Management of Emergencies in Children
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Transcript of Management of Emergencies in Children
Pediatric Critical Care Division,Child Health Department Sanglah Hospital, Faculty of Medicine University of Udayana
Introduction
providers must recognize these differences in order to provide the best possible care for an ill or injured child.
providers must recognize these differences in order to provide the best possible care for an ill or injured child.
• Children's bodies respond to significant injury and shock differently than adults.
• These differences may be subtle and difficult to recognize.
A child’s anatomy differs in four significant ways from an adult’s. They are:• Smaller airways
• Less blood volume • Bigger heads• Vulnerable internal organs
• Large tongue in relation to a small oropharynx
• Diameter of the trachea is smaller
• Trachea is not rigid and will collapse easily
• Back of the head is rounder and requires careful positioning to keep airway open
smaller airway smaller airway
• Relatively smaller blood volume
• Approximately 70 cc of blood for every 1kg (2 lbs) of body weight
• A 20 lb child has about 700cc of blood—about the volume of a medium sized soda cup
smaller airway smaller airway
less blood volume
less blood volume
• Head size is proportionally larger
• Prominent occiput and a relatively straight cervical spine
• Neck and associated support structures aren’t well developed
• Infants and small children are prone to falling because they are top heavy
less blood volume
less blood volume
bigger heads bigger heads
smaller airway smaller airway
• Internal organs are not well protected
• Soft bones and cartilage and lack of fat in the rib cage make internal organs susceptible to significant internal injuries
• Injury can occur with very little mechanism or obvious signs
bigger heads bigger heads
internal organs internal organs
less blood volume
less blood volume
smaller airway smaller airway
Infant: 1 to 12 months• Active extremity movement• Tracks object with eyes• Obstruction of the nose may cause
respiratory distress• Separation anxiety later in this
period• Provide sensory comfort such as a
warm stethoscope• Explain procedures in very simple
terms
Toddler: 1 to 3 years• Approach slowly & limit physical
contact• Most have stranger anxiety• Sit down or squat next to and use a
quiet voice• Not good at describing or localizing
pain• Use play and distraction objects• Have caregiver hold• Ask only yes/no questions• Get history from parent
Preschool Age: 3 to 5 years• Explain procedures in simple terms• Use games or distractions• Set limits on behaviors• Praise good behavior• Offer a stuffed animal or toy to hold• Do not allow to handle equipment
School Age: 6 to 12 years• Speak directly to the child• Be careful not to offer too much
information• Explain procedures immediately before
carrying them out• Don’t negotiate unless the child really
has a choice• Keep conversation with child to a
minimum
Adolescent: 12 to 15 years• Explain what you are doing and why• Show respect• Get history from patient if possible• Respect independence; address
directly• Allow parents to be involved in
examination if patient wishes• Consider asking questions about sexual
activity, drug/alcohol use privately
CNSRespiratoryCardiovascularGastrointestinalEndocrineEtc
The PAT
Appe
aran
ceW
ork of Breathing
Circulation to Skin
Respiratory distress
N
N
N
Cardiopulmonary failure
/
Shock
N
N
Primary CNS dysfunction/
metabolic abnormality
N
NN
N
N
AirwayBreathingCirculationDisabilityExposure
A state in which there is inadequate A state in which there is inadequate
tissue perfusion to meet metabolic tissue perfusion to meet metabolic
demandsdemands
It is not LOW BLOOD PRESSURE !!!It is HYPOPERFUSION…..
COMPENSATED
blood flow is normal or increased and may be maldistributed; vital organ function is maintained
UNCOMPENSATED
microvascular perfusion is compromised; significant reductions in effective circulating volume
IRREVERSIBLE
inadequate perfusion of vital organs; irreparable damage; death cannot be prevented
Hypovolemic or
Hemorrhagic
Cardiogenic
Obstructive
Distributive
Neurological: fluctuating mental status,
sunken fontanel
Cardio-pulmonary: tachypnea, tachycardia
Skin and extremities: cool, pallor, mottling,
cyanosis, poor cap refill, weak pulses
Renal: scant, concentrated urine
Always begin with Always begin with ABCsABCs
AirwayAirway: : must be patent, adequately oxygenated and ventilated
BreathingBreathing: always provide suplemental : always provide suplemental
oxygen oxygen
CirculationCirculation: vascular access, volume : vascular access, volume
expansionexpansion
Mainstay of therapy is fluid
Fluid challenge
Fluid loading
Fluid replacement
Fluid maintenance
Isotonic crystalloid is always a good choice
20 to 50 cc/kg rapidly if cardiac function is
normal
Degree of dehydration often
underestimated
Reassess perfusion, urine output, vital
signs
Treat underlying cause
Correct acidosis
Inotropic and vasoactive drugs: select to
optimized desire effect
The impaired ability of the
respiratory system to maintain
adequate oxygen and carbon
dioxide homeostasis
Two main categories:
Ventilation Oxygenation
Removal of waste CO2
Transfer of O2 from air in blood
Acute hypoxemic (Type I):
pneumoni
Ventilatory (Type II): asthma
Specific treatment vary according to
the underlying cause
Corrected hypoxemia
Reduced load on the respiratory
muscle
Optimized ventilatory pump capacity
Administration of supplemental oxygen Acute hypoxaemic or mixed respiratory
failure Simple mask, nasal cannulae, Venturi mask,
mask with rebreathing bag, oxygen tents Physiological effects of oxygen therapy Oxygen toxicity
Control of secretion Hydration
Control of secretion Mucolytic agents Chest physiotherapy Tracheal intubation and tracheostomy Respiratory stimulants
Control of infection Treatment of airways obstruction
-stimulants, ipratropium bromide, steroids
Control of lung water Optimizing ventilatory pump
capacity Malnutrition, catabolism, immobility,
metabolic disturbance Mechanical ventilatory support
Seizure : transient, involuntary alteration of
consciousness, behavior, motor activity,
sensation, and/or autonomic function
caused by an excessive rate and
hypersynchrony of discharges from a group
of cerebral neurons
Convulsion : seizure with prominent
alterations of motor activity
BREATHING
CIRCULATION
Ensure airway patency Jaw thrust, suctioning of the
oropharynx, use of adjunctive airways
(oral or nasopharyngeal) Considered intubation : hypoxia,
hypoventilation, GCS < 8 Supplemental oxygen provided and
respiration assisted as needed
BREATHING
CIRCULATION
Established intravena access or intraosseous
Hypotension or dehydration isotonoic fluid resuscitation
Hypoglycemia dextrose intravenously
Electrolyte abnormalities replaced appropirately
Diazepam 5-10 mg per rectal, max 2x, interval 5 mnt 0-10 minPrehospital
Diazepam 0.25-0.5 mg/kg iv/io, max dose 20 mg,rate 5mg/min
10-20 minHospital/ED ABC
Midazolam 0,2 mg/kg iv bolus
OR
OR
Lorazepam 0,5-1 mg/kg iv, rate < 2mg/min
Phenytoin 15-20 mg/kg iv, max 30 mg/kg,rate 20 min/50 ml NS
Phenobarbitone 20 mg/kg iv, max 1000 mg,rate >5-10 min (100mg/min)
Refracter
Midazolam 0.2-0.5 mg/kg iv bolus,followed by infusion 0.05-4 ,cg/kg/min
Pentotal 10-15 mg/kg iv then 2-5 mg/kg q 5 min to stop seizure, followed by infusion 1-3 mg/kg/hr
Tiopental 5 mg/kg iv then 1-2 mg/kg q 5 min to stop seizure, followed by infusion 3-5 mg/kg/hr
Propofol 2-5 mg/kg iv, followed byInfusion 25-65 mcg/kg/min
ICU/ED
ICU/ED
Additional 5-10 mg/kg iv
Additional 5-10 mg/kg iv
20-30 min
30-60 min
Statler KD. Status epilepticus. 2007Komisi Resusitasi Pediatrik. Konvulsi. 2006