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Emergencies in pediatrics

Department of pediatrics

Emergencies in children

Hyperthermic syndrome Convulsive syndrome Neurotoxicosis Anaphylactic shock

Febrile syndrome\generalities

The central temperature of human beings is, as in another animals with warm blood, a constant, which is naming homeothermia, in contrast with that of animals with cold blood (fish, reptiles, etc.) which is variable.

Febrile syndrome\generalities

Homeothermia rezults from equilibrium between warmth producing, or thermogenesis (alimentation, physical exercise .), and the means to combat it, or thermolysis (more or less abundant sweating, hydric intake - water). There are, however, variations of central temperature during one day by 0,6C, the lowest temperature being recorded in morning and the highest in evening.

Febrile syndrome\generalities

It is important to know that, in normal conditions, the children seems to have a temperature slightly more that the normal temperature of adults, and can, sometimes, to achieve 38 C, and even 38,5C in evening.

The thermic metabolism in newborn babies


Insufficient thermoproduction. Incapacity to increase the thermic losses in case of hyperthermia and the thermoproduction in the case of overcooling. Incapacity to present a febrile typical reaction (caused by insufficient sensibility of hypothalamic neurons to the pyrogene leucocytary substances and big concentration of arginin-vasopressin which decreases the body temperature). Only at 2-3 years in children the circadian rhythm of corporal temperature is establishing.

The forms and basic mechanisms of body t0 increasing

We speek about fever when the body temperature is more than 38C. A febrile sensation can arise when the temperature exceeds the medium normal value of 37C. Febrile state appears when the function of thermoregulation centers from hypothalamus is not desturbed, but under the action of pyrogene substances (exogenous lipopolysacharides, or endogenous macrophages, granulocytes, neutrophils, eosinophils, in result of phagocytosis the genetically determined point of body t (set point) is changing . The febrile states have a positive biologic character of organism protection.

The forms and basic mechanisms of body t0 increasing

Hyperthermic reaction (t0 higher than 38,0 38,50 C), which appears on the background of disorder and decompensation of thermoregulation mechanisms functions (intensifying with the decompensation of metabolism, pathologic disorders of thermoregulation centers. Hyperthermic reactions are often met in pediatric practice, especially in neuroinfections, different viroses etc. and have not biologic sense for organism. They have only pathologic character.

The forms and basic mechanisms of body t0 increasing

Hyperthermia corresponds to the increasing of body central temperature provoked by the thermogenesis increasing, for example, during intensive muscular exercise and/or the diminishing of thermolysis, having relationship with exterior too high temperature, diminishing of sweating and/or insufficient hydric intake (overheating, dehydration, etc).

The forms and basic mechanisms of body t0 increasing

Due to hyperthermia all forms of metabolism are decompensating, the endogenous intoxication of organism increases (cascad of intermediary metabolits), the vital centers respiratory and cardiovascular are disturbing, the convulsions appear, the cerebral edema is developing. The hyperthermic reactions are not interrupted with antipyretics, but the physical methods are useful: the rubbings of body with humid gauze and ensuring of local hypothermia in the region of head and magistral vessels (towels, humid swaddling clothes etc).

Etiology of fever
Infectious causes Viral infections Bacterial infections Infections with atypical germs: Mycoplasma. Chlamidia Parasitoses Mycoses et al.

Etiology of fever

Noninfectious Immunopathologic processes (collagenoses, systemic vasculites, allergies) Tumors (lymphogranulomatosis, lymphomas, neuroblastomas) Intracranial traumas Hemorrhages Endocrine diseases Vaccination Malignant hyperthermia etc.

Levels of fever
Subfebrile (until 380C) 0 0 Moderated fever (38,1 C 39,0 C) High fever (39,00C - >) Hyperpyrexia (more than 410C)

Continuous fever oscillation in 24 hrs no more than10C (abdominal typhus) Remittent fever - oscillation in 24 hrs more than 10C (viral and bacterial infections) Irregularly or atypical fever oscillations are irregular most spread form of fever in different pathologies Hectic fever correlation between remittent and irregular fever with oscillations more than 2-3 0C Intermittent fever short periods of high temperature which correlates with periods of physiologic temperature (tuberculosis, purulent infections) Recurrent feverthe alternation of febrile crises during 2-7 days with periods of apyrexia

Curves of fever

Clinical manifestations
Cardiovascular system: increase of pulse with 8-10 beats at increasing of fever with1 degree. In the cases of long term febrile states manifested with high values the collapse, cardiac failure, DIC syndrome are determining. Nervous system: fatigue, headache, delirium, insomnia or somnolence.

Clinical manifestations

Respiratory system in the first phase of fever the frequency of respiration decreases, then increases with 4 respiratory movements at each degree of fever. In the same time, the volume of respiration doesnt increase, but even is decreasing being the determinant of hypoxia appearance as a pathogenetic mechanism of affection in fever. Digestive system is characterizing through the decreasing of . motory and fermentative activity, decreasing of gastric juice activity, decreasing of appetite.

Management of the child with fever

The diagnosis is performing on the base of thermometry, clinical manifestations of basic disease and paraclinical routine examinations The treatment includes following measures:
Diet Physical methods of cooling Using of antipyretics

Curative management of febrile child

Antipyretics: are administering at T 38 0C

1.Paracetamol: per os-dose 10-15 mg/kg each 6 no more than 60 mg/kg/day) per rectum: unique dose- 15-20 mg/kg Ibuprofen - 10-15 mg/kg each 6-8 hours If after 30-45 min. T doesnt decrease - the i/m administering of 50% sol. of analgin (metamizol) 0,1 ml/year of life and 2,5% sol. of pipolfen till 1 yr - 0,01ml/kg, more than 1 yr - 0,1-0,15 ml/yr of life. Dose is repeated if over30-60 min. not effect. In the presence of threatening signs and/or rigidity of occipital muscles we administer the first dose of adequate antibacterial preparation and urgent HOSPITALIZATION .

Curative management of febrile child


In whitehyperthermia together with antipyretics the vasodilators are administering: papaverin or no-spa 1mg/kg per os or i/m. solution. 2% papaverin - till 1 yr of life-0,1-0,2 ml, more than 1 yr -0,1-0,2 ml/yr of life OR: S. No-spa 0,1 ml/ yr of life OR 0,25% dibazol 0,1-0,2 ml/kg. In hyperthermic syndr. T is measuring each 30-60 min. After decreasing of T until 37,5 0C the hypothermic curative measures are cancelling. Anaigin is adminstering in unique doses and no more than 3 days(.anaphylactic shock, agranulocytosis). Acetylsalicylic acid is not administering until 15 years (Ree syndrome).

CONVULSIVE SYNDROME

Peculiarities of nervous system in little age children

Immaturity of cellular elements and of nervous fibers, which determines a diffuse affection of the brain. Increased sensibility to noxious factors and decreased threshold of excitability, which can provoke convulsive status. Increased hydrophilia of nervous tissue which contributes to rapide development of cerebral edema. Intolerance of CNS to the immune system, which conditions the appearance of anticerebral antibodies in the case of hematoencephalic barrier affection. Plasticity and great compensatory possibilities of the brain.

Definition

Convulsions are paroxystic or rhythmic and saccadated muscular contractions, joined in tonic, clonic or tonico-clonic crises.

Convulsions can be by epileptic and nonepileptic (occasional) origin. The last are released by intercurrent events (fever, metabolic disorders, neuroinfections etc.).

Febrile convulsions
They represent a critical disorders which appear in children between 6 months and 5 yrs, in association with fever, but without signs of . Intracranian infection and without afebrile crises in antecedents. Majority of crises, until 90%, appear before 3 yrs age, with the pick of incidence at 15 months.

Causes of febrile convulsions


Infections of nervous system. Fever can act as the trigger factor of convulsions. Febrile convulsions, as expression of some genetic predisposition relationed with age.

Febrile convulsions
Most frequently, the crises of febrile convulsions follow the virotic infections of respiratory tract, severe gastroenteritis caused by Shigella or other infections which provoke minimal fever by 37,80 38,5 0C. Crises appear usually with the first access of fever or are the first symptom of fever manifestation in 25 42% of cases.

International classification of epilepsies, epileptic syndromes and critical disorders


Localized crises (focal, partial): I.1. Idiopathic (primary) I.2. Symptomatic (secondary) I.3. Cryptogenic Generalized crises: II.1. Idiopathic II.2. Symptomatic II.3. Cryptogenic or symptomatic Undetermined syndromes(with focal character or generalized undetermined): neonatal crises, myoclonic severe epilepsy of child, acquired epileptic aphasia, epilepsy with peak-wave continuous complexes during sleeping.

Clinical manifestations

Tonic crises sudden disturbance of consciousness, axial musculature hypertonia with members in extension, apnea, perioronasal cyanosis, contracture of masseters, revulsioned eyes; Tonico-clonic crises are characterized by tonic phase during 10-12 seconds, followed by clonic phase with muscular symmetric and bilateral clonuses, with short relaxations during until 2 minutes, the tongue wounding, sanguinolent foam, loss of urine and faeces can appear; resolutive phase is characterizing by postcritic coma with deep, noisy respirations, bilateral midriasis; Atonic crises sudden losses of muscular tonus during one or a few seconds, sudden falling of head on the chest.

Clinical manifestations

Loss of consciousness authenticated by ocular revulsion. Neuro-vegetative disorders respiratory, irregularities of rhythm, cyanosis; vasomotory (accesses of pallor).

Febrile convulsions
They appear in a child with neurologic negative anamnesis, in age from 6 months until 5 yrs, on background of fever, are primarily generalized, duration until 15 minutes, are not repeating during the same access of fever or in afebrility. The relatings about febrile convulsions in heredo-collateral antecedents are possible.

Duration more than 15 minutes, age over 10 months, can generate the state of convulsive status, are repeating in series in the same day, often are focal, with lateralization, can remain motory postcritical deficits Todd paralysis. They will develop epilepsy in 2-3% of cases.

Complicated febrile convulsions

Diagnosis
It needs to exclude some infectious diseases with localization at CNS level. This imposes a decision about the performing of some paraclinic investigations, lombar puncture, neuroimagistics, EEG.

Differential diagnosis
Epileptic origin of crises will be maintained on the basis of some crises with stereotype character recurrence, without evidence of some trigger factors, with typical changes on E.E.G. It is performing with the following diseases: primary infections of CNS; acute encephalopathy; syncope; febrile delirium;

TREATMENT of febrile convulsions in children

General principles: Selection of optimal preparation in dependence of convulsions type. Selection of optimal dose usually minimal, which allows the complete control of crises. Respecting of anticonvulsivant monotherapy (as exception 2-3 preparations in the treatment resistant convulsions after exhaustion of monotherapy), because the polytherapy can lead to chronic intoxication, undesirable interaction of preparations with therapeutic effect diminishing.

TREATMENT of febrile convulsions in children

Medicamentous treatment is administering daily at the same hour for obtain a continuous therapeutic concentration. Optimal duration of treatment from 1 until 3 months). Interruption of treatment is performing gradually with the clinical and electroencephalographic monitoring. Avoidance of factors, which releases the convulsive crises and respecting of optimal life regime (infections, traumas, intoxications, alcohol, caffee, concentrated tea, chocolate, regime of sleeping - wakefulness).

TREATMENT of febrile convulsions in children

Treatment of febrile convulsions will be performing with usual anticonvulsivants and in specific dosage, ca celor recomendate in tratamentul statusului epileptic. The means of body temperature decreasing and the treatment of infection responsible to fever.

TREATMENT of febrile convulsions in children

Recommanded medication is the phenobarbital or valproat, the self anticonvulsivants efficient in febrile convulsions. Prophylactic intermittent therapy has however a general acception. There are a lot of recommended protocols. But most often the medication is performed with Diazepam per os 0,3 mg/kg, Diazepam per rectum 0,5 mg/kg.

TREATMENT OF CONVULSIVE STATUS [after Paul Moe, Alan Seay, 1991]

Primordial measures: ABC [A air; B respiration (breath); C - circulation]:


releasing of respiratiy pathways the supply of respiration with oxygen Maintaining of pulse, AP through optimal perfusion of liquids 20-30 ml/kg.

Initial solution - glucose 20% i/v, 1 ml/kg. Monitoring of sanguine gases level, of electrolytes, urea and of anticonvulsivants level in the blood and of intracranial tension.

TREATMENT OF CONVULSIVE STATUS [after Paul Moe, Alan Seay, 1991]

Intravenous anticonvulsivant treatment: diazepam 0,1-0,3-0,5 mg/kg (20mg) can be repeated after 5-20 min, its maximal action is after 20 min: can provoke respiratory depression; lorazepam 0,05-0,2 mg/kg (has more prolonged that diazepam action); phenitoin (diphenin) 10-20 mg/kg; phenobarbital 10-20 mg/kg. Correction of metabolic disorders (acidosis, etc.).

TREATMENT OF CONVULSIVE STATUS [after Paul Moe, Alan Seay, 1991]

If the convulsions are repeated again, it is introducing: phenitoin 5 mg/kg and phenobarbital 5 mg/kg; their concentration in blood is monitoring, the respiration and blood pressure are maintaining in the normal limits; i/v paraldehid 4% or per rectrum 0,1-0,3 ml/kg (1:1 with the olives oil) valproic acid in suspension 30-60 mg/kg per os or per rectum. After convulsive status resolving the phenitoin and phenobarbital (5-10 mg/kg) and calcium preparations will be administered.

Prognosis

In febrile convulsions it is favorable. In 70% of cases only oneself convulsivant epizod will be exist and in 9 % of cases over 3 episods will be exist. Higher risk of recurrence of FC is more in children before 1 year. After 4 yrs the risk of recurrence constitutes10 %. The risk of epilepsy development is by 4 times more in children with febrile convulsions.

Hypocalciemic convulsions
Hypocalciemic convulsions (tetanic convulsions, spasmophilia) provoked by low concentration of Ca. More frequent - in the age of 6 months-1,5 yrs. Clinical picture: 1. Local convulsions: Convulsions of mimic musculature Hand of obstetrician Plant and fingers in position of flexion Laryngospasm (noisy inspiration, screaming of cock) 2. Generalized convulsions with loss of consciousness until a few minutes. Convulsions can be repeated in the type of epileptic status and are finishing at the normalizing of ions level.

Emergency treatment

In soft convulsions is administering Sol. 10% of calcium chloride or calcium gluconate 0,1-0,15 g/kg/day In severe accesses - Sol.10% of calcium gluconate 0,2 ml/kg i/v slow after dissolving in Sol. 5% of glucose 2 times. If the convulsions are continuing - Sol. 25% of magnesium sulphate o,2 ml/kg/ i/m and Sol. 0,5% seduxen 0,05-0,1 ml/kg i/m/ HOSPITALIZATION after the treatment of convulsions in the somatic department, the child continues to receive the Ca preparations 1 month and vitamin D3.

Respiratory-affective convulsions
They present accesses of convulsive apnoe which appear in the crying of children. Trigger factors: frightening, pain, joy, abusive alimentation In the time of crying the child retains respiration, the cyanosis of teguments and buccal cavity mucosae is developing. Due to hypoxia the child can loose the consciousness at short time period, tonic or clonico-tonic convulsions can appear. EMERGENCY CARE: To create an average of calming. To apply the measures for reflectory restoring of respiration. Consultation of neurologist and sedative treatment.

Neurotoxicosis - Etiology
Infectious factors(viral, bacterial, mixt), intestinal infections Premorbid pathologic factors: - perinatal pathology of central nervous system - age peculiarities of CNS - craniocerebral intranatal trauma - intrauterine asphyxia - prematurity - retardation in the intrauterine development - anemia, rickets - congenital malformations - states of immunodeficiency or immunocompression

Clinical syndromes in neurotoxicosis


cerebral syndromes: - hyperthermia - convulsions - hypertensive-hydrocephalic - meningeal - by neuro-hormonal insufficiency somatic syndromes - respiratoriy insufficiency - cardiovascular insufficiency - hepatic insufficiency - renal insufficiency - suprarenal insufficiency - hematopoetic insufficiency

Clinical manifestations
I degree State of consciousness psychomotory excitation Sleeping superficial with interruption Convulsions preconvulsive/clonic state Pupils of the eye moderated narrowing Cranial nerves without pathology Hyperkinesis tremor of extremities Bulbar disorders absent Muscular tonus increased Big fontanelle soft tensioned Meningeal signs occipital stiffness Vegetative disorders hyperemia, after that pallor

Clinical manifestations
II degree State of consciousness Sleeping Convulsions Pupils of the eyes Cranial nerves Hyperkinesis Bulbar disorders Muscular tonus Big fontanelle Meningeal signs Vegetative disorders

inhibition until sopor pronounced somnolence repeated tonicoclonic miosis, < fotoreaction rarely - III and VII pair disorders of coordination seldom after convulsions diminished diminished moderately pronounced hyperhydrosis, acrocyanosis or cyanosis

Clinical manifestations
III degree State of consciousness Sleeping Convulsions Pupils of the eyes Cranial nerves Hyperkinesis Bulbar disorders Muscular tonus Big fontanelle Meningeal signs Vegetative disorders

sopor-coma sopor-coma tonico-clonic/status miosis or midriasis III,IV,VI,VII,IX not characteristic characteristic pronounced diminishing hypotone, no pulsation pronounced or disappear hyperthermia/hypothermia

sallow grey cyanosis

Pathogenetic treatment

ALL children with neurotoxicosis are hospitalized Prehospital treatment: antipyretic therapy anticonvulsivant therapy antibioticotherapy corticotherapy in II-III degree - diuretics

Anaphylactic shock
Pathogenetic mechanism is represented by marked vasodilatation, decreased venous return and depletion of intravascular volume through the loss at capillary level, at which a moderate depression of myocardial function can be associated. More frequent causes: - antibiotics, especially from betalactamides group (penicilline on first place) - insect bites, serum, vaccines, gammaglobulins i/v, blood transfusion, excess of antigen during specific hyposensibilization for asthma and pollinosis Allergic food, excess of pneumoallergens

Anaphylactic shock/clinical picture

- onset is often very rapid, with respiratory signs:

sneezing, cough, running nose, dyspnea, wheezing, cyanosis, sometimes signs of severe obstruction of superior respiratory pathways(inspiratory stridor, laringean edema). Even pulmonary edema can appear. - cardiovascular signs: pericordial pains, palpitations, feeling of weakness, cardiac arrhythmias, marked hypotension, syncope - digestive signs: nausea, vomiting, abdominal pains, diarrhea - cutaneous signs: pallor,urticarian erruptions, angioneurotic edema.

Primary measures Medicament of choice-Sol. 0,1% adrenalin (vasoconstrictor effects,beta 1 inotrop positive and bronchodilator effects) i/m or i/v o,1 ml/yr (no more than 1,0 ml) of life dissolved in 5 ml isotonic sol. Block of further allergen absorption: proximal cuff(on 30min.) and local infiltration with adrenalin Prednisolon 5 mg/kg Antihistaminics: Sol. 1% dimedrol 0,05ml/kg(no more than 0,5 ml in a child until 1 yr of life and1,0 ml in older 1 yr). Pipolphen is not administering (marked hypotensive effect) Obligatory contriol of Ps and AP

Anaphylactic shock/treatment

Anaphylactic shock/treatment

After primary measures: - i/v S. 0,1% adrenalin o,1 ml/yr of life in10 ml of isotonic sol. - prednisolon 2-4 mg/kg, or hydrocortison 4-8 mg/kg, or 0,4% dexamethason 0,3-0,6 mg/kg - volemic loading 20-30 ml/kg isotonic or Ringer sol. During 20-30 min. Then, if the hemodynamics is not restored - Reopolygliucin or polyglucin 10 ml/kg. - If BP remains low- each 10-15 min. the Sol. 0,1% adrenalin 0,05-o,1 ml/yr of life (no more than 5 mg) or Sol. 1% mesaton o,1 ml/yr of life (no more than 1,0 ml) - In the absence of effect - Dopamin 8-10 mkg/kg/min under control of Ps and AP

Anaphylactic shock/treatment
In bronchospasm: oxygenotherapy Ensuring of respiratory pathways permeability (at necessity even tracheostomy or tracheal intubation), ventilation Sol. 2,4% euphyllini 0,5-1,0 ml/yr of life (no more than 10 ml) i/v in get with 20 ml of isotonic sol. At necessity - cardio-pulmonary reanimation After according of emergency care HOSPITALIZATION in emergency department.

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