Common Paediatric

Emergencies

Dr. Abdullah Al dhafian

Consultant PEM
 Rayyan is 3 years
old boy , Known to
have, down
syndrome, CHD, &
bronchial asthma.
 5 days Hx. of cough
and shortness of
breath.
 Decreased feeding
since last night.
 Differentials
 Asthma excacerbation.
 Heart Failure.
 Foreign Body.
 Aspiration.
 GERD.
 Bronchiectasis.
 Bronchiolitis.
 Cystic Fibrosis.
 HR 180, RR 70, BP 80/50, O2 sat 85%
on room air.
 In severe distress.
 Silent chest and severe retractions.
 Status asthmaticus
 Status asthmaticus is an acute exacerbation of
asthma that remains unresponsive to initial
treatment with bronchodilators.
 Vary from a mild form to a severe form with
bronchospasm, airway inflammation, and mucus
plugging.
 Difficulty breathing; carbon dioxide retention;
hypoxemia; and respiratory failure.
 The typical clinical presentation involves
persistent wheezing with retractions.
 Not all children with severe asthma
wheeze.
 Some may present with cough,
dyspnea, or emesis.
 History
 Presence of current illness.
 History of chronic respiratory diseases.
(eg, bronchopulmonary dysplasia,
chronic lung disease of infancy).
 Severe previous bronchiolitis.
 History of atopy.
 History of allergies.
 History
 Family history of asthma.
 Presence of pets or smokers in the
home.
 Known triggering factors.
 Home medications.
 Risk Factors/Red Flags
 Increased use of home bronchodilator
treatment without improvement.
 Previous ICU admissions, with or without
intubation.
 Asthma exacerbation despite recent or
current use of corticosteroids.
 Frequent emergency department (ED)
visits and/or hospitalization (implies poor
control).
 Risk Factors/Red Flags
 Less than 10% improvement in peak
expiratory flow rate (PEFR) from baseline
despite treatment.
 Syncope or seizures during acute
exacerbation.
 Oxygen saturation below 92% despite
supplemental oxygen.
 Severe asthma exacerbation without
wheezing (ie, the silent chest).
 Examination
 Tachycardia and tachypnea.
 Hypoxia and decreased oxygen
saturation.
 Dehydrated.
 Retractions.
 The use of accessory muscles correlates
to severity of disease.
 Examination
 Hypertension.
 With worsening hypoxemia,
hypercarbia, marked air trapping, and
hyperinflation, stroke volume is
compromised and hypotension and
bradycardia may be observed.
 Examination
 CNS status ranges from wide-awake to
lethargic, agitated to comatose.
 Abdominal muscle use can cause
symptoms of abdominal pain.
 Examination
 Bilateral expiratory and possibly inspiratory
wheezes and crackles.
 Air entry may or may not be diminished or
absent, depending on severity.
 Silent chest.
 Tension pneumothorax.
 Pneumomediastinum and subcutaneous
emphysema.
 Pulsus paradoxus.
 Workup
 Pulse oximetry.
 Blood gas determination?
 Serum electrolyte measurement.
 Serum glucose levels.
 CBC count and differential.
 Chest radiography.
 Treatment
 Oxygen.
 Beta-agonist agents, typically albuterol
or salbutamol, and terbutaline.
 Corticosteroids.
 Anticholinergics, ipratropium bromide
(Atrovent).
 Treatment
 Magnesium sulfate iv.
 Intravenous beta-agonists.
Indications for ICU admission

 Altered sensorium.
 Use of continuous inhaled beta-agonist
therapy.
 Exhaustion.
 Markedly decreased air entry.
 Rising PCO2 despite treatment.
 Presence of high-risk factors.
 Failure to improve despite adequate
therapy.
Indications for intubation and
mechanical ventilation
 Apnea or respiratory arrest.
 Diminishing level of consciousness.
 Impending respiratory failure marked by
significantly rising PCO2 with fatigue,
decreased air movement, and altered level
of consciousness.
 Significant hypoxemia that is poorly
responsive or unresponsive to
supplemental oxygen therapy alone.
 6-year-old boy presents
with decreased activity.
 2-week history of
polyuria, weight loss.
 Complains of abdominal
pain and weakness.
 Lethargic with mild
tachypnea. Skin is pale.
 HR 150, RR 45, BP 95/55, O2 sat 100%
on room air.
 Mild tachypnea with good air
exchange, no retractions.
 Skin pale and cool, skin turgor poor,
capillary refill time prolonged.
 Lethargic, arousable, cooperative
Bedside glucose check > 28 mmol/l.
 Glucose 33.
 Na 130, K 2.9, Cl 98, Bicarb 10
 BUN 25, Creatinine 0.7.
 Venous blood gas for pCO2 28 mm Hg.
 Serum ketones: Positive
 DKA is the most important complication
of type 1 diabetes mellitus.
 Insulin concentrations are low.
 Hyperglycemia with lipolysis, ketone
bodies, dehydration, acidosis
 Causes of DKA in children include:
intercurrent illness (31%), omission or
incorrect insulin administration (69%).
Clinical Features/Red Flags
 History of polyuria, polydipsia, weight
loss, nausea, and vomiting
 Signs of dehydration
 Breath with fruity odor
 Abdominal pain
 Tachypnea
 Lethargy
 Diagnostic Studies
 DKA defined as:
 Hyperglycemia (glucose > 11.1%)
 Acidosis (pH < 7.3 or bicarbonate <15)
 Ketosis (serum or urine)
 Electrolytes, BUN
 CBC not very helpful
 Fluid Management
 Most DKA patients are 7% dehydrated.
 Administer 10-20 mL/kg NS or LR over
30 to 60 min, repeat to reverse shock.
 Other fluid deficits should be replaced
gradually.
 If no evidence of hypovolemia, be less
aggressive with fluid management.
 Hyperglycemia
 Glucose is often lowered significantly
with fluid resuscitation.
 Check bedside glucose hourly. Gradual
decline by 5.6 mmol/l per hour is
preferable.
 Add glucose to IV fluid once glucose is
< 14-16 mmol/l to avoid hypoglycemia.
 Begin insulin infusion at 0.1 u/kg/hr.
 Metabolic Acidosis
 Due to lipolysis (ketoacids) and
dehydration (lactic acidosis).
 Insulin and fluids are sufficient
treatment.
 Bicarbonate treatment is not
recommended and is associated with
cerebral edema.
 Electrolytes Imbalance
 Factitious hyponatremia (hyperglycemia
effect).
 Potassium level is falsely elevated. Most
patients have true potassium depletion.
 Hypophosphatemia.
 Once urine output is established,
replace K, half as KCl and half as Kphos
(total 30-40 mEq/L).
 Cerebral Edema
 Assess mental status and neurological
exam hourly.
 CT or MRI if cerebral edema is
suspected.
 Treat with hyperosmolar agents such as
mannitol.
 Intubation/ICU admission.
 5 ys. old boy, known
asthmatic.
 Sudden onset of
swollen lips, SOB,
and urticarial rash
after ingesting
something.
 Differential diagnosis
 Angioedema
 Asthma
 Serum sickness
 Bee stings
 Shock
 Syncope
 Anaphylaxis
 Anaphylaxis
 Anaphylaxis is an acute, potentially life-
threatening syndrome.
 Mmultisystemic manifestations resulting
from the rapid release of inflammatory
mediators.
Common Triggers of Pediatric
Anaphylaxis
 Foods (most common cause in children) – Milk,
eggs, wheat, soy, fish, shellfish,peanuts.
 Drugs – Antibiotics (penicillins, cephalosporins), local
anesthetics (lidocaine), analgesics (aspirin,
nonsteroidal anti-inflammatory drugs [NSAIDS]
[ibuprofen], opiates [codeine, morphine]), dextran,
radiocontrast media
 Biologics – Venoms (bee sting, ant or snake bite),
blood and blood products, vaccines, allergen extracts
 Preservatives and additives – Metabisulfite,
monosodium glutamate
 Other – Latex, unknown/idiopathic
 Signs and symptoms
 A range of signs and symptoms from hives
with wheezing to cardiovascular collapse and
death.
 More than 80% of the patients will present
with cutaneous symptoms (eg, hives,
pruritus, facial swelling).
 Generally, at least 2 organ systems (skin,
respiratory, cardiovascular, gastrointestinal
systems).
 Symptoms may develop slowly and insidiously
over several hours or may rapidly progress
over several minutes.
 Signs and symptoms
 Parenteral agents generally have a faster
onset of symptoms than ingested ones.
 May result in respiratory failure, shock,
multiorgan system failure, and disseminated
intravascular coagulation.
 Between 5% and 20% of patients may
experience a recurrence of anaphylaxis 8-12
hours after the initial presentation.
 Prolonged symptoms can last up to 32 hours
despite treatment.
 Treatment
 ABCs.
 Patients with signs of poor perfusion
should be placed in a modified
Trendelenburg position.
 Crystalloid fluids should be given rapidly
if the patient is hypotensive or has
other signs of shock.
 Treatment
 Epinephrine as soon as the diagnosis is
suspected.
 The 1:1000 strength should preferentially be
administered intramuscularly (IM) in to the
thigh.
 IV/IO epinephrine (1:10,000) is reserved for
the patient with uncompensated shock.
 The epinephrine dose may be repeated every
5-15 minutes.
 Treatment

 Nebulized albuterol (2.5-5 mg/dose).

 Patients unresponsive to fluid resuscitation
should receive vasopressors as follows:
Epinephrine (0.1-1 mcg/kg/min IV),
Dopamine (2-20 mcg/kg/min IV) ,
Norepinephrine (0.1-2 mcg/kg/min IV).
 Treatment
 Diphenhydramine 1 mg/kg IV/IM/PO or
ranitidine, which has a low side effect
profile in children, 1 mg/kg may be
given.
 Methylprednisolone (IV), prednisone, or
prednisolone (PO) 1-2 mg/kg.
 Epi Pen.
 Allergist F/U.