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StandardTreatmentGuidelines
Edition 2June, 2010
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Standard TreatmentGuidelines
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Table of Contents
1. Resuscitation guidelines..................................................................................................... 1
2. Emergencies............................................................................................................................12
1. Acute upper airway obstruction................................................................................... 122. Anaphylaxis................................................................................................................. 133. Hereditary angiodema ................................................................................... .............. 144. Near drowning............................................................................................................. 165. Fluid management............................................................................................. .......... 186. Endocrine Emergencies................................................................................................ 21
3. Poisoning guidelines......................................................................................................... 40
1. Poisoning Management ............................................................................................... 40
4. Gastrointestinal diseases................................................................................................. 43
1. Acute vomiting ........................................................................................ ................... 432. Diarrhoea................................................................................................................. ... 43
3. Cholera................................................................................................................ ....... 474. Dysentery........................................................................................................ ............ 475. Typhoid fever...................................................................................... ....................... 486. Management at point of discharge for all diarrhoea.................................................... 497. Acute abdominal pain......................................................................................... ........ 518. Constipation.................................. ............................................................................. 529. Oral candidiasis........................................................................................................... 5310. Stomatitis............................................................................................ ....................... 5511. Peptic ulcer disease..................................................................................................... 5612. Hepatitis a infection.................................................................................................... 57
5. Ear Nose Throat................................................................................................................... 59
1. Tonsillo-Pharyngitis.................................................................. .................................. 592. Otitis media............................................................................ .................................... 603. Allergic rhinitis............................................................................................... ............ 634. Sinusitis.................................................................................................................... .. 645. Epistaxis....................... ........................................................................................... ... 666. Ludwig's angina.......................................................................................... ................ 68
7. Menierre's Disease.......................................................................................... ............. 69
6. Respiratory tract conditions.......................................................................................... 70
1. Pneumonia................................................................................................................. 702. Asthma...................................................................................................................... 723. PCP............................................................................................................................ 794. Tuberclosis................................................................................................................ 805. Viral croup........................................................................................................ ........ 83
6. Viral pneumonia/bronchiolitis................................................................................... 84
7. Genitourinary disorders................................................................................................ 85
1. Urinary tract infection.............................................................................................. 852. Minor penile inflammation....................................................................................... 863. Balanitis............................................................................................... .................... 864. Acute urine retention....................................................................................... ........ 875. Z ipper injury ................................................................................ ........................... 876. Phimosis............................................................................................................ ...... 897. Paraphimosis........................................................................................................... 898. Acute scrotal pain.................................................................................... ................ 90
8. CNS .......................................................................................................................................... 92
1. Status epilepticus...................................................................................... ............... 922. Febrile convulsions................................................................................................... 933. Bacterial meningitis.................................................................................................. 944. Coma................................................................................................................ ....... 955. Cerebral palsy............................................................................................ ............... 96
Standard Treatment Guidelines BookletDesigned and printed for Gertrude's Children'sHospitalByLila Creative Design Agency
Printed in Nairobi, Kenya
First Edition Copyright 2009Second Edition Copyright 2010Gertrude's Children's Hospital, Muthaiga
All rights reserved. No part of this book maybe reproduced, stored in a retrieval system,or transmitted in any form or by any means,electronic, electrostatic, magnetic tape,mechanical, photocopying, recording or otherwise,without permission in writing from the GertrudesChildrens Hospital.
Disclaimer
Whereas all care has been taken in the compilation on this document, it is
advised that any user of this book must exercise their clinical judgment in the
management of each patient. Gertrudes Childrens Hospital will not take any
responsibility for the use of information that is herein contained.
Review
In case you would like to propose amendments to this protocol please send
your request to:
The Secretary
Drugs and Therapeutics Committee
Gertrude's Children's Hospital
P.O. Box 42325, 00100, Nairobi
E-mail: [email protected]
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I
Compiled by
Dr. Rashmi Kumar, Paediatrician, Gertrudes Childrens Hospital
Dr. Edwine Barasa, Drug Information Pharmacist, Gertrudes Childrens Hospital
Dr. David Kiptum, Paediatrician, Gertrudes Childrens Hospital
Dr. Paul Laigong, Paediatrician, Gertrudes Childrens Hospital
Dr. Robert Nyarango, Chief Pharmacist, Gertrudes Childrens Hospital
Reviewed by
Dr. Adil Waris, Consultant Paediatric Pulmonologist
Dr. Admani Bashir, Consultant Paediatric Nephrologist
Dr. Berlinda Nganga, Pharmacist, Gertrudes Childrens Hospital
Dr. Bernadette Kimotho, Medical Officer, Gertrudes Childrens Hospital
Dr. Collins Jaguga, Pharmacist, Gertrudes Childrens Hospital
Dr. Dan Alaro, Medical Officer, Gertrudes Childrens Hospital
Dr. Doreen Karimi, Medical Officer, Gertrudes Childrens Hospital
Dr. Evans Amukoye, Consultant Paediatric Pulmonologist
Dr. Hanna Wanyika, Consultant Dermatologist
Dr. Humar Darr, Medical Officer, Gertrudes Childrens Hospital
Dr. Joel Lesan, Consultant Paediatric Surgeon
Dr. Jonathan Mwambire, Medical Officer, Gertrudes Childrens Hospital
Dr. Margaret Njuguna, Consultant Ophthalmologist
Dr. Melanie Miyanji, Consultant Dermatologist
Dr. Michelle Ogola, Medical Officer, Gertrudes Childrens Hospital
Dr. Mureithi Muchiri, Consultant ENT Surgeon
Dr. Noel Orata, Medical Officer, Gertrudes Childrens Hospital
Dr. Osman Miyanji, Consultant Paediatric Neurologist
Dr. Pauline Samia, Paediatrician, Gertrudes Childrens Hospital
Dr. Peter Ngwatu, Consultant Paediatric Gastroenterologist
Dr. Renson Mukhwana, Paediatrician, Gertrudes Childrens Hospital
Dr. Thomas Ngwiri, Paediatrician & Head Clinical Services, Gertrudes Childrens
Hospital
Dr. Timothy Panga, Pharmacist, Gertrudes Childrens Hospital
Dr. Moraa Bisase, Medical Officer, Gertrudes Childrens Hospital
Mr. Protus Letoya, Pharmaceutical Technologist, Gertrudes Childrens Hospital
Edited by
Dr. David Kiptum, Paediatrician, Gertrudes Childrens Hospital
Dr. Paul Laigong, Paediatrician, Gertrudes Childrens Hospital
Dr.Robert Nyarango, Chief Pharmacist, Gertrudes Childrens Hospital
A publication of The Drugs and Therapeutics Committee, Gertrudes
Childrens Hospital
9. CVS.......................................................................................................................................... 100
1. Rheumatic fever.................................................................................. ..................... 1002. Infective endocarditis................................................................................................ 1023. Congestive heart failure................................................................................... ......... 1034. Hypertension.............................................. .............................................................. 105
10. Burns....................................................................................................................................... 107
11. Infectious diseases........................................................................................................... 113
1. Viral infections.................................................................................................. ......... 1132. Fungal infections....................................................................................................... 115
3. Parasitic infections..................................................................................................... 117
12. Neonatology......................................................................................................................... 130
1. Neonatal sepsis......................................................................................................... 1302. Ophthalmia neonatorum............................................................................................ 130
3. Neonatal jaundice...................................................................................................... 1314. Crying baby............................................................................... ................................ 1325. Neonatal feeding................................................................................... .................... 133
13. Eye disorders....................................................................................................................... 135
1. Acute eye injuries in children..................................................................................... 1352. Ocular burns thermal, chemical............................................................................... 136
3. The acute red eye................................................................................ ...................... 137
14. Haematology........................................................................................................................ 141
1. Anaemia..................................................................................................... ............... 1412. Iron deficiency anaemia............................................................................................. 1423. Haemophilia................................................................................................. ............. 1434. Sickle cell disease................................................................................... ................... 1485. Blood product transfusion......................................................................................... 155
15. Dermatology........................................................................................................................ 161
1. Bacterial skin infections (pyoderma).......................................................................... 1612. Nappy rash..................................................................................................... ........... 1633. Atopic eczema.................................................................................. ......................... 1644. Scabies........................................................................................................ .............. 1655. Fungal skin infections................................................................................................ 1656. Viral infections.................................................................................................. ........ 166
16. Bone and connective tissue disorders...................................................................... 168
17. Endocrine disordrers........................................................................................................ 1701. Hypothyroidism......................................................................................................... 1702. Hyperglycaemia.................................................................................................. ....... 1713. Diabetes mellitus............................................................................................... ........ 1724. Diabetes insipidus..................................................................................................... 1755. Weight management................................................................................... .............. 178
18. Malnutrition.......................................................................................................................... 183
19. Procedures............................................................................................................................ 187
1. Analgesia and sedation.............................................................................................. 1872. Lumbar puncture.................................................................................................. .... 1903. Suprapubic aspirate..................................................................................... .............. 1954. Needle thoracocentesis............................................................................................. 197
20. Appendices.......................................................................................................................... 200
1. Appendix I........................................................................................... ..................... 2012. Appendix II........................................................................................... .................... 2123. Appendix II........................................................................................... .................... 2174. Appendix IV........................................................................................... ................... 224
Table of Contents
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II 1
STANDARD : CLINICAL GOVERNANCE
DEPARTMENT : CLINICAL SERVICES
PROTOCOL NO. : CGP/CS/PRO/2
PROTOCOL : STANDARD TREATMENT GUIDELINES
AUTHOR : DRUGS AND THERAPEUTICS COMMITTEE
OWNER : HEAD CLINICAL SERVICES
VERSION : 2
ACTIVE DATE : DECEMBER 1, 2009
REVIEWED DATE : JUNE, 2010
NEXT REVIEW : JUNE, 2011
NOTES
Approval:
This protocol has been approved for use by the Head of Clinical
Services who is herein identified as the protocol owner. This he has
done in consultation with the Drugs and Therapeutics Committee.
Author:
Whereas the Drugs and Therapeutics Committee appears as the
protocol author, the actual development was done by a number
of people as acknowledged in the document. The Drugs and
Therapeutics Committee coordinated the development. The Drugs
and Therapeutics Committee is a sub-committee of the Medical
Advisory Committee.
Accountability:
The Head of Clinical Services is accountable for the implementation
of this protocol
Description:
This protocol contains standard treatment guidelines to be used
in the management of the described diseases/conditions as will be
encountered at Gertrudes Childrens Hospital.
1. RESUSCITATION GUIDELINES
CARDIORESPIRATORY ARREST
Signs of shock, cyanosis, bradycardia / tachycardia, apnoea or
increasing tachypnoea are warning signs and an indication for
urgent resuscitation.
The majority of arrests in children are due to hypoxia,
hypotension and acidosis. The most common dysrhythmias
are severe bradycardia, pulseless electrical activity or asystole.
Ventricular arrhythmias (Ventricular fibrillation (VF) and
pulseless ventricular tachycardia (VT)) are seen with pre-existingcardiac disease (cardiomyopathies, hereditary prolongation of
QT interval, congenital heart disease), poisoning (e.g. tricyclic
antidepressants) and low voltage electrocution (less than 1000
volts), and may occur during resuscitation. SVT may cause
shock in newborn infants.
Assessment
A - Airway
Position the head - neutral position (
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2 3
Artificial Ventilation
Select the appropriate sized resuscitator bag
Infant up to 2 years - 500 mL bag
Child > 2 years - 2 litre bag
Select an appropriate sized mask.
Obtain an airtight seal
O2
flow rate of 10-15 l/min and attachment of a reservoir
assembly will give nearly 100% O2.
An Oropharyngeal airway will facilitate maintenance of the
airway.
Brief suction of the mouth and pharynx if needed, using a
yankeur sucker under direct vision
Ventilate to have normal chest rise and fall. Do not over
ventilate
Intubation should only be attempted by those credentialed and
skilled to do so
Endotracheal Intubation
Select the correct tube size:
Correct endotracheal tube size
Age Weight (Kg) Tube size (mm) Length at lip (cm)
Newborn 3.5 3.0 8.5
2 months 5 3.5 9
6 months 8 4.0 10
1 year 10 4.0 11
Older than 1 year: Tube size (mm) = (age in yr/4) + 4
Length at lip (cm) = (age in yr/2) + 12
C - Circulation
If there are no signs of circulation, i.e. no pulse, slow pulse
(
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4 5
External cardiac compression
DO NOT interrupt except for defibrillation.
Place the child on a firm surface. If on a bed, place the cardiac
massage board under the patient, not under the mattress
Apply massage to the lower half of the sternum in all patients
including newborns
Compress sternum one third the depth of the chest.
Use the hand technique that allows you to achieve this.
1. With large children use the heel of one hand with the other
superimposed.
2. For small children use the heel of one hand
3. For infants use two fingers.
4. For newborn infants the best technique is a two-handed hold
(encirclage) in which both thumbs compress the sternum.
Gain IV or IO access as soon as possible - at least the second
dose of adrenaline should be given via this route
Frequent changes of personnel (every few minutes) is desirable
During resuscitation do not stop to check for a pulse unless for
defibrillation or the ECG shows an organised rhythm.
After DC shock, continue CPR for 2 minutes prior to checking
rhythm.
During resuscitation
Correct treatable causes (6H, 4T)
Hypoxaemia
Hypovolaemia
Hypo/hyperthermia
Hypo/hyperkalaemia
Tamponade
Tension pneumothorax
Toxins/poisons/drugs
Thrombosis
Other drugs to consider
Atropine
For persistent asystole / bradycardia (20mcg/Kg) (Minimum
100mcg, Maximum 600mcg)
Amiodarone
Used for shock refractory ventricular fibrillation
Dose 5mg/Kg over 1 to 2minutes, may repeat up to 20mg/Kg
maximum 300mg
If patient responds, start an infusion at 10 to 15mg/Kg/ day
Lignocaine
Never give lignocaine after Amiodarone. Amiodarone is the
preferred agent
Same indications as Amiodarone. Dose (1mg/Kg) (0.1mL/Kg of 1%
Lignocaine)
Magnesium Sulphate
For hypomagnesaemia or for polymorphic VT (torsade de pointes)
50% solution: 0.05-0.1mL/Kg (0.1-0.2mmol/Kg) (Maximum 2 g)
Infuse over 5 mins.
Sodium bicarbonate, calcium and high doses of adrenaline
(>10mcg/Kg/ dose) have no place in routine resuscitation.
Other issues
Blood gas analysis
It is not a priority in initial resuscitation attempts and
obtaining a sample should not distract from other resuscitation
manoeuvres.
Arterial (and to some extent venous) blood gas analysis can
help determine degree of hypoxaemia, adequacy of ventilation,
degree of acidosis and presence of electrolyte abnormalities
such as of Sodium and Potassium.
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6 7
Diagram 1.
ContinuousCPR
Preintubation
~100compressions/min
ute
15compressionsthen2breaths
Pausecompressionsfo
reachbreath O
btainIVorIO
access
Assess
rhythm
formaximum
of10seconds
Shockable
VForpulsessVT
Non-S
hockable
Asystoleor
PulselessElectricalActivity
Adrenaline-
#
0.1mls/Kg1:10,000IVorIO
ContinueCPRfor
2minutes
Assess
rhythm
formaximum
of10seconds
OneDCShock
4J/Kg(Adult200j)
ImmediatlyresumeCPR
andgive
Adrenaline-
#
0.1
mls/Kg1:10
,000IVorIO
ContinueCPRfor
2minutes
Shockable
VForpulselessVT
OneDCShock
2mls/Kg(Adult200J)
Immediatlyresume
CPRfor2minutes
#-
Adrenaline
0.1mls/Kgof1:10,000IVorIO
Adults:1mg(1ml1:10,000)
ETTadrenalinemaybeusedfor
1stdoseifIVorIOaccessnot
readilyobtained.Itisnotthe
preferredroute.
0.1mls/Kg1:1000dilutedto3ml
Adults:5mg(5ml1:1000)
Amiodarone
5mg/kg
(max300mg)
after3rdDC
shockand
adrenaline
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8 9
Age
Length
(cm)
Weight
(kg)
Pulse
Resp.
BP
mmHg
(systolic)
BP
mmHg
(diastolic)
Temp.(C)
ETtube
(mm)
ETdepth
(cmt
ip
totip)
Laryng
Blade
LMA
NGTube
Suction
Catheter
Pre-term
1-
2
100
180
40
60
50-
60
35
45
34
.0
38
.0
2.5
6+
WT
(kg
)
0
1
5
5
6
Term
New
born
50
3-
4
100
180
40
60
60
90
40-
45
34
.0
38
.0
3.0
6+
WT
(kg
)
1
1
5
8
6
8
6mon
ths
67
7
100
160
30
60
83-
105
40-
45
34
.0
38
.0
3.5
11
1
1.5
8
8
1year
75
10
80
110
26
34
95
105
50-
65
34
.0
38
.0
4.0
11
12
1
2
10
8
10
3years
95
15
70
110
24-
26
96
110
55-
75
36
.1
37
.8
4.5
13
14
2
2
10
10
5years
110
18
70
110
20
24
96
110
55
75
36
.1
37
.8
5.0
14
15
2
2
12
10
6years
115
20
65
110
20
24
97-
112
65-
80
36
.1
37
.8
5.5
15
16
2
2.5
12
10
8years
127
25
65
110
20
24
97
112
65
80
36
.1
37
.8
6.0
17
18
2
3
14
10
12years
150
40
60
100
12
20
112-
128
70-
85
35
.9
37
.6
6.5
19
20
3
3
4
14
12
16years
>50
60
100
12
20
112-
128
70
85
35
.9
37
.6
7.0
20
24
3
3
4
18
12
Adu
lt
Fema
le
50
75
60
100
12
20
112-
130
70-
90
35
.9
37
.6
7.5
22
24
3
4
3-
4
18
14
Adu
lt
Ma
le
75-
100
60
100
12
20
112-
130
70-
90
35
.9
37
.6
8.0
22-
24
3
4
4-
5
18
14
Appropria
teinterna
ldiame
ter
(mm
)o
fETtube=
(Age
inyears
/4)+
4;
NB:
For
ETtubes
ize,
youc
hooseas
ize
largeran
das
izesma
ller
ina
ddition
tothe
indica
teds
ize.
Appropria
teleng
tho
fOra
ltube
(cm
)
=Newb
orn=
6+we
ight(kg
);Ininfan
tan
dc
hild=
(Age
inyears
/2)+
12or
three
times
interna
ltube
diame
ter
Appropria
teleng
tho
fNasa
ltube
(cm
)=
(Age
inyears
/2)+
15
ADRENALINE
Newborn: 0.1 0.3 mL/kg of 1:10,000 IV/ IO
Child: 0.1 mL/kg of 1:10,000 IV/ IO; 0.1 mL/kg of 1:1,000 ET
Adult 10 mL of 1:10,000 IV/ IO; 2.0-2.5 mL of 1:1,000 ET
Age Endotracheal Intravenous Anaphylaxis (IM)
1:1,000 1:10,000 1:1000
Pre-term 0.5 mL (1:10,000) 0.2 0.mL 0.15 mL (150 mcg)
Term NB 1 mL (1:10,000) 0.5 1 mL 0.15 mL (150 mcg)
6 months 0.7 mL 0.7 mL 0.15 mL (150 mcg)
1 year 1 mL 1 mL 0.15 mL (150 mcg)
3 years 1.5 mL 1.5 mL 0.15 mL (150 mcg)
5 years 1.8 mL 1.8 mL 0.15 mL (150 mcg)
6 years 2 mL 2 mL 0.30 mL (300 mcg)
8 years 2.5 mL 2.5 mL 0.30 mL (300 mcg)
12 years 2.5 mL 4 mL 0.30 mL (300 mcg)
16 years 2.5 mL 5 mL 0.50 mL (500 mcg)
Adult 2 2.5 mL 10 mL 0.5 0mL (500 mcg)
IM or slow IV/ IO CHLORPHEN IRAMINE HYDROCORTISONE
< 6 months 250 mcg/kg 25 mg
6 months 6 Years 2.5mg 50 mg
6 - 12 years 5 mg 100 mg
Adult or child >12 years 10 mg 200 mg
AMIODARONE: 5mg/kg IV/ IO; rapid bolus for pulseless VF/ VT; over 20-60min for perfusing
tachycardia. MAXIMUM SINGLE DOSE: 300 mg. May repeat to MAX DOSE= 15 mg/kg/Day (2.2g/Day).
DO NOT combine with procainamide.
(Adult: 300mg rapid bolus for VF/VT; may repeat 150mg a fter 3-5min prn; 150mg over 10minutes for
perfusing tachycardia; may repeat. Follow both by an infusion. MAX DOSE = 2mg/day)
ATROPINE: 0.02 mg/Kg IV/ IO or ET (MINIMUM DOSE =0.1mg; MAX SINGLE DOSE = 0.6mg for child
and 0.9 mg for adolescent); May repeat x 1
(Adult: 0.5-1.0mg; may repeat Q3-5min to MAX TOTAL= 3mg)
LIDOCAINE: 1.0-1.5mg/kg IV /IO or ET; follow by an infusion.
(Adult: 1.0- 1.5mg/kg IV/ IO; repeat 0.5-0.75mg/kg q 5-10min if needed up to MAXIMUM TOTAL
DOSE = 3mg/kg. ET dose = 2-4 mg/kg)
ELECTRICITY
DEFIBRILLATION: 4 Joules/kg (monophasic or biphasic waveform) should be used for all shocks. The
MAXIMUM DOSE for the first shock is 360 J (monophasic) or 150 200 J (biphasic) and subsequent
shocks is 360 J (monophasic) or 200 J (biphasic)
(Adult: 200 joules; then 200 300 joules; 360 joules thereafter)
Table3
Table 4
Table 5
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10 11
Post resuscitation care
Ensure airway and breathing are managed effectively including
intubation if not already performed. Do not extubate. Use
adequate sedation and analgesia.
Ventilate to normal carbia
Circulation - maintain adequate blood pressure with use of
inotropes as needed. Monitor for further arrhythmias.
Aim for core temperature of 35 degrees (do not actively warm if
core temp >32 degrees)
Ongoing anti arrhythmic drugs
Ensure normal glycaemia
CARDIOVERSION: 0.5 joules/kg; increase to 1 joule/kg if needed
(Adult: 50 Joules for SVT or atrial flutter; 100 Joules for monomorphic VT or A-fib; 200 joules for
polymorphic VT; increase to 300 and 360 joules if needed)
CRYSTALOID FLUID CHALLENGE
Choose an ISOTONIC, non-glucose-containing solution (Ringers lactate, Hartmans solution, Normal
Saline 0.9%)!
Newborn: 10 mL/kg;
Infant or child: 20 mL/kg; repeat as needed
(ADULT; 500-1,000 mL or 10-20 mL/kg; titrate to effect)
BOLUS MEDICATIONS
ADENOSINE: 0.1mg/kg rapid IV/ IO push; increase to 0.2mg/kg if needed; MAXIMUM SINGLE DOSE =
12mg
(Adult: 6mg; increase to 12mg if no effect; may repeat 12 mg x 1)
CALCIUM CHLORIDE: 20mg/kg (= 0.2 mL/kg of 10% solution) IV/ IOGIVE slowly IV / IO over 5 30minutes; may repeat after 10 minutes
(Adult: 2 10 mL; may repeat q 10minutes)
CEFOTAXIME or CEFTRIAXONE: 50mg/kg IV/ IO/IM
(Adult: 2gms)
DEXTROSE: Infant/ child 10mL/kg IV/ IO (Newborn: 5 mL/kg) of 10 % solution.
(Adult: 1 mL/kg up to 50 mL of 50% solution)
ADRENALINE, IM or SQ: (for anaphylaxis): 0.01 mL/kg of 1:1,000 solution up to max of 0.5 mL
(Adult: 0.3- 0.5 mL of 1: 1,000 solution)
FENTANYL: 2mcg/kg IM or slow IV/ IO push; consider increase to 5 10mcg/kg for better analgesia
(Adult: 2 10 mcg/kg)
PHENYTOIN: 15 20 mg/kg IV/ IO push at max rate of 100mg/min or IM; then 2 -3 mg /kg q 12
hours (Adult: same as child)
MIDAZOLAM: 0.05 0.15 mg/kg slow IV/ IO push with prn repeat upto MAXIMUM TOTAL DOSE =
6mg for child < 5 years, 10 mg for older child; Intramuscular dose for seizures: 0.2mg/kg IM up to
MAXIMUM DOSE 7mg
(Adult: 1.0 32.5 mg; repeat prn to MAXIMUM TOTAL = 10 MG)
NALOXONE: 0.1 mg/kg for newborn 5 years (MAXIMUM 2mg)
2mg for older child; IV/ IO, IM, or ET
(Adult: 0.2 2.0 mg; may repeat to total of 10mg)
PROCAINAMIDE: 15mg/kg over 30-60 minutes
(Adult: 20 mg/ minute until endpoint or 17 mg/kg TOTAL DOSE)
SALBUTAMOL: (0.5% solution): 0.10- 0.15mg/kg in 3 mL Normal Saline via nebulizer; MINIMUM DOSE
= 0.5mL/2.5 mg; MAXIMUM DOSE = 1.0 mL/5mg
(Adult: 0.5 1.0 mL/2.5mg-5mg)
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12 13
2. EMERGENCIES
1). ACUTE UPPER AIRWAY OBSTRUCTION
Description
The signs of partial acute upper airway obstruction are:
Stridor
Increased work of breathing as evidenced by suprasternal,
intercostal and subcostal retraction along with an increased use
of accessory muscles of respiration.
Management
Allow child to settle quietly on parents lap in the position
the child feels most comfortable.
Observe closely with minimal interference.
Treat specific cause
Call ICU if worsening or severe obstruction.
Oxygen may be given while awaiting definitive treatment.
This can be falsely reassuring because a child with quite
severe obstruction may look pink in oxygen.
Notes
Intravenous access should be deferred upsetting the child
can cause increasing obstruction.
Lateral cervical soft tissue x-rays do not assist in
management.
In severe airways obstruction x-rays cause undue delay in
definitive treatment and may be dangerous (positioning may
precipitate respiratory arrest).
2). ANAPHYLAXIS
Description
Anaphylaxis is a multi-systemic allergic reaction characterised by:
At least one respiratory or cardiovascular feature and
At least one gastrointestinal or skin feature.
For reactions which do not fulfill this definition, see Urticaria
guidelines
Management
Supplemental oxygen
Intra-muscular adrenaline 0.01mL/Kg of 1/1000
(maximum 0.5mL), into lateral thigh is the treatment of
choice for anaphylaxis which should be repeated after 5
minutes if patient not improving - Do not use subcutaneous
adrenaline as absorption is less reliable than the
intramuscular route. Do not use IV bolus adrenaline unless
cardiac arrest is imminent.
An adrenaline infusion should be considered if repeated
doses of IM adrenaline are required at 0.05 - 1 mcg/Kg/min
In addition to adrenaline, repeated 10-20 mL/Kg boluses of
0.9% saline may be required for shock
Nebulised adrenaline is not recommended as first-line
therapy but may be a useful adjunct to IM adrenaline if
upper airway obstruction is present.
If airway oedema is not responding to parenteral and
nebulised adrenaline, early intubation is indicated.
Corticosteroids or antihistamines should never be relied
upon as first line treatment of anaphylaxis
ICU should be notified if children require 2 adrenaline
doses or 30 mL/Kg fluid bolus for the management of
anaphylaxis or if ongoing airway concerns.
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Other therapies to consider
Nebulised salbutamol is recommended if the patient has
respiratory distress with wheezing.
Anti-histamines may be given for symptomatic relief of pruritus.
Second generation anti-histamines are preferred (promethazine
can cause hypotension).
Corticosteroids may be considered at the discretion of the
treating physician especially for bronchospasm although the
limited evidence available does not support their use.
Admission
All children with anaphylaxis should be admitted. At least 6-12hours observation is recommended and overnight admission should
be considered if any of the following circumstances apply:
Greater than one dose of adrenaline (including nebulised
adrenaline) required.
A fluid bolus required
The child lives a long distance from medical services
Discharge Plan and Follow up
Outpatient follow up is recommended.
Reference
1. Advanced Paediatric Life Support: A practical approach.
Advanced life support group. Fourth ed. London: Blackwell
Publishing, 2005.
3). HEREDITARY ANGIOEDEMA
(C1 Esterase Inhibitor Deficiency, HAE)
Description
HAE causes recurrent episodes of angioedema in the upper
respiratory, gastrointestinal tract or in subcutaneous tissues.
Acute episodes of angioedema may be triggered by infection,
stress, menstruation, surgery, dental work, trauma and some
medicines (including oestrogen-containing contraceptives and
ACE-inhibitors) or may have no clear trigger.
HAE is a rare autosomal dominant condition in which C1
esterase inhibitor levels are reduced (HAE type I) or poorly
functional (HAE type II). HAE is diagnosed by the finding of
low C1 esterase inhibitor level or function. C4 level is also low
during episodes of angioedema.
Management
Mild/moderate angioedema episodes
Treatment is conservative:
Hospital admission is not usually required
Other causes of abdominal pain may need to be excluded and
abdominal ultrasound may help by showing intestinal wall
oedema or ascites in HAE-related angioedema.
A 3 day course of tranexamic acid may be considered to shorten
the duration of symptoms (12-25mg/Kg/dose (max 1.5g) 3-4
times per day)
Severe angioedema episodes
Severe angioedema episodes can be fatal. Management includes:
Hospital admission for all severe angioedema episodes
If upper airway obstruction is present, notify a colleague
experienced in endotracheal intubation
Intravenous C1 esterase inhibitor concentrate should beadministered (see below for dosing)
Planned Surgery or Oropharyngeal Procedures
Surgery or any traumatic procedure of the oropharyngeal area
such as dental work should be carefully planned. The use of a
prophylactic agent prior to such procedures reduces the risk of
precipitating angioedema.
Consult with an ICU intensivist before the procedure
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For planned procedures, Danazol is the first choice of
prophylactic agent, (10mg/Kg/day for 5-10 days before and 2-5
days after the procedure).
For emergency or high-risk procedures, C1 esterase inhibitor
concentrate (25units/Kg infusion given 1 hour prior to the
procedure)
Due to the risk of precipitating laryngeal oedema,
oropharyngeal procedures should usually involve general
anaesthesia with endotracheal intubation
Notes
Antihistamines and Corticosteroids Antihistamines and corticosteroids have no role in the
management of HAE related angioedema.
The role of adrenaline in the treatment of HAE is not well
established.
There are anecdotal reports of efficacy using nebulised or
intramuscular adrenaline to treat upper airway angioedema,
however C1 esterase inhibitor is the treatment of choice for
airway angioedema caused by HAE.
4). NEAR DROWNING
All children should receive full resuscitative efforts after an episode
of immersion or near drowning.
Assessment and management
Rapidly assess airway, breathing, circulation and level of
consciousness
If child is in cardiorespiratory arrest proceed immediately with
cardiopulmonary resuscitation
Airway and breathing (protect cervical spine if any possibility ofinjury)
If spontaneously breathing, administer 100% oxygen by face
mask.
Intubate and ventilate if:
Inadequate respiration
Falling arterial Oxygen concentration (PaO2) despite increased
fractional inspired Oxygen
Persisting depressed level of consciousness
Monitor Oxygen saturation and perform arterial blood gas
Do a chest x-ray
Circulation
Assess pulse rate and volume, blood pressure and capillary
refill.
Insert intravenous line.
Perform Haemogram, serum glucose, electrolytes and
creatinine.
If circulation is inadequate give fluid bolus of 20 mL/Kg Ringers
Lactate.
Consider early ionotropic support
Cerebral support
Avoid any further episodes of hypoxia and hypercarbia.
Optimise circulation as best possible.
Once shock is reversed restrict fluids to 75% of maintenance.
Monitoring and control of intracranial pressure is occasionally
required.
Temperature
Actively rewarm children slowly to a core temperature of 34
degrees.
Passively rewarm over 34 degrees.
General
Admit to appropriate inpatient unit.
Corticosteroids are not recommended.
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Adverse Prognostic Factors
Immersion time > 10 minutes.
Rectal temperature < 30C.
Absence of any initial resuscitative efforts.
Arrival in hospital with CPR in progress or in coma
Requirement of cardiopulmonary resuscitation
Initial serum pH < 7.0
5). FLUID MANAGEMENT
1. Composition of IV Fluids
Fluid Na Cl K Ca Lactate Osmolality
Normal Saline(0.9% )
154 154 _ _ _ 308
StrengthNormal Saline
77 77 _ _ _ 154
StrengthNormal Saline
38.5 38.5 _ _ _ 77
Ringers
Lactate
130 109 4 3 28 275
Half strengthDarrows
62 17 _ _ 25 170
5%Dextrose - - - - - 253
Table 6
2. Body Weight Method of Calculating Maintenance Fluid
Volume
Body weight (Kg) Fluid Therapy per Day (mL)
0-10 100 mL /Kg
11- 201000 mL + 50 mL/Kg for each Kggreater than 10 Kg
>20Kgs1500mL+ 20 mL/Kg for each Kggreater than 20Kg
3. Maintenance Electrolyte Requirements
Sodium: 2-3 meq /Kg/24hr
Potassium 1-2 meq/Kg/24hr
Calcium 1-2mmol/Kg/24hr
(Glucose 4-6mg/Kg/Min)
4. Types of Dehydration
1. Hypernatremic dehydration
a. Restore intravascular volume
If in shock, administer Normal Saline 20 mL / Kg over 20 minutes.
Repeat until out of shock
b. Determine time for correction based on the initial sodium
concentration
145 157 meq/L: 24 Hours
158 170 meq/L: 48 hours
171 183 meq/L : 72 Hours
184 196 meq/L: 84 Hours
c. Administer fluid at constant rate over the time for correction
Typical fluids 5% dextrose + strength normal saline or 5%
dextrose + normal saline (both with 20 Meq/l potassium
chloride unless contraindicated)
Table 7
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Typical rate: 1.25 -1.5 times maintenance
Monitor serum sodium concentration 4 hourly
d. Adjust fluid based on clinical status and serum sodium
concentration:
Signs of volume depletion: Administer normal saline (20 mL/Kg)
If Sodium decreases too rapidly,
1. Increase sodium concentration of IV fluids
2. Decrease IV fluids infusion rate
If Sodium decreases too slowly,
1. Decrease sodium concentration of IV fluids
2. Increase IV fluids infusion rate
3. Replace ongoing losses as they occur
Fluid replacement in shock
Fix an IV line
Draw blood for analysis
Infuse 20 mL /Kg of isotonic fluid (normal saline or ringers
lactate)
Reassess after 1st infusion: If no improvement, repeat 20 mL/
Kg as quickly as possible
Reassess after 2nd infusion: If no improvement, repeat 20 mL/
Kg as quickly as possible
Reassess after 3rd infusion: if no improvement, consider giving
blood 20 mL/Kg over 30 minutes
Reassess after 3rd infusion
6). ENDOCRINE EMERGENCIES
1). DIABETIC KETOACIDOSIS
Assessment
Degree Of Dehydration - (often overestimated)
Mild (7%) poor perfusion, rapid pulse, reduced blood
pressure - in shock
Investigations
Blood glucose, urea, and electrolytes
Arterial or capillary acid/base status
Urine - Ketones, microscopy, culture
Check for precipitating cause e.g. Infection (Urine, Full
Haemogram, blood cultures; consider Chest x-ray)
Islet cell antibodies, insulin antibodies, GAD antibodies, Total
IgA, antiendomysial IgA antibody and Thyroid function test for
all newly diagnosed patients
Management
Airway, Breathing and Circulation - ABCs
Fluid Requirements
If in shock, give Normal Saline at 10-20mL/Kg stat
Repeat until perfusion is re-established (warm, pink extremities
with rapid capillary refill).
Commence rehydration with Normal Saline as below
Fluid rates (mL/hour) including deficit and maintenance fluid
requirements, to be given evenly over 48 hours
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Fluid volumes for the subsequent phase of rehydration
Weight(Kg) mL/24 hGive maintenance plus 5% of body weight per 24hours
mL/24hr mL/hr
4 325 530 22
5 405 650 27
6 485 790 33
7 570 920 38
8 640 1040 43
9 710 1160 48
10 780 1280 53
11 840 1390 58
12 890 1490 62
13 940 1590 66
14 990 1690 70
15 1030 1780 74
16 1070 1870 78
17 1120 1970 82
18 1150 2050 85
19 1190 2140 89
20 1230 2230 93
22 1300 2400 100
24 1360 2560 107
26 1430 2730 114
28 1490 2890 120
30 1560 3060 128
32 1620 3220 134
34 1680 3360 140
36 1730 3460 144
38 1790 3580 149
40 1850 3700 154
45 1980 3960 165
50 2100 4200 175
55 2210 4420 184
60 2320 4640 193
65 2410 4820 201
70 2500 5000 208
75 2590 5180 216
80 2690 5380 224
Table 8 After initial resuscitation and assuming 10% dehydration, the total
amount of fluid should be given over 48 hours. The above table
gives volumes for maintenance and rehydration per 24 hours and
per hour. If fluid has been given for resuscitation, the volume
should not be subtracted from the amount shown in the table.
Fluids given orally (when patient has improved) should be
subtracted from the amount in the table. The table is based on
maintenance volumes according to Darrrow. For body weights >32
kg, the volumes have been adjusted so as not to exceed twice the
maintenance rate of fluid administration.
Keep nil by mouth (except ice to suck) alert and stable. Insert a
nasogastric tube if patient is comatose or has recurrent vomiting;leave on free drainage.
Rehydration may be completed orally after the first 24 - 36 hours if
the patient is metabolically stable.
Bicarbonate
This is usually not necessary if shock has been adequately
corrected. Continuing acidosis usually means insufficient
resuscitation. In extremely sick children (with pH < 6.9 with or
without HCO3 < 5mmol/L), small amounts may be given after
discussion with the endocrinologist.
HCO3 dose (mmol) = 0.15 x body weight (Kg) x base deficit. Give
over 30 min with cardiac monitoring. Reassess acid base status.
Remember risk of hypokalaemia
Admission to ICU
Admit to ICU if age < 2 years, coma, cardiovascular
compromise, seizures.
Ward Transfer Instructions
Strict fluid balance
Check all urine for Ketones
Hourly observations: pulse, BP, respiratory rate, level of
consciousness and pupils
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Hourly glucose (Glucometer) while on insulin infusion; other
biochemistry as clinically indicated
4-hrly temperatures
Inpatient Treatment
Insulin
Note: Beware the rare entity of hyperglycaemic-hyperosmolar non-
ketotic coma: Insulin should ONLY be used after discussion with
endocrinologist
Add 50 units of clear/rapid-acting insulin (Actrapid HM or Humulin
R) to 49.5 mL 0.9% NaCl (1 unit/mL solution). Ensure that the
insulin is clearly labeled.
Start at 0.1 units/Kg/hr in newly diagnosed children, and those
already on insulin who have glucose levels > 15 mmol/L. Children
who have had their usual insulin and whose blood sugars are
< 15 mmol/L should receive 0.05 units/Kg/hour. Adjust the
concentration of dextrose to keep blood glucose 10-12 mmol/L.
Adequate insulin must be continued to clear acidosis (Ketonaemia).
Insulin dose may be halved for children < 5yrs of age
The insulin infusion can be discontinued when the child is alert and
metabolically stable (blood glucose < 10-12 mmol/L, pH > 7.30
and HCO3 > 15)The best time to change to SC insulin is just before
meal time. The insulin infusion should only be stopped 30 minutes
after the first SC injection of insulin.
Potassium
Start Potassium Chloride after initial fluid at a concentration of
40 mmol/L of fluid infusion if body weight less than 30Kg, or 60
mmol/L of fluid infusion if 30 Kg or more. Measure levels 2 hours
after starting therapy and 2-4 hourly thereafter. Specimens should
in general be arterial or venous. Give no Potassium if the serum
level is > 5.5 mmol/L or if the patient is anuric
Fluids
If the blood sugar falls very quickly, i.e. within the first few hours,
change to Normal Saline with 5% dextrose. When the blood sugar
reaches 12-15 mmol/L, use 0.45% Normal Saline with 5% dextrose.
Aim to keep the blood sugar at 10-12 mmol/L
If the blood glucose falls below 10-12 mmol/L and the patient is
still sick and acidotic, increase the dextrose in the infusate to 7.5-
10%. Do not turn down insulin infusion
Hazards
Hypernatraemia
Measured serum sodium is depressed by the dilutional effect of
the hyperglycaemia. To "adjust" sodium concentration, use the
following formula:
Adjusted (i.e. actual) sodium = measured sodium + 0.3 (glucose
- 5.5) mmol/L ie 3 mmol/L of sodium to be added for every 10mmol/L of glucose above 5.5 mmol/L
If Na is > 160 mmol/L, discuss with the Endocrinologist.
Sodium should rise as the glucose falls during treatment. If
this does not happen or if hyponatraemia develops, it usually
indicates overzealous volume correction and insufficient electrolyte
replacement. This may place the patient art risk of cerebral
oedema.
Hypoglycaemia
If blood glucose < 2.2 mol/L give IV 10% dextrose 5 mL/Kg. Do
not discontinue the insulin infusion. Continue with a 10% dextrose
infusion until stable. Insulin infusion may be reduced to 0.05Units/
Kg/hour
Cerebral OedemaSome degree of subclinical brain swelling is present during most
episodes of diabetic ketoacidosis. Clinical cerebral oedema occurs
suddenly, usually between 6 and 12 hours after starting therapy
(range 2 - 24 hr). Mortality or severe morbidity is very high without
early treatment
Prevention
Slow correction of f luid and biochemical abnormalities. Optimally,
the rate of fall of blood glucose and serum Osmolality should not
exceed 5mmol/L/hr, but in children there is often a quicker initial
fall in glucose. Patients should be nursed head up
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Warning signs
First presentation, long history of poor control, young age (< 5
yr)
No sodium rise as glucose falls, hyponatraemia during therapy,
initial adjusted Hypernatraemia
Headache, irritability, lethargy, depressed consciousness,
incontinence, thermal instability
Very late - bradycardia, increased BP and respiratory
impairment.
Treatment
Mannitol 20% 0.5 g/Kg IV stat. Give immediately when theclinical diagnosis is made - do not delay for confirmatory brain
scan
Severely reduce fluid input
Nurse head up
Transfer immediately to ICU
2). ADRENAL CRISIS
An adrenal crisis is a physiological event caused by an acute
relative insufficiency of adrenal hormones
It should be considered in patients with:
Congenital adrenal hyperplasia
Hypopituitarism on replacement therapy
Those previously or currently on prolonged steroid therapy.
It may occur in previously undiagnosed adrenal/pituitary
insufficient patients, or acutely in a previously well patient
Assessment
History and physical examination look for:
Glucocorticoid deficiency: weakness, anorexia, nausea and/or
vomiting, hypoglycaemia, hypotension (particularly postural)
and shock
Mineralocorticoid deficiency: dehydration, hyperkalaemia,
hyponatraemia, acidosis and prerenal renal failure
Investigations
Immediate blood glucose using a Glucometer
Serum glucose, urea, sodium and potassium
Arterial or capillary acid base
Where the underlying diagnosis not known, collect at
least 2 mol of clotted blood for later analysis (cortisol and
17-hydroxyprogesterone and ACTH)
Management
Susceptible patients who present with vomiting but who are not
otherwise unwell should be considered to have incipient adrenal
crisis. To attempt to prevent this from developing further:
Administer IV/IM Hydrocortisone 2 mg/Kg
Give oral fluids and observe for 46 hours before considering
discharge
Discuss with endocrinologist
For all other children:
Give intravenous fluids
Shock or severe dehydration:
Normal Saline 20 mL/Kg IV bolus. Repeat until circulation is
restored Administer remaining deficit plus maintenance fluid volume as
Normal Saline in 5% dextrose evenly over 24 hours
Check electrolytes and glucose frequently
After the first few hours, if serum sodium is greater than 130
mmol/L, change to half Normal Saline
10% dextrose may be needed to maintain normoglycaemia
Moderate dehydration:
Normal Saline 10 mL/Kg IV bolus. Repeat until circulation is
restored
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Administer remaining deficit plus maintenance fluid volume as
Normal Saline in 5% dextrose evenly over 24 hours
Mild or no dehydration:
No bolus
1.5 times maintenance fluid volume administered evenly over
24 hours
Hydrocortisone
Administer Hydrocortisone intravenously. If IV access is difficult,
give IM while establishing intravenous line.
Neonate: 25 mg stat and then 1025 mg, 6 hourly
1 month 1 year: 25 mg stat, then 25 mg, 6 hourly
Toddlers (13 years): 25-50 mg stat then 2550 mg, 6 hourly
Children (412 years): 5075 mg stat, then 5075 mg, 6 hourly
Adolescents and adults: 100 150 mg stat, then 100 mg, 6
hourly
When stable reduce IV Hydrocortisone dose, then switch to
triple dose oral Hydrocortisone therapy, gradually reducing to
maintenance levels (1015 mg/m2/day).
In patients with mineralocorticoid deficiency start Fludrocortisone
at maintenance doses (usually 0.1 mg daily) as soon as the patient
is able to tolerate oral fluids
Treat hypoglycaemia
Hypoglycaemia is common in infants and small children. Treat with
IV bolus of 2- 5 mL/Kg 10% dextrose. Maintenance fluids should
contain 510% dextrose
Treat hyperkalaemia
Hyperkalaemia usually normalises with fluid and electrolyte
replacement.
If potassium is above 6mmol/L perform an ECG and apply cardiac
monitor as arrhythmias and cardiac arrest may occur.
If potassium is above 7 mmol/L and hyperkalaemia ECG changes
are present (e.g. peaked T waves, wide QRS complex), give 10%
calcium Glucometer 0.5 mL/Kg IV over 35 mins. Commence
infusion of insulin 0.1units/Kg/hr IV together with an infusion of
50% dextrose 2 mL/Kg/hr
If the serum Potassium is above 7 mmol/L with a normal ECG, give
Sodium bicarbonate 12 mmol/Kg IV, over 20 mins with an infusion
of 10% dextrose at 5 mL/Kg/hr
Identify and treat potential precipitating causes such as sepsis.
Admit to appropriate inpatient facility.
Prevention
Prevention of a crisis if possible, is essential and may involve:
Anticipating problems in susceptible patients
Giving triple normal oral maintenance steroid dose for 23 days
during stress (e.g. fever, fracture, laceration requiring suture)
Giving intramuscular Hydrocortisone when absorption of oral
medication is doubtful like in vomiting or severe diarrhoea
Increasing parenteral Hydrocortisone (12 mg/Kg) before
anaesthesia, with or without an increased dose postoperatively
3). PHAEOCHROMOCYTOMA CRISIS
Crisis is caused by the action of unopposed high circulating levels
of catecholamines acting at adrenoreceptors: -receptors cause a
pressor response with increases in blood pressure, while -receptor
activation has positive inotropic and chronotropic effects, any
patient presenting with acute hypertension and tachycardia should
be considered at risk of Phaeochromocytoma, especially if young or
in an at risk group
Risk factors
Spontaneous
Associated conditions:
Multiple Endocrine Neoplasia type 2.
Neurofibromatosis type 1.
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Von Hippel-Lindau syndrome.
Ataxia telangiectasia.
Tuberous sclerosis.
Sturge-Weber syndrome.
Precipitating factors
Spontaneous
Haemorrhage into Phaeochromocytoma
Other
Exercise.
Pressure on abdomen.
Urination.
Drugs: Guanethidine, glucagon, Naloxone, Metoclopramide,
ACTH, cytotoxics, tricyclic antidepressants
Clinical features
Hypertension, palpitations, sweating, pallor, pounding
headache, anxiety and tremulousness, pulmonary oedema,
feeling of impending death, hyperhydrosis, nausea and
vomiting, abdominal pain (tumour haemorrhage), paralytic
ileus, hyperglycaemia, altered consciousness (hypertensive
encephalopathy), myocardial infarction, and stroke
Flushing is not a feature of Phaeochromocytoma.
The attacks last between 15 60 minutes.
Signs of end organ hypertensive damage; hypertensive
retinopathy and papilloedema, left ventricular hypertrophy,
renal impairment, and proteinuria
Biochemical diagnosis
Biochemical diagnosis is made by:
Collecting urine into acidified bottles for estimation of 24-hour
free catecholamines and metanephrines
Plasma metanephrines and catecholamines are also increasingly
be used for this diagnosis.
Treatment
Should not wait for biochemical confirmation
Phenoxybenzamine (alpha blocker) is the drug of choice, with
a starting dose of 0.25-1.0mg/kg orally three times a day,
increasing to a maximum dose of 240 mg/24 hour. Doses
above 40 mg three times a day are seldom required. Dose
titration is performed every 48 hours until control of blood
pressure is achieved
After the first 48 hours addition of Propranolol 0.5-4 mg/kg/
day PO/ divided every 8hours; not to exceed 60 mg/day orally
three times a day may be added
Important pharmacological issues in treatment
It is vital that 48 hours of a-blockade precede -blockade to
avoid exacerbating a crisis through the unopposed action of
catecholamines at -receptors
Alpha-antagonists such as doxazosin, and calcium channel
antagonists, while increasingly used for maintenance
therapy before operation for Phaeochromocytoma, are not
recommended for management of crisis.
Labetalol is not recommended as this has relatively greater
-blocking action compared to its -blocking action, and hence
can even precipitate or worsen Phaeochromocytoma crisis.
4). ACUTE HYPERCALCAEMIA
Causes of hypercalcaemia
Endocrine
Hyperparathyroidism (adenoma, hyperplasia, carcinoma)
Multiple endocrine Neoplasia
PTH related protein production by solid tumours
Neoplastic
Carcinoma and bone invasion.
Myeloma.
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Granulomatous
Sarcoidosis
Tuberculosis
Berylliosis
Iatrogenic
Vitamin D toxicity
Thiazides
Vitamin A
Renal failure
Tertiary hyperparathyroidism. Aluminium toxicity
Miscellaneous
Pagets disease of bone
Familial hypocalciuric hypercalcaemia.
Hypophosphataemia.
History
History of polyuria and polydipsia, and there can be dehydration,
bone pain, confusion, anorexia, and constipation. Relevant drug
and family histories must be taken
The cornerstone of differential diagnosis is the measurement of
serum parathyroid hormone (PTH)
Investigations at presentation should include;
Parathyroid Hormone, PTH
Serum total protein with immunoglobulin electrophoresis for
myeloma, Albumin, Phosphate, Magnesium
Erythrocyte sedimentation rate, full blood count
ECG
Chest radiography
Fractional excretion of Calcium
Treatment
Any precipitating drugs should be stopped
The mainstay of treatment is adequate volume repletion with
intravenous Normal Saline
Loop diuretics such as Frusemide, which has calciuretic effects,
should only be used after initial volume expansion
Intravenous bisphosphonates, such as sodium pamidronate at
a dose of 3090 mg are extremely effective in the treatment of
hypercalcaemia of malignancy, with duration of action that lasts
days to weeks
It is important to remember that serum PTH will rise after an
acute fall in serum calcium induced by such treatment and
hence it is vital that the initial sample for PTH is obtained before
bisphosphonate treatment
Cases of primary Hyperparathyroidism should be referred to
endocrine surgeons
Corticosteroids (Prednisolone 1-2mg/Kg each day) are the drugs
of choice If granulomatous diseases such as Sarcoidosis, or
vitamin A or D intoxication are considered
In subcutaneous fat necrosis, intravenous fluids, diuretics, and
corticosteroids should be used
5). THYROID STORM
Precipitating factors
General
Infection
Non-thyroidal trauma or surgery
Psychosis
Parturition
Myocardial infarction or other acute medical problems
Thyroid specific
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Radioiodine
High doses of iodine-containing compounds (for example,
radiographic contrast media)
Discontinuation of antithyroid drug treatment
Thyroid injury (palpation, infarction of an adenoma)
New institution of Amiodarone therapy
Cardinal features
Include severe tachycardia, fever (usually 38.5C), gastrointestinal
dysfunction (vomiting, diarrhoea, and occasional jaundice),
agitation, confusion, delirium, or coma. Congestive heart failure
may occur, particularly in the elderly, and most patients havesystolic hypertension
Biochemical features
Include hyperglycaemia, leucocytosis, high free T3 and T4, low TSH,
mild hypercalcaemia, and abnormal liver function tests. Adrenal
reserve may be impaired
Treatment
Carbimazole/Methimazole 0.5-1mg/kg/day orally in 2 or
3divided doses, or Propylthiouracil in a dose of 5-7 mg/Kg/day
is given. They inhibit thyroid hormone synthesis and conversion
of thyroxine to tri-iodothyronine
One hour after starting any of the above medications, iodide
(like, eight drops of Lugols iodine every six hours) is given to
inhibit thyroid hormone release
High doses of b-blocker should be given, and Propranolol at a
dose of 2-4mg/Kg/day every six hours is recommended
Cholestyramine, 4 g every 612 hours, binds thyroid hormone in
the gut and thus interrupts the modest enterohepatic circulation
of thyroid hormone; its use will lead to a more rapid lowering of
circulating thyroid hormones
In exceptional cases, peritoneal dialysis or plasmapheresis may
be needed
Treatment of any underlying illness follows the usual lines
Supportive treatment includes the use of external cooling,
possibly supplemented by chlorpromazine, cautious intravenous
fluids, or Oxygen as determined by appropriate assessment and
empirical administration of intravenous Hydrocortisone 100 mg
every eight hour
6). MYXOEDEMA COMA
Precipitating factors
Hypothermia
Infections especially pneumonia
Myocardial infarction or congestive heart failure Cerebrovascular accident
Respiratory depression due to drugs (for example Anaesthetics,
sedatives, tranquillizers)
Trauma or gastrointestinal blood loss
Clinical features
The three main features are:
Altered mental state ranging from poor cognitive function
through psychosis to coma
Hypothermia (as low as 23C) or absence of fever in spite of
severe infection (prognosis worsens as the core temperature
fall)
The presence of a precipitating event.
Other features
The physical signs of hypothyroidism are usually obvious and
most patients have respiratory depression secondary to a
decreased hypoxic ventilatory drive and an impaired response to
hypercapnia: the more severe the latter, the more likely coma is
Cardiac enlargement, bradycardia, decreased ventricular
contractility, hypotension, and ECG changes (low voltage, non-
specific ST wave changes and sometimes torsades des pointes
with a long QT interval) are common
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Many patients have anorexia, abdominal pain and distention,
and constipation and these changes may rarely lead to paralytic
ileus and megacolon
Biochemical abnormalities include:
Hyponatraemia, normal or increased urine sodium excretion,
Raised creatine phosphokinase and lactate dehydrogenase
Hypoglycaemia
Normocytic or macrocytic anaemia
Thyroid stimulating hormone values may only be modestly
raised (and will be normal or low in secondary hypothyroidism)
but free thyroxine levels are usually very low
Treatment
The three principles of management are;
Rapid institution of thyroid hormone replacement
Treatment of the precipitating cause
Provision of ventilatory and other support
Thyroxine institution may be done in two ways:
1. High dose replacement thus;
Intravenous thyroxine can be given as a bolus of 300500
mcg, followed by 50100 mcg daily
Intravenous dose of tri-iodothyronine is 1020 mcg initially,
followed by 10 mcg every four hours for 24 hours, then 10 mgevery six hours
2. Give 200 mcg thyroxine with 10 mcg tri-iodothyronine
initially, and then tri-iodothyronine 10 mcg every 12 hours and
thyroxine 100 mcg every 24 hours, until the patient resumes
normal thyroxine orally
Oral treatment with similar doses is also possible
The low dose approach would suggest 25 mcg of thyroxine
daily for a week, or 5 mcg of tri-iodothyronine twice daily with a
gradually increasing dose.
Treatment of the underlying precipitant is usually straightfor-ward
All patients should be admitted to intensive care or the HDU: most
patients require ventilatory support for 12 days
Hypothermia should be treated with space blankets, since active
rewarming leads to circulatory collapse
Cautious volume expansion using intravenous saline usually
suffices, but hypertonic saline may need to be considered if the
serum sodium is very low (< 120 mmol/L) and intravenous glucose
may be required for hypoglycaemia
There is often a degree of temporarily impaired adrenal function,
and most authorities advocate routine intravenous administrationof 50100 mg Hydrocortisone every eight hours until recovery
7). ACUTE PITUITARY APOPLEXY
Causes
Acute pituitary apoplexy occurring in
0.6%9.1% of all surgically treated pituitary tumours, but is
potentially life threatening
Haemorrhagic infarction of a pituitary tumour
Normal pituitary gland
Risk factors include
Spontaneous
Anticoagulationpre-existing haemodialysis, cardiac surgery
Hypertension
Raised intracranial pressure
Dynamic pituitary testinginsulin tolerance test, thyroid
releasing hormone test, gonadotrophin releasing hormone test,
corticotrophin releasing hormone test
Drugsoestrogens, Bromocriptine, Aspirin.
Pituitary radiotherapy
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Treatment
If pituitary apoplexy is suspected
Hydrocortisone 2mg/kg IV/IM stat, then 100mg/m2 in 4-6hrly
doses intramuscularly six hourly, or 4 mg/hour intravenously
should be administered without delay and continued until the
crisis is over
Before administration bloods should be drawn for cortisol,
prolactin, follicle stimulating hormone, luteinising hormone,
oestradiol (women), testosterone (men), sex hormone binding
globulin, free thyroxine, thyroid stimulating hormone, insulin-
like growth factor-1, and preferably ACTH (needs immediate
cold centrifugation and freezing at -220C), urinary and plasmaOsmolality blood glucose should be monitored and treated
accordingly
Standard cardiopulmonary supportive measures are needed
Early neurosurgical intervention is associated with improved
neuro-ophthalmic outcome
8). PITUITARY CRISIS
Causes
Not matching Glucocorticoid dose to stress in known patient
with pituitary deficiency
Undiagnosed Hypopituitarism
Pituitary adenomas or other intrasellar and parasellar tumors
Inflammatory and infectious destruction
Surgical removal and traumatic brain injury (TBI)
Radiation-induced destruction of pituitary tissue
Subarachnoid hemorrhage
Postpartum agalatasia pituitary necrosis (Sheehan syndrome)
Clinical presentation;
Weakness, fatigue, or altered mental status without a clear
diagnosis,
Hypotonia, bradycardia, decreased skin and nipple pigmentation,
muscle weakness, vomiting, nausea, constipation, hypothermia,
and hypoventilation
A postpartum galactic is often the first sign of Sheehan's syndrome
Investigations
TBC, serum electrolytes
Cortisol level, prolactin level
Evaluate the hypothalamic-pituitary-adrenal axis -corticotropin
stimulation test
Assess thyroid function- serum thyrotropin (TSH) and thyroxine
(T4)
24hour fluid balance then a water deprivation test and an
aqueous vasopressin stimulation test
Radiologic
A lateral skull film can delineate contours of the sella turcica
Both MRI and CT scans should be obtained with intravenous
contrast to increase sensitivity of the tests.
Treatment
Standard resuscitation with IV fluids, Vasopressors
Hypoglycemia must be sought and treated
Electrolyte imbalance is corrected following the usual guidelines
Hormone replacements
Hydrocortisone high dose
Thyroxine
ADH analogues
Note
Do not start on thyroxin therapy before confirmation of normal
cortisol levels, or Hydrocortisone replacement
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3. POISONING GUIDELINES
POISONING MANAGEMENT
The management of acute poisoning is discussed in detail in the
Gertrudes Childrens Hospital Poisoning Management Guidelines.
Below is summary guideline. The actions below are not necessarily
outlined in any particular order of implementation.
1. Manage patients as per general guidelines below and specific
management as per the Gertrudes Childrens Hospital
Poisoning Management Guidelines
2. Refer to the Gertrudes Childrens Hospital PoisoningManagement Guidelines
3. Call the Gertrudes Drug and Poison Information unit on
extension 237/240 or 020 7206237/ 0207206240 for
information support
4. Consult consultant on call
5. Admit patient
General Management
Maintain adequate airway
Provide adequate oxygenation
Treat convulsions in any and make efforts to establish the
etiology of the seizures so that appropriate treatment can be
administered Treat coma if patient is in coma. It is important to consider
other causes of depressed sensorium, including ruling out
structural lesions such as subdural haematoma. The following
agents can be utilized in the poisoned patient with altered level
of consciousness:
100% oxygen in suspected cases of poisoning with carbon
monoxide, hydrogen sulphide, cyanide and asphyxiants
Thiamine to prevent Wernickes encephalopathy in an alcohol
intoxicated patient: Dose is 100 mg IV
Glucose to reverse the effects of drug-induced hypoglycaemia:
Dose is 25 mL of glucose 50% solution in adults or 0.5-1g
glucose/kg body weight in children (e.g. 5-10 mL/kg of 10%
glucose)
Naloxone in cases of possible opioid toxicity
Flumazenil in cases of coma known to be caused by
benzodiazepines ALONE (because of the risk of provoking
convulsions or arrhythmias, flumazenil should not be given
when the patient is suspected of having taken other drugs as
well).
Correct metabolic abnormalities. The following metabolic
abnormalities should be corrected: Hypokalaemia
Hyperkalaemia
Hypomagnesaemia
Hypothermia
Hyperthermia
Hypoglycaemia
Hypocalcaemia
Acid-base abnormalities, particularly metabolic acidosis
Prevent absorption of poisons by gut decontamination using
single-dose activated charcoal or gastric lavage as may be
indicated if a patient has taken a potentially toxic amount of a
poison up to one hour following ingestion. Avoid emesis. Washoff skin and/or eye exposure of poisoning if indicated.
Enhance elimination of poison through multiple activated
charcoal doses if indicated.
Provide supportive care as will be indicated
Monitor vital signs (blood pressure, heart rate, respiratory
rate, temperature)
Monitor fluid input and output
Monitor level of consciousness, pattern of breathing and
regularity of the heart rate
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Monitor oxygen saturation using a pulse oximeter
Administer intravenous fluids for maintenance and fluid loss
replacement
Carry out intensive nursing care to avoid aspiration or the
development of bed sores
Treat metabolic disturbances such as electrolyte
abnormalities, hypoglycaemia and metabolic acidosis
Manage underlying illnesses that may be aggravated by
existing problem of poisoning
Use specific antidotes if indicated
4. GASTROINTERSTINAL DISEASE
1). ACUTE VOMITING
Description
Vomiting of abrupt onset
Management
Oral rehydration: oral: child 1month- 1yrs;
1-1.5times usual feed volume. Child 1-12yrs; 200mLs after
every loose motion. Child 12-18yrs; ORS 200-400mLs after
every loose motion.
NB: After reconstitution, the oral rehydration solution should be
discarded in an hour after preparing or after 24hrs if stored in
the refrigerator
Use IV fluids if necessary
Investigate cause and manage appropriately
2). DIARRHEA
Diarrhoea is defined as increased fluidity and frequency of stool.
There is a significant variability in stooling frequency among babies
and children. Breastfed babies usually stool more frequently.
Types of diarrhoea presentation
Acute diarrhoea with severe, some and no dehydration
Severe persistent diarrhoea with and without malnutrition
Non severe diarrhoea with and without malnutrition
Acute diarrhea with severe dehydration
Description
Diarrhea of abrupt onset associated with frequent passage of
loose or watery stools, fever, chills, anorexia, vomiting and
malaise
Diarrhea associated with two or more of the following signs
present
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Lethargy or unconsciousness
Sunken eyes/unable to drink or drinks poorly
Skin pinch goes back very slowly (> 2 seconds)
Management
Administer oral rehydration fluids while setting up drip
Administer IV fluids immediately Hartmans solution or Normal
saline (0.9% Nacl) if Hartmans is not available: This should be
given at a dose of 100ml/kg as follows
Rehydration fluid volume and duration
First give 30 ml/kg in: Then , give 70 ml/kg in:
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Not able to drink or drinks poorly
Thirsty and drinks eagerly
Sunken eyes
Skin pinch goes back slowly
Persistent Diarrhea
Severe persistent diarrhea without malnutrition
Description
Diarrhea, with or without blood which begins acutely and lasts
for 14 days or longer
When there is some or severe dehydration, persistent diarrhea is
classified as severe
Management
Assess the child for signs of dehydration and manage with
fluids appropriately
Investigate for intestinal infections and treat appropriately
Investigate for non intestinal infections such as pneumonia,
sepsis, urinary tract infections, oral thrush and Otitis media and
treat appropriately
Give multivitamins plus micronutrients supplementation for
2weeks
Treat persistent diarrhea with blood in the stool with an oral
antibiotic effective for Shigella
Feeding
Feeding is essential for all children with persistent diarrhea
Non severe Persistent Diarrhea without Malnutrition
Description
Children with diarrhea lasting 14 days or longer who have no signs
of dehydration and no severe malnutrition
Management
Treat as outpatient
Give multivitamins plus micronutrients for 14 days.
Prevent dehydration
Give fluids as for acute diarrhea with no dehydration (ORS)
Identify and treat specific infections
Persistent Diarrhea with Malnutrition Refer to section onmalnutrition
3). CHOLERA
Description
An acute infectious disease caused by Vibrio cholera.
Characteristics include severe diarrhea with extreme fluid and
electrolyte depletion, muscle cramps and prostration. Vomiting may
be a feature
Usual course:
Acute; chronic; relapsing
Cholera should be suspected in children over 2 years with acute
watery diarrhea and signs of severe dehydration, if cholera is
occurring in the local area
Management
Assess and treat dehydration as for other acute diarrhea Give an oral antibiotic guided by culture and sensitivity
Zinc supplementation when able to tolerate orally:
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Identify the causative organism by stool examination and/or
blood culture and refer to relevant section for management.
Maintain hydration.
5). TYPHOID FEVER
This is caused by Salmonella typhi and Salmonella paratyphi.
Consider typhoid fever if a child presents with fever, plus any of
the following: diarrhoea or constipation, vomiting, abdominal pain,
headache or cough, particularly if the fever has persisted for 7 or
more days and malaria has been excluded
Complications
Complications of typhoid fever include convulsions, confusion or
coma, diarrhoea, dehydration, shock, cardiac failure, pneumonia,
Osteomyelitis and anaemia. In young infants, shock and
hypothermia can occur.
Treatment
Supportive care
If the child has high fever, give Paracetamol.
Monitor haemoglobin level and, if they are low and falling,
consider transfusion
Third generation Cephalosporins such as Ceftriaxone 80 mg/kg
IM or IV, once daily or Cefotaxime 50mg/Kg IV once a day
Ciprofloxacin may be used in areas where there is known
resistance to these drugs
If there are signs of gastrointestinal perforation, pass a
nasogastric tube, keep nil per oral and get surgical opinion
MANAGEMENT AT POINT OF DISCHARGE FOR ALLDIARRHOEA
Counsel the mother on:
Giving extra fluid (as much as the child can take)
Give Zinc supplements:
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Some children suffer recurrent non-specific abdominal pain
with no organic cause identifiable. Constipation is often an
important contributing factor. Psychogenic factors (e.g. family,
school issues) need to be considered. These children should be
referred for general paediatric assessment.
Some less common diagnoses need to be considered in patients
with certain underlying chronic illnesses. Hirschsprungs
disease can be complicated by enterocolitis, with sudden
painful abdominal distension and bloody diarrhoea. These
patients can become rapidly unwell with dehydration, electrolyte
disturbances, and systemic toxicity and are at risk of colonic
perforation. Primary bacterial peritonitis can occur in children
with Nephrotic syndrome, post splenectomy and those with
ventriculo-peritoneal shunts.
7). CONSTIPATION
Description
Constipation is defined variably on the basis of the frequency of
defecation, discomfort in passing stools, delayed intestinal transit
and weight of the stools. Children complaining of constipation can
describe stools that are too small, too big, too infrequent, painful
or difficult to expel or that leave a feeling of incomplete evacuation
Management
General measures
Eliminate medications that may cause or worsen constipation
Encourage exercise/activity
Eliminate foods identified that may cause constipation
Encourage adequate fluid intake
Encourage high fibre diet
Encourage toilet habits; sit on the toilet 5-10min after meals;
takes advantage of the gastrocolic reflex
Differential diagnosis of acute abdomen
Diagnosis Typical features
History Examination
Acuteappendicitis
Abdominal painbecomes increasinglysevere and oftenlocalizes to right iliacfossa
Tenderness, guarding andrebound. Tenderness usuallygreatest in right iliac fossa,though may be more diffuse.
Intussusception Intermittent colickyabdominal pain,vomiting and thepassage of bloodand/or mucus
per rectum. Thereis frequently apreceding respiratoryor diarrheal illness.
Pallor, lethargy. A sausage-shaped mass is palpable inabout two-thirds of cases,crossing the midline in theepigastrium or behind the
umbilicus
Midgut volvulus Bowel obstruction- abdominal pain,distension; usuallybile-stained vomiting
Distension, tenderness
Constipation Can present withquite severeabdominal painin children; oftenrecurrent
Firm stool palpable in lowerabdomen (sometimes entirecolon)
UTI Infants: Fever,
vomiting, lethargy.Older children:dysuria, haematuria
Fever; suprapubic tenderness;
loin tenderness if associatedpyelonephritis; leukocyteesterase, and nitrites may bepositive
Pneumonia Fever; may havecough, vomiting
Fever; tachypnea, chestindrawing focal signs at onebase
Gastroenteritis Vomiting, diarrhea,fever
Tenderness, increased bowelsounds; signs of dehydration
Table 10
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times daily. Retain near lesion for as long as possible, before
swallowing. Child 6-12yrs: 5ml 4 times daily. Child 12-18yrs:
5-10ml 4 times daily.
NB: Miconazole should be given after food or feeding. Treatment
should continue for at least 48hrs after lesions have healed.
Orthodontic appliances should be removed at night and also
brushed with the gel.
2nd line (severe or refractory)
Fluconazole oral/iv: Neonates below 2 weeks: 3- 6mg/kg/
day. Neonates of 2-4 weeks 6mg/Kg stat, then 3-6mg/kg/day.
Child 1month 12yrs: 3- 6mg/kg/day start (day 1) then 3mg/
kg (max 100mg)/daily for 7-14days. Maximum 14 days unlessin immunocompromised. Child 12-18yrs: 50mg daily (100mg in
unusually difficult infections) for 7-14 days.
9). STOMATITIS
Description
Generalized inflammation of the oral mucosa of many possible
etiologies
Treatment
Supportive
Oral toilet quarter strength hydrogen peroxide (6% - approx.
20vol): Rinse the mouth for 2-3min. With 15ml diluted in a
tumblerful of warm water 2-3 times daily.
Topical anesthetic gel: Mostly combinations of Choline
salycilate, Benzalkonium chloride and Lignocaine hydrochloride.
This serves as a local analgesic, antiseptic and surface
anaesthetic respectively. 1-2 drops or paste is applied to the
index finger and gently rubbed on the affected areas when
necessary.
Analgesics: Paracetamol 10-15mg/kg 6- 8 hourly
Children over 10years can rinse mouth and gargle with a
Chlorhexidene or iodine based gargle: Chlorhexidene should be
Medicines
1. Check for fecal impaction: If there is fecal impaction;
Enema rectally
2. Maintenance
Give osmotic laxatives Lactulose or magnesium hydroxide
Stimulant laxatives may be used intermittently as rescue
therapy to prevent recurrence of impaction but be avoided for
long-term, daily use
Lubricant laxatives; for those with hard painful/blood streaked
stools; liquid paraffin
Bulk laxatives; for those with low fibre in diet; bran, ispaghula
Drugs acting locally on rectum for anal fissures to relieve pain;
lignocaine creams/ointments
If no improvement, refer to a gastroenterologist
8). ORAL CANDIDIASIS
Description
An Oral mucocutaneous disorder (in the oral cavity) caused by
infection with various species of Candida.
Treatm
