Pediatric Emergencies

Presented by : Ziyad Salih

Al-Qadisiya Collage of Medicine
Iraq
 INTRODUCTION
Accurate assessment of a child with an acute illness or injury requires special
knowledge and skills.
The majority of children presenting in the ED have mild moderate illness and
injury and remain alert.
For the critically ill child, determining the primary physiologic problem may
be difficult, because inadequate oxygenation, ventilation or perfusion from
any cause will eventually progress to the picture of cardiopulmonary failure.
CONTENTS :-

• Shock
• Status asthmatics
• Status epileptics
• Poisoning
SHOCK

Shock is a syndrome that results from inadequate oxygen

delivery to meet metabolic demands
If untreated  metabolic acidosis, organ dysfunction and death
SHOCK
• Hemorrhage
Hypovolemic • Serum/Plasma loss
• Sever diarrhea and vomiting

• Analphylactic
Distributive • Neurogenic
• Septic

• Myocardial
Cardiogenic • Dysrrhythmia
• CHD-(duct dependant)

• Pneumothorax
Obstructive • Tamponade
• Dissection

• Heat, CO, Cyanide

Dissociative • Endocrine
SHOCK
Clinical Presentation
 Early diagnosis requires a high index of suspicion
 Diagnosis is made through the physical examination
focused on tissue perfusion
 Extreme hypotension is a late and pre-morbid sign
SHOCK
Clinical Presentation
Neurological: Fluctuating mental status, sunken fontanel
Skin and extremities : Cool, pallor, cyanosis, poor cap refill,
weak pulses, poor muscle tone
Cardio-pulmonary: Hyperpnea, tachycardia
Renal: Scant, concentrated urine
SHOCK
Management
Airway If not protected or unable to be maintained, intubate
Breathing Always give 100% oxygen to start Saturation
monitor
Circulation Establish IV access rapidly Cardio-Respiratory
monitor & Frequent BP
SHOCK
Management
Draw blood and send for
1. ABG
2. Blood sugar
3. Electrolytes CBC
4. PT/PTT
5. Blood type and cross matching
SHOCK
Management
Treatment of hypovolemic shock
A . 20 cc/kg of NS over an appropriate period of time. If in
shock, get it in as rapidly as possible and give more as
needed. If the patient is unstable remember your ABC’s and
intubate patient.
B . This may be repeated once if patient still seems
hemodynamically compromised due to dehydration
C . Further fluid boluses should be guided by the CVP, BP.
SHOCK

Anaphylactic shock
A systemic reaction (usually life-threatening) that occurs
secondary to an IgE mediated antigen induced reaction
(allergen) or exposure to mast cell de-granulating agents
(anaphylactoid).
SHOCK

Anaphylactic shock
Both reactions cause mediator release (histamine,
leukotrienes, etc.) which produce the symptoms. While there
is often a history of prior exposure to a given antigen, in the
non-IgE mediated (anaphylactoid) reactions, symptoms may
occur during the first exposure.
SHOCK

Anaphylactic shock
A.Symptoms usually occur within seconds to 60 min. of Ag
exposure.
B.Variable: Initial symptoms may be mild or life threatening.
Generally, the earlier the onset, the more severe the reaction.
SHOCK

Anaphylactic shock
C .Symptoms :-
cutaneous (urticaria/angioedema, pruritus).
respiratory (bronchospasm, stridor, pulmonary edema.
laryngeal edema), rhinitis.
cardiovascular (hypotension, arrhythmias, myocardial
ischemia, vasodilation, flushing),
SHOCK

Anaphylactic shock
C .Symptoms :-
gastrointestinal (nausea, emesis, diarrhea, pain)
Also there could be asymmetric swelling of a limb or perioral
area.
SHOCK

Anaphylactic shock
Most Common Etiologic Agents
A.Antibiotics (for instance penicillin, although any could be
involved)
B.Insect (hymenoptera) stings
C.Foods (nuts, eggs, seafood)
SHOCK

Anaphylactic shock
D.Immunotherapy
E.Non-IgE (Anaphylactoid) mediated mast cell
degranulation:
1.Morphine
2.Codeine
3.Polymyxins
SHOCK
Anaphylactic shock
Management
A. ABC’s
B. Stop antigen administration - if insect bite or allergy shot,
isolate antigen site with tourniquets and inject 0.01 cc/kg epi.
(1:1000) SQ into site after tourniquet applied. Flick off (do
not squeeze) any stinger present.
SHOCK
Anaphylactic shock
Management
C. Epinephrine:
1.Mainstay of treatment
2.Sc or IM 0.01 cc/kg of 1:1000, max 0.3 cc, may repeat
3. Rarely IV 1:10,000 by drip and titrate to achieve response,
begin at drip of 0.1 mcg/kg/min (only in refractory
hypotension requiring CPR).
SHOCK
Anaphylactic shock
Management
D.Immediate IV placement with IVF (LR/NS, bolus 20 cc/kg as needed for
shock).
E.Continue to observe for 24 hrs, as symptoms may recur.
1.Subjective: SOB, anxiety.
2.Objective: stridor, retractions, wheezing, cyanosis, pallor.
3.BP: q 5-10 min initially, then q 1 hr.
4.Continuous EKG monitor or A-line as needed.
SHOCK
Anaphylactic shock
Management
F. Other drugs as needed (NOT a substitute for epi.).
1.H1 Antihistamine - Benadryl 0.5-1.0 mg/kg po or slow IV
push.
2.Steroids - 1-2 mg/kg methylprednisolone to prevent late
phase response.
SHOCK
Anaphylactic shock
Management
3.Cimetidine IV 5-10 mg/kg given over 5 min - given in
association with H1 antihistamines may reverse profound
hypotension unresponsive to fluids/pressors (this is
controversial).
4.Glucagon may be effective in reversing hypotension in rare
cases, especially if beta-blockade is present. (Dose: < 10 kg:
0.1mg/kg IM, > 10 kg: 1 mg/dose IM).
STATUS ASTHMATICUS
is a life threatening form of asthma that is defined as a
condition in which a progressively worsening attack is
unresponsive to the usual appropriate therapy that leads to
pulmonary insufficiency. The primary mechanical event in
status asthmaticus is a progressive increase in airflow
resistance. Mucous plugging and mucosal edema or
inflammation are the major causes for the delayed recovery
in status asthmaticus.
STATUS ASTHMATICUS
The combination of hypoxia, hypercapnia, and acidosis may
result in cardiovascular depression and cardiopulmonary
arrest.
STATUS ASTHMATICUS
II. History:
A. Known asthmatic?
B. Asthma meds? Compliance? Time of last dose/nebulizer
Tx?
C. Previous clinic/ED visits?
D. Previous hospitalizations, intubations, steroid courses?
E. When did current wheezing/resp distress begin?
STATUS ASTHMATICUS
III.Physical Exam:
A.Vital Signs:
1.T: Fever may indicate URI, atelectasis or pneumonia
2.P: Usually elevated, especially if treated w/epi
3.R: Often tachypneic .
STATUS ASTHMATICUS
Treatment
1.Beta-agonist nebulizer treatment,
may give 5-10 mg nebs if minimal initial response.
a. Albuterol 0.15 mg/kg (max 10 mg/dose)
2.Atropine 250 mcg (<2 y.o.), 500 mcg (>2 y.o.), add to 2 nd or
3 rd beta-agonist neb
STATUS ASTHMATICUS
Treatment
3.Subcutaneous injection - subcutaneous epi. rarely done
today as nebulizers are so commonplace
A .Epinephrine: 1:1000 0.01 cc/kg/dose (0.3 cc max)
B .Terbutaline 0.05% solution, 0.01 mg/kg/dose with a max. of
0.25 mg q 20 - 30 minutes.
STATUS ASTHMATICUS
Treatment
4.Steroids: Solumedrol 2 mg/kg IV, then 1-2 mg/kg IV Q 6
hours. If mild exacerbation or quick response to above, may
consider oral prednisone 2 mg/kg.
5.Oxygen
A .In younger patients, the distress caused by fighting the
mask may only make the wheezing worse.
STATUS ASTHMATICUS
Treatment
B .Humidified 02 should be placed on all patients who show
evidence of hypoxia (O2 sat <90% on sat monitor/pulse
oximeter) or respiratory distress. Remember the sat monitor
gives no information regarding ventilation and pCO2.
STATUS EPILEPTICUS
STATUS EPILEPTICUS
Is an epileptic seizure of greater than 30 minutes
There are three major subtypes of status epilepticus in
children:
1- Prolonged febrile seizures lasting for >30 min, particularly
in a child younger than 3 yr of age, is the most common cause
of status epilepticus.
STATUS EPILEPTICUS
2- Idiopathic status epilepticus, in which a seizure develops
in the absence of an underlying CNS lesion or insult. It
includes :
•  Sudden withdrawal of anticonvulsants.
•  Anticonvulsants given on an irregular basis
STATUS EPILEPTICUS
3- Symptomatic status epilepticus: when the seizure occurs
as a result of an underlying neurologic disorder or a
metabolic abnormality.
Status epilepticus may also be the initial presentation of
epilepsy. Sleep deprivation and an intercurrent infection tend
to render epileptic patients more susceptible to status
epilepticus
STATUS EPILEPTICUS
I.Initial Management: position on side, protect from injury,
loosen clothing.
A.Airway
1.Jaw lift
2.Bite block or oral airway if able (no tongue blade or fingers
in mouth)
3.Suction secretions or emesis 4.Roll on side.
STATUS EPILEPTICUS
B.Breathing
1.O2 by mask
2.Intubate if needed
may need to intubate for respiratory depression secondary to
meds given.
C.Circulation - start IV, monitor BP, O2 SAT.
STATUS EPILEPTICUS
Quick history :
1.Description: [precipitating event, onset: focal/generalized,
duration], was child post-ictal ?
2.Fever? S/S illness?
3.Previous seizures? (degree, control, etc.)
4.Chronic seizure meds? (dose, compliance, levels)
5.Hx. trauma? (Accidental or non-accidental)
STATUS EPILEPTICUS
6.Toxin ingestion?
7.Chronic medical problems? Hx. of syncope?
8.Behavior changes?
9.Vomiting? / diarrhea? - Consider inborn error of metabolism
in infants.
STATUS EPILEPTICUS
III.Physical Exam
A.Vital Signs
1.Evidence of increased ICP / herniation ?
increased BP, tachycardia (early), bradycardia (occurs late
and is an ominous sign), dilated pupils, papilledema
2.Decreased BP from sepsis, toxins
3.Fever from meningitis
STATUS EPILEPTICUS
III.Physical Exam
A.Vital Signs
B.Mental Status / Level of Consciousness, Glasgow Coma
Scale
C.Respiratory Pattern
1.Assure good air exchange
2.Abnormal patterns with worsening level of consciousness
STATUS EPILEPTICUS
III.Physical Exam
Also examine
1.Pupils (size, reactivity)
2.Fundi (papilledema, hemorrhage)
3.Signs of head trauma
4.Signs of meningismus
5.Neuro. Exam - focal signs, level of consciousness
STATUS EPILEPTICUS
Treatment
Airway petency
Breathing
Circulation
STATUS EPILEPTICUS
POISONING
KEROSENE POISONING
This is a common problem among young children.
Over half of the children with all forms of poisoning admitted
to the ED.
This problem usually seems to arise from kerosene being kept
within reach of the child.
POISONING
KEROSENE POISONING
Kerosene is poorly absorbed by the GIT, but there is often
aspiration into the respiratory tract especially if the child
vomits. This causes pneumonitis which may be so severe as
to cause pulmonary oedema and hypoxaemia. Such features
usually occur within hours but may be seen a day or so after
ingestion when the child becomes breathless and feverish up
to 40ºC.
POISONING
KEROSENE POISONING
CNS complications most commonly include lethargy and
much less often semi-coma, coma and convulsions .
Bone marrow toxicity and haemolysis are not common.
Possibility of heart rhythm problems (such as atrial
fibrillation and ventricular fibrillation) and hepatic and renal
failure.
POISONING
KEROSENE POISONING
Treatment
Immediately remove the child from the source of the
poisoning and ensure the airway is open (this is always the
first priority).
Remove contaminated clothing and thoroughly wash the skin
with soap and water.
POISONING
KEROSENE POISONING
Treatment
If possible perform pulse oximetry and give supplemental
oxygen if indicated.
Intubation and mechanical ventilation may be needed in a
patient with severe hypoxia, respiratory distress or decreased
consciousness.
POISONING
KEROSENE POISONING
Treatment
Avoid gastric lavage because of the risk of inhalation and
hence pneumonitis. If very large amounts of kerosene have
been ingested less than an hour earlier then lavage may be
considered if the airway can be protected by expert
intubation.
POISONING
KEROSENE POISONING
Treatment
There is no evidence that corticosteroids are helpful. Some
texts recommend the routine use of antibiotics but this
remains controversial.
Thanks for your listening