Pediatric Emergencies and Critical

Care

General Directions:
1. Fill in the tables.
2. Follow the format of the table provided.
3. No direct lifting of answers from any source.
4. Have a copy of your submitted work on the day of the feedback lecture.
 Pediatric Emergencies and Critical
Care

Table 1. Respiratory Emergencies

Upper Airway Obstruction Lower Airway Obstruction
Croup Anaphylaxis Foreign Body Ingestion Bronchiolitis Bronchial Asthma
History, suggestive of … Age 6 months – 5 years Edema Choking or coughing Gradual onset Rhinorrhea
Inspiratory stridor. Itching Cough
Hoarseness Flushing episodes + new • Preceded by Wheezing
Apnea Hives(urticaria) onset wheezing Chest Pain
Upper respiratory tract Swelling Drooling URTI Allergy
infection Rhinorrhea, Tearing chest discomfort • Fever, Sinusitis
Pharyngitis, Nasal congestion cough or wheezing Rhinitis
Mild cough Sneezing Pain conjunctiva Eczema
Low-grade
fever for 1-3 days
Coryza
Cough
Vomiting
Episode of shortness of
injection, rhinitis, Nasal polyps

Barking cough, Hoarseness breath dry hacking, non-

Symptoms worse at night Sensation of tightness in the Suspicion of aspiration
throat productive
cough
• Chest pain –
older children
Apnea
Wheezing
cough and rhinorrhea
Low grade fever
Cough

Physical Examination harsh cough (barking or Redness Dysphagia 3-7 days to noisy, raspy High CO2
Findings, suggestive of… brassy) Sneezing food refusal breathing and audible Stiff lungs
Hoarseness, inspiratory Runny nose Emesis, hematemesis wheezing Nocturnal
stridor, low-grade fever, and Tongue swelling Foreign body sensation Young infants infected with History
respiratory distress. Metabolic taste sore throat rsv frequency
Anteroposterior radiographs Peak Serum tryptase levels Stridor, Prolongation of the severity
- steeple sign Severe angioedema of the Abdominal distention expiratory phase of precipitating factor

Normal to moderately
inflamed pharynx,
Sightly increased respiratory
rate.
Nasal flaring;
Suprasternal, infrasternal,
and intercostal retractions
Continuous stridor
Hypoxia and Low O2
saturation
Diagnostic/s, requested Anteroposterior radiographs
for… PCR (polymerase chain
reaction)
CBC
Pulse oximeter
Laryngoscopy
Mostly clinical
Radiograph shows Steeple
sign (Posteroanterior veiw)
Intervention Oral supportive care and
Immediate givecorticosteroids:Dexamet
Specific management hasone, if symptoms persist
or get worst then Nebulised
racemic Ephinephrine and
give Supportive oxygen for
hypoxia
Pediatric Emergencies and Critical
Care
tongue and lips. Hematochezia breathing family history of asthma
Stridor Fever Nasal flaring allergy
Loss of voice, Hoarseness, Gagging Intercostal retractions decrease in blood pressure
Dysphonia. Coughing Suprasternal retractions with inspiration
Air trapping with hyper poor aeration from airway
expansion of the lungs. obstruction
Hyperresonance on Positive skin test results-
percussion identifying sensitization to
Auscultation reveals diffuse aeroallergens
wheezes and crackles Wheezing or whistling sound
In case of severe disease, from lungs
grunting and cyanosis may Swelling in nose or throat
be present Skin showing atopic
Flaring dermatitis
Retraction Unequal breath sounds
Allergy testing ABCs Examination Pulse oximetry Spirometry
Skin allergy testing Examination of: cardiorespiratory monitoring Allergy skin testing
Blood testing  Neck polymerase chain reactions Enzyme-linked
tryptase level  Chest Chest radiographs immunosorbent assay
 Abdomen PCR (ELISA)
Plain chest and abdominal x-ray
radiographs exhaled nitric oxide analysis
Contrast x-ray Lung function tests
Endoscopy Spirometry
CT Scan of chest Exhaled nitric oxide test
Peak flow test
Place in Trendelenburg Immediate Immediate Immediate:
position Suctioning of mouth Oxygen supplementation Short acting beta agonist
Give Oxygen through nasal Let the child be in comfort Specific management Oral corticosteroids
cannula position Maintain O2 saturation of Intubation
Epinephrine 90%
H1 and H2 antagonist Observation Specific:
Corticosteroid therapy Discharge with advice Specific management Anti inflammatory drugs like
Maintain airway  Bronchodilators mometasone, flunisolide,
Placing tourniquet at the site In case of severity, refer for  Corticosteroids corticosteroids
Supplement iv for stabilizing removal (ENT, SURGERY  chest physiotherapy Inhaled bronchodilators
the BP OR GASENTEROLOGY) hypertonic saline Ipratropium (Atrovent)
Specific medical treatment of asthma
Abdominal thrusts includes several key
Tapping of back components:
 Pediatric Emergencies and Critical
Care
Environmental control
Pharmacologic therapy
Patient education
Self-management skills

Influenza immunization
medications can be divided
into:
Long-term control
medications
Quick-relief medications

Lung Tissue Disease Disordered Control of Breathing

Pneumonia Pulmonary Edema Increased Intracranial Poisoning and Over-dose Neuromuscular Disorder
Pressure
History, suggestive of … Cough Dyspnea Seizures Altered mental health Paradoxical breathing
Wheezing Tachypnea CNS infections Seizure Tachypnea
Hemoptysis Cough- frothy, pink-tinged TBI Cardiovascular compromise Head bobbing
Chest Pain sputum Brain tumor Metabolic abnormality Poor feeding
Abdominal Pain Hydrocephalus Increasing muscle weakness
Failure to Thrive Hypotonic
Acidemia Night sweats
Previous upper respiratory Hyperactivity
tract infections
Contact with other people
with lung infection
Recent injury to rib area
Travelled recently
Use of alcohol or illegal

drugs
Smoking cigarettes
Physical Examination Auscultation findings include
Findings, suggestive of… lack of normal breath
sounds
Presence of crackling
sounds (rales)
Cough with phlegm
Increased loudness of
whispered speech
(whispered pectoriloquy)
Diagnostic/s, requested RUL Consolidation ,
for…
Perihilar infiltrates,
Pneumatocoeles
51
52
Chest X-ray
Complete blood count
Pulse oximetry
Sputum test
Intervention Immediate:
Immediate Macrolides
Specific management Bronchodilators
NSAIDs
Specific:
Antibiotics like amoxicillin
and doxycycline
Antiviral agents like
Acyclovir and Ganciclovir
Supportive therapy like oral
rehydration therapy and IV
fluids
Chest radiographs- diffuse Variable or irregular
hazy infiltrates respiratory rate
Interstitial edema (Kerley B Variable respiratory effort
lines)- seen Shallow breathing ( usually
hypercarbia and hypoxemia)
Cushing's triad
Chest radiograph CT scan
X ray
MRI
Positioned Establish airway , intubate if
Upright posture necessary
Give supplemental o2 Give supplemental oxygen
and medications
Cardiogenic pulmonary Monitor vitals and ICP
edema
Diuretic therapy
Rapidly acting IV inotropic In TBI preserve cervical
agents spine and give oxygen to
avoid hypoxemia
CPAP or intubation with If poor perfusion give
positive pressure ventilation isotonic crystalloid LR NS
high positive end-expiratory Medications for increased
pressures (PEEP) may be ICP
required Avoid hyperthermia
Full 12-lead
electrocardiogram- suspect
the ingesting toxic
substances
Urine screens- confirm
suspected ingestion of
medications
Quantitative toxicology
assays- identify the specific
drug
provide guidance for therapy
Full 12-lead
electrocardiogram
Urine screens
Quantitative toxicology
assays
Supportive care
Mainstay of treatment
Protecting and maintaining
the airway, establishing
effective breathing, and
supporting the circulation.
Decontamination
Syrup of ipecac
Single-dose activated
charcoal
Polyethylene glycol
(golytely)
Enhanced elimination
Multiple-dose activated
charcoal
Pediatric Emergencies and Critical
Care
Increased respiratory rate
Serum enzyme- elevated
creatine kinase
Muscle biopsy- vastus
lateralis is sampled
Electromyography-
recording the electrical
potential in various states of
contraction
Imaging of muscle
Molecular genetic marker
Electromyography
Muscle biopsy
ECG
Nerve biopsy
Physiotherapy exercise
Pharmacologic-
Cholinesterase
Pyridostigmine
Prednisone
Thymectomy
 Pediatric Emergencies and Critical
Care
Alkalinization of urine
Dialysis
Specific antidotes.

History, suggestive of …
Physical Examination Findings, suggestive of…
Pediatric Emergencies and Critical
Care
Table 2. Shock
Hypovolemic (blood volume problem) Cardiogenic (Blood pump problem)
Non-hemorrhagic Hemorrhagic Bradyarrhythmia Tachyarrhythmia
History of any Intravascular due to trauma, History of previous cardiac History of previous cardiac
volume loss (eg, from History of any surgery, disease, use of, previous MI, disease, use of cocaine,
gastroenteritis, burns, diabetes trauma/injury, gastrointestinal
or previous cardiac surgery smoking, drug abuse.
insipidus, heat stroke) bleeding. and a history of
hyperlipidemia, left ventricular
(LV) hypertrophy,
hypertension or a family
history of premature coronary
artery disease (CAD),
previously healthy children
secondary to viral myocarditis,
dysrhythmias, or toxic or
metabolic abnormalities or
after hypoxic-ischemic injury
pulse rate increase, cardiac Due to hemorrhage usually appear ashen or Tachycardia may impair
output decrease, systolic bp additionally decreases cyanotic, have cool skin and coronary blood
decrease, peripheral vascular oxygen-carrying capacity mottled extremities flow, which decreases
resistance increase (cold), through the direct loss of Peripheral pulses are rapid myocardial oxygen delivery.
jugular venous pressure available hemoglobin. and faint and may be irregular Low volume pulse
decrease (loss of circulating pulse rate increase, cardiac if arrhythmias are present Cold clammy extremities
blood volume), Decreased output decrease, systolic bp Jugular venous distention and >>CFT
preload, decrease, peripheral vascular crackles in the lungs are Pulmonary edema, Crackles,
resistance increase (cold), usually (but not always) RD, Tachypnea
jugular venous pressure present; peripheral edema Jugular venous distension
decrease (loss of circulating also may be present. Hepatomegaly
blood volume), Decreased Heart sounds are usually Hypotension
preload. distant, and third and fourth Oliguria, changes in mental
heart sounds may be present status, crackles , tachypnea ,
The pulse pressure may be hepatomegaly , jugular turgor,
low. peripheral edema
Patients show signs of
hypoperfusion, such as altered
mental status and decreased
urine output

Diagnostic/s, requested for…
Intervention
Immediate
Specific management
analysis of the CBC,
electrolyte levels (eg, Na, K,
Cl, HCO3, BUN, creatinine,
glucose levels), lactate,
prothrombin time, activated
partial thromboplastin time,
ABGs, urinalysis (in patients
with trauma)
imaging – FAST, CT,
ENDOSCOPY imaging – FAST, CT,
ENDOSCOPY
GOAL – RESTORE GOAL – RESTORE
CIRCULATING VOLUME AND CIRCULATING VOLUME AND reduce SVR- dobutamine,
TISSUE PERFUSION , CONTROL FUTHER BLOOD milrinone, dopamine, and
CORRECT THE CAUSE LOSS
1.Assess airway
2.Administer oxygen
3.Establish IV access
4.Fluid bolus of 20ml/kg
isotonic fluid given
5.Continue fluid boluses
(maximum of 3) until perfusion
improves or hepatomegaly
develops
6.In case of shock refractory to
fluids, start inotrope
(dopamine)
Distributive (Blood vessel problem)
analysis of the CBC,
Laboratory studies –
electrolyte levels (eg, Na, K,
biochemical
Cl, HCO3, BUN, creatinine,
profile(electrolytes, urea –
glucose levels), lactate,
creatinine, LFT –
prothrombin time, activated
AST,ALT,LDH)
partial thromboplastin time,
CBC
ABGs, urinalysis (in patients
Cardiac enzymes – troponins
with trauma)
(T & I)
Arterial blood gases
Lactate
Brain natriuretic peptide
Imaging – Echocardiogram,
chest radiography, USG.
Immediate
epinephrine
1.Assess airway
2.Administer oxygen
3.Establish IV access
4.Fluid bolus of 20ml/kg
isotonic fluid given
5.Continue fluid boluses
(maximum of 3) until perfusion
improves or hepatomegaly
develops
6.In case of shock refractory to
fluids, start inotrope
(dopamine)
Pediatric Emergencies and Critical
Care
Laboratory studies –
biochemical
profile(electrolytes, urea –
creatinine, LFT –
AST,ALT,LDH)
CBC
Cardiac enzymes – troponins
(T & I)
Arterial blood gases
Lactate
Brain natriuretic peptide
Imaging – Echocardiogram,
chest radiography, USG.
Non-invasive ventilation
(PEEP/ PEEP+ Pressure
support ventilation)
Endotracheal Intubation,
invasive mechanical
Vasopressors- to treat low ventilation
blood pressure Transfusion to obtain
Inotropic agents. hemoglobin ≥ 10 g/dl
Aspirin. Or loop diuretics (Furosemide)
Antiplatelet medication. AFTERLOAD: mechanical
antiarrhythmic agents ventilation Pericardocentesis,
pleural drainage (tension
pneumothorax),
antibiotics, antidotes,
immunoglobulins.
Adenosine, striadyne,
antiarrhythmic agents,
synchronized
cardioversion, anticholinergic
treatment, transient
pacemakers
Electrolytic disorders
treatment (hypoglycemia,
hypocalcemia,
hypophosphatemia, hypo-
hyperkaliemia, metabolic
acidosis. hypomagnesemia)
 Pediatric Emergencies and Critical
Care
Septic Neurogenic Anaphylactic
History, suggestive of … Bacterial infection- sore throat Carbon monoxide Asthma,
cough poisoning Allergies,
Methemoglobinemia Previous anaphylaxis
Trauma/ injury to spine/brain
Physical Examination Findings, suggestive of… diminished pulses dizziness Angioedema
Bounding pulses Nausea Urticaria
Well perfused skin Vomiting Respiratory distress with
Low blood pressure Blank stares stridor or wheezing
fever Fainting Tachycardia
Tachycardia Increased sweating
Anxiety
Pale skin
Bradycardia
Faint pulse
Diagnostic/s, requested for… mixed venous oxygen Bacterial and viral cultures, Bacterial and viral cultures,
saturation, analysis of the CBC, analysis of the CBC,
Bacterial and viral cultures, electrolyte levels (eg, Na, K, electrolyte levels (eg, Na, K,
analysis of the CBC, Cl, HCO3, BUN, creatinine, Cl, HCO3, BUN, creatinine,
electrolyte levels (eg, Na, K, glucose levels), lactate, ABGs. glucose levels), lactate, ABGs.
Cl, HCO3, BUN, creatinine,
glucose levels), lactate, ABGs.
Intervention Immediate management Fluid immediate- norepinephrine immediate- epinephrine
Immediate Resuscitation Specific- dopamine, injection.
Specific management Specific management- vasopressin Specific- glucocorticoid and
Vasoactive Drugs, ionotropes antihistamines

Obstructive
Ductal dependent Pneumothorax Cardiac Tamponade
History, suggestive of … Congenital cardiac obstructive trauma (both penetrating and Cardiac surgery for congenital
disease, Tension blunt trauma), asthma, cystic heart diseases,
pneumothorax fibrosis, and pneumonia penetrating trauma

Physical Examination Findings, suggestive of… severe cyanosis, hypotension, Hypoxemia, cyanosis, Pulsus paradoxus,
respiratory distress, shock, or tachycardia, and respiratory Muffled heart sounds,
collapse distress due to compression Tachycardia
and collapse of lung
segments, overt hypotension
(late sign).

Diagnostic/s, requested for…
Laboratory assessment o
Electrolytes and CBC (if not
already done) o Arterial blood
gas and lactate (if in distress)
Type and screen
Diagnostic studies - Chest X
ray , Electrocardiogram /
Echocardiogram , Renal
ultrasound
Pediatric Emergencies and Critical
Care
Chest radiography (AP and Cardiac enzymes – troponins
lateral) (T & I)
Arterial blood gases
Lactate
Brain natriuretic peptide
Imaging – Echocardiogram,
chest radiography, ECG,

Intervention Immediate - prostaglandin is
1. Immediate the elective therapy (PGE
2. Specific management 0.01-0.03 mcg/kg/min)
Intravenous fluids o D10W @
60 ml/kg/day
Fluids and nutrition - IV fluids
or TPN: 80-100 ml/kg/day
Respiratory: If apneic,
decrease PGE, If refractory →
HFNC → CPAP → Intubation
Specific - surgery
Pediatric Emergencies and Critical
Care
Immediate Immediate:
- Administering 100%
oxygen via a - 20 mL/kg NS/LA bolus, repeat
nonrebreathing face mask PRN
hastens the absorption of
loculated gas. - Consultation with an expert
Specific- Specific:
emergent needle
decompression, usually - Thrombolytics & anticoagulants
performed by placing a sterile
needle in the second
intercostal space along the
midclavicular line. Definitive
treatment requires
thoracostomy tube placemen