Standard Treatment Protols

Standard Treatment Protocols
Paediatrics
2019
Mauzoom Ali Zahir
1
Table of Contents
Chapter 1
Anatomical & Physiological differences in children

Basic Layout of Emergency Department
Normal Parameters
Paediatric vital signs and equipment
SBAR (Situation, Background, Assessment, Recommendation)
Structured Approach Blue Print
Paediatric Triage Format 1
Paediatric Triage Format 2
Management of an inhaled foreign body
Paediatric Observation charts 1-to-4yrs
Paediatric Observation charts 3-to-12-months
Paediatric Observation Charts 5-to-11yrs
Paediatric Observation charts 12yrs and over
Paediatric Observation charts under 3 months
Chapter 2
Asthma Severe
Epiglottitis
Community Acquired Pneumonia
Upper Airway Obstruction
Viral Croup
Chapter 3
Diarrhoea & Dehydration

Fluid & Electrolytes
SLCP- Septic Shock
SLCP-Anaphylactic Shock
Chapter 4
Febrile Child
Chapter 5
Snake bite
Poisoning
Chapter 6
Guideline for managing children with AKI

Hypertension standard protocol
2
ANATOMICAL & PHYSIOLOGICAL DIFFERENCES IN CHILDREN
Children are not just small adults; they are small adults with big heads.
1. Airway
a. Neonates are obligatory nasal breathers
b. Big tongue &Big occiput
c. Large head, small jaw and strong muscular tongue
d. Hyperextension can block the airway.
e. Larynx higher in neck and more anterior“Look up” when intubating.
f. Epiglottis at 45 degrees angle, large and floppy.
g. Cervical spine more cartilaginous and flexible.
h. Trachea is short, ETT are easily dislodged or pushed down into the right main bronchus;
Recheck ETT after all movement.
2. Airway position
a. Infants – neutral airway (Infant with big occiput - towel under shoulders )
b. Children – sniffing air
c. Hyperextension or hyperflexion can cause airway block.
d. Upright for upper airway obstruction
e. In the parent’s lap if the child is upset.
3. Breathing differences
a. Thorax more pliable and they are Belly breathers
b. Higher normal respiratory rate for the age.
c. Higher metabolic rate relative oxygen consumption and lower functional residual capacity
result in rapid oxygen desaturation even with pre-oxygenation
4. Circulation differences
a. Higher resting pulse rate for the age and tolerate much higher pulse rate
b. Limited capacity to increase cardiac output / stoke volume.
c. Age appropriate blood pressure ; lower normal blood pressure
i. Systolic BP: [Age*2] + [70-90]
ii. Hypertension in children is pre morbid
d. Child in shock
e. Predominantly chronotropic response to shock
f. Volume resuscitation is with isotonic crystalloid solutions
5. Disability – Don’t Forget Dextrose

 AVPU (Alert/ Responds to Voice/ Responds to Pain/ Unresponsive)
 “P” or “U” means that the child has an unprotected airway.
 GCS: age appropriate modification (two charts under 4 years and over 4years).
 Children have limited Glycogen stores; Check BSL in all sick children.
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6. Exposure/Environment
 Large surface area in relation to size results in rapid heat loss.
 Check core temperature in sick children.
 Look for rashes in skin folds and pressure areas.
7. Normal paediatric parameters- Weight, HR, BP, RR chart
8. Formulae for calculating a child’s weight and blood pressure

a. Estimating body weight
b. Broselow tape
4
BASIC LAY OUT OF THE PAEDIATRIC EMERGENCY DEPARTMENT
Triage in the waiting area.

 Patients are triaged by the nurses. They will go through the patients and refer to the necessary
facility.
Resuscitation Bay (Category 1 & 2)

 The patients with triage category 1 and 2(Red) are sent to resuscitation bay.
 However if there may arise situations where one has to keep the patient for a longer period due
to limitations of bed availability in the continuum care in the units or ICU. Eg. Ventilated child.
 All patients admitted to resuscitation beds (two red beds) should be immediately seen by the
medical officers and nurses on the floor immediately.
 Intervention
 Patients should be stabilised by the Doctors and nurses before shifting the patient out.
 Airway & Breathing and circulation should be stabilised using necessary equipment.
 In the event peripheral IV canulation failure, IO access should be tried.
 Documentation
 These patients should have the properly filled notes made by the doctors in the outside page.
 The nurses should continue to monitor these patients on the inner side of the observation chart.
.
 Intervention carried out by the doctors and nurses should be clearly documented in the
respective columns.
PCU - Emergency Treatment unit (Green Area) – Category 3 & 4

 Triage category 3 & 4 Green should be admitted to these 8 beds.
 All these patients should be seen by the Medical officers and nurses in the unit as early as
possible.
 These patients should have properly filled notes made by the doctors in the outside page.
 The nurses should continue to monitor these patients on the inner side of the observation chart.
.
 Intervention carried out by the doctors and nurses should be clearly documented in the
respective columns
Short stay Unit (Overflow Bay – Yellow area) – Category 5
 SSU should be physically separated from the Resuscitation Bay and the PCU beds.
 Maximum time period that a patient can be managed in the PCU is 4 hours.
 Patients admitted to PCU, should be observed for improvement or deterioration with ongoing
treatment.
 The patients who deteriorate, may be transferred to PCU or Resuscitation bay depending on the
clinical situation.
 The decision to admit patients who are in the SSU, is taken by the Emergency Physician /
Paediatrician or by the senior medical officer on duty (in the absence of the ED consultant.
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Continuum of care
 If discharge of the patients is not possible within 4hrs patient will be admitted/ handed over to
the continuum care section ( ward /OT/ ICU )
 If the Specialist team (MICU & SICU) is not in a position to accept the patient, it is the
responsibility of the relevant consultant of the specialized unit to accommodate the patient and
release the medical officers on duty at the ETU. This type of problems should be conveyed to
the Director of the hospital and amicability settled with the Director of the hospital.
 Discharge Plan
Ambulatory care (yellow area) – chairs – Patients with fever, mild to moderate asthma, AGE, will
be assessed and re-assessed before discharge. The decision to discharge and to give a review
appointment where necessary will be done by the Medical Officer in consultation with the
Consultant or by the Consultant on duty.
On discharge, care plan for follow up appointment should be issued.
Human resources of the PCU
 PCU – Human resources
On the floor
 Consultant Paediatricians / Resident Paediatricians
 Paediatric Senior Registrars – On call basis
 Medical Officers ( one of the senior medical officers should take responsibility as SMO)
 PG Trainees of emergency medicine / DCCM
 Nursing Sister
 Nursing Officers
 Minor Employees
On call doctors
 General Paediatricians  Endocrinologist

 Intensivist  Vascular Surgeon
 GenaralSurgeons  Aneasthesiologists
 Orthopeadic Surgeon  Neurologist
 Neuro Surgeon  Neonatalogist
 ENT Surgeon  Psychiatrist
 Eye Surgeon  Radiologists
Education & Training of Staff

All the medical officers should undergo modules like APLS, NLS, Paediatric Basic Training periodically.
Nurses should undergo PLS courses. Both categories should undergo regular skills testing. In order to
improve the team work Mock Scenarios should be performed in the unit itself.
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STANDARD EQUIPMENT IN EACH category
 Within the PCU only minimal furniture and all equipment necessary for emergency patients should
be made available.
 Tables within the PCU should be a minimal number.
 Resuscitation Bay Emergency Beds Short Stay unit

 Resucitation Beds Resucitation Beds Beds
 Multipara Monitors x 2 Multipara Monitors x 2 Reclining chairs
 Pulse oxymeters Pulse oxymeters Nebulizers
 Nebulizers Nebulizers
 Defibrillators with disposable pads Set of Collars & Splints
 Anesthetic Machine
 Ventilator with Non-invasive facilities
 Set of Collars & Splints
Common Equipment Surgical equipment

Blood Gas Analyser Small curved artery forceps x 2
Portable X ray machines Straight forceps (needle holders) x 2
USS machines Toothed forceps x 2 (tweezers)
Hand-held Doppler scans Scissors x 2
ECG Machines
Maggie Boards / White Boards
Dusters x 6
White pens
Multi plugs x 4
Calculator
Oxygen Cylinder with regulator
Crash cart equipment / Retrieval ambulance equipment
Airway & Breathing Tongue depressor Laryngoscope blades & handle-

O2 mask and reservoir bags and Yankauer sucker / suction (straight & curved)
tubes nozzles Magills forceps
Nasal prongs Suction tubes (black, blue , CO2 detector
Pocket mask green) LMA &i-gel
anatomical / round Face masks Guedel airways, sizes 1, 2, 3, 4 Bougie
x 4 (sizes 2, 3 & 5) Nasopharyngeal airway NG tubes
Ambubag& O2 tubing – infant & Stethoscope Venturi Masks
adult (450ml, 1400ml) & oxygen ETT sizes 4.0–8.0 (include
tubes cuffed)
Lubricant spray
Stylet, Laryngoscope
paediatric(straight & curved)
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Circulation Blood collecting bottles Syringes -
IV cannulas(pupule, yellow,- EDT bottles 1ml, 2ml, 5ml,
Blue, Green, pink, white,ash, Plain bottle 10ml, 20ml, 50ml
orange) Sugar bottles Rapid Infusion Sets with blood
Non allergic Hypoallergnic Tape Blood culture bottles Arterial Warmer
Intra-osseous needle (secured & catheters CVP lines
taped) IV connectors Transducers
Intra osseous gun 3 way taps Non-invasive BP cuffs
Additional equipment Defibrillators with pads

Intercostal Catheter (ICC) Batteries 2- AA, 2-C size
Urinary catheter Cricothyroidotomy insertion sets
Torch Splinting meterials
Drugs IV fluids Consumables

Adrenaline syringe 0.9% N.saline Sterile dressings
Amiadarone syringe 10% Dextrose- Cotton tape x 2 rolls
NaHCO3 syringe Sterile water Gauze squares x 5
Adenosine syringe Ringer lactate Sutures 2.0 silk x 5 (curved
Morphine syringe 10% Dextran – 40 needle)
Cefotaxime syringe N/2 saline Tape- micropore
Ceftriaxone syringe 3% saline Blueys x 6
Scoline 50% Dextrose Gloves
Propofol N saline / Dextrose Sharps container
Adrenaline 0.9% N saline ampules
Heparine pack
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NORMAL PAEDIATRIC VITAL PARAMETERS
Age Weight (kg) Heart rate Respiratory rate BP Systolic (mmHg)

(per min)
Premature 1 145 <40 42 ± 10
Newborn 2-3 125 60 ± 10
1 month 4 120 24-35 80 ± 16
6 month 7 130 89 ± 29
1 year 10 130 20-30 96 ± 30
2-3 years 12-14 120 99 ± 25
4-5 years 16-18 100 99 ± 20
6-8 years 20-26 100 12-25 105 ± 13
10-12 years 32-42 75 112 ± 19
>14 years 50 75 12-18 120 ± 20
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PAEDIATRIC VITAL SIGNS AND EQUIPMENT
Age Preterm Newborn Infant Infant 1-3 years 4-6 years 7-8 years 9-10 11-12
1-6 Mo 7m-1y years Years
1-2 kg 3.5kg 7kg 10kg 15kg 20kg 25kg 30Kg 40kg
Resp rate 30-60 30-60 24-40 20-40 20-30 18-25 18-25 16-20 14-20
Heart Rate 90-180 90-180 85-170 80-140 70-120 65-110 70-110 65-110 60-110
Sys BP 50-70 50-70 65-106 72-110 78-114 80-116 84-122 90-130 94-136
ETT size 2.5 – 3 3-3.5 3.5-4 4-4.5 4.5-5 5-5.5 6-6.5 65.-7 7
ETT distance at lip 8 8-9.5 9.5-11 11-12.5 12.5-14 14-15.5 17-18.5 18.5-20 20
Lary blade 0 1 1 2 2 2 2 3 3
Suction catheter 5-6 6 8 8 8 10 10 12 12
N-G Tube 5 8 8 10 10 12 12 14 14
Foley 5 5 5 8 10 10 10 12 12
Chest tube 8-10 8-10 12-16 14-20 18-22 20-28 28-32 28-32 28-32
Paediatric Physiological Values

Approximate weight Kg
Approximate BP mmHg [2 x age ] + 9
Newborn = 60
Approximate blood volume 70ml/kg in adults
80 ml/kg in children
Tidal volume 7ml/kg
Cardiac Enzyme Time Sequence

Earliest rise (hours) Peak (hours) Normalise (days)
CK 6–8 24 – 30 hours 3–4
CKMB 3–4 18 – 24 hours 2
LDH 12 – 24 48 – 96 hours 7 – 10
Troponin T 4 10 – 14 days
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15 lead ECG lead placement
Standard leads
V1 – 4th ICS just right of the sternum
V2 – 4th ICS just left of the sternum
V3 – midway between V2 and V4
V4 – 5th ICS, midclavicular line
V5 – level of V4 at anterior axillary line
V6 – level of V5 at mid axillary line
Posterior leads
V7 – the inferior border of the scapula on the patient’s left posterior thorax
V8 – halfway between the left paraspinal muscles posteriorly and V7P
With a paper speed of25 mm/sec

1 small square = 0.04 sec
5 small squares = 0.20 sec
P wave = 0.08 sec / 2mm high

PR interval = 0.12 – 0.20 sec
QRS = 0.08 – 0.12 sec
QT interval = < 50% RR interval
QTc = QTm + (√RR); Normal 0.42 ±0.03 sec
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SBAR (SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION)
• SBAR is a structured method for communicating critical information that requires immediate
attention and action
• SBAR improves communication, effective escalation and safety
• Its use is well established in many settings including the military, aviation and some acute medical
environments
Why use SBAR?

• To reduce the barrier to effective communication across different disciplines and levels of
staff.
• SBAR creates a shared mental model around all patient handoffs and situations requiring
escalation, or critical exchange of information (handovers)
• SBAR is memory prompt; easy to remember and encourages prior preparation for
communication
• SBAR reduces the incidence of missed communications
How can SBAR help me?

• Easy to remember
• Clarifies what information needs communicating quickly
• Points to action.
Uses and settings of SBAR

• Inpatient or outpatient
• Urgent or non-urgent communications
• Conversations with a physician, either in person or over the phone
• - Particularly useful in nurse to doctor communications
- Also helpful in doctor to doctor consultation
• Discussions with allied health professionals
- e.g. Physiotherapy
• Conversations with peers
• Escalating a concern
• Handover from an ambulance crew to hospital staff
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 Introduce yourself / location of where you are
S Situation  Identify the patient
 Brief description of current situation / concerns
For example: "This is Dr.Wasula, apaediatric house officer on Ward 3. The reason I'm calling is that 9
months old patient called Supun in bed 25 has become suddenly short of breath, his oxygen saturation
has dropped to 88 per cent on room air, his respiration rate is 60 per minute, his heart rate is 150 and
his blood pressure is 70/60.”
 Brief patient history 

B Background
 Recent vital signs
 Current treatments
For example: "He was admitted from home with a 3 day history of fever and cough. He has been on
intravenous antibiotics and appeared, until now, to be doing well. He is normally fit and well and NKDA.”
His CRP was 140, wbc- 22,000, CXR done on admission - R/LL Pneumonia
A  Your assessment of the patient’s condition

Assessment  Vital signs – stable / deteriorating
 Actions you have taken & response
For example:Supun’s vital signs have been stable from admission but deteriorated over the last 2 hours.
He has increased work of breathing with significant recessions, and increased RR. On auscultation, he
has deduced air entry to right base and stony dull to percussion.
You need to think critically when informing the senior doctor of your assessment of the situation. This
means that you have considered what might be the underlying reason for your patient's condition.
If you do not have an assessment, you may say: “I’m not sure what the problem is, but I am worried.”
What is your recommendation

R  Patient review
Recommendation
 Tests required
 Children’s
"Would you like me get a stat CXR? and ABGs? I would like you to come immediately
Summary
• Incorporating SBAR may seem simple, but it takes considerable training.
• It can be very difficult to change the way people communicate, particularly with senior
staff.
• But, regular practice can make it a habit and it will eventually help in saving human lives.
That would be Good Medical Practice.
•
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EMERGENCY MANAGEMENT OF THE SERIOUSLY ILL CHILD
Blue Print
TRIAGE Place the child in a resuscitation area and commence the initial
stabilization
INITIAL STABILIZATION Simultaneous assessment and treatment
Position the patient Optimally for the clinical circumstances
Keep patent. This may require a combination of standard airway opening

Airway manoeuvres – Head tilt & Chin Lift or Jaw thrust. If there is any likelihood of
cervical spinal injury, perform in-line immobilization followed by the application
of a soft cervical collar. Sniffing position > 1 year; Neutral position <1 year
WOB - RR, Rhythm, recession, accessory muscles, alae nasi flaring, noises,
Breathing Effect of breathing - AE, Tracheal position, chest expansion, SpO2 in air & FiO2,
paradoxical breathing
If in cardiac arrest  Commence CPR, attach cardiac monitor and assess

Circulation rhythm (shockable / Non-shockable )
Measure pulse rate, pulse volume, CRFT, Line of coldness, BP
Insert IV cannula  Blood sugar, Blood culture, FBC, SE, Grouping & DT, VBG
If in shock give fluid bolus and inotropes
Measure AVPU and Glasgow Coma Scale and record pupillary response and
Disability posture. If GCS < 8 and not rapidly improving, consider endotracheal intubation
to protect the airway from aspiration.
Measure Temperature and finger prick blood sugar. If hypoglycaemia is found give 10%
dextrose 3-5ml/ kg and then remeasure the RBS.
Monitor ECG, SpO2, BP
Reassess Reassess the above steps and treat any further abnormalities that may have
developed. Airway – Mask is fogging, Breathing-Chest expansion, SpO2,
DIRECTED HISTORY AND Focus on the features relevant to the patient's immediate illness
EXAMINATION
COMMENCE SPECIFIC Identify and perform patient intervention which may be pivotal or time critical
TREATMENT to patient's outcome.
• features relevant Admit to an area with appropriate staffing and equipment AND/OR
ONGOING CARE Ensure appropriate patient handover with clear instructions (ISBAR principles)
to the patient's for ongoing management. AND/OR, Arrange medical retrieval if indicated.
immediate illness
Sri Lanka College of Paediatricians / 2019 / APLS group 14

PAEDIATRIC TRIAGE
TRIAGE SCALE: DESCRIPTORS FOR CATEGORIES
ATS Response Description of the category Clinical description
category Category only
Category 1 Immediate Immediately life threatening Airway & Breathing
Red area simultaneous Conditions (or imminent risk of Respiratory Arrest
assessment deterioration) and require Impending Respiratory Arrest (Respiratory
and immediate aggressive intervention. rate <10/min or hypoventilation)
treatment Extreme respiratory distress
Circulation
Cardiac Arrest
Severely shocked child/infant
Disability
Unresponsive or responds to pain only (GCS <
9)
Ongoing / prolonged seizure
IV overdose and unresponsive
Severe behavioural disorder with immediate
threat of dangerous violence
Category 2 Assessment Imminently life – threatening. Airway risk – severe stridor or drooling with
Red area and The patient's condition is serious distress
treatment enough or deteriorating so rapidly Severe respiratory distress
within 10 that there is the potential of threat Circulatory compromisation
minutes to life, or organ / system failure, if Clammy or mottled skin, poor perfusion
(assessment not treated within ten minutes of hypotension with haemodynamic effects
and arrival or Important time - critical severe blood loss
treatment treatment Disability
often should The potential for time - critical Drowsy, decreased responsiveness from any
be treatment (e.g. antidote) to make a cause (GCS< 13)
simultaneous) significant effect on clinical Acute hemiparesis/dysphasia
outcome depends on treatment Very severe pain of any cause
commencing within a few minutes Measurement & Monitoring
of the patient's arrival in the ED BSL < 3 mmol/l
OrVery severe pain Fever with signs of lethargy (at any age)
Humane practice mandates the Suspected meningococcaemia
relief of very severe pain or distress Exposure
within 10 minutes Acid or alkali splash to eye – requiring
irrigation
Major multi trauma (requiring a rapid
organised team response)
Severe localised trauma – major fracture,
amputation
Directed High- risk history:
-Significant sedative or other toxic ingestion
-Significant/dangerous envenomation
-Severe pain suggesting PE, AAA or ectopic
pregnancy
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Category 3 Assessment Potentially Life Threatening Airway & Breathing
Green and The patient's condition may Moderate shortness of breath
treatment to progress to life or limb threatening, SAO2 90 –95%
start within or may lead to significant morbidity Circulation
30 if assessment and treatment are not Severe hypertension
mins commenced within thirty minutes Moderately severe blood loss – from any
of arrival cause
or Persistent vomiting
Situational Urgency Dehydration
There is potential for adverse Disability
outcome if time-critical treatment is Seizure (now alert)
not commenced within thirty Any fever if immuno-supressed e.g.oncology
minutes patient, steroid Rx
or Head injury with short LOC-now alert
Humane practice mandates the Moderately severe pain – of any
relief of severe discomfort or causerequiring analgesia
distress within thirty minutes Measurement & Monitoring
BSL >16 mmol/l
Exposure
Moderate limb injury –deformity, severe
laceration, crush injuries
Limb –altered sensation, acutely absent pulse
Trauma -high-risk history with no other high-
risk features
Stable neonate
Child at risk of abuse/suspected non-
accidental injury
Behavioural/Psychiatric:
-very distressed, risk of self-harm
-Acutely psychotic or thought disordered
-situational crisis, deliberate self-harm
-agitated / withdrawn
-potentially aggressive
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Category 4 Assessment Potentially serious Airway & Breathing
Green and The patient's condition may Foreign body aspiration, no respiratory
treatment to deteriorate, or adverse outcome distress
start within may result, if assessment and Difficulty swallowing, no respiratory distress
60 treatment is not commenced within Circulation
mins one hour of arrival in ED. Symptoms Mild haemorrhage
moderate or prolonged Vomiting or diarrhoea without dehydration
or Disability
Situational Urgency Minor head injury, no loss of consciousness
There is potential for adverse Exposure
outcome if time-critical treatment is Chest injury without rib pain or respiratory
not commenced within hour or Distress
significant complexity or severity Moderate pain, some risk features
Likely to require complex work-up Eye inflammation or foreign body –normal
and consultation and/or in-patient vision
management Minor limb trauma –sprained ankle, possible
or fracture, uncomplicated laceration requiring
Humane practice mandates the investigation or intervention –Normal vital
relief of discomfort or distress signs, low/moderate pain
within one hour Tight cast, no neurovascular impairment
Swollen “hot” joint
Non-specific abdominal pain
Behavioural/Psychiatric:
-Semi-urgent mental health problem
-Under observation and/or no immediate risk
to self or others
Category 5 Assessment Less Urgent Minimal pain with no high risk features
Yellow and The patient's condition is chronic or Low-risk history and now asymptomatic
treatment to minor enough that symptoms or Minor symptoms of existing stable illness
start within clinical outcome will not be Minor symptoms of low-risk conditions
120 minutes significantly affected if assessment Minor wounds - small abrasions, minor
and treatment are delayed up to lacerations (not requiring sutures)
two hours from arrival Scheduled re-visit e.g. wound review,
or complex dressings
Clinico-administrative problems Immunisation only
Results review, medical certificates, Behavioural/Psychiatric:
prescriptions only -Known patient with chronic symptoms
-Social crisis, clinically well patient
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TRIGGERS DISABILITY AIRWAY BREAHTING CIRCULATION PAIN
Lethargy / Stridor Rate, Rhythm Colour (pale Limited
Drowsiness, Snoring Recessions, mottles, movement
Floppy, Weak Drooling noises, Accessory cyanosis) Distressed
cry, Irritable, Position (tripod) muscles - AE, Peripheral pulses Obvious
(inconsolable cry Chest expansion, (normal to deformity
by parent/carer) abdominal thready) Guarding or
breathing, posturing
Tracheal position, Inconsolable
SpO2 in air
1 Unresponsive Obstructed Apnoea , No pulse
Responds only to Partially obstructed Hypoventilation, Bradycardia
pain + Severe respiratory
Severe respiratory distress
distress
2 Response only to Partially Respiratory Severe Severe pain (Pain
voice obstructed + distress haemodynamic score 8 – 10)
Severe decrease in moderate (severe to compromise,
activity respiratory distress moderate) uncontrolled
bleeding
CRFT>4seconds
3 Moderate Partially Moderate Moderate pain

decrease in activity obstructed + haemodynamic (pain score 5-7)
Recent seizure mild respiratory moderate) compromise ,
distress distress (mild to Moderate
Respiratory dehydration , CRFT
2-4sec
4 Alert to mild Normal Mild Respiratory Mild Mild Pain

decrease in activity distress to normal haemodynamic (Pain score 1-4)
compromise , mild
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dehydration,
CRFT<2 seconds
5 Normal Normal Normal Normal No pain

MANAGEMENT OF AN INHALED FOREIGN BODY
Points in favor of inhaled foreign body

 Making a comfortable diagnosis is extremely difficult
 Age group – older infants / toddlers
 High degree of suspicion
 Positive history must never be ignored
 Negative history may be misleading
 Children who present with 1st episode of wheezing
 Absence of fever or preceding illness
Clinical features
 Violent paroxysms of (intermittent episodes)
 Coughing
 Choking
 Gagging
 Possible wheezing
 Cyanotic episodes
 Asymptomatic intervals
 When FB gets dislodged
 Complications
 Fever, cough
 Haemoptysis
 Pneumonia
 Atelectasis
Management Strategies
 Assess the work of breathing, effort, and efficacy of breathing
 Follow the APLS choking child protocol
 CXR (both expiratory & inspiratory films) if child is stable
 Inform ENT surgeon, Anesthetist, Paediatric intensivist and reserve a bed in the PICU
 Transfer to PICU in the most comfortable position of the child
 Discuss with the ENT surgeon on the need for video bronchoscopy.
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STANDARD PAEDIATRIC Name: Target Parameters:
OBSERVATION CHART Age: Ward Number:
BHT Number: Respiratory rate:
1 to 4 Years Date: Time
SpO2:
Admission to ETU Pulse rate:
Lady Ridgeway Hospital Admission to Ward Systolic BP:
for Children Admission to ICU Other:
Date Date Date Date
Time Time Time Time
Alert Alert
Consciousness
80 80
Level of
Verbal Verbal
75 75 Pain Pain
DISABILITY
70 70 Unresponsive Unresponsive
65 65
Enter appropriate letter. A= Alert, V= Rousable only by voice (consider GCS). P= Rousable only by central pain (conduct GCS). U=Unresponsive
60 60
(breaths per minute)
55 55 Severe (7-10) Severe (7-10)
Pain Score
Respiratory Rate
50 50 Moderate (4-6) Moderate (4-6)

45 45 Mild (1-3) Mild (1-3)
40 40 Nil Nil
35 35 41 41
30 30 40.5 40.5
25 25 40 40
AIRWAY / BREATHING
39.5 39.5
20 20 39 39
Temperature (oC)
(Check unit policy)
15 15
EXPOSURE
38.5 38.5
10 10 38 38
5 5 37.5 37.5
37 37
Severe Severe 36.5 36.5
Respiratory
36 36
Distress
Moderate Mod
35.5 35.5
Mild Mild 35 35
Normal Normal 34.5 34.5
34 34
100 100
95 95 BGL BGL
90 90
85 85 Weight Weight
SpO2 %
80 80
75 75 Initials Initials
<70 <70
Probe Probe
Change Change
L/min L/min
Oxygen
or % or %
Device Device
220 220
210 210
200 200
190 190
180 180
170 170
160 160
(beats per minute)
150 150
Heart Rate
140 140
130 130
120 120
110 110
100 100
90 90
80 80
CIRCULATION
70 70
60 60
Capillary
≥ 3 Seconds ≥ 3 Seconds
Refill
< 3 Seconds < 3 Seconds

150 150
140 140
130 130
Blood Pressure (mmHg) > <
120 120
110 110
SBP is the trigger
100 100
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
Initials Initials
Increase Frequency of Observations Clinical Review Rapid Response
20
21
Date: Time
3 - 12 months SpO2:
Date Date Date Date
Time Time Time Time
Alert Alert
Consciousness
80 80
Level of
Verbal Verbal
75 75
Pain Pain
DISABILITY
65 65
60 60 Enter appropriate letter. A= Alert, V= Rousable only by voice (consider GCS). P= Rousable only by central pain (conduct GCS). U=Unresponsive
55 55 Severe (7-10) Severe (7-10)
Pain Score
Respiratory Rate

45 45 Mild (1-3) Mild (1-3)
40 40 Nil Nil
35 35 41 41
30 30 40.5 40.5
25 25 40 40
AIRWAY / BREATHING
20 20 39.5 39.5
39 39
Temperature (oC)
15 15
(Check unit policy)

EXPOSURE
38.5 38.5
10 10 38 38
5 5 37.5 37.5
37 37
Respiratory
36 36
Distress
Moderate Mod 35.5 35.5

Mild Mild 35 35
34 34
100 100
95 95 BGL BGL
90 90
85 85 Weight Weight
SpO2 %
80 80
<70 <70
Probe Probe
Change Change
L/min L/min
Oxygen
or % or %
Device Device
220 220
210 210
200 200
190 190
180 180
170 170
160 160
(beats per minute)
150 150
140 140
Heart Rate
130 130
120 120
110 110
100 100
90 90
CIRCULATION
80 80
70 70
60 60
Capillary
Refill

130 130
120 120
110 110
100 100
SBP is the trigger
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
Initials Initials
22
23
Date: Time
5 to 11 Years SpO2:
Admission to Ward Systolic BP:
Lady Ridgeway Hospital
Admission to ICU Other:
for Children
Date Date Date Date
Time Time Time Time
Alert Alert
Consciousness
60 60
Level of
Verbal Verbal
55 55 Pain Pain
DISABILITY
45 45
Respiratory Rate
40 40
Severe (7-10) Severe (7-10)
Pain Score
35 35
Moderate (4-6) Moderate (4-6)
30 30
Mild (1-3) Mild (1-3)
25 25 Nil Nil
20 20
41 41
15 15 40.5 40.5
AIRWAY / BREATHING
10 10 40 40
5 5 39.5 39.5
39 39
Temperature (oC)
(Check unit policy)
EXPOSURE
Respiratory
38 38
Distress
Moderate Mod
37.5 37.5
Mild Mild 37 37
36 36
100 100 35.5 35.5
35 35
95 95 34.5 34.5
90 90 34 34
85 85
SpO2 %
80 80 BGL BGL
75 75
Weight Weight
<70 <70
Probe Probe Initials Initials
Change Change
L/min L/min
Oxygen
or % or %
Device Device
180 180
170 170
160 160
150 150
140 140
130 130
(beats per minute)
120 120
Heart Rate
110 110
100 100
90 90
80 80
70 70
60 60
50 50
40 40
CIRCULATION
Capillary
Refill
160 160
150 150
140 140
130 130
120 120
SBP is the trigger
110 110
100 100
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
Initials Initials
24
25
Date: Time
12 Years and Over SpO2:
Date Date Date Date
Time Time Time Time
Alert Alert
Consciousness
60 60
Level of
Verbal Verbal
55 55 Pain Pain
DISABILITY
45 45
Respiratory Rate
40 40
Severe (7-10) Severe (7-10)
Pain Score
35 35
Moderate (4-6) Moderate (4-6)
30 30
Mild (1-3) Mild (1-3)
25 25 Nil Nil
20 20
41 41
15 15 40.5 40.5
AIRWAY / BREATHING
10 10 40 40
5 5 39.5 39.5
39 39
Temperature (oC)
(Check unit policy)
EXPOSURE
Respiratory
38 38
Distress
Moderate Mod
37.5 37.5
Mild Mild 37 37
36 36
100 100 35.5 35.5
35 35
95 95 34.5 34.5
90 90 34 34
85 85
SpO2 %
80 80 BGL BGL
75 75
Weight Weight
<70 <70
Probe Probe Initials Initials
Change Change
L/min L/min
Oxygen
or % or %
Device Device
180 180
170 170
160 160
150 150
140 140
130 130
(beats per minute)
120 120
Heart Rate
110 110
100 100
90 90
80 80
70 70
60 60
50 50
40 40
CIRCULATION
Capillary
Refill

200 200
190 190
180 180
170 170
160 160
150 150
140 140
SBP is the trigger
130 130
120 120
110 110
100 100
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
Initials Initials
26
27
STANDARD PAEDIATRIC Target Parameters:
Name:
OBSERVATION CHART Age: Ward Number: Respiratory rate:
BHT Number: SpO2:
Under 3 months Date: Time
Pulse rate:
Admission to ETU
Date Date Date Date
Time Time Time Time
Alert Alert
Consciousness
90 90
Level of
85 85 Verbal Verbal
Pain Pain
80 80
DISABILITY
Unresponsive Unresponsive
75 75
70 70 Enter appropriate letter. A= Alert, V= Rousable only by voice (consider GCS). P= Rousable only by central pain (conduct GCS). U=Unresponsive
65 65 Severe (7-10) Severe (7-10)
Pain Score
Respiratory Rate

55 55 Mild (1-3) Mild (1-3)
50 50 Nil Nil
45 45 41 41
40 40 40.5 40.5
35 35 40 40
39.5 39.5
AIRWAY / BREATHING
30 30 39 39
Temperature (oC)
(Check unit policy)
EXPOSURE
25 25 38.5 38.5
20 20 38 38
15 15 37.5 37.5
37 37
36.5 36.5
Severe Severe 36 36
Respiratory
Distress
Moderate Moderate 35.5 35.5

Mild Mild 35 35
34.5 34.5
Normal Normal 34 34
100 100
95 95 BGL BGL
90 90 Weight Weight
85 85
SpO2 %
75 75
<70 <70
Probe Probe
Change Change
L/min L/min
Oxygen
or % or %
Device Device
220 220
210 210
200 200
190 190
180 180
170 170
(beats per minute)
160 160
Heart Rate
150 150
140 140
130 130
120 120
110 110
100 100
90 90
CIRCULATION
80 80
70 70
60 60
Capillary
Refill

120 120
110 110
100 100
SBP is the trigger
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
Initials Initials
28
29
ACUTE SEVERE ASTHMA / LIFE THREATENING ASTHMA
Clinical assessment
 Pulse rate
 Respiratory rate and degree of recessions
 Use of accessory muscles of respiration
 Degree of agitation and conscious level
 SpO2 on air and if post nebulisation SpO2 <92% needs intensive treatment ; Aim is maintain
SpO2 94-98%
 PEFR if possible and the child is cooperative
Acute Severe Asthma

 SaO2 <92% in air
 Heart rate >140/min (<5years)
 Heart rate >125/min (>5 years)
 Respiratory rate >40/min (<5 years)
 Respiratory rate >30/min ( 5 years)
 Use of accessory muscles of respiration
 Difficulty in talking, agitated
Life threatening asthma

 (Presence of any one of these)
 SaO2 <92% in air
 Silent chest
 Poor respiratory effort
 Cyanosis
 Altered consciousness
 Exhaustion
Assessment Current Status

 Duration of attack
 Assessment of severity
 Treatment (dose / frequency of nebs, IV therapy, steroids)
Assessment Past History

 Frequency of attacks
 Routine medications
 Number of courses of systemic steroids
 Previous ICU admissions + intubation
30
Initial Management of Acute Severe Asthma
a. Oxygen
Children with severe or life threatening asthma or SpO2 <92% should receive high flow
oxygen via a tight fitting mask or nasal cannula to achieve normal saturation.
b. Nebulised bronchodilators
Children with severe or life threatening asthma should receive frequent or back to back
doses of salbutamol (2.5 – 5mg). (Always driven by 6-8 liters/min O2) 2.5mg <5 years;
5mg >5 years.
Add ipratropium bromide nebulizers. Usual doses of ipratropium bromide is 250mcg(0.5mg)

>12 years (125mcg for < 2years). Give every 20 minutes for 1 hour
a. Steroids Therapy
Steroids should be given early. Benefits are seen in 3- 4 hours. In severe asthma 4mg/kg IV
hydrocortisone (2-5 years : maximum 50mg, 5-18 years : Maximum 100mg) may need to be
given 4 hourly since most children are unable to tolerate oral prednisolone (<12 years: 1-
2mg/kg (max 40mg) OD for 3-5 days. If the child has been taking oral corticosteroids –
2mg/kg (max 60mg) OD for 3-5 days).
.
b. Magnesium Sulphate
MgSO4 may be useful as an adjunct in acute severe asthma. If poor response after 3 nebs
give IV MgSO4 40mg – 50mg /kg (max 2g) single dose should be given by slow infusion over
30 minutes and continue neblulised treatment. Reassess every 20 minutes. This may be
repeated in 1-2 hours.
IV MgSO4 can be administered on any ward as a recue therapy.

Serial Mg levels measurement is indicated if further doses are being considered.
Hypotension caused due to vasodilatation is the most likely side effect but is quiet rare.
If patient has not improved or deteriorated, move to life threatening pathway.

Continue Observation
Inform Consultant PICU
Poor response or Deteriorating
Continuous nebulised ß2 agonist + ipratropium; Will need CXR & Blood gases
c. IV Aminophylline
Aminophyllin may be useful in children with refractory severe or life threatening

bronchospasm. A 5mg/kg loading dose (maximum 500mg should be given over 20 minutes
31
with ECG monitoring. A loading dose must not be given to patients on oral theophylline
treatment.
The loading dose is usually followed by a continuous infusion at 1mg/kg/hour(more than 12

years infusion rate: 0.5-0.7mg/kg/hour).
d. IV Salbutamol
Consider early addition of a 15 meg/kg bolus of salbutamol given over 15 minutes

(maximum 250mcg).
Follow this up with a continuous infusion in refractory asthma (usually 1-2 mcg/kg/min).
Higher doses up to a maximum of 5mcg/kg/min (200mcg/ml solution) should be discussed with
the Consultant.
Reduced infusion rate if side effects occur: lactic or metabolic acidosis, tachycardia,
arrhythmias, tremor, severe hypokalaemia, hyperglycaemia and hypophosphataemia.
Note: increasing tachypnoea on IV salbutamol may indicate toxicity and metabolic acidosis
rather than worsening of asthma.
Patients on IV salbutamol should have continuous ECG monitoring and regular monitoring
of Potassium.
e. Indication for intubation
Blood gas analysis is not a substitute for clinical assessment.
a. Consider intubation in any child with the following
 Tiredness and exhaustion

 Reduced conscious level
 Worsening hypoxaemia
b. Intubation (Always contact a Paediatric Intensivist before intubation)
 The most experienced person available should intubate the child.

 Pre-oxygenate
 10-20mls /kg colloid / crystalloid
 You will need a tight fitting ETT as the ventilator inspiratory airway pressure may
be high. Consider a cuffed tube.
 Consider modified “Rapid Sequence Induction” with Ketamine 1-2mg/kg (has
some bronchodilator activity) and suxamethonium 1-2mg/kg.
32
 Inhalational agents (have bronchodilatory properties) such as Fentanyl,
midazolam / Ketamine and vecuronium may be used for sedation and paralysis.
 Avoid morphine and atracurium (they cause histamine release)
33
COMMUNITY ACQUIRED PNEUMONIA IN CHILDREN
Clinical Definition
Community Acquired Pneumonia (CAP) is an acute infection of the pulmonary
parenchyma acquired outside of a hospital setting and is one of the most common
serious infections in children.
Symptoms of Respiratory Tract Infections

 Fever
 Cough
 Tachypnea
Signs of severe pneumonia

 Tachypnoea(requires a full one-minute count while the child is quiet and is the best
predictor of pneumonia of children in all age groups)
 Grunting
 Chest in drawing / Recessions
 Use of accessory muscles
 Nasal Flaring (Alveolar pathology)
 Expiratory Grunt (Alveolar pathology)
 Bilateral chest expansion
 Auscultation – Crackles, Decreased Breath Sounds
 SpO2 in air and with High flow oxygen
 Look for signs of deterioration & exhaustion
WHO defined tachypnoea

< 2 months of age over 60 breaths/ min
2-12 months over 50 breaths/ min
1 – 5 years over 40 breaths/min
> 5 years over 30 breaths/ min
Triage & Position

 Triage Category
 Prop up position
Airway & Breathing

 Increased work of breathing
 Increase effort of breathing
34
 Airway Opening maneuvers
 Check SpO2 with pulse oixymery
 High flow oxygen 10 – 15 liters per minute
 Check – Mask is fogging
Circulation
 IV cannula
 RBS
 Full blood count
 CRP / ESR
 Blood culture
 Mycoplasma antibody test
 IV antibiotics
 IV fluid resuscitation
Measure & Monitor

 RBS, Temperature
 RR, Pulse rate, BP, SpO2, ECG, Blood gas, SE
Directed History & Examination

 Children with chronic disorders such as cystic fibrosis, immune compromise, history of
neonatal cardiopulmonary disease or complex anomaly of the airway anatomy.
 Children who are not improving, Consider foreign body aspiration, Pulmonary TB,
Immunodeficiency, Anatomical abnormality of the lung.
 These patients must be urgently discussed with the relevant team who will decide
upon whether admission is necessary.
 NPA positive for a viral pathogen, consider Oseltamivir
 CXR for type of pneumonia
 Mantoux test and Sputum for routine bacterial mc&s for TB
Specific Treatment
 Lobar Consolidation (X-Ray or Clinical) – IV antibiotics
 Mycoplasma/Chlamydia pneumonia - Oral Clarithromycin 7 days
 Probable Viral Cause – Consider withholding antibiotics.
 For Staph Pneumonia (Staphylococcus aureus (cavitations, multiple lesions, effusions,
empyema) – Flucloxacillin intravenous50 mg/kg/dose (max 2g) 6 hourly
 Community acquired MRSA is suspected or proven intravenous Vancomycin 25
mg/kg/dose up to maximum 1g 12 hourly until sensitivity results known.
35
Complications
 Pneumothorax
 PIE
 Pleural Effusion
 Empyema
 Septic shock
Any patient with severe pneumonia who appear toxic, must be urgently discussed with
the paed registrar / consultant on call as early as possible in the admission process.
CHILDREN WHO ARE LESS THAN 3 MONTHS, URGENLTY DISCUSS WITH YOUR CONSULTANT
36
MANAGEMENT FOR EPIGLOTITTIS
Do’s
 Call for senior help
Paediatric registrar /
Consultant Anaesthetist registrar /
Consultant ENT surgeon
ConsultantPaediatrician
 Allow the child to remain in its favoured position.
 The child should be constantly supervised by someone skilled in intubation.
 Give humidified oxygen as tolerated
Don’t
 Attempt oropharngeal examination, since this may precipitate complete obstruction.
 Attempt insertion of an IV cannula or take blood.
 Send the child for neck X-ray or other X-ray
 Upset the child e.g removing parents.
 Leave the child unsupervised
 Rely only on pulse oximetry
1. Indications for intubation

a. Suspected epiglottitis
b. Inhalational injury
c. Fall in conscious level
d. Increasing respiratory failure
e. Rising pCO2
f. Exhaustion
g. Hypoxia (SpO2 <92% despite high-flow O2 by mask >5 L/min)
2. Management of intubation
a) The most experienced anaesthetist must be present at the intubation. Most anaesthetists
would favour a gas induction. The resuscitation team have a backup oxygenation strategy
prepared.
b) It may be necessary to use croup tubes rather than standard ETT. These are longer than
standard ETT, but come in similar sizes, and may be necessary in situations where severe
airway narrowing mandates a much smaller ETT than indicated by age (e.g. a 4.0 mm ETT for
a 6 year old).
Management following intubation

c) Once the airway obstruction is bypassed, most children are easy to ventilate. Exceptions
might be in case of bacterial tracheitis (with pulmonary involvement), inhalational injury
(ARDS), or anaphylaxis(bronchoconstriction).
d) Ensure that the ETT is securely taped.
37
4. Transport considerations
 Children with an unstable airway should not be transported without a detailed discussion
with the on call consultant.
 ETCO2 monitoring is mandatory during transfer to maintain continuous correct ETT
placement.
 Use continuous muscle relaxation during retrieval to ensure safety of ETT.
 If transporting an un-intubated child with suspected foreign body obstruction, avoid
unnecessary delay and transfer immediately to the ENT center of a Teaching or Provincial
hospital directly to operating theatre if necessary. The team must have a strategy to manage
unexpected obstruction or hypoxia.
3. Use sedation and paralysis to ensure safety of ETT.

a. Following a difficult intubation, an ETT should only be changed if there is a clear clinical
reason which justifies this risk.
b. Start adjunctive treatments such as iv dexamethasone (0.15 mg/kg qids) in case of
croup; or ceftriaxone (80 mg/kg) in case of epiglottitis or bacterial tracheitis.
c. Blood cultures must be taken in suspected cases of infection.
d. In case of inhalation injury and burns, start fluid replacement as per burns guidelines.
e. Patients with bacterial tracheitis may become septic, and need fluid resuscitation and
inotropic support.
38
UPPER AIRWAY OBSTRUCTION (UAO)
1. Assessment
The most pertinent clinical sign is stridor, which is usually an inspiratory noise, but sometimes can
be both inspiratory and expiratory.
Not to be confused with:

 Wheeze: expiratory whistling noise; a sign of lower airway obstruction and narrowing.
 Stridor- may also signify upper airway collapse in children with decreased conscious state,
pharyngeal hypotonia or swallowing problems.
Causes of stridor:
Common Viral laryngo-tracheobronchitis (croup)

Superimposed infection on subglottic stenosis or laryngomalacia
Uncommon Epiglottitis
Bacterial Tracheitis
Laryngeal foreign body
Inhalational injury (burns)
Anaphylaxis
Severe bilateral tonsillar enlargement
Rare Angio-neurotic oedema
Diphtheria
Retropharyngeal abscess
Key message:
Identify and treat serious upper airway obstruction. Once the airway is secure, time can be
spent on identifying the specific cause or aetiolgyfor UAO.
Specific points in history:

• Is this the first presentation?
• Is there a history of previous intubations or previous difficulty with intubation?
• Is the airway stable?
Danger signs and useful pointers to the cause of UAO:

• Sudden or rapid onset – foreign body, epiglottitis, tracheitis, anaphylaxis
• Soft or low pitched stridor – epiglottitis, tracheitis
• Toxic appearance and high fever - epiglottitis, tracheitis, retro-pharyngealabscess
• Drooling, open mouth, sitting forward - epiglottitis, retro-pharyngealabscess, severe tonsillar
obstruction
39
2. Initial management
Irrespective of the cause for UAO, some general management guidelines apply:
2.1 General management: AVOID UPSETTING THE CHILD

 Leave child with a parent and in a comfortable position
 DO NOT insert a tongue depressor
 DO NOT attempt IV access or blood tests
 DO NOT ask for a Chest or lateral neck X-ray
 DO NOT force an oxygen mask over face.
 Adrenaline nebulisation may temporarily relieve severe airwayobstruction, usually
in a dose of 0.5 ml/kg of 1:1000 solution, up toa maximum of 5 ml. The effect of
adrenaline is temporary.
 Pulse oximetry is a poor guide to severity when oxygen is delivered
2.2 Specific management of selected conditions:
Viral croup: summarized in flow chart given in the next page.
Stridor Recession Cyanosis Level of Croup Score

0 – none 0-none (SpO2<92% in consciousness mild croup
1 – at rest 1-mild recession air) 0-none 2-7 Moderate
audible with 2-moderate 0-none 5-altered mental croup
stethoscope recession 1-with agitation state >8 severe croup
2 – at rest 3-severe 2-at rest
audible without recession
stethoscope
 Foreign body obstruction: The management depends on the site and severity of airway
obstruction. Intubation may result in further impaction of the foreign body, and should be
considered ONLY when there is impending/actual cardio-respiratory arrest. The anaesthetist
will then try to visualize/clear the object under direct laryngoscopy. Otherwise, examination
under an anaesthetic with rigid bronchoscopy by the ENT team is the best option.
 Bacterial tracheitis: Stridor may be soft or absent even in severe airway obstruction.
Consider early intubation by anaesthetist. After intubation the ET tube may become blocked
with secretions.
 Inhalational injury: Along with the history, other pointers may include soot in sputum,
singed nasal hair, soot around mouth and face, and facial burns involving mouth and nose.
The airway must be secured at the earliest opportunity. Delay can lead to progressive airway
obstruction due to oedema and a situation where intubation becomes impossible. Call
anaesthetic team and intubate electively
40
THE SCHEME OF MANAGEMENT FOR VIRAL CROUP
Clinical signs
 Inspiratory stridor
 barking cough
 Hoarse voice
 Variable degree of respiratory distress
 Symptoms worse at night
Important points in the history to make the diagnosis

 During winter
 6 months – 5 years
 Mild fever <38.5
 Acute coryza
 Exclude a FB inhalation
Mild Croup (Score 0-1)

• Stridor only with agitation
• Normal RR
• No recession Reassure
• Normal pulse rate Consider dexamethasone 0.15mg/kg orally
• Normal SpO2 Discharge home if no stridor or improved
• Normal conscious level
Moderate Croup (Score 2-7)

 Normal or raised RR
Dexamethasone 0.6mg/kg orally (max 8mg) single dose
 Mild recession
or nebulised budesonide 2mg if oral route is not
 AE decreased but easily audible
possible.
 increased pulse rate
Observe for improvement or deterioration for 2-3 hours
 SpO2 >93%
Discharge home if no stridor or improved
 Normal conscious level
Severe Croup (Score >8)

 Raised RR Call for senior help
 Moderate/marked recession Paediatric Registrar
 AE decreased, not easily audible Senior registrar in PICU
 increased pulse rate Anaesthetist on call
 SpO2 >93% ENT surgeon on call
 Altered level of conscious Stay with the child and closely observe.
Give nebulised adrenaline 0.5ml/kg of 1:1000 solution upto a
maximum of 5mls.This dose can be repeated.
Child might require urgent intubation and transfer to PICU.
41
 Leave the child in comfortable position
 Avoid unnecessary upset to the child
 Child to be with mum in seated position
 Try distraction maneuvers to reduce the distress
 Do not force an oxygen mask over face
 Do not insert tongue depressor
 Do not insert IV line or take blood
 Consider SpO2 , EGC monitoring
 No radiography
 If no improvement or worsening, re-score and act accordingly
 Open access to the ward
42
DIARRHOEA AND DEHYDRATION
1. Assessment of dehydration
It is important to assess the degree of dehydration in children. Infants and small children are at a higher
risk of dehydration. Weight loss is useful in estimating the degree of dehydration if weight prior to
admission is known.
Dehydration Some dehydration Severe dehydration >10%

Less than 5% 5-10%
Fluid deficit in ml/kg <50 ml/kg 50-100 ml/kg >100 ml/kg
body weight
General Condition Well, alert Restless, Irritable Lethargic or unconscious or
Eyes Normal Sunken floppy
Tears Present Absent Very sunken and dry
Mouth & tongue Moist, Dry Absent
Thirst thirsty Thirsty, drinks Very dry
eagerly Drinks poorly or not able to drink
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
2. Management of Dehydration
 Correction of the existing water and electrolyte deficit
 Replacement of ongoing losses.
 Provision of normal daily fluid requirement
3. No dehydration
a. Give the child more fluids than usual to prevent dehydration
b. Home based fluids and ORS solutions such as conjee should be used.
c. Give as much fluid as the child wants.
d. As a guide approximately 50 ml of fluid should be given after each stool.
e. Watch for signs of dehydration.
4. Some dehydration (5 – 10%)

a. Approximate amount of ORS solution to be given in the first four hours is 75ml/kg in
first 4 hours
5. Severe dehydration >10% dehydration

a. Children with severe dehydration need intra venous fluids, as there is a risk of
impending shock
b. Start IV Ringer’s Lactate fluid (Hartman Solution) immediately. If the patient can drink,
ORS should be given while the drip is set up.
c. Normal saline could be used if Ringer’s Lactate solution is not available.
d. If intra venous access is impossible attempt intra- osseous administration or give ORS
through naso-gastric tube
e. Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more
rapidly.
43
Hypovolaemic shock
 High flow oxygen 10 – 15 liters per minute

 N Saline 20ml/kg over 20 minutes until shock resolves
Severe Dehydration
 30 ml /kg over one hour (Infants <12 months)

 30 ml /kg over half an hour (Infants >12 months)
and then
 70 ml /kg over 5 hour (Infants <12 months)
 30 ml /kg over 2½ hour (Infants >12 months)
44
NORMAL FLUID & ELECTROLYTES
Physiology:
Tonicity: is normally maintained between 280 – 295 mosmol/L by ADH and thirst control mechanisms.
Volume regulation of water is via ADH, thirst and renin-angiotensin-aldosterone system. Note that
volume regulation overrides osmotic regulation.
Urine output:
The minimal urine output that maintain homeostasis varies with e.g. being 1.4ml/kg/hr at 4 weeks,
1ml/kg/hr at 6 months and 0.5ml/kg/hr at 1 year.
Compartments:
Newborn Infant Adult

Total BodyWater(TBW) 75% 60% 60%
Intra Cellular Volume(ICV) 35% 35% 40%
Extra Cellular Volume(ECV) 40% 25% 20%
Blood Volume 8% 7.5% 7.5%
Measured parameters that aid assessment are

 Weight
 Haematocrit
 Serum and urinary osmolality
 Acid base balance
Body weight Fluid requirement per Fluid requirement per
day hour
First 10kg 100ml/kg 4ml/kg
10 – 20 kg 50ml/kg 2ml/kg
> 20kg 20ml/kg 1ml/kg
Maintenance Fluid – 0.9% Normal Saline + KCL 20 mmol/l
Actual volume of insensible loss is related to:

 Caloric content of feeds, ambient temperature, humidity of inspired air, presence of pyrexia and
the quality of the skin.
 Usually between 0 and 10 ml/kg/day are lost in stools
 (may exceed 300 ml/kg/day in diarrhoea)
 Urinary losses are usually between 1-2 ml/kg/day
 (approx 30ml/kg/day)
Body Weight Serum Na mmol/kg/day Serum K mmol/kg/day

First 10kg 2-4 1.5-2.5
Second 10kg 1-2 0.5-1.5
Subsequent kg 0.5-1 0.2-0.7
45
 How to calculate the percentage of dehydration
o Percentage dehydration x weight x 10
o Percentage dehydration means the number of grams of fluid lost per 100 gm of body
weight.
o Percentage x 10 converts this volume into ml/kg
 Shock occurs as a result of rapid loss of 20ml/kg from the intravascular space. If the intravascular
volume is maintained, clinical dehydration is only evident after losses > 25ml/kg of total body water.
 It is possible to be shocked and not dehydrated, dehydrated and not shocked, or dehydrated and
shocked
Composition of common IV fluids
0.9% N Saline Hartmans 5% dextrose ½ NS

Na+ mmol/l 150 130 75
K+mmol/l 4–5
Cl-mmol/l 150 109 75
Ca+ 3
Lactate 28
Dextrose g/l 50
Osm mosm/l 300 274 278 150
pH 4.0 – 7.0 5.0 – 7.0 3.5 – 6.5 4.0 – 7.0
46
ANAPHYLACTIC ALGORITHM
Assess for Signs & symptoms of anaphylactic reactions

 Acute onset of illness
 Life threatening Airway, and/or Breathing and/or Circulation problems
 Skin changes
Prepare
 Remove causative agent

 Be prepared
 Oragnise the team
 Organise Adrenaline
 Monitored resuscitation area
Airway & Breathing

 Airway - angio-oedema Establish airway
 Hoarseness High flow oxygen
 Stridor Nebulised salbutamol or
Nebulised adrenaline 0.5ml/kg of 1:1000 to a
 Aphonia
maximum of 5ml as for croup
 Breathing – bronchospasm
IM Adrenaline 1:1000; 0.01ml/kg IM
 Respiratory distress
May be repeated every 5 minutes
 Critical wheeze,
 Silent chest
Circulation
Compensated or Uncompensated shock
 Call for help
 Keep the patient flat
 Raise patient’s legs
 IM Adrenaline 1:1000; (May be repeated every 5 minutes)
 0.01ml/kg IM
o <6 years – 0.15ml
o 6 – 12 years – 0.3ml
o >12 years - 0.5ml
 IV Crystalloid 20ml/kg -- Repeat as necessary
 Watch for pulmonary oedema  NIPPV / IPPV
 Consider Intubation – if >40ml/kg fluid is needed
Age Chlorpheniramine IM or slow IV Hydrocortisone IM or slow IV

<6 months 250mcg/kg 25mg
6 months-6 year 2.5mg 50mg
6 years – 12 years 5mg 100mg
>12 years 10mg 200mg
47
48
RECOGNITION & MANAGEMENT OF SEPTIC SHOCK
Recognition
Think: could this child have SEPSIS or SEPTIC SHOCK?
If in doubt, consult a senior clinician.
If a child with suspected or proven infection AND has at least 2 of the following:
 Core temperature < 36°C or > 38.5°C
 Inappropriate tachycardia (Refer to local criteria / APLS Guidance)
 Altered mental state (including: sleepiness / irritability / lethargy / floppiness)
 Reduced peripheral perfusion / prolonged capillary refill / Flash sign
 BP – wide pulse pressure
Age Heart rate Respiratory Rate Systolic BP

< 1 year >180 ; <100 >60 or requiring respiratory < 70 mmHg
support
2 – 5 year >140; <90 >50 or requiring respiratory < 70 + age x 2
support
6 – 12 year >130 >18 or requiring respiratory < 70 + age x 2 up to 10 years
support <90 beyond 10 years
Management within the first hour of admission
1. Give high flow oxygen:
2. Obtain intravenous/ intra-osseous access & take blood tests:

a. Blood cultures
b. Blood glucose - treat low blood glucose
c. Blood gas (+ FBC, lactate & CRP as able for baseline)
3. Give IV or IO antibiotics: - Broad spectrum cover as per local policy
4. Consider fluid resuscitation:

a. Aim to restore normal circulating volume and physiological parameters
b. Titrate 20 ml/kg Isotonic Fluid over 5 - 10 min and repeat if necessary
c. Caution with fluid overload > Examine for crepitations& hepatomegaly
5. Involve senior clinicians / specialists early:
6. Consider inotropic support early:

a. If normal physiological parameters are not restored after ≥ 40 ml/kg fluids
b. N adrenaline or dopamine may be given via peripheral IV or IO access
49
Definitions (adapted from the International Paediatric Sepsis Consensus Conference definitions):
1. Infection - Proven infection by positive culture, microscopy, or PCR test caused by any pathogen OR -
Clinical syndrome associated with a high probability of infection, as evidenced from clinical examination,
imaging, or laboratory tests
2. Sepsis - Infection + Systemic Inflammatory Response Syndrome (tachycardia, tachypnoea, core

temperature >38.5°C or <36°C white cell count elevated or depressed for age.
3. Severe sepsis – Sepsis plus one of the following: cardiovascular dysfunction OR acute respiratory
distress syndrome OR - Two or more other organ dysfunctions (respiratory, renal, neurologic,
hematologic, or hepatic)
4. Septic shock - Severe Sepsis with cardiovascular dysfunction
50
FEBRILE CHILD
Temp >380C is a normal response to infection
Fever >39oC With appearance of a “toxic” child

 The child’s general state of alertness and well being
 With significant limb pain (DF or Influenza A)
 With coryza – Viral fever
 Vital signs, PR and RR (both increase in early sepsis)
 Peripheral perfusion assessment by capillary return
Indications for admission
 Age < 3 months or

 Very Unwell
 Drowsy or lethargic
 Significant vomiting
 Lower chest in drawing & Nasal flaring
 Saturation < 92% in air or
 Extensive consolidation or Pleural effusion
Focus evident on history, examination

 Viral fever (NPA)
 UTI (Urine collection)
 Otitis Media (ear examination)
 Viral exanthemetous fever (petechial rash esp under axilla, neck, groin, inside the mouth)
 DHF (Hess’s test & FBC, Platelet count)
 Pneumonia (respiratory signs & Consider CXR )
 Septicaemia ( FBC, Blood culture, Blood picture, CRP)
 Meningitis (neck stiffness & kernick’s sign) – consider LP
Management
 RBS, SE,
 Decide on admission
 Assess degree of dehydration & fluid intake & urine output during last 24 hrs
 Risk of a pneumococcal bacteraemia

 WBC > 15,000 – 17%
 WBC > 30,000 – 40%
 Admit to Emergency Department / PCU
 Consider empirical antibiotic therapy
 Consider IV dexamethasone
 Consider IV fluids
 Monitor vitals
51
MANAGEMENT OF ACUTE POISON INGESTION IN CHILDREN
 Steps in the management

o Relive anxiety
o ABCD
o Reducing drug absorption
o Enhancing drug elimination
o Detoxification – Antidotes
o Supportive care
 Blue Print
o Triage
o Initial Stabilisation
 Position
 Airway
 Breathing
 Circulation
 Disability
 Measurement
 Monitoring
 Reassess
o Directed History and Examination and Ix –
 Depends on parents or bystander
 somebody at home may be on medications
 Exceptions – teenager patient
 Investigations – Blood & Urine tests (for diagnosis, complications & comorbid
problems)
o Reassess
o Commence Specific Treatment
o Ongoing Care
 Reducing Drug Absorption

 Surface irrigation
 Gastric emptying
 Emesis
 Lavage
 Activated charcoal
 Whole bowel irrigation
Reducing drug absorption

 Emesis – no longer practiced
 Gastric lavage – unproven efficacy, high complications
52
Gastric lavage
 Effective within 2hrs of poisoning
 Airway protection should be ensured
 L/lateral, Head down position
 wide bore OG tube ( >24G)
 position accurately confirmed
 Oral airway to prevent biting
 N Saline10-20 ml/kg (5ml/kg, 3 cycles)
 Continue till effluent is clear
Single dose Activated Charcoal

 Effective within 2hr of poisoning ( Except for substances with delayed gastric emptying)
 Dose 1g/kg – Drinking / via OG/NG
Whole Bowel Irrigation

 Polyethylene glycol
 labour intensive
 Until effluent is clear ( Mean duration 4 hrs)
 Dose 15-30 ml /kg/ hr –via NG tube
 Indications
o Iron, Lithium, ingested button batteries, ingested illicit drug packets Overdose of sustained
release/ enteric coated drugs
Enhancing Drug Removal

 Forced urinary alkalinisation / enuresis
 Saline diuresis
 Multiple dose charcoal
 Dialysis
 Extracorporeal removal of drugs:
 haemodialysis
 charcoal haemoperfusion
Multiple dose activated charcoal

 Enhances elimination of poisons by either interrupting the entero-enteric or entero-hepatic
circulation.
 May reduce absorption of controlled release drugs and oleander seeds.
 Dose 1-2 g/kg – Drinking / via OG/NG
 Dose repeated every 4 hours
53
Detoxification – Antidotes
Drug Antidote Drug Antidote
Beta Blocker Glucagon Heparin Protamine
Benzodiazepines Flumazenil Iron Dexferrioxamine
Calcium chan blockers CaCl2 Isoniazid Pyridoxine
Carbon Monoxide Oxygen MetHb Methylene Blue
Cholinergics Atropine Methanol Ethanol
Chloroquine Diazepam Methotrexate Folinic acid
Clonidine Naloxone Narcotics Naloxone
Cyanide Hydroxycodalamin Organophosphate Atropine , Pralidoxime
Kelocyanor
Digoxine Specific Fabs Paracetamol NAC
Ethylene Glycol Ethanol TCS Alkalinization
Fluoride Calcium gluconate
Hydrofluoric acid Calcium gluconate
Common poisonings in children

• Drugs - Paracetamol, Iron, Mercury,
• Agrochemicals
• Insecticides – OP
• Weedicides
• Rodenticides – rat poisons
• Plants
• House hold chemicals
• Detergents
• Cosmetics
• Hydrocarbons
• Vehicle maintenance chemicals
• Insect repellants
Acute paracetamol poisoning

 Acute large ingestion >200mg/kg
 Repeated supra-therapeutic dose ingestion
Investigations
 PCM level at 4 hrs after ingestion (interpret on the chart)
 LFT
 Clotting profile
Treatment
 NAC,
 Methionine
54
Plant poisoning
 Oleander කනේරු (Arrythmias, Hyperkalaemia)
 Daturaඅත්තන (Anticholinergic)
 Abrusඔළිඳ (Shock, Haemolysis)
 Hondala (Necrotizing enteritis, liver failure)
 Ricinus / Jatropaඑඬරු (GI symptoms, hypoglycaemia)
 Gloriosasuperbaනියඟලා (GI, Blood disorders, cardiac, neuro, hepatic, renal)
 Difenbachiaහබරල (Corrosive effects)
Hydrocarbons
 Volatile / Liquid
 No gastric lavage
 High risk of aspiration aspiration pneumonia
 ?Use of steroids, Antibiotics
Example of a Toxidrome
Cholinergic = DUMBELS • H ypertension
• Diarrhoea • Tachycardia
• Urination • Mydriasis
• Miosis • Fasciculation
• Bronchorrhoea, bradycardia, NICOTINIC
bronchospasm
• E mesis
• L acrimation
• Salivation
MUSCARINIC
Important points
 The most common error in the management of a poisoned patient is inadequate management
of airway, breathing or circulation
 Emesis is no longer part of the in-hospital management of a poisoned patient
 Seek expert advice early in regard to antidote use (National Hospital Poisons Centre)
 Gastric lavage is of unproven efficacy, complication fraught if the patient not intubated
 Activated charcoal is an important decontamination method, but is not always indicated
 Whole bowel irrigation is useful in certain serious overdoses
55
MANAGEMENT OF SNAKE BITES IN CHILDREN
Pre-hospital management (First aid)

• Reassurance
• Wash and clean the area
• Minimum mobilization
• No tourniquet
• Analgesia with – PCM ( No NSAID)
• Remove rings/ anklets
• Past history
• Similar incidences in their locality
• Examination
• Flange marks on the right ankle
• Little oozing of blood
• Investigations
• Whole Blood Clotting Time (WBCT)
• Coagulation profile (PT, INR)
Hospital Management
• Blue print
• Assessment of Envenomation (ASK ABOUT)
• Event
• Previously normal
• Slept on the floor
• Symptoms
• Abdominal pain
• Vomiting
Indications for polyvalent antivenin

• Witnessed bite + first symptom
• Evidence of systemic envenomation
Witnessed bite
• Cobra
• Krait
• Russell’s viper
• Saw scaled viper
56
Early nonspecific features
 Nausea / Vomiting
 Abdominal pain
 Neutrophilia
Local envenomation
 Swelling with redness and pain
 Blistering
 Necrosis
Specific features
 Coagulopathy
 Neuropathy
 Rhabdomyolysis
Antivenom not indicated

 Humped nose viper
 Green pit viper
 Sea snake
Initial Investigations
• Blood tests
• RBS
• Coagulopathy Ix
• Whole Blood Clotting Time (WBCT)
• Coagulation profile (PT, INR)
• FBC- Polymorphoneuclearleucocytosis
• Renal – Urea/Creatinine/Serum Electrolytes
• LFT – SGPT/SGOT
• Urinalysis – negative for blood
• ECG
ANTIVENIN ADMINISTRATION
• Antivenin a total of 10 vials is given as a single dose for all ages. (Russell’s viper requires 20
vials)
• Each vial is reconstituted in 10 ml of Normal Saline.
• In infants and small children this can be given directly with an infusion pump
• In older children the reconstituted antivenin can be further diluted to make total of 400 ml with
normal saline.
• 10 vials initially
• Second 10 vials can be considered after 6hrs depending on the severity of the envenomation.
• Review of diagnosis
• Supportive care
• Expert opinion
• More than 20 vials is not encouraged.
57
Dilution
• One vial in 10 ml of N Saline
• Minimize bubbling by avoiding shaking
• Further dilution depending on age and weight
• First vial to be given over 15 min
• Look for signs of anaphylaxis
• Complete 10 vials in 1 hour
Administration of antivenin who already had allergic reaction

• Call for help
• A–B–C–D–E
• Adrenaline subcutaneously
• Start antivenin
• Have IM adrenaline ready
• Close observation for allergic reactions (Don’t leave the patient)
58
Acute Kidney Injury
Definition
Acute kidney injury (AKI) is the rapid decline in glomerular filtration rate resulting in impairment of
excretion of nitrogenous waste products and loss of water, electrolyte and acid base regulation.
 All critically ill children should be stratiﬁed for risk of AKI according to their susceptibilities and
exposures according to table 1.
 Evaluate patients at increased risk for AKI with repeated measurements of serum creatinine and
urine output to detect AKI (see relevant sections of the guideline).
 Individualize frequency and duration of monitoring based on patient risk and clinical course.
 Evaluate patients with AKI promptly to determine the cause; pre-renal, intrinsic renal or post-renal,
with special attention to reversible causes.
 Evaluate patients 3 months after AKI for resolution, new onset or worsening of pre-existing CKD.
Staging of AKI for severity according to pRIFLE criteria (table 1)
Stage Estimated creatinine clearance (eCCl) Urine output

Risk eCCl decrease by 25% <0.5ml/kg/h for 8 hours
Injury eCCl decrease by 50% <0.5ml/kg/h for 16 hours

Failure eCCl decrease by 75% <0.3ml/kg/h for 24 hours
or or
eCCl <35ml/min/ 1.73 m2 Anuria for 12 hours
Loss Persistent failure > 4 weeks
End Persistent failure for > 3 months
stage
Only one criterion needs to be fulfilled (eCCl or urine output)
*Calculation of eCCl = Ht (cm) x k (ml /min/1.73m2)

Creatinine (µmol/l)
(Consider k = 40 for all ages for the calculation of eCCl approximately )
59
Scenarios in which children can be at high risk of developing AKI
1. Sepsis
2. Hypoperfusion or dehydration
3. Hypoxic events
4. History of exposure to drugs ( ACE/ARB, NSAIDS, aminoglycosides, calcineurin inhibitors)
or toxins that may adversely affect renal functions
5. Underlying renal disease or urinary obstruction
6. Major surgery
7. Cardiac or liver disease
8. Malignancy and / or bone marrow transplant
9. Dependence on others for access to fluids
Important factors to consider in the initial & daily clinical assessment
Evaluation
Important factors to consider during initial and daily assessment of the patient
 Fluid status – Body weight – Required daily or twice daily
Hydration status
Accurate fluid balance – fluid input, urine output, any other fluid loss (eg: drain, GI
losses)
 Blood Pressure
 Evidence of pulmonary oedema – tachycardia, gallop rhythm, basal crepitations
 Neurological Examination - level of consciousness, reflexes, puplis for evidence of uraemia,
papilloedema
 Evidence of infection
Investigations
Basic Investigations – Table 2(*repeat daily or more frequently as determine by the clinical condition)
Urine Blood Radiological & other

Urinalysis – proteins, red cells, Full blood count* & blood Renal ultrasound
casts, epithelial cells picture
Culture & ABST ESR CXR if respiratory or cardiac
signs
Osmolality CRP ECG
Sodium, creatinine Blood culture
Urea Urea & Electrolytes*
Creatinine*
VBG*
Ca, PO4, Alkaline phosphatase
LFT
Group & cross match
Coagulation screen
60
Consider the following investigations on clinical grounds (table 3)
Suspected clinical condition Investigation

Urinary obstruction MCUG, DTPA, IVU
Glomerulonephritis Throat swab, ASOT, C3, C4, immunoglobulin A,
ANA, dsDNA
HUS Stool culture, blood film, direct Coomb’s test,
Lactate dehydrogenase (LDH)
Vasculitis ANCA, anti-GBM, anti- cardiolipin antibodies
Acute on chronic renal failure PTH, X ray left wrist
Rhabdomyolysis Creatinine kinase & urine myoglobulin
Ultra sound scan in the diagnosis of the cause of AKI
Ultra Sound
B/L dilated pelvicalyceal B/L large echobright kidneys B/L small kidneys or
systems or calculi (suggests an acute process) cysts
( suggests CRF)
Urological cause Acute renal parenchymal Acute on Chronic

(PUV,PUJ, severe VUR) disease of any aeitiology renal failure
Urinary Electrolytes and Urea excretion in AKI
 Urine osmolality, electrolytes and urea (done before starting diuretics) can be used to differentiate
fluid responsive pre-renal AKI from acute tubular necrosis (ATN) due to structural damage. (Table 4)
 Calculate the fractional excretion of sodium (Fe Na%) from the formula as below: Fractional
excretion of Urea (Fe urea %) is also similarly calculated.
Table 4
Fe Na% = Urine Na x Plasma creatinine x 100 Pre - enal ATN

Plasma Na Urine creatinine Osmolality mosm/l >400 <350
Urine Na mmol/l <10 >40
Fe Na % <1 >2
*Fe Urea % <35% >35%
*
*may not be reliable in sepsis
61
Prevention of AKI in high risk patient
patientspatientsgroups
 It is possible to prevent development of acute kidney injury in the susceptible child by:
 adequate fluid therapy +/- inotropic support to maintain renal perfusion
 avoiding nephrotoxins.
 Children at risk of kidney injury can be prevented from progressing into renal failure by:
 frequent monitoring of the urine output & creatinine
 early intervention to restore the urine output
 Regular monitoring of creatinine until stable.

 Record fluid balance accurately and review 6-12hourly.
Monitor  Monitior PR, RR, BP frequently: 1-4hrly
 Daily / twice daily weight
 Any signs of sepsis should be urgently investigated and treated.
 Assess circulatory volume status to ensure adequate perfusion

pressure.
 Treat hypoperfusion and hypoxia urgently with protocol based
crystalloid or colloid therapy, inotropic support and oxygen
Maintain adequate therapy (Refer relevant guideline).
renal perfusion  Achieve and maintain hemodynamic and oxygenation
parameters.
 CRFT < 2 s
 Age appropriate systolic blood pressure
 SPO2 > 94%
 Review, adjust dose and monitor medications that may

adversely affect renal functions ( aminoglycosides, ACE/ARB,
NSAIDs, calcineurin inhibitors) -follow instruction in Paediatric
BNF.
 Avoid IV contrast as far as possible.
Minimize further  Avoid using aminoglycosides for the treatment of infections
unless no suitable, less nephrotoxic, therapeutic alternatives
injury to the kidneys
are available.
 In patients with normal kidney function in steady state,
administer aminoglycosides as a single dose daily rather than
multiple-dose daily treatment regimens.
 Use topical or local preparations of aminoglycosides (e.g.,
respiratory aerosols), rather than IV application, when feasible
..and suitable.
62
Management of confirmed AKI
 Recognize and treat the underlying cause.

 Patient should be assessed by a Consultant on an urgent basis.
 Patient management should be discussed with a PaediatrIc Nephrologist on an urgent basis.
 Catheterize the patient if urine output cannot be reliably measured on an hourly basis.
Fluid Management
 Fluid therapy depends on the strict assessment of the volume status.
 Aim is to maintain isovolaemia and prevent fluid overload of >10%,
which is associated with high risk of mortality.
Hypovolaemic patient Volume overloaded patient Euvolaemic patient

 Boluses of normal saline • Give furosemide 2- 5mg/kg IV •Fluid challenge with 10-20ml/kg
10-20ml/kg repeated till bolus over 15 mints or 0.9%saline
euvolaemic. infusion of 0.1- 1mg/kg/hr. •If no improvement in UOP in
 Reassess UOP in 1-2 hrs.  If diuresis is established 1-2 hrs,
 If it improves, give 100% of with furosemide, restrict  restrict intake to
urine output+ insensible fluids to 50-75% of UOP to insensible loss* + previous
loss* + any ongoing losses allow a negative balance till UOP + other losses.
over the next calculated euvolaemic. Thereafter,  consider the need to start
hours. replace 100% of UOP & other RRT on a daily basis.
losses
• If no improve in UOP in 1-
2hrs,
 restrict fluids to insensible
loss* + 50%- 75% of
UOP to create a negative
balance
 stop further furosemide,
 consider RRT.
2
*Insensible loss – 400ml/m /day, UOP- Urine output
63
Monitoring
• Hourly BP, PR, RR

• Body weight - twice daily
• Hourly input , output recording
• Neurological observation with frequency determined by clinical picture
• U&E, creatinine, VBG, Ca, PO4, FBC - up to 6hourly until the onset of recovery
• Calculate % fluid overload daily, using the following equation and adjust the fluid regime accordingly.
% Fluid Overload = Total fluid in (l) – Total fluid out (l) x 100
Body weight on admission (kg)
Minimize further injury
 Review, adjust and monitor medications especially aminoglycosides, ACEs, ARBs, NSAIDs,
calcineurin inhibitors ( Refer Paediatric BNF) .
 Avoid radio contrast
 Treat infection vigorously
Manage electrolyte and acid base disturbances

 Treat any K+ and Na+ disturbances (commonly hyperkalaemia and hyponatraemia) and acid base
disturbance (commonly metabolic acidosis) according to relevant guideline.
 Treatment of hyperkalaemia includes stopping exogenous K intake ( diet, medication).
Management of hypocalcaemia and hyperphosphataemia
 If hypocalcaemia is associated with hyperkalaemia, connect patient to ECG monitor to look for
changes of acute hyperkalaemia ( refer to guideline on hyperkalaemia).
 If, ECG changes of hyperkalemia are present, give 10% Calcium gluconate 0.5 -1ml/kg IV over
10-15 mints with ECG monitoring for arrhythmias.
 Hypocalcaemia will improve if hyperphosphataemia is treated.
 If serum PO4 is high for the age(see below) , restrict dietary phosphates and use a calcium based
phosphate binder provided the serum Ca is low or normal: eg calcium carbonate.
 0 – 6 years > 2.1 mmol/l
 6 -12 years > 1.8 mmol/l
 Above 12 years > 1.4 mmol/l
64
Management of hypertension
 Often due to fluid overload.

 Use diuretics – furosemide , if responsive.
 Vasodilators can also be used- Ca channel blockers ( Nifedipine), α blockers (Prazosine).
 Avoid ACEs/ ARBs as they reduce the glomerular filtration resulting in an increase in creatinine and
worsening of hyperkalemia.
 Follow relevant guideline on hypertension.
 Consider RRT if there is severe hypertension that is refractory to management with
antihypertensives.
Nutrition
 Adequate nutrition will prevent catabolism, control metabolic abnormalities and help recovery.
 Consider nasogastric or parenteral feeding if unable to meet nutritional requirements enterally.
 Caloric requirement
Body wt (kg) Daily caloric requirement (kcal/day)
3-10 100 kcal/kg
10-20 1000 + 50kcal/kg for each kg > 10kg
>20 1500 + 20 kcal/kg for each kg > 20kg
 Protein requirement
Blood urea level (mmol/l) Protein intake
>40 Protein free
30-40 0.5 g/kg/day
20-30 1g/kg/day
<20 2g/kg/day
• Restrict potassium and phosphates depending on blood values

• Replace vitamins and micronutrients
Drug therapy
• Correct drug doses according to GFR by following instructions in Paediatric BNF.

• Revise the drug doses regularly with changes in the GFR.
• Many drugs require either dose reduction or increase in dosing interval.
• Avoid nephrotoxic medications at all times.
65
Acute Renal Replacement Therapy
 After the initial management, an assessment has to be made whether to continue conservative
management or to start renal replacement therapy
 Review this decision on a daily basis.
 An euvolaemic child can be managed conservatively for a few days even in the presence of oliguria
with adequate nutrition and fluid restriction.
 All patients with established renal failure should be discussed with a Paediatric Nephrologist on a
daily basis for further management.
 Available options
 Peritoneal dialysis
 Hemodialysis
 Continuous Renal Replacement Therapy
 Traditional Indications for commencing dialysis

1. Hyperkalaemia > 6.5 mmol/l
2. ECG changes irrespective of K+ value
3. Severe fluid over load with hypertension, pulmonary oedema and cardiac failure
4. Urea > 40 mmol/l (>30 mmol/l in neonate)
5. Severe acidosis pH <7.2 refractory to HCO3 therapy
6. Multi-organ failure
7. Severe hypo/hypernatraemia with oliguria
8. Anticipation of prolonged anuria: eg HUS
9. To create space for nutritional intake, administration of fluids and IV drug infusions and blood
products due to fluid restriction.
 Consider early institution of dialysis in the critically ill child with AKI in order to maintain
homeostasis and create enough volume space to allow nutritional and therapeutic needs as above.
66
Management during recovery phase
 Polyuria may develop in the recovery phase.

 Monitoring – twice daily weight
Hourly input- output
Hourly observations of vital signs
U & E, creatinine, VBG twice daily
 Fluid therapy
 Replace 100% of UOP and insensible loss with normal saline for 24 – 48hrs
 If renal functions continue to improve, a slight fluid restriction is recommended until
polyuria settles.
 In the absence of polyuria with decline in creatinine, can proceed to normal
maintenance fluid.
 Dialysis can be stopped when the urine output is sufficient to allow an adequate nutritional
intake and the creatinine continues to decline.
Follow up
• Children with AKI are at risk of developing CKD subsequently

• Therefore, they should be followed up for development of hypertension, proteinuria and CKD.
Patients with pre-renal ARF are and exception.
• Monitor GFR, BP and urine protein: urine creatinine ratio 3months and 12 months after ARF.
• Annual BP & urine for protein thereafter.
• Refer to a Paediatric nephrologist if any abnormality is detected.
References
1. Kidney Disease: improving Global Outcomes ( KDIGO). Acute Kidney Injury Work group. KDIGO
Clinical Practice Guideline for Acute Kidney Injury. Kidney Int 2012;2:S1-S138.
2. Rees L, Webb NJA, Bockenhauer D,Brogan PA. Acute Kidney Injury. In: Oxford Specialist
Handbooks in Paediatric Nephrology. 2nd ed. Oxford University Press.2012; 377-408.
3. Andreoli SP, Acute kidney injury in children. Pediatr Nephrol 2009;24: 253-263.
4. Yap HK, Liu ID, Ng KH, Resontac LPR. Acute Kidney Injury. In : Pediatric Nephrology On-The-Go.
3rd ed.Yap HK, Liu ID, Ng KH. 2018; 1-16.
67
Hypertension in children and adolescents
Key notes in diagnosing hypertension (HTN)

 All efforts should be made to measure blood pressure (BP) accurately (Refer
last page of this guideline)
 If BP is above the 90th percentile, then take 2 additional readings at the same
visit and average them; this averaged value is used to determine the BP
category. In asymptomatic patients, repeat BP on at least 2 other occasions
before making a diagnosis
 Please refer following links for the updated BP normative charts for age, sex,
and height
1. Children 1 – 18 years –Clinical Practice Guideline for Screening and Management
of High Blood Pressure in Children and Adolescents.-(revised in 2017)
http://www.svhta.net/recursos/PublicacionesPDF/peds.2017-1904.full.pdf
2. Infants 0 - 12 months: Report of the Second Task Force on Blood Pressure Control
in Children—(1987).https://www.ncbi.nlm.nih.gov/pubmed/3797155
3. New borns: Hypertension in infancy: diagnosis, management, and outcome –
(2012) https://www.ncbi.nlm.nih.gov/pubmed/21258818
BP category/Criteria Children age 1-13 years Children age 13-18 years

Average SBP/DBP
Normal <90thpercentile <120/<80 mmHg
th th
Elevated BP >90 – 95 percentile or 120/ <80 -129/<80 mmHg
120/<80 - 129/<80mmHg
(whichever is lower)
Stage 1 HTN >95thpercentile- 130 -139 / 80 -89 mmHg
th
(95 +12mmHg)
or130/80 - 139/89 mm Hg
Stage 2 HTN ≥ (95thpercentile + 12 mm >140/90mmHg
Hg) or≥140/90 mm Hg
68
Acute severe hypertension:
This is a medical emergency and is defined as acute and sudden rise of BP associated with a
failure of auto regulatory functions. BP values are usually well above stage II HTN; however,
acute severe HTN is not strictly deﬁned by numerical values. This is categorized into 2 entities
based on presence or absence of acute target organ damage (TOD)
Acute severe hypertension

Hypertensive emergencies Hypertensive urgencies
Symptomatic: nausea, vomiting, headache, Minor symptoms like nausea, headache and
blurred vision, dyspnoea, seizures blurred vision
Evidence of rapidly progressing acute TOD No acute TOD
like cerebral infarction, cerebral haemorrhage, Common in children
encephalopathy, left heart failure, congenstive
heart failure, acute pulmonary oedema, grade
III-IV retinopathy (exudates, haemorrhage,
papilloedema,), acute renal impairment and
rarely myocardial infarction or aortic
dissection.
69
Evaluation of a child with hypertension
All children with HTN need careful evaluation to exclude a secondary cause.
Screening
Stage 1 & 2 Specific evaluation
History/Examination/BMI Renovascular or Cardiovascular
HTN
Sustained or SE/Creatinine/Urinalysis Abnormal Renal angiogram
episodic Captopril DMSA
Renal U/S ± Doppler Plasma renin level
Glomerular
Normal Urine protein: creatinine ratio
Immune markers
Renal biopsy
Anatomical defects of kidney
Normal ± Obesity
Specific radiological imaging
±Positive family history
Endocrine
Specific hormone assays
Specific evaluation
MIBG/Imaging
Primary hypertension
Monogenic
Uric acid/fasting lipids/glucose
Hormone assays
Genetic mutation analysis
Renovascular hypertension Others
Captopril DMSA
Renal angiogram
Plasma renin level
Refer to a paediatric nephrologist / endocrinologist according to the possible aetiology if there is:
 Secondary hypertension OR
 Uncontrolled HTN despite receiving 2 antihypertensive agents
70
Treatment approaches for a child with hypertension
Goals of Therapy
1. To reduce BP to <90th percentile
2.To consider aggressive BP control (<50th percentile) in some patient groups (e.g. chronic
kidney disease)
Lifestyle advice
 Dietary advice regarding healthy eating (including reducing salt intake)

 All children with HTN need dietary advice
 Regular physical activity (30-60 minutes/day)
 Weight reduction if overweight or obese
 Interventions to improve sleep if sleep apnoea identified
 Advice regarding alcohol, caffeine and drugs
Lifestyle advice should be given to all children with HTN and may be all that is required in
children within the elevated BP range.
Pharmacological Intervention indicated in:
 Symptomatic HTN
 Secondary HTN
 HTN with associated TOD
 Diabetes (types 1 and 2)
 Persistent HTN despite non pharmacologic measures
Selection of an appropriate anti-hypertensive drug depends upon the age of the patient, the
clinical setting and the presence of any contraindications.
71
Acute severe hypertension
Acute and sudden rise of BP usually > 95th percentile + 12 mm Hg or > 140/90mmHg (whichever
is lowest); but not essentially defined by numerical values.
Immediate clinical evaluation
Evidence of acute TOD OR Minor symptoms only

Life threatening symptoms /signs Nausea/ Vomiting/Headache
Hypertensive Emergency Hypertensive Urgency
Admit to PICU/HDU Admit to ward
Continuous
ALWAYS EXCLUDE
monitoring of
BP, pulse, RR INTRACRANIAL LESIONS
pO2
GCS,
ECG
If aetiology unknown
Identify precipitating Factors Arrange blood for
- Non-adherence to drugs  BUN, creatinine, electrolytes,

- Fluid over load (Eg: AGN, ESRD) calcium, phosphorous,
magnesium, and uric acid levels
Identify other Specific causes of
 plasma renin activity, plasma
Hypertension
cortisol, aldosterone,
- Raised ICP
- Coarctation of aorta Urine samples for VMA, and urinalysis.
- Sympathomimetic drugs USS abdomen with doppler studies, 2D
- Severe pain / Stress
Echo
RR= respiratory rate, GCS = Glasgow Coma Scale, AGN = acute glomerular nephritis, ESRD = end stage renal disease,
ICP = intracranial pressure
72
Pharmacotherapy of acute severe hypertension
Hypertensive Emergency Hypertensive Urgency
Goal Goal:
To reduce BP to a satisfactory To normalize BP within 24 hours
level to limit further TOD
Iv Drugs No
- Labetalol / hydralazine Able to tolerate PO
- GTN/ Nicardipine
Bolus doses or infusions Yes
Keep 2 large bore IV canulae
Short acting oral drugs
Eg:
- Short acting Nifedipine
Decrease SBP & DBP or MAP by (it available)
- Prazosin
25% of the desired reduction
- Minoxidil
within 1st 8 hour
- Clonidine
(MAP = 1/3 PP + DBP)
Set a BP threshold for PRN treatment

Gradually normalize the BP over next Eg-: 10mm Hg above 95th percentile in
24-48 hour 2 occasions 15min apart
If worsening symptoms, consider IV drugs
Frequent monitoring of vital signs

If BP reduces too fast decrease the infusion rate of IV drugs.
If BP drops acutely stop the IV infusion and consider rapid IV fluid bolus
MAP = mean arterial pressure, PP= pulse pressure
73
Consider these agents in the following unique situations of
secondary hypertension
Fluid over load: Loop diuretics & / or dialysis
Pheochromocytoma: Phenoxybenzaminne or α-blocker
followed by β-blocker
Drug overdose: Phentolamine and lorazepam
Pregnancy: Labetalol or hydralazine
When BP improves:
Convert to scheduled oral drugs
Consider modification of drug dosages
Correct precipitating factor
Consider expert opinion/ further imaging as per organ involvement
74
Anti-hypertensive medications in hypertensive urgencies or emergencies
Oral drugs
 Oral drugs are useful when patient has stage II HTN especially due to renal aetiologies
with or without mild to moderate symptoms. It also may be used until IV drugs are
prepared.
 Hypotension may occur following administration of oral drugs given here, especially
after the 1st dose and patients need to be monitored closely after use and ambulation
avoided until completely free of orthostatic hypotensive symptoms.
Oral drug Dosage Onset Duration Caveats

Short- acting Oral Initial 0.2– 15- 2-5 Contraindications : CCF,
Nifedipine 0.25mg/kg/dose, Repeat 20mins hours post cardiac arrest, severe
capsules (if SOS in 30min (Total dose LVH, acute CNS injury,
available) ≤0.5mg/kg ; max≤ 10mg) hypovolaemia, high output
Repeat 0.25- 0.5mg/kg q 4 states, concurrent use of
– 8H SOS large doses of β blockers,
Swallow whole or bite and and <1 year of age
swallow the 10mg cap;
If dose <10mg draw the Reports of MI in adults;
contents of capsule into a recommended safe in
1cc syringe and then children
swallow
Minoxidil Oral initial 0.1 -0.2mg/kg ≤30min Long Contraindications :

(Max 5mg) 12 -24 hourly (Max duration Pheochromocytoma
and then can increase over effect of action
few days up to 1mg/kg/day 2-
(Max; if<12yrs 50mg/day 8hours
if >12yrs 100mg/day)
Prazosin Oral test dose 10mcg/kg 30-90 7 -10
(max 0.25mg), min hours
6-12hrly; can increase (Max
gradually to 0.5mg /kg /day effect
(adult 20mg/day) 2-4hrs)
Clonidine Oral initial 0.5 - Need dose adjustment in
1mcg/kg/dose and then renal impairment
increase gradually to 5- Avoid in cerebrovascular
10mcg/kg/day disorders
6-12hrly (max Rebound hypertension after
25mcg/kg/day or rapid withdrawal
1.2mg/day)
75
Parenteral drugs
 Generally start with low doses and increase dosage by 25% every 5 -15mins until desired
BP is reached.
 If BP drops rapidly stop the IV infusion and consider small IV fluid boluses
 It is important to keep supine and monitor closely until a few hours after cessation of
parenteral drugs; BP can reduce drastically and syncope can develop.
Parenteral Dosage Onset Duratio Advantages Caveats

drug n
Glyceryl Continuous IV At 3-5 Rapid onset and Bradycardia
trinitrate infusion once minutes cessation Tachycardia
0.5 – 5 Relieves coronary Headache
mcg/kg/min spasm Methaemoglobinae
(Max 400 Reduces preload mia
mcg/min) and to a lesser Vomiting
(<30kg 3mg/kg extent after-load;
in 50ml 5% Less expensive
dextrose at and freely
0.5 -5ml/hour, available
>30kg 3mg/kg
made up to
100ml in 5%
dextrose at 1-
10ml/hour)
Use special non
PVC tubing
Labetalol IV 0.2 – 0.5 <5 2-4hrs Favorable cardiac Contraindicated in

(5mg/ml mg/kg bolus minute effect acute heart failure;
vial) over 2-3mins,If s Favorable CNS Dose reduction in
Diluents: D, no response (max effect: liver impairment
NS, Ringers increase the dose effect Useful in patients Extreme caution
and repeat every 5-15 with raised with
10-15min x 2; min) intracranial bronchospasm
max 1mg/kg pressure Excessive
(adult 20mg) OR administration may
continuous IV result in prolonged
infusion 0.4-1.0 hypotension and/or
mg/kg/hour bradycardia.
(max 3
mg/kg/hour) Monitor closely
Preferred until several hours
dilution: 1mg/ml after cessation of
76
treatment and keep
In fluid supine (3hrs)
restriction, can Expensive drug
send undiluted comes in
drug 100mg/20ml vial;
(100mg/20ml) should not be the
0.04ml -0.2 first choice in
ml/kg/hour = most patients.
0.4-1.0
mg/kg/hour
(Max
0.6ml/kg/hour =
3 mg/kg/hour)
Hydralazine 0.1-0.2 mg/kg 5 -20 3-8 Useful in cardiac Increase ICP; may
(adult 10 mg) minute hours or other disorders lead to non-
slow IV / IM s when CCB and B homogeneous
over 3-5 blockers are cerebral perfusion,
minutes, repeat contraindicated commonly cause
lower dose after tachycardia, severe
5 -20min and headache and fluid
then every 4-6 retention
hours OR Can induce lupus
continuous
infusion 4-6
mcg/kg/min
(adult 300
mcg/min)
Furosemide IV 1-5 2-5 2 hours Very useful in Hyponatraemia

(use mg/kg/dose 6H minute CCF or acute Hypokalaemia
undiluted (Maximum dose s glomerulonephriti
/minimally 240 mg) OR s with fluid
diluted continuous IV overload
solution in infusion 0.1-1.0
fluid mg/kg/hour
restriction)
Parenteral Dosage Onset Duratio Advantages Caveats

drug n
Nicardipine Continuous IV Within 2-6hrs No deleterious Can Increase ICP
(2.5mg/ml infusion 1-3 minute (TPN) risk of myocardial (avoid in those at
vial) mcg/kg/min; s depression risk of raised ICP)
Max 5 Also Promotes May cause
77
mcg/kg/min natriuresis Tachycardia
(adult 250 Especially useful
mcg/min) after kidney
transplant
 IV labetalol and nicardipine are especially useful after transplantation
 In pheochromocytoma and drug induced hypertension due to excess catecholamine

(cocaine intoxication, monoamine oxidase inhibitor crisis)use alpha adrenergic blocker
and avoid initial B blocker
Key points in measuring the blood pressure
1. Children should be comfortably seated with the right arm supported

2. Infants should be in supine position
3. Cubital fossa should be at heart level
4. The length and the width of the bladder of the cuff should cover 80 -100% and
40% of the mid arm circumference respectively.
5. Wrap the cuff around the midpoint between acromian and the olecranon with
its bottom edge 2-3 cm above the crease of the elbow
6. Stethoscope should be placed over the brachial artery pulse, proximal and
medial to the cubital fossa
7. The cuff should be inflated to only 20–30 mm Hg above the point at which the
radial pulse disappears, and then deflated at a rate of 2–3 mm Hg per second.
8. Onset (K1) and disappearance (K5) of the tapping Korotkoff sounds are taken
as SBP and DBP respectively.
9. If Korotkoff sounds can be heard up to zero, then listen with less pressure.
10. If DBP is still very low, consider the muffling of the sounds (K4) as the DBP.
11. If BP ≥ 90th percentile repeat it 2 times and take the average.
12. BP in the legs, is best measured in the prone position, cuff placed at mid-thigh
and the stethoscope placed over the popliteal artery.
13. The SBP in the legs is usually 10%–20% higher than the brachial artery pressure
Oscillometric devices can be used for screening of BP. However if readings are higher
than the 90th percentile, then 2 additional readings should be taken by auscultation
and averaged before determining the BP category.
78
References:
1. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and
Management of High Blood Pressure in Children and Adolescents. Pediatrics.
2017;140(3):e20171904
2. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on
Blood Pressure Control in Children—1987. National Heart, Lung, and Blood Institute,
Bethesda, Maryland. Pediatrics 1987; 79:1–25.
3. Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management, and
outcome. PediatrNephrol 27(1):17-32.
4. Demetrius Ellis Management of the hypertensive child. Ellis D Avneretal. Pediatric
Nephrology 7th edition
5. Frank Shann. Drug doses 17th edition 2017
6. Hui-Kim Yap etal Pediatric Nephrology on-the-go 3rd edition 2018
7. https://www.drugs.com
8. Nottinham university hospitals, NHS trust Jan 2019 Guidelines in childhood hypertension
79
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Standard Treatment Protols

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Standard Treatment Protols

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Standard Treatment Protocols

Anatomical & Physiological differences in children

Diarrhoea & Dehydration

Guideline for managing children with AKI

5. Disability – Don’t Forget Dextrose

7. Normal paediatric parameters- Weight, HR, BP, RR chart

8. Formulae for calculating a child’s weight and blood pressure

Triage in the waiting area.

Resuscitation Bay (Category 1 & 2)

PCU - Emergency Treatment unit (Green Area) – Category 3 & 4

Short stay Unit (Overflow Bay – Yellow area) – Category 5

Human resources of the PCU

 PCU – Human resources

 General Paediatricians  Endocrinologist

Education & Training of Staff

 Resuscitation Bay Emergency Beds Short Stay unit

Common Equipment Surgical equipment

Crash cart equipment / Retrieval ambulance equipment

Airway & Breathing Tongue depressor Laryngoscope blades & handle-

Additional equipment Defibrillators with pads

Drugs IV fluids Consumables

Age Weight (kg) Heart rate Respiratory rate BP Systolic (mmHg)

Premature 1 145 <40 42 ± 10

Newborn 2-3 125 60 ± 10

1 month 4 120 24-35 80 ± 16

1 year 10 130 20-30 96 ± 30

2-3 years 12-14 120 99 ± 25

4-5 years 16-18 100 99 ± 20

6-8 years 20-26 100 12-25 105 ± 13

10-12 years 32-42 75 112 ± 19

>14 years 50 75 12-18 120 ± 20

Paediatric Physiological Values

Cardiac Enzyme Time Sequence

With a paper speed of25 mm/sec

P wave = 0.08 sec / 2mm high

Why use SBAR?

How can SBAR help me?

Uses and settings of SBAR

 Brief patient history 

A  Your assessment of the patient’s condition

What is your recommendation

INITIAL STABILIZATION Simultaneous assessment and treatment

Position the patient Optimally for the clinical circumstances

Keep patent. This may require a combination of standard airway opening

If in cardiac arrest  Commence CPR, attach cardiac monitor and assess

Sri Lanka College of Paediatricians / 2019 / APLS group 14

3 Moderate Partially Moderate Moderate pain

4 Alert to mild Normal Mild Respiratory Mild Mild Pain

5 Normal Normal Normal Normal No pain

Points in favor of inhaled foreign body

55 55 Severe (7-10) Severe (7-10)

50 50 Moderate (4-6) Moderate (4-6)

< 3 Seconds < 3 Seconds

Increase Frequency of Observations Clinical Review Rapid Response

55 55 Severe (7-10) Severe (7-10)

50 50 Moderate (4-6) Moderate (4-6)

(Check unit policy)

Moderate Mod 35.5 35.5

< 3 Seconds < 3 Seconds

Increase Frequency of Observations Clinical Review Rapid Response

< 3 Seconds < 3 Seconds

Increase Frequency of Observations Clinical Review Rapid Response

< 3 Seconds < 3 Seconds

Increase Frequency of Observations Clinical Review Rapid Response