Pediatric Emergencies

Pediatric EmergenciesBy: Adam Khoo Christabel Amanina Yee Lai Mei Ameera Yeong Uen Yea

Assessment of a Child Pediatric Assessment TriangleAppearanceEffort of BreathingCirculation to Skin

Appearance

TICLSTechniques: Observe from a distance, allow child to be with caregiver, use distractions like bright lights, get down to eye level with child. Hands on approach may cause child to cry, making examination difficult.

The apparently well child:Severe acute intoxication by paracetamol, iron, cyclic antidepressants may cause a child to have early benign presentations and develop lethal complications in minutes or hours. Children with blunt traumaThe irritable/inconsolable childSign of inadequate brain perfusionAlternate between lethargy and irritabilityGlassy eyed stare a sign of altered consciousness.

Severe acute intoxication by paracetamol, iron, cyclic antidepressants may cause a child to have early benign presentations and develop lethal complications in minutes or hours.Children with blunt trauma may be able to maintain core perfusion despite internal bleeding by increasing cardiac output and systemic vascular resistance. When compensatory mechanisms fail, the child may progress rapidly to clinical shock.

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Effort of BreathingListen: Abnormal breath soundsLook: Increased respiratory effortAbnormal Breath SoundsVisual signsAltered tone of voice/Stridor= Upper airway obstructionGrunting = hypoxia/ lower airway obstruction

Head bobbing/tripoding: abnormal positionsRetractions: increased effort of to move air into lungsNasal flaring: effort to increase ventilationand oxygenation = hypoxia

Grunting = attempt to keep alveolar sacs open for maximum gas exchangeHead bobbing/tripoding: a childs instinctive attempt to increase airway patencyRetractions: Suprasternal, intercostal and subcostal recessions5

Combining Appearance and Effort of BreathingNormal appearance + increased effort of breathing = Respiratory distress

Abnormal appearance + increased effort of breathing = Early respiratory failure

Abnormal appearance + decreased effort of breathing = Late respiratory failure

Circulation of Skin

When cardiac output is inadequate, the body reduces perfusion of blood from the non essential organs ie. Skin to the essential organs ie. Brain, liver, kidneys.

Pallor is an early sign of shock. Late signs are mottling and cyanosis, which signify a loss of compensatory mechanisms.

# Cold may give false positive skin signs like mottling and cyanosis.

Primary SurveyAirway Breathing Circulation

AirwayAbnormal breath sounds indicate ANY upper or lower airway obstructions.Head Tilt chin lift maneuvre in children with no neck or head trauma. Jaw thrust otherwise.Intubate if indicated.

Asthmatic children in severe distress may have minimal wheeze. Obstruction just below vocal cords may cause little stridor.Size of ETT : 4 + (Age in years / 4) 11

BreathingRapid rates may be due to anxiety, pain or high fever. Normal rates may be due to fatigue from breathing rapidlyVery rapid (>60 breaths/min: any age) with abnormal appearance and retractions may indicate respiratory distress or failure.Abnormally slow indicate respiratory failure Watch out:< 20/min for child < 2 years old or< 10/min for child > 2 years old. Through ETT: 100% oxygen at a rate of 12 20 breaths/min, using tidal volume necessary for adequate chest rise and relieve cyanosis.

CirculationChildren in compensated shock are tachypnoiec.Pulse and Capillary refill timeBlood pressure: low BP in decompensated shock, normal BP in compensated shock. Heart rate: Inverse with ageMay be due to hypoxia or low tissue perfusion or due to fever, anxiety or pain

Effortlesstachypnea, no retractions, as an attempt to overcome metabolic acidosis. 13

Shock

Hypovolemic shock

Loss of blood (external/internal)Loss of plasma (burns)Loss of fluids (vomiting, diarrhea, sweating)Traumatic shock: associated with neurogenic shock; severe pain inhibits vasomotor center

Cardiogenic ShockFailure of the heart as an efficient pump to maintain cardiac outputMyocardial infarctionArrythmiaValvular disorder

Obstructive ShockObstruction of diastolic filling of the heartPulmonary embolismCardiac tamponadeTension pneumothorax

Distributive ShockDue to massive exudation of plasma from blood vessels to the interstitial spaces. Neurogenic shock: due to marked reduction in sympathetic vasomotor tone (deep GA, spinal anesthesia, spinal injury, brain concussion)Anaphylactic shock: reduced TPR due to release of histamine. Vasodilation and increased capillary permeability leading to excessive exudationSepticemic shock: bacterial toxins that produce vasodilation. Acts systemically by stimulation cellular metabolism and produce fever.

Cushings ReflexCerebral Perfusion Pressure = CPPIntracranial Pressure = ICPMean Arterial Pressure = MAPCPP = MAP ICPCardiovascular receptors: Carotid and aortic sinus (Baroreceptors)

Carotid sinus: dilation of internal carotid artery above bifurcation of common carotid. Aortic sinus: transverse part of aortic arch, adjacent to the root of the left subclavian artery19

Cushing ReflexFirst StageSecond StageThird Stage

Triage System

Triage System at UMMCPrimary TriageProactive triage: outside A&EStatic Triage: counterSecondary TriageVital signs assesmentFirst aid and initial treatmentDefinitive TriageTriage and rapid sequence examination at various zones of patient management

Triage ZonesRed Zone; T1Life threatening (ABCD problems)Limb threateningTime Critical (Thrombolytic Therapy)Yellow Zone; T2May progress to life/limb threatening conditions or morbidity if not treated in 30 mins. Relief of severe painIn a trolleyGreen Zone; G1, G2, G3, G4

G1, Fast-trackSenior citizen >65 years oldAcute back or flank pain, Score 15 minutesGeneralized seizureFocal seizureDoes not recur during the febrile episode>1 seizure during the febrile episodeResidual neurological deficit post-ictally (i.e. Todds paralysis)

Question 3DDX

DifferentialExampleInfection meningitis/ encephalitis UTITrauma brain lesion (in head trauma, intracranial bleed) shaken baby syndromeMetabolic hypoglycemia hypocalcemia / hypomagnesemia hypo- or hypernatremiaOthers poisons/toxins/drugs hypoxic ischemic insult

Question 4Must be done if (unless contraindicated)Any signs of intracranial infectionPrior antibiotic therapyPersistent lethargy and not fully interactive 6 hours after the seizureStrongly recommended ifAge < 12 months old1st complex febrile convulsionIn district hospital w/o peadiatricianParents have a problem bringing the child in again if deterioration at home

Question 5Indications:To exclude intracranial pathology especially infectionFear of recurrent fitsTo investigate and treat the cause of fever besides meningitis or encephalitisTo allay parental anxiety, especially if they are staying far from the hospital

Question 6Disadvantages:LethargyDrowsinessAtaxiaMasking of CNS infection

Question 7Febrile seizures remain a benign condition

Prognosis in febrile seizuresFebrile convulsions are benign events with excellent prognosis 3-4% of population have febrile convulsions 30% recurrence after 1st attack 48% recurrence after 2nd attack 2-7 % develop subsequent afebrile seizure or epilepsy no evidence of permanent neurological deficits following febrile convulsions or even febrile status epilepticus no deaths were reported from simple febrile convulsion

Control fever:Take off clothing and tepid spongingAntipyretic i.e. syrup or rectal Paracetamol 15mg/kg 6 hourly*antipyretic is indicated for patients comfort, but has not been shown to reduce the recurrence rate of febrile convulsion.

First aid measuresKeep calm and note time of onset of fitLoosen childs clothing, esp. around the neckPlace child in the left lateral position with the head lower than the bodyWipe and vomitus or secretion from the mouthDo no insert any object into the mouth even if the teeth are clenchedDo not give any fluids or drugs orallyStay near the child until the convulsion is over and comfort the child as he/she is recovering

Question 5 month old child presents to the emergency room with generalized tonic clonic seizure activity of about 30-min duration that stops upon administration of lorazepam. The most helpful information to gather from the mother would be:Whether the child has had congestion without fever for the past 3 daysWhether the child is developmentally normal, as are his siblingsWhether the mother has been diluting the infants formula to make it last longerThe number of pets at homeWhether the mother works as a secretary in an energy trading firm

Answer is C lol45

A 8-year old girl Fever , RN , cough 4 daysAbrupt onset of high grade fever + chillsFever reduced by Paracetamol but recurredGeneralised rashesAbdominal pain , vomiting 1-2 times and diarrhea 4-5 times per dayReduced appetite and reduced activityNo recent travel history and eating outside foodPast medical hx bronchial asthma (well-controlled)No drug or food allergy

SCENARIO 2

Differential diagnosisDengue fever

Acute gastroenteritis

URTI secondary to bronchial asthma

What to look for in physical examinationAssess mental state ans GCS scoreAssess hydration statusAssess haemodynamic status skin colourCold/warm extremitiesCRT (normal 2s)BLOOD PRESSURENORMALNORMAL/LOWLOW/UNRECORDABLEURINARY OUTPUTREDUCEDREDUCEDMARKED OLIGURIAPULSE RATENORMALRAPIDRAPID,WEAK,MAY IMPALPABLEEYESNORMAL OR SUNKENSUNKEN GROSSLY SUNKENANTERIOR FRONTANELLEFLATSUNKENVERY SUNKEN

InvestigationsFull blood count- WCC: high indicate bacterial infection:low indicate dengue fever-platelet:low dengue fever-haematocrit : high dengue fever ( can also be low after hydration)BUSE- to see the hydration status and any electrolyte imbalanceLiver function test- AST / ALT increase in dengue feverABG , coagulation profileDengue serology

Management (dengue fever)Whether to admit or go back homeIf admission not indicated, daily or frequent f/up is necessaryespecially from day 3 illness untill patient becomes afebrile for at least 24-48hCriteria for admission-sx: warning signs, bleeding manifestations, inability to tolerate fluids orally,reduced urine output,seizure-signs: dehydration, shock, bleeding, any organ failure-rising HCT accompanied by thrombocytopenia

Febrile phaserest antipyreticno aspirin (why?)no antibiotic is necessaryORS / IV therapy food should be given according to appetitePlatelet 50000& risingNo respiratory distress

QUIZDengue fever :-What kind of rash can you see in dengueList the warning signs

ANSWERA) isles of white in the sea of red & blanchingB) intense abdominal pain- persistent vomiting-clinical fluid accumulation-mucosal bleed-lethargy, restlessness-liver enlargement >2cm-lab : increase Hct with concurrent rapid decrease in Plt count.

Scenario 3A 3 year old Malay boy presents to ED by his parents with 2 days history of coughing. He has low grade fever, rapid breathing and audible wheeze.

DDxCommonAsthma, URTI, pneumonia, bronchiolitis, viral wheeze

Less common but 'important not to miss'Aspiration of foreign body, whooping cough

UncommonCongenital lung abnormality, congenital cardiovascular abnormality

History3rd attack of cough and wheeze, no hospitalization before, attack once yearly

Antenatal history was normal, SVD, full term

No developmental delay, Immunization is up to date

History of eczema & allergic rhinitis NKD/FA

Not compliance to the inhaler with spacer

Negative family history

Positive sick contact at day care

There is cat at home

Father is a smoker and smokes even at home

Rapid Triage Assessment

RR: 44 breaths/min (Tachypnoea)

HR: 140 bpm (Tachycardia)

SpO2: 90% (Low)

Temperature: 37.8 C (Low-grade)

Physical ExaminationGeneral examination: alert, looks agitated, respiratory distress (tachypnea, nasal flaring, use of accessory muscles), injected pharynx, no cyanosis or clubbing

Respiratory system: audible wheeze, subcostal and intercostal recession, hyperresonance, generalized rhonchi

Absence of liver dullness and cardiac dullness.

Other systemic examinations were normal.

InvestigationO2 saturation -90%Peak Expiratory Flow Rate(PEFR) - not done as the child is under 5y/oCXR and blood investigations- notroutinely indicatedMonitor electrolyte (hypoK is complication of 2-agonist)

Management Pharmacological method:Reassure the child and parentsGive oxygen via mask Short-acting 2-agonist(SABA), salbutamol via nebulizer Oral steroid, Prednisolone 1-2mg/kg (14 mg) is started and continues SABA (patients weight: 7kg)

SEVERE ASTHMA EXACERBATION!!!

The patient improves with the treatment given. He has no more dyspnea, audible wheeze and his lung is clear. He is then discharged home.

Non-pharmacological method:Educate the parents and child about importance of compliance to inhaler, allergen avoidance, smoking cessation as well as Influenza and pneumococcal vaccination.

Quizzes (True/False with negative marking)

Asthma usually leads to permanent damage of the lungs if not treated.

Childrens asthma is commonly caused by allergy.

Child with moderate asthma exacerbation should use nebulizer instead of using Aerochamber.

Antibiotics are useful in treating asthma.

Inhaled steroids have severe side effects.

Answers

Asthma usually leads to permanent damage of the lungs if not treated. (T)

Childrens asthma is commonly caused by allergy. (T)

3) Child with moderate asthma exacerbation should use nebulizer instead of using Aerochamber. (F)

4) Antibiotics are necessary in treating asthma. (F)

5) Inhaled steroids have severe side effects. (F)

SCENARIO 42 weeks-old, Chinese baby boyIncreased work of breathingPoor feedingIrritabilityX 2/7Sudden onset

-Older children usually complain of lightheadedness, dizziness or chest discomfort or they note the fast heart rate, -but very rapid rates may be undetected for long periods in young infants until they develop a low cardiac output state and shock. -This deterioration in cardiac function occurs because of increased myocardial oxygen demand and limitation in myocardial oxygen delivery -during the short diastolic phase associated with very rapid heart rates.- If baseline myocardial function is impaired (e.g. in a child with a cardiomyopathy), SVT can produce signs of shock in a relatively short time.70

DDXCardiac - congenital heart disease, arrhythmiaDiet - coffee,drugsPsychological stress, anxietyOther- electrolyte imbalance, febrile, hyperthyroidism, dehydration

HISTORYSVD, no complicationsNKD/FANo significant past medical historyNot on any medicationFamily history negative

VITAL SIGNSTemperature: 36 CSpO2: 92%PR: 240 bpm RR: 48 bpmBP: normotensive

-very rapid rates may be undetected for long periods in young infants until they develop a low cardiac output state and shock. -This deterioration in cardiac function occurs because of increased myocardial oxygen demand and limitation in myocardial oxygen delivery -during the short diastolic phase associated with very rapid heart rates.- If baseline myocardial function is impaired (e.g. in a child with a cardiomyopathy), SVT can produce signs of shock in a relatively short time.

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PHYSICAL EXAMINATIONS

General appearance : pale, irritable, alert, mild mottling, no cyanosisA: patentB:clear breath sounds, no retractionsC: strong pulses, CRT220 bpm, and often 250300 bpm. Lower heart rates occur in children during SVT. The QRS complex is narrow, making differentiation between marked sinus tachycardia due to shock and SVT difficult, particularly because SVT may also be associated with poor systemic perfusion

The following characteristics may help to distinguish between sinus tachycardia and SVT: 1. Sinus tachycardia is typically characterised by a heart rate less than 200 bpm in infants and children whereas infants with SVT typically have a heart rate greater than 220 bpm. 2. P-waves may be dif?cult to identify in both sinus tachycardia and SVT once the ventricular rate exceeds 200 bpm. If P-waves are identi?able, they are usually upright in leads I and AVF in sinus tachycardia while they are negative in leads II, III and AVF in SVT. 3. In sinus tachycardia, the heart rate varies from beat to beat and is often responsive to stimulation, but there is no beat-to-beat variability in SVT. 4. Termination of SVT is abrupt whereas the heart rate slows gradually in sinus tachycardia in response to treatment. 5. A history consistent with shock (e.g. gastroenteritis or septicaemia) is usually present with sinus tachycardia75

MANAGEMENTNON-PHARMACOLOGICAL

Manouvre that enhances vagal activityDiving reflex One-sided carotid sinus massage

A valsalva maneuver increases the pressure in the chest. This triggers a nerve impulse which transiently slows conduction through the normal conducting pathways. This can often break the electrical circuit and thereby stop an episode of SVT. A valsalva maneuver can be performed in a number of ways. The easiest way is to bear down by squatting or blowing into an occluded straw. If these maneuvers do not work, then a child with SVT should be taken promptly to the emergency room for further treatment. Usually in the emergency room SVT is terminated by the use of a medicine called adenosine. Adenosine transiently blocks conduction in the normal pathway and thus terminates the circuit. - See more at: http://pediatricheartspecialists.com/articles/detail/supraventricular_tachycardia_svt#sthash.Yjth8dtT.dpufTry vagal stimulation while continuing ECG monitoring. The following techniques can be used: -Elicit the diving reflex, which produces an increase in vagal tone, slows atrioventricular conduction and interrupts the tachycardia. This can be done by the application of a rubber glove filled with iced water over the face, or if this is ineffectual, wrapping the infant in a towel, and immersing the face in iced water for 5 seconds. -One-sided carotid sinus massage. -Older children can try a Valsalva manoeuvre. Some children know that a certain position or action will usually effect a return to sinus rhythm. Blowing hard through a straw may be effective for some children. Do not use ocular pressure in an infant or child, because ocular damage may result.

Diving reflex- ice cold cloth/water on faceValsava manouvreDeep inspiration with nose pinced and mouth closed during expirationForceful coughingPulling of tngueGag reflexBreath holdingDeep breathingBlowing into a straw

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PHARMALOGICALAcute : AdenosineChronic: Digoxin, B-blocker

IF hypotensive, poor perfusion??

It is unsafe to give verapamil and propranolol to the same patient because they both have negative inotropic actions. It is, however, safe to give propranolol and digoxin.77

What is the common tachyarrthmia in paediatrics?

What is the common presentation in1)neonates? 2)older children?

How do you manage it?non-pharmacology pharmacologyQuizzes

What is the common tachyarrthmia in paediatrics? SVT

What is the common presentation in1)neonates? (poor feeding, restlessness, irritability)2)older children? (palpitation, SOB, chest discomfort)

How do you manage SVT?non-pharmacology (diving reflex, valsava maneuvre)Pharmacology (adenosine)Answers

Case Scenario 5 -A 5-month-old infant arrives at the emergency center strapped to a backboard with a cervical collar in place. -The father was holding him in his lap in the front passenger seat of their car when the driver lost control and crashed. The child was ejected from the car through the windshield.

-He loss conscious after the accident. He had a self-limited, 2-minute generalized tonic-clonic seizure when transfer to the hospital.

*ref: Eugene CT, Robert JY, Rebecca GG, et al. Case Files: Pediatrics. The McGraw- Hill Companies, Inc. 3rd edition, 2009. pg321-328.

Approach:

1. Rapid Primary Survey resuscitationAirway maintenance with cervical spine controlBreathing CirculationDisability (GCS)Exposure and Environment (temperature control)

1. Rapid Primary Survey resuscitationAirwayBreath spontaneouslyRespiratory rate = 50 bpm.SpO2 = 90% GCS= 6 (opens eyes to pain, moans to pain, and demonstrates abnormal extension)What to do?Open airway jaw thrust Endotracheal intubation

Indication for intubation:Unable to protect airway (GCS < 8; airway trauma)Inadequate oxygenation with spontaneous respiration (SpO2