPU rapid assessment of level ofconsciousness – more detailed evaluation is with theGlasgow Coma Scale (see Table 6.2)
A ALERTV Responds to VOICEP Responds to PAINU UNRESPONSIVE
A score of P means that the child’s airway is at risk and will need tobe maintained by a manoeuvre or adjunct.
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Examples
Meningitis/encephalitis
Trauma/non-accidental injury
AppendicitisPeritonitis
CausePresentation
HypovolaemiaDehydration – gastroenteritis Diabetic ketoacidosisBlood loss – trauma
ShockMaldistribution offluid
SepticaemiaAnaphylaxis
CardiogenicArrhythmiasHeart failure
Respiratorydistress
Upper airway obstruction(stridor)
Croup/epiglottitisForeign bodyCongenital malformationsTrauma
Lower airway disorders
AsthmaBronchiolitisPneumoniaPneumothorax
Post ictal Status epilepticus
Infection
The drowsy orunconsciousor seizingchild
Metabolic
Diabetic ketoacidosis, hypoglycaemia,electrolyte disturbances (calcium,magnesium, sodium), inborn errorof metabolism
Head injury
Drug/poison ingestion
Intracranial haemorrhage
Acute abdomenSurgical emergencies
Intestinal obstructionIntussusceptionMalrotationBowel atresia/stenosis
Presentation and causes of serious illness in children
Figure 6.4 The main modes of presentation of serious illness in children and their causes.
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Basic life support
Open airway:• Head tilt, chin lift• Jaw thrust (if unsuccessful)
Check breathing for max 10 secs:• Look, listen, feel
No breathing
BreatheRemove any obvious obstructionGive 5 initial rescue breaths
No pulse or <60/min
No response
Compress chestRate: 100 compressions/minCompression: Ventilation ratio forall children:Two rescuers – 15:2Lone rescuer – 30:2
Shout for helpApproach with careFree from dangerEvaluate ABC
SAFE approach
Chin lift in infants• Head in neutral position• Avoid overextension• Remove secretions/foreign body under direct vision
Chin lift in childrenHead in 'sniffing' positionJaw thrustTwo fingers of each hand behindeach side of the mandible and pushthe jaw forward
AirwayAirway opening using head tilt/chin lift manoeuvre
BreathingInfant: Mouth over infant's nose and mouthChild: Pinch nose, mouth to mouthThe chest should rise with each breath
CirculationOptimal position for chest compression
a) Infant. Two thumbs on lower third of sternum with hands round the thorax (needs two rescuers).b) Small child. Heel of one hand over lower third of sternum.c) Large child. Both hands over lower third of sternum. Depress the sternum by onethird of the depth of the chest
Check responsiveness:Ask 'Are you all right?'StimulateDo not shake children withsuspected cervical spine injury
Check pulse for max 10 secs: >1 year old – carotid<1 year old – brachial
a
c
b
Figure 6.5 Basic life support. (Adapted from Resuscitation Guidelines, Resuscitation Council (UK), 2005.)
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Advanced life support
Establish Basic Life Support
Airway and BreathingIntubate and ventilate with highconcentration O2
CirculationOnce intubated:Compression rate 100/min continuouslyVentilation rate 10/minEstablish intravenous access, if delayuse intraosseous route
Internal diameter (mm) = (age/4) + 4Length for oral tube (cm) = (age/2) + 12Lengh for nasal tube (cm) = (age/2) + 15
Formula for endotracheal tube size by age in whole years
Technique to establish intraosseous infusion in the tibia• 18 gauge trochar with needle• Anterior surface, 2–3cm below tibial tuberosity
Shockable
Ventricular fibrillation(VF) or pulselessVentricular tachycardia (VT)
Attachdefibrillator/monitor
Assess rhythm
Non-shockable
Pulseless electrical activity(PEA) or asystole
1st DC shock 4 J/kg or AEDContinue CPR for 2 min
Check monitor - still VF/VT:2nd DC shock 4 J/kg or AEDResume CPR for 2 min
Check monitor - still VF/VT:Amiodarone 5 mg/kg IV4th DC shock 4 J/kg or AED
Resume CPR for 2 min cyclesGive epinephrine (adrenaline)before every other shock
Considerreversiblecauses
Check monitor - still VF/VT:Epinephrine (adrenaline)10 μg/kg (0.1 ml/kg of 1 in1000 solution) IV or IO3rd DC shock 4 J/kg or AEDResume CPR for 2 min
During CPR:Correct reversible causes:• Hypoxia• Hypovolaemia• Hypo/hyperkalaemia• Hypothermia <33 °C• Tension pneumothorax• Tamponade• Toxins• Thromboembolism
Check electrode position and contactEstablish IV/IO access
If automated external defibrillator (AED):• child 1–8 years – deliver paediatric-attenuated adult shock energy• child >8 years old – use adult shock therapy
Ventilate with highconcentration O2Continue CPR
Epinephrine (adrenaline)10 µg/kg (0.1 ml/kg of 1 in1000 solution) IV or IO
Consider reversiblecauses andalkalisingagents
Continue CPRRepeat epinephrine(adrenaline) every 3–5 min
Figure 6.6 Advanced life support. (Adapted from Resuscitation Guidelines, Resuscitation Council (UK), 2005.)
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The seriously injured child
Management of the seriously injured child musttake account of potential injury to the cervical spineand other bones and internal injuries (Fig. 6.7).
Shock
Shock is present when the circulation is inadequateto meet the demands of the tissues. Critically ill
children are often in shock, usually because ofhypovolaemia due to fluid loss or maldistributionof fluid, as occurs in sepsis or intestinal obstruction.
Why are children so susceptible to fluidloss?
Children normally require a much higher fluid intakeper kilogram of body weight than adults (Table 6.1).This is because they have a higher surface area tovolume ratio and a higher basal metabolic rate.Children may therefore become dehydrated if:
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Management of the seriously injured child
Primary survey
Secondary survey (once condition stabilised)
Airway andcervicalspine
Assume cervical spine damageNeck movements may injure spine
Only use jaw thrust and chin lift to open airwayNo neck extensionSecure neck with rigid cervical collar and sandbagsDiscontinue immobilisation only after cervicalspine X-rays and neurological examination arefound to be normal
Breathing Give high-flow O2 via face mask.If inadequate commence ventilation
Asymmetry of percussion note or breath sounds• consider: pneumothorax or haemothorax, which need to be drained immediately, misplaced endotracheal tube
Disability
Assess consciousness
Secure airwayProvide respiratory support if GlasgowComa Scale < 8 or at ‘P’ on AVPU scale
Assess pupil size and reactivity If unequal or abnormal – serious headinjury
Exposure
Examine all parts of bodyConsider analgesiaConsider gastric tube (not nasaltube in head injury)
Remove all clothingAvoid hypothermia and embarrassment!
ExaminePerform furtherinvestigations
Circulationandhaemorrhagecontrol
Bleeding from superficial wound?
If in shock, is there internal bleeding?Consider X-rays of chest and pelvisShock does not occur from isolatedhead injury beyond infancy
Apply pressure to stop bleeding.
Insert two large venous cannulaeTake blood for FBC, group and cross-matchGive crystalloid 20 ml/kg and reassessSeek surgical opinion, as likely to be rupturedliver, spleen or fractured pelvis or longbone
Identify all injuriesProvide emergencytreatment and definitivecare
Figure 6.7 Management of the seriously injured child.
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• they are unable to take oral fluids• there are additional fluid losses due to fever,
diarrhoea or increased insensible losses (e.g. due toincreased sweating or tachypnoea)
• there is loss of the normal fluid-retainingmechanisms, e.g. burns, the permeable skin ofpremature infants, increased urinary losses orcapillary leak.
Clinical features
The clinical features of shock are due to compen-satory physiological mechanisms to maintain thecirculation and the direct effects of poor perfusionof tissues and organs (Box 6.2). In early, com-pensated shock, the blood pressure is maintainedby increased heart and respiratory rates, re-distribution of blood from venous reserve volumeand diversion of blood flow from non-essentialtissues such as the skin in the peripheries, whichbecome cold. In shock due to dehydration, there isusually >10% loss of body weight (see Ch. 13) and aprofound metabolic acidosis and it is compoundedby failure to feed and drink whilst severely ill. Afteracute blood loss or redistribution of blood volumebecause of infection, low blood pressure is a latefeature. It signifies that compensatory responses are failing. In late or uncompensated shock,compensatory mechanisms fail and blood pressurefalls and lactic acidosis increases. It is important torecognise early, compensated shock, as this isreversible, in contrast to uncompensated shock,which may be irreversible.
Management priorities
Fluid resuscitationRapid restoration of the intravascular circulatingvolume is the priority (Fig. 6.8). This will usually bewith 0.9% saline, or blood if following trauma.
Subsequent management
If there is no improvement following fluid resus-citation or there is progression of shock andrespiratory failure, a paediatric intensive care unitshould be involved and transfer arranged as thechild may need:
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Shock
0.9% saline or blood(20 ml/kg)
Improvement
Correction ofhypovolaemia
x2 if necessary
No improvement
Intensive care
Shock in children:• is often from hypovolaemia• the early signs of compensated shock are from
increased sympathetic tone – tachycardia, pallorand peripheral vasoconstriction (prolongedcapillary refill time); its recognition is importantas at this stage it is reversible
• fluid therapy is the key to its successfultreatment.
Summary
Box 6.2 Clinical signs of shock
Early (compensated) Late (decompensated)Tachypnoea Acidotic (Kussmaul) Tachycardia breathingDecreased skin turgor BradycardiaSunken eyes and Confusion/depressed fontanelle cerebral stateDelayed capillary refill Blue peripheries(>2 s) Absent urine outputMottled, pale, cold skin HypotensionCore–peripheral temperature gap (>4°C)Decreased urinary output
Table 6.1 Fluid intake at different ages
Body weight Fluid requirement/24 h Volume/kg per hour (approximate)
First 10 kg 100 ml/kg 4 ml/kgSecond 10 kg 50 ml/kg 2 ml/kgSubsequent kg 20 ml/kg 1 ml/kg
Examples of calculationsWeight of child Fluid requirement/24 h Volume per hour (approximate)
Infant 7 kg 700 ml 28 ml/hChild 18 kg 1000 + 400 = 1400 ml 40 + 16 = 56 ml/hAdolescent 62 kg 1000 + 500 + 840 = 2340 ml 40 + 20 + 42 = 102 ml/h
Figure 6.8 Initial fluid resuscitation in shock.
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• tracheal intubation and mechanical ventilation• invasive monitoring of blood pressure• inotropic support• correction of haematological, biochemical and
metabolic derangements• support for renal or liver failure.
The febrile child
Most febrile children have a brief, self-limiting viral infection. Mild localised infections, e.g. otitismedia or tonsillitis, may be diagnosed clinically.The clinical problem lies in identifying therelatively few children with a serious invasivebacterial infection which needs prompt treatment.
Factors which need to be considered are:
• past medical history• illness of other family members• if a specific illness is prevalent in the community
• immunisation status• recent travel abroad, e.g. malaria, typhoid• contact with animals, e.g. brucellosis• predisposition to infection, e.g. nephrotic
syndrome, sickle cell disease, HIV infection,chemotherapy for malignant disease or, rarely, a primary immunodeficiency.
Initial assessment, investigations andmanagement
Some diagnostic clues to evaluating the febrile childare shown in Figures 6.9 and 6.10. Infants andtoddlers often present with non-specific signs. Ifthey are suspected of having a severe bacterial in-fection, urgent investigations called a septic screen(Box 6.3) are performed and intravenous antibiotictherapy given immediately to avoid the illnessbecoming more severe and to prevent rapid spreadto other sites of the body. In febrile infants less
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Upper respiratory tract infectionVery common, may be
coincidental with anothermore serious illness
Osteomyelitis or septicarthritisSuspect if painful bone or jointor reluctance to move limb
Otitis mediaAlways examine tympanic
membranes in febrile children
Periorbital cellulitisRedness and swelling of theeyelids.May spread to orbit of the eyeTonsillitis
Erythema or exudate onthe tonsils
RashViral exanthem?Purpura from meningococcalinfection (Fig.6.10)?
Abdominal painAppendicitis?Pyelonephritis?Hepatitis?
PneumoniaIn infants, only raised
respiratory rate andincreased respiratory effort
may be present, with noabnormality on
auscultation – diagnosis may require chest x-ray
DiarrhoeaGastroenteritis?Fever with blood and mucusin the stool:Shigella, Salmonella orCampylobacter
Urinary tract infectionUrine sample needed for anyseriously ill young childor any febrile illness that doesnot settle
SeizureFebrile convulsion?Meningitis?Encephalitis?
SepticaemiaCan be difficult to recognise in
absence of rash before shockdevelops.
Need to start antibioticson clinical suspicion without
waiting for culture results
Meningitis/encephalitisLethargy, loss of interest in
surroundings, drowsiness orunconscious or seizures.
Neck stiffness, arching of the back,bulging fontanelle, positive
Kernig’s sign (pain on legstraightening)?
Only non-specific symptoms andsigns may be present in young
children < 18 months
Prolonged feverBacterial infection e.g. UTI,bacterial endocarditisOther infections – viral, fungal,protozoalKawasaki's diseaseDrug reactionMalignant diseaseConnective tissue disorder
StridorEpiglottitis?Viral croup?
Bacterial tracheitis?
The febrile child
Figure 6.9 Some diagnostic clues to evaluating the febrile child.
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than 2 months old, identifying serious bacterialinfection is unreliable from clinical examinationalone, and a septic screen and antibiotic therapy are indicated. Other factors which influence theselection of which children to investigate and treatare shown in Figure 6.11. Children who are notseriously ill can be managed at home with regularreview by the parents as long as they are given clearinstructions (e.g. what clinical features shouldprompt reassessment by a doctor).
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Box 6.3 Septic screen
Full blood count including differential white cellcountBlood cultureAcute-phase reactant, e.g. C-reactive proteinUrine for microscopy, culture and sensitivityCSF (unless contraindicated) for microscopy,culture and sensitivityChest X-ray
Threshold for urgentinvestigation(septic screen) andintravenous antibiotics Low
High
Factors indicativeof illness severity
Young age (treat if <2 months old)Systemically ill
High or prolonged feverFeatures of potentially serious illness
e.g. osteomyelitis, septic arthritis,septicaemia, meningitis/encephalitis
No localising featuresPredisposition to infection
e.g. immunodeficiency
Older childNot systemically ill
Low grade feverNo features of potentially
serious illnessLocalised, minor illness,e.g. URTI, otitis media
Normal child
The febrile child:• upper respiratory tract infection (URTI) is an
extremely common cause• check for otitis media• serious bacterial infection must be considered• if fever in an infant is unexplained, exclude a
urinary tract infection• the younger the child the lower the threshold
for performing a septic screen and startingantibiotics.
SummaryFigure 6.10 The glass test for meningococcal purpura.Parents are advised to suspect meningococcal disease iftheir child is febrile and has a rash that does not blanchewhen pressed under a glass. (Courtesy of Dr ParvizHabibi.)
Figure 6.11 Evaluation of the need for urgent investigation and treatment in the febrile child.
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Septicaemia
Bacteria may cause a focal infection or proliferate in the bloodstream, leading to septicaemia. Insepticaemia, the host response includes the releaseof inflammatory cytokines and activation of endo-thelial cells which may lead to septic shock. Thecommonest cause of septic shock in childhood ismeningococcal infection, which may or may not be accompanied by meningitis. Fortunately, itsincidence in the UK has fallen markedly sinceimmunisation was introduced. Pneumococcus is thecommonest organism causing bacteraemia, but it is unusual for it to cause septic shock. In neonates,the commonest causes of septicaemia are group Bstreptococcus or Gram-negative organismsacquired from the birth canal.
Clinical features
See Box 6.4.
Management priorities
Children with septic shock will need to be rapidlystabilised and may require transfer to a paediatricintensive care unit.
AntibioticsChoice depends on the child’s age and anypredisposition to infection.
FluidsSignificant hypovolaemia is often present, owing to fluid maldistribution, which occurs due to therelease of vasoactive mediators by host inflamma-tory and endothelial cells. There is loss of intra-vascular proteins and fluid which may occur due tothe development of a ‘capillary leak’ caused byendothelial cell dysfunction. Circulating plasmavolume is lost into the interstitial fluid. Centralvenous pressure monitoring and urinary catheter-isation may be required to guide the assessment offluid balance. Capillary leak into the lungs causespulmonary oedema, which may lead to respiratoryfailure, necessitating mechanical ventilation.
Circulatory supportMyocardial dysfunction occurs as inflammatorycytokines and circulating toxins depress myocardialcontractility. Inotropic support may be required.
Disseminated intravascular coagulation (DIC)Abnormal blood clotting causes widespread micro-vascular thrombosis and consumption of clotting
factors. If bleeding occurs, clotting derangementshould be corrected with fresh frozen plasma andplatelet transfusions.
SteroidsThere is no evidence that steroids are of benefit inseptic shock.
Coma
In coma, there is disturbance of the functioning of the cerebral hemispheres and/or the reticularactivating system of the brainstem. The level ofawareness may range from excessive drowsiness to unconsciousness. It is assessed by rapidly usingAVPU or the Glasgow Coma Scale (Table 6.2).
The immediate assessment of a child in coma isshown in Figures 6.12 and 6.13. The causes, clinicalfeatures and investigations of coma are listed inTable 6.3. In contrast to adults, most children have a diffuse metabolic insult rather than a structurallesion.
The history, examination and investigation ofcoma are directed towards the cause. Treatmentshould be directed to treatable causes, especiallyinfection.
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Box 6.4 Clinical features of septicaemia
History ExaminationFever FeverPoor feeding Purpuric rash Miserable (meningococcal Lethargy septicaemia)History of focal infection, e.g. Irritabilitymeningitis, osteomyelitis, Shockgastroenteritis, cellulitis Multi-organ failurePredisposing conditions, e.g. sickle cell disease, immunodeficiency
Septicaemia:• the most common cause of septic shock in
children is meningococcal disease• may occur without meningitis• early antibiotic therapy and fluid resuscitation
are life-saving• may need admission to paediatric intensive care
for multi-organ failure.
Summary
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Com
a
Primary assessmentand
resuscitation
Airway – is it secure?Breathing – is respiratory effort sufficient?Circulation – treat shock Disability – check blood glucose – AVPU or Glasgow Coma ScaleExposure – e.g. look for meningococcal purpuric rash
Secondary assessmentand
emergency treatment
Examination• Is there raised intracranial pressure – abnormal breathing, posture, pupils (Fig. 6.13), fundi (papilloedema or retinal haemorrhages)?• Bradycardia and hypertension suggest impending brain stem herniation
Treat the treatable:• hypoglycaemia• poisoning• diabetes mellitus• septicaemia/meningitis• herpes simplex encephalitis
Intubate and ventilate if necessary, transfer to paediatric/neurosurgicalintensive care unit
Initial assessment and management of coma
Pinpoint, fixedOpiates/barbituratesPontine lesion
Fixed, dilatedSevere hypoxiaDuring/post-seizuresAnticholinergic drugsHypothermia
Unilateral dilated pupilExpanding ipsilateral lesionTentorial herniationThird nerve lesionSeizures
Figure 6.12 Initial assessment and management of coma.
Table 6.2 Glasgow Coma Scale, incorporating Children’s Coma Scale
Glasgow Coma Scale Children’s Coma Scale(4-15 years) (<4 years)
Response Response Score
Eyes Open spontaneously Open spontaneously 4Verbal command React to speech 3Pain React to pain 2No response No response 1
Best motor responseVerbal command Obeys Spontaneous or obeys verbal command 6Painful stimulus Localises pain Localises pain 5
Withdraws Withdraws 4Abnormal flexion Abnormal flexion (decorticate posture) 3Extension Abnormal extension (decerebrate posture) 2No response No response 1
Best verbal response Oriented and converses Smiles, orientated to sounds, follows 5objects, interacts
Disoriented and converses Fewer than usual words, spontaneous 4irritable cry
Inappropriate words Cries only to pain 3Incomprehensible sounds Moans to pain 2No response No response to pain 1
A score of <8 out of 15 means that the child’s airway is at risk and will need to be maintained by a manoeuvre or adjunct.
Figure 6.13 Pupillary signs in coma.
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Table 6.3 Causes, history and examination, and investigation of coma
Cause History and examination Diagnostic investigations
InfectionMeningitis or Fever Full blood countmeningoencephalitis Irritability, lethargy, drowsiness Culture of blood, urine, infected sites,
Poor feeding CSF (unless contraindicated) for bacteria Rash, e.g. meningococcal purpura and virusesSeizures Acute-phase reactantOverseas travel Rapid bacterial antigen/PCR tests for
organisms
MetabolicDiabetes mellitus Previously diagnosed diabetes mellitus Blood glucose, plasma electrolytes
Diabetic ketoacidosis Urine for glucose and ketonesBlood gas analysis
Inborn errors of metabolism Previous history of loss of consciousness Blood glucoseSudden collapse Blood gas analysisConsanguinity Blood ammonia, lactateDevelopmental delay Urine amino and organic acidsDeath or illness of siblings Plasma amino acidsHepatomegaly
Hepatic failure Jaundice Abnormal liver function testsAbnormal bleeding Prolonged prothrombin time
Acute renal failure Oliguria Abnormal creatinineHypertension
Hypoglycaemia Any acutely ill child Low blood glucoseKnown diabetes mellitusSudden onset of coma
Poisoning Accidental – poison usually identified Toxicology screenDeliberate – tablets may be found, also Plasma level for paracetamol and illicit drugs and alcohol salicylates
Status epilepticus or Past history of seizures Blood glucosepost-ictal Neurocutaneous lesions on the skin Electrolytes – sodium, potassium, calcium,
Developmental delay magnesiumOngoing seizure activity, e.g. abnormal Drug levels if on anticonvulsantseye movements EEGFocal neurological signs CT scan
Trauma – accidental/ History of road traffic accident, fall, etc. Radiological – plain X-rays or CT/MRI scansnon-accidental Bruising, haemorrhage
Fractures – cervical spine, etc.Focal neurologyRetinal haemorrhages
Intracranial tumour or Raised intracranial pressure: Cranial CT/MRI scanhaemorrhage/infarct/ • headache worse on lying down Coagulation screenabscess • early morning vomiting Screen for procoagulant disorders (protein
• focal neurological signs, e.g. squint, C and S deficiency)ataxia Echocardiogram to exclude infective
• personality change endocarditis• papilloedema/retinal haemorrhage• hypertension
Hypertension Symptoms and signs of raised intracranial Left ventricular hypertrophy on ECGpressure or echocardiographyFundoscopy – hypertensive changes Creatinine and electrolytesHigh blood pressure
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Status epilepticus
This is a seizure lasting 30 minutes or longer, orwhen successive seizures occur so frequently that
the patient does not recover consciousness betweenthem. After immediate primary assessment andresuscitation, the priority is to stop the seizure asquickly as possible (Fig. 6.14).
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No response in10 min
Airway, Breathing, Circulation
Check blood glucoseIf blood glucose is <3 mmol/L, give glucose IV
and recheck blood glucose
Vascular access
IV access
No vascular access
No IV accessNo response in10 min
No response in 10 mincall for senior help
No response in5 min
Lorazepam 0.1 mg/kg IV
Lorazepam 0.1 mg/kg
Paraldehyde 0.4 ml/kg PR
Phenytoin 18 mg/kg IV/IO over 20 min orPhenobarbital 15 mg/kg if on oral phenytoin
Rapid-sequence induction with thiopentoneMechanical ventilation
Transfer to PICU
Stop fitting withanticonvulsant
All these drugs maycause or compound
preexisting respiratorydepression, and
mechanical ventilationmay be required
Call anaesthetist or intensivistNo response in 20 min
Diazepam 0.5 mg/kg PRor Midazolam (buccal) 0.5mg/kg
Management protocol for status epilepticus
Figure 6.14 Management protocol for status epilepticus. (Adapted from Advanced Paediatric Life Support, BMJPublishing Group, London, 2005.)
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Anaphylaxis
In children, the most common causes are ingestionor contact with nuts, egg, milk or drugs. Urticariaand angioedema causing facial swelling are treatedwith an oral antihistamine (e.g. chlorphenamine)and observed over 2 hours for possible complica-tions. Anaphylaxis is life-threatening, from laryn-geal oedema, brochoconstriction and shock. Itsmanagement is outlined in Figure 6.15. Childrenwho have had a serious allergic reaction shouldcarry an epinephrine (adrenaline) auto-injector (e.g.Epipen) with them so that treatment can be initiatedimmediately.
Apparent life-threatening events (ALTE)
These occur in infants and are a combination ofapnoea, colour change, alteration in muscle tone,choking or gagging, which are frightening to theobserver. They may occur on more than one occa-sion. ALTEs may be the presentation of a potentiallyserious disorder, although often no cause isidentified.
Management requires a detailed history andthorough examination to identify problems withthe baby or in care-giving. The infant should beadmitted to hospital. Causes and investigations tobe considered are listed in Box 6.5. Multi-channelovernight monitoring is usually indicated.
In most, the episode is brief, with rapid recovery,and the baby is well clinically. Baseline investiga-tions and overnight monitoring of oxygen satura-tion, respiration and ECG are found to be normal.The parents should be taught resuscitation and willfind it helpful to receive follow-up from a specialistpaediatric nurse and paediatrician.
Detailed specialist investigation and assessmentwill be required if clinical, biochemical or physiol-ogical abnormalities are identified.
The death of a child
The risk of death is four times greater duringinfancy than at any other age in childhood. In many,a serious condition will have been diagnosed beforeor after birth, such as a congenital abnormality orcomplications of prematurity. Deaths which occursuddenly and unexpectedly in infancy are knownas sudden unexpected death in infancy (SUDI). In some, a previously undiagnosed congenitalabnormality, e.g. congenital heart disease, will befound at autopsy. Rarely, an inherited metabolic
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History compatible with severe allergic reactionStridor, wheeze, respiratory distress or shock+/- urticaria
Evaluate ABCOxygen if available
Epinephrine (adrenaline) IM(If profound shock – consider slow IV infusion of epinephrine (adrenaline) wheeze)If stridor – consider inhaled epinephrine (adrenaline)salbutamol
Repeat epinephrine (adrenaline) IM in 5 minutesif no improvementIf shock – give 20 ml/kg IV fluids
Antihistamine (chlorphenamine) IMHydrocortisone IM or slow IV
Immediate management of anaphylaxis
Figure 6.15 Management of anaphylaxis.
Box 6.5 Causes and investigations to be consideredin apparent life-threatening events
Causes
Infections – respiratory syncytial virus (RSV),pertussisSeizuresGastro-oesophageal reflux (present in one-third ofnormal infants)Upper airways obstruction – natural or imposedNo cause identified
Uncommon
Cardiac arrhythmiaBreath-holdingAnaemiaHeavy wrapping/heat stressCentral hypoventilation syndromeCyanotic spells from intrapulmonary shunting
Investigations to be considered
Blood glucose (as soon as possible)Blood gas (as soon as possible)Oxygen saturation monitoringCardiorespiratory monitoringEEGOesophageal pH monitoringBarium swallowFull blood countUrea and electrolytes, liver function testsLactateUrine (collect and freeze first sample)– metabolic studies– microscopy and culture– toxicologyECG – for QTc conduction pathway abnormalityChest X-rayLumbar puncture
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disorder is identified, in particular the fatty acidoxidation defect medium-chain acyl-CoA dehydro-genase deficiency (MCAD), which can very rarelyresult in sudden death in infants, but is increasinglyidentified in the UK from routine biochemicalscreening (Guthrie test) as the test for this disorderis being introduced more widely. After 1 month ofage, in most instances of sudden and unexplaineddeath, no cause is identified and the death isclassified as sudden infant death syndrome (SIDS).The vast majority of such deaths, even whenoccurring several times in the same family, are dueto natural causes. Rarely, the death may be due tosuffocation or other forms of non-accidental injury. In 2003, in the UK, three mothers imprisonedafter the loss of more than one infant had theirconvictions overturned. This followed concernabout the standard of proof required from medicalexpert witnesses in the absence of eye witnessevidence of harmful conduct and about the qualityof the procedures adopted during the investigationof the deaths. Since then, new procedures have beenrecommended in order to prevent unwarrantedincrimination of parents whilst also protectingother infants and children in the family from risk ofinjury.
Sudden infant death syndrome
This is defined as the sudden and unexpected deathof an infant or young child for which no adequatecause is found after a thorough postmortemexamination. There is marked variation in theincidence of SIDS in different countries, suggestingthat environmental factors are important (Box 6.6).SIDS occurs most commonly at 2–4 months of age(Fig. 6.16). The risk for subsequent children isslightly increased.
In the UK, the incidence of SIDS has fallendramatically during the last few years (Fig. 6.17),coinciding with a national ‘Back to Sleep’ campaign(Fig. 6.18). This advocates that:
• infants should be put to sleep on their back (not their front or side)
• overheating by heavy wrapping and high roomtemperature should be avoided
• infants should be placed in the ‘feet to foot’position
• parents should not smoke near their infants
85
The death
of a child
Box 6.6 Factors associated with SIDS (based on datafrom Fleming P et al, Sudden unexpected deaths ininfancy, The Stationery Office, London, 2000, withpermission)
The infant
Age 1–6 months, peak at 12 weeksLow birthweight and preterm (but 60% are normalbirthweight term infants)Sex (boys 60%)Multiple births
The parents
Low income*Poor or overcrowded housingMaternal age (mother aged <20 years has threetimes the risk of a mother aged 25–29 years, but80% of affected mothers are >20 years old)*Single unsupported mother (twice the rate ofsupported mothers)High maternal parity*Maternal smoking during pregnancy (1–9cigarettes/day doubles the risk: >20/day increasesthe risk fivefold)*Parental smoking after baby’s birth
The environment
The infant sleeps lying proneThe infant is overheated from high roomtemperature and too may clothes and covers,particularly when ill
*Three of these four factors are present in over 40% of SIDS but only8% of control families.
20
15
10
5
0
Age (months)
1 2 3 4 5 6 7 8 9 10 11 12
%
Figure 6.16 Age distribution of SIDS. (Based on datafrom Fleming P et al, Sudden unexpected deaths ininfancy, The Stationery Office, London, 2000, withpermission.)
Figure 6.17 Decline in the number of deaths from SIDSin the UK from 1.9/1000 live births in 1989 to 0.41 in2004.
Year
SID
s p
er 1
000
live
bir
ths
2
0
1.6
1.2
0.8
0.4
19901992
19941996
19982000
20022004
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• parents should seek medical advice promptly iftheir infant becomes unwell
• parents should have the baby in their bedroom forthe first 6 months of life
• parents should avoid bringing the baby into theirbed when they are tired or have taken alcohol,sedative medicines or drugs
• parents should avoid sleeping with their infant ona sofa, settee or armchair.
Following the sudden death of a child
The sudden death of a child is one of the mostdistressing events that can happen to a family. Ifclose family members are absent, arrangementsshould be made for them to come, if this is possible.The family should be spoken to sympatheticallyand in private (see Ch. 5). An outline of therecommended management after an infant has died suddenly and unexpectedly is shown in Figure 6.19.
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6Paediatric em
erg
encies
Following an unexpected death:• the parents should be offered the opportunity
to see and hold their child• the coroner must be informed and a
postmortem performed• the parents should be informed about the
postmortem, that investigations will beperformed and that the police will be involvedand reassured that this is standard practice
• follow-up and bereavement counselling shouldbe offered.
Summary
°C
40
30
20
10
-10
0
Lie infant on back Do not smoke during pregnancy orin the same room as infant
No. of cigarettes smoked/day20 plus
x10
x8
x6
x4
x2
010-191-9
Incr
ease
in ri
sk o
f SID
S
Avoid overheating Place in ‘feet to foot position’
Keep head uncovered
Hot
Cold
Comfortable(16-20°C)
Prevention of sudden infant death syndrome
Sudden infant death syndrome (SIDS):• is the commonest cause of death in children
aged 1 month to 1 year• the peak age is 2–4 months• has been dramatically reduced by lying babies
on their back to sleep.
Summary
Figure 6.18 Key features of the ‘Backto Sleep’ campaign.
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87
The death
of a child
ResuscitationInfant found dead at home – take to Accident and Emergency DepartmentInitiate resuscitation unless inappropriate
Care ofparents
Should be cared for by specific member of staffHistory should be obtained
Babypronounced dead
Detailed clinical examination by consultantRemove endotracheal tube and intraosseous needles but retain venous linesRetain child's clothes and any bedding and nappy for policeInvestigations performed:• Nasopharyngeal aspirate for virology and bacteriology• Blood for toxicology, metabolic screen (on Guthrie card), chromosomes if dysmorphic• Blood culture • Urine (catheter specimen) – for biochemistry, toxicology and freeze immediately• Lumbar puncture – CSF for virology and routine culture, if clinically indicatedSUDI paediatrician, coroner, police and primary care team and other healthcare professionalsinformed
Performed by the paediatrician. Explain that the police and coroner will be involved,a post-mortem is required, tissue blocks and slides will be taken and retained permanentlyas part of the medical record.Give parents the opportunity to donate tissues and organsInform them that the involvement of the police does not imply that they are beingblamed for their child's death
Parents should be offered the opportunity to see and hold their child. Encourage as helpsthem accept the reality of their child's death. They may wish to see the child again withinthe next few days. The family may wish a minister of religion to be called.
Initial strategydiscussion
SUDI paediatrician and supervising police officerSocial services review to identify if previously involved or any child protection issues
Home visitwithin 24 hours
Police visit the home to talk with the parents and examine the place where the baby diedSUDI paediatrician may also attendDetailed history obtainedReport compiled for the coroner
Post-mortem Performed by paediatric pathologistPreliminary post-mortem result
Case discussion
Multi-agency meeting, including SUDI paediatrician, police, GP/health visitor and,where appropriate, the social workerAll relevant information reviewedPossibility of abuse or neglect consideredReport is sent to the coronerPaediatrician writes a detailed letter to the parents providing information about thecause of the infant's death and arranges to meet them
Follow-up andbereavementcounselling
Follow-up to provide family an opportunity to discuss the final results of the postmortemand consider its implications for future pregnancies. Genetic counselling may be indicated.Bereavement counselling – available from health professionals and other agencies
Breaking thenews to theparents
Parents offeredto see and holdtheir baby
Management of the sudden unexpected death of an infant
Figure 6.19 A recommended approach to the management of the sudden unexpected death of an infant. There arelocal variations in its implementation. (Adapted from Sudden Unexpected Death in Infancy. RCPCH, London, 2004.)
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Further reading
Goldman A, Hain R, Lieben S 2005 The Oxfordtextbook of palliative care in children. OxfordUniversity Press, Oxford. Medical, psychological andpractical issues of caring for terminally ill children andtheir families
Advanced Life Support Group 2005 AdvancedPaediatric Life Support. The Practical Approach, 4th Edn. Blackwell BMJ Books
RCPCH 2004 Sudden unexpected death in infancy.The report of a working group convened by the RoyalCollege of Pathologists and The Royal College ofPaediatrics and Child Health. RCPCH, London(www.rcpath.org and www.rcpch.ac.uk).
Resuscitation Council (UK) 2005 Updated guidelineson paediatric life support
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