Pediatric Emergency.
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Transcript of Pediatric Emergency.
EMERGENCY EMERGENCY PEDIATRICPEDIATRIC
PICU Subdiv. Child Health DeptMedical Faculty, University of Hasanuddin
Dr. Wahidin Sudirohusodo Hospital Makassar
DEMAM BERDARAH DENGUEDEMAM BERDARAH DENGUE
ETIOLOGI :
Dengue Virus (Den 1, Den 2, Den 3,
Den 4)
PATOGENESIS :
Tidak jelas
1. Hipotesis Infeksi Heterolog Sekunder
2. Teori virulensi virus
Patokan WHOPatokan WHO
LABORATORIUMLABORATORIUM
DIAGNOSA
Klinis :Klinis :
• Demam 2- 7 hari
• Perdarahan
• Hepatomegali
• Renjatan
• Trombositopeni (< 100.000/mm)
• Hemokonsentrasi (Ht Akut - Konv > 20% )
• Ht konv
WHO CLASSIFICATION OF DHF (1975)
KLASIFIKASI DERAJAT DBD
MONITORING
TREATMENT DBD derajat III & IV
1. Oksigenasi (berikan O2 2-4 l/menit)2. Penggantian volume plasma (cairan kristaloid isotonis) Ringer laktat/NaCl 0,9 % / Asering Bolus 100 -200 ml (10-30 menit) DBD Grade IV
20 ml/kgBB/jam ( 1 jam) DBD Grade IIIEvaluasi 30 menit, apakah syok teratasi ?
Syok teratasi Syok tidak teratasiKesadaran membaikNadi teraba kuatTekanan nadi > 20 mmHgTidak sesak nafas sianosisEkstremitas hangatDiuresis cukup 1 ml/kgBB/jam
Kesadaran menurunNadi lembut / tidak terabaTekanan nadi < 20 mmHgDistres pernafasan / sianosisKulit dingin dan lembabEkstremitas dinginPeriksa kadar gula darah
Cairan dan tetesan disesuaikan 10 ml/kgBB/jam (4-6 jam)
Pantau tanda vital tiap 15 menitCatat balans cairan selama pemberian intravena
Lanjutkan cairan 20 ml/kgBB/jam
Evaluasi ketatTanda vitalTanda perdarahanDiuresisHb, Ht, trombosit
Tambahkan koloid/plasma Dekstran/FPP10-20 (max 30) ml/kgBB/jam
Stabil dalam 24 jam/Ht < 40Tetesan 5 ml/kgBB/jam
Syok teratasiSyok belum teratasi
Koreksi asidosis Evaluasi 1 jam
Ht turun Ht tetap tinggi/ naikTetesan 3 ml/kgBB/jam
Infus stop tidak melebihi 48 jamsetelah syok teratasi
Tranfusi darahSegar 10 ml/kgBBdiulang sesuai kebutuhan
Koloid 20 ml/kgBB
RENJATAN SEPTIK
ETIOLOGI
Patofisiologi terjadinya syok septikInfeksi Bakteri
Endorfin Produk Bakteri mis. endotoksin
Aktivasi Komplemen
Makrofag
SitokinFaktor JaringanAktivasi PMN.
Pelepasan PAF, produkArakidonat dan
Substansi toksik lainAktivasi koagulasi
fibrinolisis
Aktivasi kalikreinkinin
Vasodilatasi,Kerusakan endotel
kapilerSyok Septik
Kebocoran kapiler,kerusakan endotel
Kegagalan Organ Berganda
Menggigil, hipertermi Takikardi Takipneu Hipotensi Apatis Gelisah Manifestasi perdarahan (peteki, purpura) Neonatus tdk spesifik (letargi, muntah, hipotermi/hipertermia)
DIAGNOSIS
PENGOBATAN
DIARE DEHIDRASI
TIPE DEHIDRASI
DERAJAT DEHIDRASI
1. Jumlah kehilangan cairan (PWL,NWL,CWL)
PemeriksaanPemeriksaan
Angka PenilaianAngka Penilaian
11 22 33
Gambaran KlinikGambaran Klinik
Keadaan umumKeadaan umum
MataMata
MulutMulut
PernapasanPernapasan
TurgorTurgor
NadiNadi
BaikBaik
NormalNormal
NormalNormal
20-30 per menit20-30 per menit
BaikBaik
Kuat / kurangKuat / kurang
120 per menit120 per menit
Lemah/hausLemah/haus
CekungCekung
KeringKering
30-40 per menit30-40 per menit
KurangKurang
120-140120-140
per menitper menit
Gelisah/renjatanGelisah/renjatan
Sangat cekungSangat cekung
Sangat keringSangat kering
40-60 per menit40-60 per menit
JelekJelek
Lebih 140Lebih 140
per menitper menit
Derajat dehidrasiDerajat dehidrasi skor 6skor 6
diare tanpadiare tanpa
dehidrasidehidrasi
skor 7-12skor 7-12
diare dehidrasidiare dehidrasi
ringan/sedangringan/sedang
skor 13 / lebihskor 13 / lebih
diare dehidrasidiare dehidrasi
beratberat
2. Manifestasi klinis ( sistem skoring)
PENGOBATAN
UmurUmur
Cara PemberianCara Pemberian
PermulaanPermulaan LanjutanLanjutan
DiareDiare
InfantilInfantil- PWL 125 mlPWL 125 ml- NWL 100 mlNWL 100 ml- CWL CWL 25 ml25 ml
250 ml250 ml
KoleraKolera
PWL 100 ml/kgPWL 100 ml/kg
4 jam pertama4 jam pertama
60 ml/kg60 ml/kg
1 jam pertama1 jam pertama
30 ml/kg30 ml/kg
20 jam berikut20 jam berikut
190 ml/kg190 ml/kg
7 jam berikut7 jam berikut
70 ml/kg70 ml/kg
PWL 100 ml/kgPWL 100 ml/kg
Bayi kurang12 bulanBayi kurang12 bulan
Anak sama atau lebih 12 Anak sama atau lebih 12 bulanbulan
1 jam pertama1 jam pertama
30 ml/kg30 ml/kg
½ jam pertama½ jam pertama
30 ml/kg30 ml/kg
5 jam berikut5 jam berikut
70 ml/kg70 ml/kg
2 ½ jam berikut2 ½ jam berikut
70 ml/kg70 ml/kg
IVFD : 2 tahun : Asering/R. asetat sist 24
jam 4 jam I : 5 tetes/kgbb/menit 20 jam II : 3 tetes/kgbb/menit > 2 tahun : Ringer laktat sistem 8
jam 1 jam I : 10 tetes/kgbb/menit 7 jam II : 3 tetes/kgbb/menit
STATUS ASMATIKUS
ETIOLOGI
PATOGENESIS
Classification of Severity of Acute Asthma Exacerbations
ParametersParametersMildMild ModerateModerate SevereSevere Respiratory Respiratory
Arrest Arrest ImminentImminent
BreathlessnessBreathlessness While While walkingwalking
While talkingWhile talking While at restWhile at rest
TalksTalks SentencesSentences PhrasesPhrases WordsWords
PositionPosition Can lie Can lie downdown
Prefers sittingPrefers sitting Sits uprightSits upright
AlertnessAlertness May be May be agitatedagitated
Usually Usually agitatedagitated
Always Always agitatedagitated
Confused/ Confused/ drowsydrowsy
CyanoticCyanotic -- -- ++ ++++++
WheezeWheeze Moderate, Moderate, often only often only end end expiratoryexpiratory
Loud, Loud, throughout throughout expiratoryexpiratory± inspiratory± inspiratory
Extremely loud, Extremely loud, can be heard can be heard without without stethoscopestethoscope
Absence of Absence of wheezewheeze
Breathlessness Breathlessness MinimalMinimal ModerateModerate SevereSevere
Use of accessory Use of accessory musclesmuscles
Usually notUsually not CommonlyCommonly AlwaysAlways
RetractionsRetractions Shallow, Shallow, intercostalsintercostals
Moderate, + Moderate, + suprasternalsuprasternal
Deep, + Deep, + flare of alae flare of alae nasinasi
--
Respiratory rateRespiratory rate IncreasedIncreased IncreasedIncreased IncreasedIncreased DecreasedDecreased
Guide to rates of breathing in awake children:Guide to rates of breathing in awake children:Age:Age: Normal rate:Normal rate:< 2 month < 60 / minute< 2 month < 60 / minute2-12 months < 50 / minute2-12 months < 50 / minute1-5 years < 40 / minute1-5 years < 40 / minute6-8 years < 30 / minute6-8 years < 30 / minute
PulsePulse NormalNormal TachycardiaTachycardia TachycardiaTachycardia BradycardiaBradycardia
Guide to normal pulse rates in children:Guide to normal pulse rates in children:Age:Age: N Normal rate:ormal rate:
2-12 months < 160 / minute2-12 months < 160 / minute1-2 years < 120 / minute1-2 years < 120 / minute3-8 years < 110 / minute3-8 years < 110 / minute
Pulsus Pulsus ParadoksusParadoksus
None None < 10 mmHg< 10 mmHg
(+) (+) 10-20 mmHg10-20 mmHg
(+) (+) > 20 mmHg> 20 mmHg
NoneNone
PEFR or FEV1PEFR or FEV1-before b.dilator-before b.dilator-after b.dilator-after b.dilator
(% pedicted (% pedicted vavalue)lue)> 60%> 60%> 80% > 80%
(( % best value) % best value)40-60%40-60%60-80%60-80%
< 40%< 40%< 60 %< 60 %respons < 2 respons < 2 jamjam
SaO2SaO2 > 95%> 95% 91-95%91-95% ≤≤ 90%90%
PaO2PaO2 NormalNormal > 60 mmHg> 60 mmHg < 60 mmHg< 60 mmHg
PaCO2PaCO2 < 45 mmHg< 45 mmHg < 45 mmHg< 45 mmHg > 45 mmHg> 45 mmHg
GEJALA KLINIS
Acute asthma algorithm
Clinic/ERAsses attack severity
1st management• nebulitation -agonis 3x, 20 min interval
•3rd nebulitation + anticholinergic
Moderate attack (nebulization 2-3x,
partial response)• give O2
• asses: Moderate – ODC
• IV line
Mild attack
(nebulization 1x, complete response)
• persist 1-2 hr: discharge
• symptom reappear: Moderate attack
Severe attack (nebulization 3x,
no response)
• O2 from the start•IV line•asses: Severe -
hospitalized• CXR
One Day Care (ODC)• Oxygen therapy• Oral steroid • Nebulized / 2 hour• Observe 8-12 hours, if stable discharge• Poor response in 12h, admission
Admission room• Oxygen therapy• Treat dehydration and acidosis • Steroid IV / 6-8 hours• Nebulized / 1-2 hours• Initial aminophylline IV, then maintenance• Nebulized 4-6x good response per 4-6 h• If stable in 24 hours discharge• Poor response ICU
Discharge• give -agonist (inhaled/oral)• routine drugs• viral infection: oral steroid • Outpatient clinic in 24-48 hours
Notes:• In severe attack, directly use -agonist + anticholinergic• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times •Oxygen therapy 2-4 l/min should be early treatment in moderate and severe attack
31
Figure. Jet nebulizer
32
Figure. Ultrasonic nebulizer
34
Dosis Obat untuk nebulizer
Obat NebulizerJet Ultrasound
NaCl 0.9% (ml) 5 10
2-agonist• Alupent sol. 2% (gtt)• Berotec 0.1% (gtt)• Ventolin nebule (mL)• Bricasma respule (mL)
3 – 5511
3-5511
Time (minutes) 10 - 15 3 - 5
PENANGANAN PICU
Obat di bgsl lanjut
Mechanical ventilator
STATUS EPILEPSI
NewbornNewborn 1-2 months1-2 months Infancy &childhoodInfancy &childhood
AcuteAcute CNS infectionCNS infection
Intracranial Intracranial HemorrhageHemorrhage
Hypoxic ischemicHypoxic ischemic
CNS infectionCNS infection
Subdural Subdural HemorrhageHemorrhage
AnoxiaAnoxia
CNS infectionCNS infection
Intracranial Intracranial HemorrhageHemorrhage
AnoxiaAnoxia
MetabolicMetabolic Electrolyte Electrolyte ImbalanceImbalance
Electrolyte Electrolyte ImbalanceImbalance
Electrolyte Electrolyte ImbalanceImbalance
MalformatiMalformationon
Neuronal Neuronal migrationmigration
Sturge-weber Sturge-weber
NeurofibromatosisNeurofibromatosis
OtherOther ToxinToxin
DrugsDrugsToxinToxin
DrugsDrugsFebrile ConvulsionFebrile Convulsion
DrugsDrugs
ETIOLOGI
PATOFISIOLOGI
KLASIFIKASI
PENGOBATAN
Tatalaksana status konvulsi
Kejang Diazepam rectal 0,5 mg/kgbb atau
BB < 10 kg :5 mg, BB > 10 kg :10mg Kejang (+)
Diazepam rectal 5 menit
Di Rumah Sakit
Pencarian akses venaLab: darah tepi, gula darah, elektrolit, ureum, kreatinin
Kejang (+) Diazepam IV 0,3 -0,5 mg/kgbb
Kecepatan 0,5-1 mg/menit (3-5 menit) (Hati-hati depresi nafas)
Kejang (+)
Fenitoin Initial dose bolus iv= 10 – 20 mg/kgbb/x dilarutkan dengan NaCl 0,9% dalam syringe pump sampai 50 cc dengan kecepatan 0,5-1 mg/kg/menit.
(Mulai dosis 10 mg bl tdk berespon naikkan jadi 20 mg)
Kejang (+) Kejang (-)
Phenobarbital 5-15mg/kg/hr/bolus iv Fenitoin maintanance dose : 5-7 mg/kg/hr
midazolam 0,2 mg/kg dilanjutkan (per 12 jam) dlm syringe pump 50 cc
Kejang (+) Ventilator mekanik
dilanjutkan 1-6 mg/iv/drips atau
dengan 0,1 – 4 mg/kg/jam
INTUSUSEPSI
PATHOFISIOLOGY Intussusceptions
Intususepsi ileoilealis, ileokolika, kolokolika
ETIOLOGI
GEJALA KLINIS
DIAGNOSIS
PENGOBATAN
HERNIA DIAFRAGMATIKA
Morgagni hernia
(Bochdalek Hernia)
(Hiatus esoph)
ETIOLOGI
GEJALA KLINIK
•Sesak•Takipnu•Sianosis
•Dinding torak yg tidak simetris•Takikardi
•Abdomen yg cekung•Bunyi nafas m’hilang di tempat defek•Bising usus dapat terdengar di paru
DIAGNOSIS
PENGOBATAN
SUDDEN INFANT DEATH SYNDROME
INSIDEN
PENYEBAB SIDS Belum diketahui Menidurkan bayi dgn posisi
tertelungkup Keterlambatan pada perkembangan sel
saraf dalam otak (aurosal/kewaspadaan thd hipoksia )
Rebreathing asphyxia: re-breathe carbon dioxide
Hypertermia
FAKTOR RESIKO SIDS
PEMERIKSAAN DAN TEST
PENANGANAN SIDS Saat di rumah (Telp RS /Call 911 for emergency medical
services, jika ada org tua atau pengasuh yg pernah diajarkan CPR bayi, mereka harus melakukan CPR sebelum paramedis datang)
Saat tiba Paramedis Oleh tim emergency sesuai pediatric
advanced life support protocols: Penanganan airway, breathing, nadi, gula darah. Pasang ETT, pasang infus, obat untuk memperbaiki denyut jantung.