Pediatric Emergencies for Rural Pediatrics

Ron Kaplan, MD, FAWMClinical Associate Professor Of Pediatrics Division of Emergency MedicineUniversity of Washington School of MedicineSeattle Children’s Hospital

Pediatric Emergencies for Rural Pediatrics

• Many pediatric emergencies can be managed initially in the remote setting

• Principles may be applied in the tertiary care setting

Pediatric Emergencies for Rural Pediatrics

• Dehydration associated with acute GI illness• Status asthmaticus• Status epilepticus

Objectives

• Provide rehydration and symptomatic treatment for the child with acute GI illness without an IV

• Provide emergency treatment for the child with status asthmaticus without power

• Manage the child with status epilepticus without an IV

Dehydration

Dehydration: Background

• 2.5 million childhood deaths annually worldwide

• In the US:• >200,000 hospitalizations• >1.5 million outpatient visits• 300 deaths• Estimated costs >1 billion dollars

Oral Rehydration Therapy

• Steady decline in mortality over the last few decades

• Decrease in ED visits, hospitalizations and cost

• Established guidelines by WHO, CDC, AAP • Two meta-analyses of RCTs document

efficacy

Oral Rehydration Therapy

• Two meta-analyses comparing ORT to IVT in children younger than 15 with gastroenteritis• 16 trials from 1988-2003

• 1545 children• 11 countries• One-half in developing countries

• 18 studies from 1982-2005• 1811 patients• One-half in developing countries

Oral Rehydration Therapy

• Across all 16 trials, ORT failure rate 4%• Reduced hospital stay with ORT in three

trials in developed countries• No difference in frequency of stools, duration

of diarrhea or weight gain• IVT more expensive• No significant difference in major adverse

events

Oral Rehydration Therapy

• Across18 studies slightly more treatment failures with ORT• One failure for every 25 patients with ORT

compared to IVT• Reduced hospital stay with ORT in 6 trials• No difference in weight gain, duration, total

fluid intake, hypo- or hypernatremia

Oral Rehydration Therapy

• ORT is as effective as IVT in children with mild to moderate dehydration caused by diarrhea

• ORT IS THE TREATMENT OF FIRST CHOICE

Oral Rehydration Therapy

• Standard commercial ORS• Treatment divided into two phases

• Rehydration• Maintenance

Oral Rehydration Therapy: Rehydration Phase

• Fluid deficit replaced over 3-4 hours• Frequent small amounts by spoon, syringe,

NG tube• 5 ml every 1-2 minutes = 150-300 ml/hr• 50 ml/kg over 4 hours for mild dehydration• 100 ml/kg over 4 hours for moderate dehydration

• Continue breastfeeding

Oral Rehydration Therapy: Maintenance Phase

• Ongoing losses replaced with ORS• 10 ml/kg per diarrheal stool• 2 ml/kg per emesis

• Rapid return to unrestricted diet

Oral Rehydration Solutions

• Total osmolality 200-310 mmol/L• Equimolar concentrations of glucose and

sodium• Glucose concentration < 20g/L (111 mmol/L)• Sodium concentration 60-90 meq/L

ORT: Physiologic Basis

Oral Rehydration Solutions

• Standard commercial ORS• WHO ORS, Pedialyte, etc.

• Sports drinks, juice, soft drinks, Jell-O, popsicles?• Too much sugar, too little sodium

• Chicken soup???• Too much sodium

Oral Rehydration Solutions

Oral Rehydration Solutions

Dehydration: Symptomatic Treatment

• Antiemetics?• Antidiarrheals?• Antibiotics?• Probiotics?

Dehydration: Antiemetics

• Meta-analysis of 11 trials of antiemetics in gastroenteritis• Ondansetron

• Decreases further vomiting• Reduced need for IV fluids• Decreases hospitalization rates

• Others• No evidence of efficacy• Potentially dangerous

Dehydration: Ondansetron

• 2 mg for 8-15 kg• 4 mg for 15-30 kg• 8 mg for >30 kg

Dehydration: Diarrhea

• Antidiarrheals• Avoid in general• ? antimotility agent with antibiotics for severe

travelers’ diarrhea• Antibiotics

• Ditto• Probiotics

• Lactobacillus GG

Dehydration: Summary

• ORT is as effective as IV hydration in mild-moderate dehydration

• ORT is the treatment of first choice in these patients

• Ondansetron is useful for vomiting• Avoid antibiotics and antidiarrheals except

some travelers’ diarrhea• Lactobacillus GG couldn’t hurt• Remember the NG tube!

Status Asthmaticus

Status Asthmaticus

• Treatment aimed at reversing airflow obstruction due to bronchospasm and airway inflammation• Inhaled beta agonists• Systemic glucocorticoids• Other

• Treatment principles are the same in the remote setting as in the ICU

Inhaled Beta Agonists

• MDI vs Nebulizer• MDI convenient, cost-effective• High rate of lost drug with neb• Lower risk of bacterial contamination with MDI• MDI technique-dependent

• Clinical trials and meta-analyses suggest MDI is at least as effective as neb

MDI with Spacer

• Spacer corrects for poor MDI technique• Can be used in very small children• Spacer can be made from a 500 ml plastic

bottle

Homemade Spacer

MDI with Spacer: Technique

• Assemble, shake• Place in mouth or apply mask• Breathe normally• Actuate MDI at start of inspiration• One puff at a time• Deep breath, hold for 10 seconds• For small child, 6 breaths per puff• Wait 30-60 seconds between puffs

Albuterol MDI: Dosing

• Four puffs = 2.5 mg neb• Standard dose 4-8 puffs• 30 mg/hr neb = 48 puffs!!!

Asthma: Steroids

• Effects within 2-4 hours• NAEPP guidelines: oral preferred to IV

• Effects are equivalent• Less invasive• Consider IM if oral dose vomited

• Prednisone vs. Dexamethasone• ? Inhaled steroids

Asthma: Steroids

• Prednisone 2 mg/kg initial dose• Half-life 18-36 hours

• Dexamethasone 0.6 mg/kg• Half-life 36-72 hours• 4 mg tablets convenient, crush and mix with food

Asthma: Steroids

• Single dose of IM dex as effective as 5 days of PO pred

• Single dose of PO dex similar to 5 days of BID prednisolone

• Two doses of PO dex similar to 5 days of PO pred with improved compliance, fewer side effects

Asthma: Treatment

• Inhaled steroids: mixed results, not routinely recommended

• Ipratropium MDI• Don’t use if peanut or soy allergy

• Subcutaneous epinephrine or terbutaline

Status Asthmaticus: Summary

• Albuterol MDI with spacer at least as good as nebs• Don’t be shy with dosing

• Oral steroids as good as IV• Dex convenient, long acting, better compliance

• Consider subcutaneous epi or terb• Ipratropium MDI if no peanut/soy allergy• Inhaled steroids if you don’t have PO

Status Epilepticus

Status Epilepticus

• Many seizure meds may be given without an IV• IV access may be delayed or impossible even

if available• Strict EMS/ED protocols may result in

unnecessary IV therapy in many children• Unnecessary IV therapy may cause excessive

sedation and respiratory depression

Status Epilepticus

• Alternative routes of administration• Oral• Intramuscular• Transmucosal

• Rectal• Buccal• Intranasal

Seizure Medications: Oral

• Oral loading may be possible if the child is conscious and not actively seizing• Phenobarbital• Phenytoin• Valproic acid• Oxcarbazepine• Levetiracetam

Seizure Medications: Intramuscular

• Benzodiazepines• Fosphenytoin• Barbiturates• Paraldehyde

Seizure Medications: Transmucosal

• Safe, effective, well tolerated, absorbed quickly

• Avoids treatment delays related to transport and IV access

• Allows earlier treatment at home or in the field

Seizure Medications: Rectal

• Diazepam• Paraldehyde• Anything available as an oral suspension

• Clonazepam• Carbamazepine, Oxcarbazepine• Valproate• Levetiracetam

Seizure Medications: Rectal Diazepam

• Effective and safe• Rectal gel in prefilled syringe• Long shelf life• Does not require refrigeration• Respiratory depression extremely rare

Seizure Medications: Rectal Diazepam

• Round dose to 2.5, 5, 7.5, 10, 12.5, 15, 17.5 and 20 mg/dose

• Diastat® 2.5 mg rectal gel• Diastat Accudial®

• 10 mg [delivers a 5mg, 7.5mg, or 10mg dose] • 20 mg [delivers a 10mg, 12.5mg, 15mg, 17.5mg,

or 20mg dose]

Diastat Accudial®

Seizure Medications: Buccal Midazolam

• At least as effective as rectal diazepam• More socially acceptable

• Shorter time to treatment with buccal midazolam compared to IV diazepam

• Similar risk of respiratory depression

Seizure Medications: Buccal Midazolam

• IV preparation• 6-12 months: 2.5 mg• 1-4 years: 5 mg• 5-9 years: 7.5 mg• > 10 years: 10 mg

Seizure Medications: Intranasal Midazolam

• IV or IN preparation• 0.2 mg/kg

• Faster cessation of seizures, less respiratory depression compared to rectal diazepam

• Preferred to rectal diazepam in community settings

Mucosal Atomization Device

Seizure Medications: Intranasal Midazolam

• Prehospital IN midazolam protocol using Mucosal Atomization Device• Controlled seizures better than rectal diazepam• Fewer respiratory complications• Fewer admissions

Status Epilepticus: Summary

• Transmucosal benzos are treatment of choice if IV not available• Rectal diazepam• Buccal/Intranasal midazolam

• Consider IM benzos, fosphenytoin• Consider oral loading if conscious, not

actively seizing

Pediatric Emergencies for Rural Pediatrics

• Common pediatric emergencies may be managed without sophisticated equipment• ORT, symptomatic treatment for dehydration• MDI, oral steroids for asthma• Transmucosal meds for seizures

• Principles apply in the tertiary care center