Mpilo Central Hospital

Department of Paediatrics
Resuscitation Manual 3rd
Edition
(Adapted from APLS manual 5th edition)

Complied by:
Dr G Tawodzera
Dr F Mlotshwa
Dr S Chibhowa
Dr K Ndlovu
Dr G Aadland
Dr T Nyamutowa
Dr S Ndlovu
Dr N Washaya
Dr L Chakawata

Editors:
Dr L Chakawata & Dr N Washaya

Dr Gapu. (Specialist Paediatrician _ Consultant) , Dr Musiyarira, Dr Mutara, Dr

Tawodera, Dr Kurauvone, Dr Mahlanze, Dr Sibanda, Dr Mlotshwa, Dr Ziyera, Dr
Zhakata, Dr Mugwindiri, Dr Shumbayawonda, Dr Chapfuwa (2016)

Consultants:
Dr M Nyathi
Prof M Ikeogu
Dr W Ndebele
Dr P Gapu

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INTRODUCTION
Mpilo Central Hospital is the third largest Hospital in Zimbabwe. It is the tertiary referral
centre for five provinces (Bulawayo, Matabeleland North, Matabeleland South, Masvingo
and Midlands), a population of just over 5 million (2012 Census: actual figure of 5 186 278).
This represents 40% of Zimbabwe’s total population. It is estimated that 41% of the
Zimbabwean population is below the age of 15 years meaning we potentially serve 2 million
paediatric aged citizens. Serving children is one of the most noble endeavours on earth, and it
is our aim to give the children of Zimbabwe the best treatment and management there is. Part
of managing this paediatric population involves the ability to institute timely and lifesaving
emergency management.

Daily in our casualty or wards, it is not uncommon to meet a child who needs some form of
resuscitation. Common examples include patients with gastroenteritis( with severe
dehydration or shock), patients with airway compromise (aspiration of a foreign body, croup,
asthma etc.). Outcome is affected by many factors including disease severity, presence of
comorbidities, availability of emergency equipment etc. A major determinant of outcome,
which is not listed above, is the quality of resuscitative management instituted and this
includes early identification of problems, immediate institution of corrective measures and
adequate follow up. This manual is pre-course reading material for a resuscitation practical
session as a means of improving the quality of emergency care we give to our paediatric
patients.

The manual contents are

 Why children are different from adults

 Basic life support
 Airway and breathing
 Circulation and Shock
 Cardiac arrest
 Convulsions and status epilepticus
 Neonatal resuscitation
 Examination of the new-born

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WHY CHILDREN ARE DIFFERENT
Children are a very diverse group varying greatly in weight, size, intellectual ability and
emotional responses. Competent management of a seriously ill child will require knowledge
of these anatomical, physiological and emotional differences.

Rapid changes in a weight

Weight rapidly INCREASES from birth to 1yr and at puberty.

Drugs are given per kg body weight.
The method used to estimate the weight should be quick and accurate.
In an emergency
 Can use the most recent weight.
 The broselow/sandell tape uses height to estimate child’s weight.
 Can estimate the child’s weight using the age.

I. Estimated weight in kgs = (Age in years+ 4) x 2

II. In children less than 1 year = (0.5 x age in months)

In children 1 -5 years = (2 x age in years) + 8
In children 6 - 12years = (3 x age in years) + 7

Airway anatomical differences

Large head and short neck tends to cause flexion and airway narrowing.
Teeth may be loose.
Large tongue; may obstruct the airway in an unconscious child and may impede the view in
laryngoscopy.
Infants less than 6 months are obligate nasal breathers and their airway may easily be
compromised by mucous secretions in the nose.
3 - 8 year olds are prone to adeno-tonsillar hypertrophy
Intubation is easier with a straight blade versus a curved one due to a high anterior larynx and
a horseshoe shaped epiglottis.
Cricoid is the narrowest portion of airway in children (adults’ narrowest portion is the
larynx.)
Also prone to oedema hence un-cuffed ETTs are preferred in pre-purbetal children.

Breathing

Narrow upper and lower airways and are prone to obstruction even by seemingly small things
for example a peanut.
Have diaphragmatic breathing and are more prone to muscle fatigue because they have fewer
type 1 muscle fibres.
Type 1 muscle fibres; slow twitch, highly oxidative and fatigue resistant fibres
Ribs are horizontal and contribute less to chest expansion.

Circulation

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A child’s circulating blood volume is approximately 70- 80mls/kg and is higher than that of
an adult.
However the actual volume is small therefore relatively small amounts of blood loss can be
critically important.
Blood Pressure varies with age, height and sex*.
*estimated expected systolic BP
50th centile= 85 + (age in years x 2)
5th centile =65 + (age in years x 2)

Body surface area

Body Surface Area to weight ratio decreases with increasing age.

Small children have a higher ratio and are more prone to losing heat more rapidly and are
prone to hypothermia.

Psychosocial differences
Limited communication and explanation of symptoms. This requires the use of non-verbal
clues e.g. facial expression/posture.
Prone to fear and their respiratory rate and pulse rate can be due to fear.
Play can help allay anxiety
Parents/caregivers should be next to the child always where possible.

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TRIAGING
The word “triage” means sorting. Triage is the process of rapidly examining all sick children
when they first arrive in hospital in order to prevent children from dying of a treatable
condition whilst waiting in the queue for their turn.

Many deaths in hospital occur within 24 hours of admission. Some of these deaths can be
prevented if very sick children are quickly identified on their arrival and treatment is started
without delay. In many hospitals around the world, children are not checked before a senior
health worker examines them; as a result, some seriously ill patients have to wait a very long
time before they are seen and treated.

Triaging should not take much time. For a child who does not have emergency signs, it takes
on average 20 seconds. The health worker should learn to assess several signs at the same
time. A child who is smiling or crying does not have severe respiratory distress, shock or
coma. Triage should be carried out as soon as a sick child arrives in the hospital, well before
any administrative procedure such as registration. This may require reorganizing the flow of
patients in some locations. Triage can be carried out in different locations – e.g. in the
outpatient queue, in the emergency room.

Emergency treatment can be given wherever there is room for a bed or trolley for the sick
child and enough space for the staff to work on the patient, and where appropriate drugs and
supplies are easily accessible. If a child with emergency signs is identified in the outpatient
queue, he/she must quickly be taken to a place where treatment can begin immediately.
Triaging is done by all clinical staff involved in the care of sick children should be prepared
to carry out rapid assessment in order to identify the few who are severely ill and require
emergency treatment. In addition, people such as gatemen, record clerks, cleaners, janitors
who have early patient contact should be trained in triage for emergency signs and should
know where to send people for immediate management.

Triage of patients involves looking for signs of serious illness or injury. Triaged children are
put in 3 categories;

E Emergency – need urgent immediate care

P Priority _ needs assessment and rapid care

Q Queue (non-urgent) _ can wait their turn

With those with EMERGENCY if you find any emergency signs, do the following
immediately

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- Start to give appropriate emergency treatment.

- Call a senior health worker and other health workers to help.

- Carry out emergency laboratory investigations.

Those with PRIORITY SIGNS, indicating that they should be given priority in the queue, so
that they can rapidly be assessed and treated without delay.

Those who have no emergency or priority signs and therefore are NON-URGENT cases.
These children can wait their turn in the queue for assessment and treatment.

Emergency signs

These signs can be remembered with the ABCD concept

A-airway

B-Breathing

C-Circulation plus Convulsion and Coma

D-Dehydration

Priority signs

These signs can be remembered with the symbols

3 TPR - MOB

Tiny baby: any sick child aged under two months, Temperature: child is very hot, Trauma or
other urgent surgical condition

Pallor (severe), Poisoning, Pain (severe)

Respiratory distress, Restless, continuously irritable, or lethargic, Referral (urgent)

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Malnutrition (visible severe wasting), Oedema of both feet, Burns

HOW TO TRIAGE?

Keep in mind the ABCD steps:

Airway, Breathing, Circulation, Coma, Convulsion, and Dehydration.

Airway and Breathing

Is the child breathing? Is the airway obstructed?, Is the child blue (centrally cyanosed)?

Look, listen and feel for air movement. Obstructed breathing can be due to blockage by the
tongue, a foreign body, a swelling around the upper airway (retropharyngeal abscess) or
severe croup which may present with abnormal sounds such as stridor.

Does the child have severe respiratory distress? Is the child having trouble getting breath so
that it is difficult to talk, eat or breastfeed? Is he breathing very fast and getting tired, does he
have severe chest retractions any wheezes?

Circulation

Does the child have warm hands? If not, is the capillary refill time longer than 3 seconds?,
And is the pulse weak and fast?

In the older child the radial pulse may be used; however, in the infant, the brachial or femoral
pulses may need to be felt.

Coma

A rapid assessment of conscious level can be made by assigning the patient to one of the
AVPU categories:

A –Alert V-responds to Voice P-responds to Pain U-Unresponsive

A child who is at V is lethargic’

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If the assessment shows that the child does at P or U the child is referred to as having coma
and the child needs to be treated accordingly.

Dehydration

If the child is lethargic or unconscious? If the child has sunken eyes?, If the skin pinch goes
back very slowly?,

When ABCD has been completed and there are no emergency signs, continue

To assess the priority signs.

Priority signs

If the child does not have any of the E signs, the health worker proceeds to assess the child on
the priority signs. This should not take more than few seconds.

Remember 3 TPR-MOB;

Tiny infant (less than two months of age)

Small infants are more difficult to assess properly, more prone to getting infections (from
other patients), and more likely to deteriorate quickly if unwell. All tiny babies under two
months should therefore be seen as a priority.

Temperature: Hot (fever - high Temperature)

A child that feels very hot may have high fever. Children with high fever on touch need
prompt treatment. Take the waiting child to the front of the queue and take locally adopted
action, like having the temperature checked by thermometer, giving an antipyretic, or doing
investigations like a blood film for malaria.

Trauma (or other urgent surgical condition)

Usually this is an obvious case, but one needs to think of acute abdomen, fractures and head
injuries in this category.

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Severe Pallor

Severe pallor is a sign of severe anaemia which might need urgent transfusion. It can be
detected by comparing the child’s palms with your own.

Poisoning

A child with a history of swallowing drugs or other dangerous substances needs to be

assessed immediately, as he can deteriorate rapidly and might need specific treatments
depending on the substance taken.

Severe Pain

If a child has severe pain and is in agony, she/he should be prioritized to receive early full
assessment and pain relief. Severe pain may be due to severe conditions such as acute
abdomen, meningitis, etc.

Lethargy or Irritable and Restless

A lethargic child responds to voice but is drowsy and uninterested (V in the AVPU scale).The
continuously irritable or restless child is conscious but cries constantly and will not settle.

Respiratory distress

When you assessed the airway and breathing, did you observe any respiratory distress? If the
child has severe respiratory distress, it is an emergency. There may be signs present that you
do not think are severe in this case, the child does not require emergency treatment but can be
made a priority Decisions on the severity of respiratory distress come with practice.

Urgent Referral

The child may have been sent from another clinic. Ask the mother if she was referred from
another facility and for any note that may have been given to her. Read the note carefully and
determine if the child has an urgent problem.

Severe wasting (Severe Malnutrition)

To assess for this sign, look rapidly at the arms and legs as well as the child’s chest.

Oedema of both feet

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Oedema of both feet is an important diagnostic feature of kwashiorkor, another

Form of severe malnutrition. Other signs are changes in the skin and hair.

Major Burns

Burns are extremely painful and children who seem quite well can deteriorate rapidly. If the
burn occurred recently, it is still worthwhile to cool the burnt area with water, for example,
by sitting the child in a bathtub with cool water. Any child with a major burn, trauma or other
surgical condition needs to be seen quickly. Get surgical help or follow surgical guidelines.

Triage all sick children. Do not proceed to the next step before treatment is begun for a
positive sign.

If the child has no emergency signs, check for priority signs. After the examination for
priority signs has been completed, the child will be assigned to one of:

Priority (P): the child should be put at the front of the queue

Queue (Q): if the child has no emergency or priority signs

EXAMPLE 1!

A 3-year-old girl is carried in her mother's arms wrapped in a blanket; in the line breathing is
ok. Child has cool hands with capillary refill of 1.5 seconds and child alert with a history of
diarrhoea for 2 days - mom says 4 to 5 loose watery stools; skin pinch takes 3 seconds and
eyes appear sunken a bit

Triage this child!

Airway and Breathing? Breathing ok….proceed to circulation

Circulation? Cool hands with normal capillary refill proceed to assess coma and convulsion

Coma? Child alert

Convulsion? Child not convulsing

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Dehydration? Skin pinch goes back slowly and eyes sunken!!!!!!!!!! Triage as emergency and
rush for immediate assessment and treatment

EXAMPLE 2!

2 year old male. Mother rushes in- he convulsed 30 minutes ago and she is frightened, child
breathing slightly fast but no cyanosis, no distress, no signs of obstructed breathing. Child
feels very hot and capillary refill fast- less than a second, fast but strong pulse and responding
to voice by crying. History of diarrhoea today and skin pinch less than 2 seconds but eyes not
sunken and crying with big tears with no visible wasting or oedema and severe pallor

Triage this child!

Airway and Breathing? No distress….proceed to circulation

Circulation? Fast strong pulse proceed to assess coma and convulsion

Coma? Child at responding to voice

Convulsion? Child convulsed 30 minutes ago but no longer convulsing

Dehydration? Skin pinch goes normal and eyes not sunken Not an emergency proceed to
check for priority signs

Priority signs? Very hot and severe pallor. This child triaged as priority….move to front of
queue for urgent reassessment

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BASIC LIFE SUPPORT
Structured approach to emergency paediatrics

In an emergency a structured approach helps in ensuring that vital steps are not forgotten.

First: Identify immediate threats to life and treat (resuscitation) e.g. obstructed airway/absent
or distressed respirations, pulselessness and shock.
Second: Emergency treatment to start to treat the child’s illness or injury.
Third: Stabilize the child and transfer to a definitive care environment.

General Approach

 Primary Assessment
o Airway
o Breathing
o Circulation
o Disability (Neurological), DEFG (Don’t ever forget glucose)
o Exposure

 Resuscitation
o As you identify the problems in ABC you rectify them

 Secondary Assessment
o Short History past 24hrs what is relevant, in-depth examination of the different
systems

 Emergency Management
o May be antibiotics etc. depending on the condition

 Stabilisation & transfer to definitive management

WAFLES (Preparing for the patient)

Weight kg
Adrenaline: 1 in 1000 made up to 10 ml then give 0.1ml/kg (i.e. 10 micrograms/kg)
Fluid: 20mls per kg
Lightning: 4J/Kg (if defibrillating) or 2J/kg (if cardioverting)
ETT: Prepare actual size, one size smaller and one size bigger
Sugar: 2ml/kg 10% dextrose

Making 10% dextrose water from 50% dextrose water

 One part 50% dextrose water + four parts sterile water

Important points
 preparation
 Teamwork
 Communication

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Primary assessment and resuscitation

Step 1 (Safety, stimulate and shout)

Safety is important especially in an external environment because the rescuer should not
become the second victim.
Stimulate - gently shake and ask e.g. Are you alright?
Summon someone to call for help while you start resuscitation. (If alone call for help yourself
if no one comes within a minute of CPR).
If in a hospital, help is usually a shout away.

Step 2 (Airway)

Open the airway – head tilt/chin lift or jaw thrust

Neutral position in infants and sniffing position in children
Check patency -LOOK, LISTEN and FEEL.
Look for chest movement
Listen for breath sounds with ear just above the nose
Feel the breath on your cheek above the mouth

Step 3(Breathing)

If patient’s airway is patent and patient breathing-turn the child to his/her side and put
him/her in recovery position and maintain the open airway.
If breathing is still ineffective, give 5 rescue breaths.

Step 4 (Circulation)

Start chest compressions if

 No signs of life-no movement, not coughing ,absent or abnormal breathing
 No pulses- use brachial in infants and carotid or femoral in children
 Pulse less than 60b/minute

Compress the lower half of the sternum to a depth of at least one third of the chest diameter
(infants roughly 4cm).Chest wall should completely recoil before the next compression.
In infants use the hand encircling technique. If alone use the two finger technique employing
the other hand to maintain the airway. In children can use the two hands or the one hand
technique.
Ratio 15: 2 for all age groups
Compressions should be continuous because pausing unnecessarily will decrease coronary
perfusion pressure to zero and several compressions will be required before adequate
coronary perfusion recurs.
Total compressions; 100-120beats/minute for all ages

Step 5 (Recovery position)

No specific position in children-place in stable lateral position ensuring an open airway and
free drainage from mouth to prevent aspiration.

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AIRWAY AND BREATHING
Learning outcomes

1. Knowledge of types and use of adjuncts and equipment used in supporting the airway
and breathing.
2. Know how to support breathing with simple equipment
3. Know how to respond to an airway/breathing problem

Introduction

Effective resuscitation of an airway has to be applied quickly particularly in children since

deterioration of respiratory function, particularly in this age group, is high.
Differences between adults and children must be realised
Basic simple techniques are often effective and lifesaving

Equipment for managing the airway

• Face masks
• Airway including laryngeal mask airways (LMAs)
• Self-inflating bags – valve mask devices
• Tracheal tubes, introducers and connectors
• Suction devices
• Cricothyroidotomy cannula

Familiarity with the above equipment is necessary before an emergency situation

1. Face masks - come in different sizes

Sizing a face mask – it should be big enough to cover the nose and mouth, but small
enough no not go over the eyes and should not override the chin. The mask is meant
to form a tight seal. If you have a shaped mask use it down side up in infants.

2. Oropharyngeal airway - used in unconscious or obtunded patients, maintains patency

between tongue and post pharyngeal wall.
Correct size assessed by placing the airway with its flange at the centre of the incisor
teeth then round face to the angle of the mandible.
Technique of insertion - select correct size, open airway by chin lift, use a tongue
depressor to assist insertion of airway with right way up and provide oxygen by bag
and mask or pocket mask.

3. Laryngeal mask airway - Ventilate patient first, check if cuff is working with a
syringe.
Deflate cuff and lubricate back and sides of mask. Tilt patient head and open mouth
fully and insert tip of the mask along hard palate and further along the posterior
pharyngeal wall until resistance is felt as it lies at the upper end of the oesophagus.
Inflate the cuff fully and secure the mask with an adhesive tape.
Check if in the correct position as for a tracheal tube.

4. Laryngoscopes - Two types (straight bladed and curved)

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 a) Straight bladed - used for directly lifting the epiglottis uncovering the vocal folds.
Disadvantage vagal stimulation, laryngeal spasms and bradycardia.
b) Curved - moves epiglottis forward by lifting it from in-front - less vagal
stimulation.

In general straight bladed for infants and curved for greater than 1 year.

5. Endotracheal tubes –

i) Uncuffed tubes
Preferred in children less than 10 years.
Estimating size Internal diameter in mm = age/4 + 4
Length (cm) Age/2 + 12 (Oral endotracheal tube)
Length (cm) Age/2+15 (Nasal endotracheal tube)
Neonates require size 3- 3.5 mm and preterms size 2,5mm

ii) Cuffed tubes

Not recommended in children less than 10 years
Size estimation for less than 2 years - Internal diameter (mm) = Age/4 + 3.5
Infants that are 3kg up to 1 year olds size 3
1-2 years size 3.5

6. Cricothyroid cannula
Not commonly done or used in our setting
Involves passing a needle through the cricoid membrane and attaching it to an oxygen
flow meter

7. Introducers
Soft and flexible or firm and pliable are used to allow easy introduction of the tracheal
tubes

Intubation procedure -
• Oxygenate child for at least 3 minutes
• prepare and check your equipment
• With the laryngoscope held in the left insert it to the right side of the mouth
displacing the tongue to the left, lift epiglottis forward and look for the vocal
cords in the midline.
• Insert tube through the vocal cords but not too far to avoid bronchial intubation,
bag via the tube
• Inspect - chest for equal movement
- auscultate chest
- listen over epigastrium to rule out oesophageal intubation

Equipment for providing oxygen and ventilation

1. Oxygen source 2. Face masks 3. Self-inflating bags

4. T piece and open ended bags 5. Mechanical ventilators 6. Chest tubes
7. Gastric tubes

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Airway & breathing management

Primary assessment

Involves rapid physiological assessment

Airway
Breathing
Circulation
Disability
Exposure

General approach (safety, stimulate, shout for help)

• Look
• Listen
• Feel - for airway obstruction, respiratory arrest, depression or distress
• Assess effort of breathing
• Count the respirations
• Listen for stridor / wheeze
• Auscultate for breath sounds
• Assess skin colour

Respiratory rate according to age at rest

Age (years) Respiratory rate
<1 30-40
1-2 25-35
2-5 25-30
5-12 20-25
>12 15-20

Respiratory rate is higher in infancy and falls with increasing age.

At rest tachypnoea indicates either lung or airway disease or metabolic acidosis. A slow
respiratory rate indicates fatigue, cerebral depression or a pre- terminal state.

Recessions

Intercostal, subcostal, sternal, suprasternal (tracheal tug) all show increased effort of
breathing
Caveat: In an exhausted child recessions may be absent!!!

Inspiratory and expiratory noises

Inspiratory noise or stridor is a sign of laryngeal or tracheal obstruction. Stridor may occur in
severe obstruction. Wheeze indicates lower airway narrowing and is more pronounced during
expiration. Volume of noise indicates severity of the disease and but tends to disappear in the
pre-terminal phase. Hence, in an asthmatic child who is not improving the loss of wheeze is
an indication of worsening distress.

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Grunting

Is produced by exhalation against a partially closed glottis. It is seen in children with severe
respiratory distress e.g. in pneumonia, pulmonary oedema, raised intracranial pressure,
abdominal distension and peritonism.

Accessory muscle use

Sternocleidomastoid muscle may be used as an accessory respiratory muscle and causes head
nodding with each breath in children.

Flaring of nostrils

Seen in children with respiratory distress

Gasping

A sign of severe hypoxia and may be a pre-terminal event

There is absence of evidence of increased effort of breathing in the following cases

1. Exhausted child or infant

2. Cerebral depression from raised intracranial pressure, poisoning or encephalopathy due to
reduced respiratory drive
3. Neuromuscular disease like muscular dystrophy or spinal muscular atrophy.

This means that in the above 3 scenarios a child may be in severe respiratory distress and yet
‘obvious’ indicators of respiratory distress are absent.

Hence in such cases other signs of respiratory inefficacy need to be looked for example
• degree of chest expansion
• Pulse oximetry (SPO2)
• Heart rate - hypoxia leads to tachycardia although anxiety and fever may lead to
tachycardia. Severe or prolonged hypoxia on the other hand leads to bradycardia
• Hypoxia leads to vasoconstriction and pallor. Cyanosis is a late and pre terminal sign
of hypoxia and usually appears when SPO2 is <70%
• Mental state - the hypoxic child may be drowsy or agitated and eventually
consciousness may be lost.

Airway management

Perform basic airway opening manoeuvres - (head tilt/chin lift or jaw thrust)
(Sniffing position – >1yr and neutral position – all infants)
Give Oxygen
Suction (as needed)
Place airway adjuncts
Proceed to intubation if necessary

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Breathing

Establish adequate ventilation via bag and mask

Perform chest compressions if necessary
Initiate pulse oximetry and other monitoring at this stage

Secondary assessment

Thorough physical examination and investigations

Examine airway, head, neck and chest
Identify swelling bruising or wounds
Re-examine for symmetry of breath sounds and movement
Don’t forget to inspect and listen at the back of chest
NB – primary assessment and resuscitation phase can be integrated in a very sick child.

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APPROACHING A CHILD IN SHOCK
Shock is cardiac output that insufficient to meet the metabolic requirements of the body
Shock is a common cause of morbidity and mortality in Zimbabwe.

Causes
 Hypovolemic – Acute Gastroenteritis, Haemorrhage, Burns
 Cardiogenic – arrhythmias, Heart Failure, cardiomyopathy, valvular disease
 Distributive – sepsis, anaphylaxis, spinal cord injuries, vasodilators
 Obstructive – tension pneumothorax, cardiac tamponade
 Dissociative – profound anaemia, carbon monoxide poisoning, methaemoglobinemia

Phases of Shock
 There are three phases which generally overlap
 Compensated
o In the first phase the body aims to maintain vital organs (brain, heart, and
kidney). The Sympathetic nervous system kicks in so does the Rennin
Angiotensin Aldosterone System (RAAS).
o Clinically this manifests as Irritability, pallor, ↑ HR, cold peripheries, ↓
capillary refill, ↓ urine output.

 Uncompensated
o Failure of compensatory mechanisms to maintain cardiac output hence
anaerobic respiration ensues.
o Clinically BP may be normal or ↓.may be acidotic +/- ↓ LOC
o Caveat – low BP is a late sign. A patient may have a normal BP and yet be
in shock!!

 Irreversible
o Untreated shock progresses to this. In this scenario cellular damage occurs and
o Regardless of restoration of cardiovascular function patient will die. This is
because multi-organ failure would have occurred

Approach to the child in shock

Primary Assessment

Airway
Breathing
Circulation
 Vital signs: HR, Pulse volume, BP
 Skin and mucous membrane perfusion: capillary refill ( central& peripheral), T ⁰C, ,
colour
 Organ perfusion : effects on breathing (acidotic?), LOC, Urine output
 Disability
Exposure

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Resuscitation

Airway and breathing

Ensure patent airway, may need suction, and may need intubation
Give high flow oxygen per face mask to all patients in shock.

Circulation

Classify degree of dehydration and manage accordingly.

a) Severe shock & severe dehydration

Signs of severe dehydration - lethargic, reduced LOC, not able to drink or drinking
poorly and very slow skin turgor.
Signs of shock – decreased LOC, Cold clammy peripheries despite warm ambient
temperature, no radial and/or brachial pulse, and capillary refill greater or equal 3
seconds

Gain Intravenous or intraosseous access if IV access difficult (take bloods FBC, U&E,
Cross match, ABGs etc.)
Check glucose (DEFG-Don’t ever forget glucose)
Rapid bolus 20ml/kg crystalloid (Normal saline/ Ringer lactate), may need repeat
bolus. If using ½ DD it becomes 30ml/kg. Remember to exclude severe wasting or
oedema first before giving rapid boluses. You can repeat bolus up to 60MLS/KG.
CAUTION: severe anaemia, severe malaria, etc.
Check for signs of improvement after each bolus e.g. pulse rate, better pulse volume.
If improved move to 70ml/kg per hour over 4 hours over 2 ½ to 5 hrs. than review
Patients in septic shock may need up to 200ml/kg in the first 24 hrs.
If a patient needs more than 60mls/ kg of crystalloid boluses to consider giving
albumin and whether patient requires intubation
Treat cause e.g. if gastroenteritis fluid replacement, sepsis antibiotics, if anaphylaxis
give IM adrenaline.

These patients need constant review for adjustment of fluids and review of progress.
Measure urine output, empower the caregiver by educating him/her to measure and
document urine output.

Cardiac/Malnutrition/Raised Intracranial pressure/known kidney disease in

shock

Give 10ml/kg instead of 20ml/kg be cautious with fluid boluses

Signs of fluid overload

In trying to correct shock you may end up in fluid overload in your patient, this will
result in a poor outcome.
Signs of over hydration include puffy eyes, respiratory distress, distended neck veins,
chest crepitations, gallop and hepatomegaly.

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 Management of over hydration – consult senior, oxygen, prop up patient, reduce/stop
fluids, furosemide 1-2mg/kg IV (if there is good urine output)
***Fitting after fluid boluses may be a sign of cerebral oedema especially in
hypernatremia dehydration.

b) Some dehydration

Clinical signs-restless or irritable, sunken eyes, drinks eagerly, skin pinch slow.
Rehydrate orally with 5-10mls/kg per hour of ORS or Resomal if malnourished for 4-
6hrs then reassess…rehydration is done alternating Resomal with F75 for 4-10 hours
Secure an IV line because you may need it.
Small frequent sips or teaspoon by teaspoon helps prevent vomiting.
If patient is vomiting, switch to intravenous route.

c) No dehydration

Give ORS 10ml/kg per loose stool, Zn sulphate, continue with normal diet and tell
mother when to come back.
In malnourished use Resomal

Hypernatremia dehydration

Clues that might help you suspect hypernatremia are; a chubby baby, on formula feeds,
irritable/inconsolable, history of salt rubbing, remember child may not seem to be too
dehydrated +/- doughy skin, may be acidotic, and has been having a lot of diarrhoea
If in shock give bolus as above then switch to oral or slow IV
Principle is correct fluid deficit over 48hrs – 72hrs
Oral fluid replacement has better outcome than intra venous

Setting up an intraosseous line

Tibia: anteromedial 2 cm below and medial to tibial tuberosity.

Femoral; anterolateral surface, 3cm above the lateral condyle.
Use: 18 gauge needle or the biggest needle available or use intra-osseous needles if available.
NB: This is done in emergency settings and as soon as an alternative line can be found it
should be put

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CARDIAC ARREST
Background

Definition: The absence of an effective cardiac out put

Children have restricted respiratory and circulatory capacity compared to adults. Cardiac
arrest in children presents usually as asystole or pulseless electrical activity (PEA). It usually
is secondary to respiratory and/or circulatory failure. Primary heart disease as the cause is
rare, and if present it is usually of the congenital type.

Cardiac arrest in children has a poor outcome with high mortality, especially outside
hospitals. Children who survive cardiac arrest have high frequency of severe neurological
damage. That is because they often will be hypoxic before the cardiac arrest and so the brain
is at risk for irreversible sequel.

IT IS IMPORTANT TO NOTE THAT THOUGH CARDIAC ARREST HAS POOR

OUT COME IN CHILDREN, MOST OF THE CAUSES ARE REVERSIBLE AND
WHEN IDENTIFIED EARLY PREVENTIVE MEASURES CAN BE INSTITUTED

Causes of cardiac arrest

Can be summarised as the 4 Hs and 4Ts

5 H’s
Hypoxia
Hypovolemia
Hyperkalaemia,
Hypothermia,
Hypoglycaemia

4 T’s
Tension pneumothorax
Tamponade (cardiac)
Toxins & drugs
Thromboembolic phenomena (rare in children)

The most important cause for cardiac arrest in children is hypoxia (respiratory failure)
followed by hypovolemia (circulatory failure).

Respiratory failure causes:

 Lung and airways disease ( pneumonia, bronchiolitis, asthma)
 Trauma ( lung -contusion, foreign body or pneumothorax)
 Hypoventilation ( convulsions, head trauma, toxins, drugs ( e.g. opiates),
neuromuscular diseases)

Hypovolemia causes:

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  See chapter on shock

In our setting children who get hypoxia and/or hypovolemia who are at greater risk cardiac
arrest include:
 Children with poorly controlled HIV & other chronic diseases
 Children with kidney failure
 Children with heart disease
 Children with chronic lung disease
 Malnourished

Approaching a child with cardiac arrest

When there is cardiac arrest, good cardiopulmonary support is the basis of all resuscitation.
Health-workers should be competent in administering effective basic life support.

Guidelines point towards a better outcome when you have quality cardiac compressions as
well as the shortest “hands off time”. In short you must “push hard and fast”.

The types of arrest rhythms children get can be classified in to shockable rhythms and non-
shockable rhythms

Non-shockable rhythms

Asystole
Pulseless Electrical Activity (PEA)

Shockable rhythms

Ventricular fibrillation
Pulseless ventricular tachycardia

Signs of life

Coughing/gaging
Regular respiratory effort
Spontaneous movement
Eye opening
Sudden ↑ in end tidal CO2

Return of Spontaneous Circulation (ROSC)

Signs of life and Pulse > 60bpm

Approach to a patient with a Non -shockable rhythm

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Always begin with CPR, Adrenaline after 2 mins of effective CPR

General Approach

Check Airway and Breathing

You will note poor respirations or no spontaneous respirations
Manage as for airway (e.g. bag mask ventilation)

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Caveat it is useless to give good chest compressions without ensuring adequate
ventilation. Hence ensure chest is rising and ventilation is adequate. This is because the
aim of CPR is to support coronary perfusion i.e. move oxygenated blood to the coronary
and cerebral circulation.

Circulation

Start chest compressions. Ensure chest compressions are continuous except when assessing
the rhythm which should take less than 10s. Unnecessary interruption of chest compressions
is associated with poor outcome
Give Adrenaline 10micrograms/kg IV or IO. Then normal saline flush 2 – 5 ml
Every 2 mins (roughly every 5 cycles) – check pulse and precordium briefly (< 10s) (it is
better to listen to the precordium or feel for brachial or carotid pulses)
Every 4 mins repeat adrenaline
As soon as feasible intubate. Once intubated compressions can be continued continually and
ventilation to be done at the physiological rate for the age. (That is every 3-5 seconds / every
3 seconds for the new-born)
Team leader to ensure that the ventilation is adequate
Identify and sort out 5Hs & 4 Ts
CPR is tiring switch roles after every few cycles

When to stop resuscitation

No Return of spontaneous circulation (ROSC) after 20 mins of effective CPR and 5Hs and
4Ts corrected and in the absence of recurring or refractory VF/VT

Exception
 Poisoning
 Hypothermia primary insult
 Near drowning
In the above three resuscitation is continued beyond 20 minutes

Drugs used in cardiac arrest

Adrenaline

First line drug in cardiac arrest

Formulations
 1 in 10 000 (1000mg per 10000ml i.e. 1mg per 10ml). To give 10mcg/kg give
0.1ml/kg
 1 in 1000 (1000mg per 1000ml i.e. 1mg per ml). To give 10mcg/kg make it up to
10mls then give 0.1ml/kg

Mechanism of Action
 α adrenergic vasoconstriction
 ↑ aortic diastolic pressure during chest compressions thus coronary perfusion
pressure
 ↑ contractility
 Stimulates spontaneous contraction
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Endotracheal adrenaline
 SHOULD BE AVOIDED
 Variable absorption (10 X the dosage)
 Transient β adrenergic effects

High dose adrenaline (100mcg/kg) is associated with poorer outcome but may have a role in
β blocker overdose

Alkalising agents (Bicarbonate)

Routine use not beneficial (1mmol/kg)

May be used in Hyperkalaemia, TCA poisoning, refractory acidosis
Causes calcium to precipitate so do not give in same line as calcium
Inactivates adrenaline & dopamine therefore flush between drugs
Do not give via ETT

Atropine

No role. It is used for vagal stimulation causing bradycardia in a perfusing patient e.g.
bradycardia due to suctioning or intubation

Calcium

No role unless ↓ Ca ↑ K ↑Mg

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CONVULSIONS AND STATUS EPILEPTICUS
Learning outcomes

1. The causes of convulsions in paediatric patients

2. How to resuscitate the child with convulsions
3. Emergency treatment of the different causes of convulsions in children

Introduction

Generalised convulsive (tonic–clonic) status epilepticus (CSE) is currently defined as

 a generalised convulsion lasting 30 minutes or longer

 Or when successive convulsions occur so frequently for than 30-minute period that
the patient does not recover consciousness between them.

Although the outcome of CSE is mainly determined by its cause, the duration of the
convulsion is also relevant. In addition, the longer the duration of the episode, the more
difficult it is to terminate it.

In general, convulsions that persist beyond 5 minutes may not stop spontaneously, so it is
usual practice to institute anti-convulsive treatment when the episode has lasted 5 or more
minutes.

Common causes of convulsions in children include

 fever ( 6 months to 6 years)

 HYPOGYCEMIA (DEFG!!)
 meningitis
 epilepsy
 hypoxia
 metabolic abnormalities
 electrolyte imbalances

Status epilepticus can be fatal, but mortality is lower in children than in adults – at about 4%.
Death may be due to complications of the convulsion, such as obstruction of the airway,
hypoxia, and aspiration of vomit, overmedication, and cardiac arrhythmias or to the
underlying disease process.

Complications of prolonged convulsions include cardiac arrhythmias, hypertension,

pulmonary oedema, hyperthermia, disseminated intravascular coagulation and
myoglobinuria.

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Neurological outcomes (persistent epilepsy, motor deficits, learning and behavioural
difficulties) are age dependent, occurring in 6% of those over 3 years but 29% of those under
1 year.

Approach to a convulsing patient

It also begins with the primary assessment (A, B, C s) and then secondary assessment

However it may be difficult to secure the Airway, Breathing and Circulation when a
patient is fitting hence your first step in this case would be to stop the fit

EMERGENCY TREATMENT OF THE CONVULSION

Step 1

Undertaken 5 minutes after the seizure has started or a seizure that has started in the
prehospital setting. In our setting this may include a seizure which may be subtle that the
caregiver has not noticed. So when you witness a fit begin taking steps to stop it because you
may not know for how long it has been going on for and it will probably take you time to get
the benzodiazepam ready.

Give a benzodiazepine
 intravenous/rectal diazepam 0.3 - 0.5mg/kg or
 buccal midazolam 0.5mg/kg or
 IV lorazepam 100mcg/kg.

Step 2

If convulsion persists for 5 minutes after first dose of benzodiazepam, give the second dose of
a benzodiazepine and call for senior help.
Do not give more than two doses of a benzodiazepine including that which was given in
prehospital setting.
Start preparing phenobarbitone/phenytoin for step 3.
Reconfirm it is an epileptic fit- differentials include posturing, dystonia or pseudo epilepsy.

Step 3

If fits persist, senior help should be present and arrange for ICU bed and anaesthetic help.

Give
 Phenobarbitone 10 - 20mg/kg iv infusion over 5 minutes or 1mg/kg/min
 Or phenytoin 20mg /kg IV infusion over 20 minutes. After the start of the infusion,
paraldehyde 0.4mg/kg mixed with an equal volume of olive oil can be given after
consulting.
 Alternatives include sodium valproate and levetiracetam.

Step 4

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If patient is still fitting 20 minutes after the beginning of step 3, reassess.
Airway, breathing, circulation, check glucose, U&E with calcium, arterial blood gas.
Treat any abnormalities and give antipyretic if pyrexial.
Consider mannitol 250-300mg/kg IV over 30minutes or 3% saline 3mls/kg if indicated.

Give
 Sodium thiopentone (STP) 4-8mg/kg IV as rapid sequence induction with a short
acting paralysing agent and ventilate.
 Consider pyridoxine trial in children less than three years with a history of chronic
active epilepsy.

STP is not an effective long term anticonvulsant and its principal use is to facilitate
ventilation, other antiepileptic medication should be continued.

Step 5 (General measures)

Maintain a normoglycemic state -5% glucose solution infusion as maintenance.

Assess and maintain electrolyte balance, especially sodium.
Insert naso-gastric tube and aspirate gastric contents. Perform gastric lavage if indicated

Appropriate management of raised intracranial pressure if present.

 Prop up at 20 degrees.
 Supportive ventilation-maintain PCO2 of 4.5-5.5kPa.
 Give mannitol 250-500mg/kg over 15 minutes (equivalent to 1.25-2mls/kg of 20%
mannitol over 15minutes.)
 Give dexamethasone (500mcg/kg bd for oedema surrounding a space occupying
lesion.
 Catheterise the bladder.

Repeated assessment and management of the underlying cause.

Back to primary assessment

This is especially important postictal. During a fit, though important, it may be difficult to
carry out the primary survey hence stop the fit then assess.

Airway

Assess airway patency

Breathing

Assess as noted earlier.

Remember respiratory failure has effects on other physiology including

28 | P a g e
  heart rate
 skin colour
 mental status

Give high flow oxygen but if hypo ventilating support with bag mask
ventilation and proceed accordingly.

So remember a restless post ictal patient may as well be hypoxic

Circulation

As noted before

Heart rate: The presence of an inappropriate bradycardia may suggest

raised intracranial pressure.

Blood pressure: Significant hypertension indicates a possible cause for

the convulsion or more likely is a result of it.

Remember a hypoxic individual may become restless

Disability

Mental status/conscious level (AVPU)

Pupillary size and reaction

Posture: Decorticate or decerebrate posturing in a previously normal

child should suggest raised intracranial pressure. These postures can be
mistaken for the tonic phase of a convulsion. Consider also the
possibility of a drug-induced dystonic reaction or a psychogenic,
pseudo-epileptic attack. All these movement disorders are
distinguishable from tonic–clonic status epilepticus as long as they are
considered

Look for neck stiffness in a child and a full fontanelle in an infant, which
suggest meningitis

Remember Cushing’s triad for raised intracranial pressure – High blood

pressure, bradycardia and irregular breathing. But please not this is a
pre-terminal sign.

Exposure

Rash: If one is present, ascertain if it is purpuric as an indicator of

meningococcal disease or non-accidental injury.

Fever: A fever is suggestive evidence of an infectious cause

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Consider the evidence for poisoning: History or characteristic smell.

Glucose

Every fitting patient should have their glucose checked early in their
management and corrected if abnormal.

Secondary assessment and looking for key features

While the primary assessment and resuscitation are being carried out a
focused history of the child’s health and activity over the previous 24
hours and any significant previous illness should be gained.

Specific points for history taking include:

● Current febrile illness

● Recent trauma

● History of epilepsy

● Poison ingestion

● Last meal

● Known illnesses

The immediate emergency treatment requirement, after ABC

stabilisation and exclusion or treatment of hypoglycaemia is to stop the
convulsion.

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RESUSCITATION OF THE NEW BORN
Normal physiology

In utero, the lungs are fluid filled and respiratory function is carried out by the placenta. At
birth the respiratory function baton is passed from the placenta to the lungs.
Clearing of lung fluid is facilitated by
1. At the end of pregnancy, the pulmonary cells stop producing fluid and start absorbing
it.
2. During NVD, some fluid is expelled as the baby passes through the birth canal.
(Reason why children born via caesarian section tend to have more respiratory
distress).
3. Initial breaths, crying and chest recoil cause fluid to be displaced from the airways
into the lymphatics and circulation.

The major stimulus for initiation of respiration is hypoxia which occurs when the umbilical
cord is clamped.

Abnormal

The asphyxiated neonate undergoes abnormal transition. There is failure to initiate and
maintain respirations, leading to hypoxia. Prolonged hypoxia results in failure of the
respiratory centre to sustain respirations. This leads to primary apnoea and secondary apnoea.

Primary apnoea occurs after initial deprivation of oxygen. It is preceded by fast breathing for
2-3 minutes but as the hypoxia continues there is failure of the respiratory centre. Clinically
the signs are apnoea, bradycardia; however the blood pressure is maintained. During primary
apnoea breathing can be stimulated by tactile stimulation or oxygen. A new born in primary
apnoea may ‘resuscitate’ themselves and resume respiration. After a latent period of primary
apnoea-primitive spinal centres stimulate gasping respirations.

Secondary apnoea is preceded by deep gasps. The rate is 6-12 times a minute and there is
involvement of all accessory muscles. If hypoxia is not corrected secondary (terminal)
apnoea occurs. Clinically the signs are apnoea, bradycardia and in this case the blood
pressure drops.
A patient in terminal apnoea will not resume respiration without positive pressure ventilation.

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Strategy for assessment and resuscitation

Ideally someone trained in new born resuscitation should be present at each delivery.
Preparation is key-environment, equipment and personnel.
Call for help-if you expect or encounter any difficulties.
Start the clock or note the time of birth.
At birth dry the baby quickly and effectively and wrap in warm dry cloth/blanket
As you do so assess the new born and decide whether any intervention is required.

Clamping the cord

No need to rush it in stable babies who do not need urgent resuscitation and can wait for at
least one minute but it is essential to keep the baby warm while at it.

Temperature control

Hypothermic babies have increased oxygen consumption, are prone to hypoglycemia,

acidosis and have a higher mortality. Aim to keep baby warm.

Initial Assessment

Respirations-rate and quality

Heart rate-tachycardia, bradycardia or absent. It is better to auscultate the heart. Some use the
umbilical cord but this is only accurate if the rate is greater than a 100
Oxygen saturation monitors where available are also helpful
Colour-pink, cyanosed or pale
Tone-unconscious, floppy
After assessment babies can be categorized as needing resuscitation or not.

Apgar Scores

It is an objective method of quantifying the newborn’s condition, and is useful for providing
information about the overall status and response to resuscitation

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Resuscitation should commence before Apgar score is assigned.
It is normally assigned at 1 minute and 5 minutes of age if <7 at 5 minutes it should be
repeated at 10 minutes and so on.
It is not used to determine need for resuscitation.

Airway

Head in neutral position and do not overextend.

A jaw thrust or a 2cm towel folded and put under the neck may help maintain the position
especially in floppy babies.
Visible secretions can be suctioned by a Yankaeur or a 12-14 gauge suction catheter.

Meconium stained liquor

Meconium stained liquor is fairly common and occurs in approximately 10% of deliveries.
Meconium aspiration however is a rare event.

Suction using a bulb syringe or suction catheter (8F or 10F). Starting with mouth first, then
nose with a negative pressure <100 mm Hg/136 cm H2O. Penguin suckers are good.
However large trials have demonstrated no benefit of routine suctioning when the head
is still on the perineum and might delay resuscitation. HENCE DO NOT ROUTINELY
SUCTION NEONATES.

Deliver baby-if vigorous no specific action is required.

If baby not vigorous which is defined as depressed respiratory effort, poor muscle tone +/-
heart rate< 100b/min. Perform a direct laryngoscopy then aspirate any particulate material
using a wide bore catheter. Intubation if possible can be done to suction the trachea. If
Intubation not possible-clear the oropharynx and start mask inflation. Do not suction for more
than 5 seconds each time.
If HR falls to <60 during suctioning, stop and start ventilation. And get atropine.

Breathing

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First 5 inflation breaths- to replace lung fluid with air. Should be 2-3 seconds of sustained
breaths.
Increase in heart rate is a good indicator of adequacy of ventilation.
Chest might not rise during the first 1-3 breaths as fluid is displaced.
Continue ventilation at 30-40 breaths/minute until regular breathing is established.
If oxygen is not readily available you can bag with room air. There is strong evidence to
support resuscitation with room air in term babies.
If heart rate has not responded, check for chest movement and airway. Poor ventilation is the
most common cause of a heart that is not responding. As a result reassess airway, repeat
airway opening manoeuvres and repeat inflation breaths.

Positive pressure ventilation methods

 Bag and mask ventilation
o Self-inflating bag
o Flow inflating bag
o T-piece
 Laryngeal mask airway ventilation
 Endotracheal intubation

Circulation

If heart rate remains slow/absent, despite adequate ventilation for 30seconds (as shown by
chest movement), then chest compressions should be started.
Rate 3:1, depressing to 1/3 of the chest.
Compressions aim to move oxygenated blood to the coronary arteries to initiate cardiac
recovery.
Chest compressions without adequate ventilation are therefore fruitless.
With good ventilation and compression technique, the heart beat responds in 20-30seconds.
Once heart beat is > 60b/minute, chest compressions can be discontinued.
Maintain ventilation till effectively breathing or mechanical ventilation is established

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Drugs

The most common reason for poor response is failure to achieve lung inflation. Hence there is
no point giving drugs if airway is not dealt with. Airway and breathing must be reassessed
before drugs are considered.

Adrenaline for profound unresponsive bradycardia.

Glucose –treat hypoglycaemia with 2.5ml/kg of 10% dextrose IV and continuing a 10%
dextrose drip for maintenance

IV fluids-in hypovolemia. Hypovolemia can be due to known or suspected blood loss -

APH, unclamped cord or loss of vascular tone in asphyxiated babies.
Normal saline @ 10ml/kg.
Uncross matched O - Rh negative blood or gelofusine can be used.

Bicarbonate-use remains controversial and may only be considered when all resuscitative
efforts have failed.
Naloxone- not a drug of resuscitation but is useful in mother who received opiates. It is given
in babies who have been resuscitated, are pink with a good heart rate but cannot maintain
spontaneous breaths due to possible maternal opiates taken within 4hrs of delivery.

Preterm babies

Unexpected outside deliveries are commonly preterm.

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Apgar scores are not usually indicative of asphyxia but rather of the degree of prematurity.
Preterm babies are at greater risk of hypothermia and hypoglycemia as compared to term
babies.
Their poorly developed lungs, surfactant deficiency and poor chest musculature mean they
generally need more ventilatory support.
Lungs are more fragile and more prone to barotrauma when over distended during bagging or
mechanical ventilation

Discontinuing resuscitation

Outcome for a baby with no detectable cardiac output for 10 minutes or more is poor; we
generally get up to 20 and at times 30min.
Stopping resuscitation early or not resuscitating may be appropriate in certain circumstances
E.g. severe prematurity <23wks/400g, severe lethal congenital abnormalities like
anencephaly etc.

Communicating and giving information to parents about the progress of the baby is
essential and should be routinely done whenever possible

EXAMINATION OF THE NEWBORN

Weight, length, head circumference documentation

Check: pmtct, rpr

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Temperature
Breastfeeding and elimination: stool and urine (if male stream).
On examination
Fontanelle- anterior and posterior
Cataracts
Jaundice
Ears- malformations, pits etc.
Mouth- teeth, palatal cleft, bifid uvula
CVS- murmurs + all pulses especially femorals
Congenital hip dysplasia (ortolani & Barlow test)
Talipes equinovarus
Back-spina bifida occulta
Genitalia- check both testis in males
Anal atresia, Examine patency

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