EMERGENCY PEDIATRIC

Dr. Idham Jaya Ganda, SpA(K)

PICU Subdiv. Child Health Dept
Medical Faculty, University of Hasanuddin
Dr. Wahidin Sudirohusodo Hospital Makassar
DENGUE SHOCK
SYNDROME
ETIOLOGY
 Dengue Virus

PATHOGENESIS
 Unclear
 The Secondary Heterologous Infection
Hypothesis
CLINICAL MANIFESTASION
 Fever: acute, high, continuously, 2-7 days
 Bleeding manifestation

 Liver enlargement

 Shock
 LABORATORIUM
 Thrombocytopenia ( 100.000/mm3 or less)
 Hem concentration ( Hct 20% or more)
 CLASSIFICATION
WHO CLASSIFICATION OF DHF (1975)
 Grade I
Fever, Tourniquet test (+)
 Grade II
Grade I + spontaneous bleeding
 Grade III
Grade II + Circulatory failure
 Grade IV
Profound shock
Grade III & IV  DSS
TREATMENT DBD derajat III & IV

1. Oksigenasi (berikan O2 2-4 l/menit)

2. Penggantian volume plasma (cairan kristaloid isotonis)
Ringer laktat/NaCl 0,9 % / Asering
20 ml/kgBB secepatnya (bolus dalam 30 menit)
Evaluasi 30 menit, apakah syok teratasi ?
Pantau tanda vital tiap 10 menit
Catat balans cairan selama pemberian intravena
Syok teratasi
Kesadaran menurun Syok tidak teratasi
Kesadaran membaik
Nadi teraba kuat Nadi lembut / tidak teraba
Tekanan nadi > 20 mmHg Tekanan nadi < 20 mmHg
Tidak sesak nafas sianosis Distres pernafasan / sianosis
Ekstremitas hangat Kulit dingin dan lembab
Diuresis cukup 1 ml/kgBB/jam Ekstremitas dingin
Periksa kadar gula darah
Cairan dan tetesan disesuaikan Lanjutkan cairan
10 ml/kgBB/jam 20 ml/kgBB/jam
Tambahkan koloid/plasma
Evaluasi ketat
Tanda vital Dekstran/FPP
Tanda perdarahan 10-20 (max 30) ml/kgBB/jam
Diuresis Koreksi asidosis
Hb, Ht, trombosit Evaluasi 1 jam
Stabil dalam 24 jam/Ht < 40
Tetesan 5 ml/kgBB/jam Syok belum teratasi
Syok teratasi
Tetesan 3 ml/kgBB/jam Ht turun Ht tetap tinggi/ naik
Tranfusi darah
Segar 10 ml/kgBB Koloid 20 ml/kgBB
Infus stop tidak melebihi 48 jam diulang sesuai kebutuhan
setelah syok teratasi
MONITORING
 Vital signs
 Hct
SEPTIC SHOCK
 DEFINITION
 Septic syndrome
 Hypotension
 Responsive to treatment
 ETIOLOGY
 Neonates: E. coli, Staphylococcus aureus, Streptococcus
group B.
 Child: Streptococcus pneumonia, H. influenzae group B,
Salmonella, S. aureus, Streptococcus group A.
Patofisiologi terjadinya syok septik
Infeksi Bakteri

Endorfin Produk Bakteri Aktivasi Komplemen

mis. endotoksin

Makrofag
Aktivasi PMN.
Faktor Jaringan Sitokin Pelepasan PAF, produk
Arakidonat dan
Substansi toksik lain
Aktivasi Aktivasi
koagulasi kalikreinkinin
fibrinolisis
Vasodilatasi,
Kebocoran kapiler,
Kerusakan endotel Syok Septik
kerusakan endotel
kapiler

Kegagalan Organ Berganda

CLINICAL MANIFESTATION
 Chilling
 Tachycardia
 Hyperventilation/tachypnea
 Hypotension
 Apatetic
 Agitation
 Bleeding manifestation (petechiae, purpura, etc)
 Neonates with immune disorder: unspecific (lethargy,
vomiting, abdominal pain, hypotermia/hypertermia)
 DIAGNOSIS
 Clinical manifestation
 Risk factor
 Focus of infection
 Laboratory examination (blood smear/culture)
 TREATMENT
 Infection control : ampicillin & aminoglycoside
Blood culture & sensitivity test
 Recovering tissue perfusion : fluid resuscitation,
acid base correction, cardiovascular medicines.
 Respiratory function support : oxygen/ ventilator
 Renal support : diuretic medicines (furosemide)
 Corticosteroid
DIARRHEA WITH
DEHIDRATION
 DEFINITION

Watery stool
Frequency  3X/ 24 hours.
 DEHYDRATION TYPES
 Isotonic
Na concentration 130-150meq/L or 280
mosm/L
 Hypertonic:
Na concentration > 150meq/L or 413
mosm/L
 Hypotonic:
Na concentration <130meq/L or 200mosm/L
DEHYDRATION GRADE

 Cumulative losses (pwl, cwl, nwl)

Mild : 5%
Moderate : 5-10%
Severe : >10%
 Clinical manifestation ( scoring system)
 Angka Penilaian
Pemeriksaan
1 2 3

Gambaran Klinik
Keadaan umum Baik Lesu/haus Gelisah/renjatan
Mata Normal Cekung Sangat cekung
Mulut Normal Kering Sangat kering
Pernapasan 20-30 per menit 30-40 per menit 40-60 per menit
Turgor Baik Kurang Jelek
Nadi Kuat / kurang 120-140 Lebih 140
120 per menit per menit per menit
Derajat dehidrasi skor 6 skor 7-12 skor 13 / lebih
diare tanpa diare dehidrasi diare dehidrasi
dehidrasi ringan/sedang berat
 TREATMENT

 Fluid therapy (Ringer Lactat or Ringer

Asetat)
 Antibiotic therapy
 Acidosis therapy
 Cara Pemberian
Umur Permulaan Lanjutan

Diare 4 jam pertama 20 jam berikut

Infantil 60 ml/kg 190 ml/kg
- PWL 125 ml

- NWL 100 ml

- CWL 25 ml

250 ml
Kolera 1 jam pertama 7 jam berikut
PWL 100 ml/kg 30 ml/kg 70 ml/kg
PWL 100 ml/kg 1 jam pertama 5 jam berikut
Bayi kurang 30 ml/kg 70 ml/kg
12 bulan ½ jam pertama 2 ½ jam berikut
Anak sama atau lebih 12 30 ml/kg 70 ml/kg
bulan
ASTHMATIC STATE
 DEFINITION

A severe asthma exacerbation which is not

responsive to drugs that are usually given for
asthma exacerbation.
ETIOLOGY
Multifactor
 Allergen
 Restlessness
 Emotion
 Infection
 Inherited
 PATHOGENESIS
Hyper responsiveness & inflammation process
of bronchus
 Hyper secretion
 Edema
 Bronchoconstriction
Classification of Severity of Acute Asthma Exacerbations
Mild Moderate Severe Respiratory
Parameters Arrest
Imminent
Breathlessness While While talking While at rest
walking
Talks Sentences Phrases Words

Position Can lie Prefers sitting Sits upright

down
Alertness May be Usually Always Confused/
agitated agitated agitated drowsy
Cyanotic - - + +++
Wheeze Moderate, Loud, Extremely loud, Absence of
often only throughout can be heard wheeze
end expiratory without
expiratory ± inspiratory stethoscope
Breathlessness Minimal Moderate Severe

Use of accessory Usually not Commonly Always

muscles

Retractions Shallow, Moderate, + Deep, + -

intercostals suprasternal flare of
alae nasi
Respiratory rate Increased Increased Increased Decreased

Guide to rates of breathing in awake children:

Age: Normal rate:
< 2 month < 60 / minute
2-12 months < 50 / minute
1-5 years < 40 / minute
6-8 years < 30 / minute
Pulse Normal Tachycardia Tachycardia Bradycardia

Guide to normal pulse rates in children:

Age: Normal rate:
2-12 months < 160 / minute
1-2 years < 120 / minute
3-8 years < 110 / minute
Pulsus None (+) (+) None
Paradoksus < 10 mmHg 10-20 mmHg > 20 mmHg

PEFR or FEV1 (% pedicted ( % best < 40%

-before b.dilator value) value) < 60 %
-after b.dilator > 60% 40-60% respons < 2
> 80% 60-80% jam
SaO2 > 95% 91-95% ≤ 90%

PaO2 Normal > 60 mmHg < 60 mmHg

PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg

CLINICAL MANIFESTATION
 Cough
 Wheezing
 Tachypnea
 Dyspnea
 Prolonged expiration
 Retraction
 Cyanosis
 Tachycardia
 Acute asthma algorithm
Clinic/ER
Asses attack severity

1st management
• nebulitation -agonis 3x, 20 min interval
•3rd nebulitation + anticholinergic

Mild attack Severe attack

(nebulization 1x,
Moderate attack (nebulization 3x,
(nebulization 2-3x, no response)
complete response) partial response) • O2 from the start
• persist 1-2 hr: • give O2 •IV line
discharge • asses: Moderate – •asses: Severe -
• symptom reappear: ODC hospitalized
Moderate attack • IV line • CXR
 One Day Care (ODC) Admission room
Discharge • Oxygen therapy • Oxygen therapy
• give -agonist • Oral steroid • Treat dehydration and
(inhaled/oral) • Nebulized / 2 hour acidosis
• routine drugs • Observe 8-12 hours, • Steroid IV / 6-8 hours
• viral infection: if stable discharge • Nebulized / 1-2 hours
oral steroid • Poor response in 12h, • Initial aminophylline IV,
• Outpatient clinic in  admission then maintenance
24-48 hours • Nebulized 4-6x 
good response per 4-6 h
• If stable in 24 hours 
discharge
• Poor response  ICU

Notes:
• In severe attack, directly use -agonist + anticholinergic
• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times
•Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
Figure. Jet nebulizer

34
Figure. Ultrasonic nebulizer

35
 Drug dosage for nebulizer

Nebulizer
Drugs Jet Ultrasound

NaCl 0.9% (ml) 5 10

2-agonist
• Alupent sol. 2% (gtt) 3–5 3-5
• Berotec 0.1% (gtt) 5 5
• Ventolin nebule (mL) 1 1
• Bricasma respule (mL) 1 1
Time (minutes) 10 - 15 3-5

38
 TREATMENT IN PICU
 Medicines at ward is
continued
 Mechanical ventilator
ACUTE RESPIRATORY
FAILURE
 DEFINITION

Respiratory system is unable to maintain its

function → hypoxia & hypercapnea.
 ETIOLOGY

 Increasing of co2
 Ventilated disorder without lungs dysfunction
 Ventilated disorder with lungs dysfunction
 Ventilated disorder of death space
CLINICAL MANIFESTATION
 Symptoms of lungs disorder :
wheezing, grunting, flaring of alae nasi,
retraction, tachypnea, bradypnea, apnea, cyanosis.
 Signs of heart disorder :
bradycardia/tachycardia,
hypotention/hypertention, cardiac arrest.
 Symptoms of CNS disorder :
apatic, headache, convulsion, coma.
 TREATMENT
 Airway (position, suction, ET)
 Breathing (oxygen)
 Humidification
 Bronchial washing
 Physiotherapy
 Rehydration
 Causal therapy
 Specific therapy (mechanical ventilator)
 Acidosis therapy
EPILEPTIC STATUS
 DEFINITION

 Prolonged convulsion attack

(30 minutes or more)
 Recurrent convulsion in a short time as if no
recovery
 ETIOLOGY
 Febrile convulsion
 Idiopathic
 Symptomatic
PATHOFISIOLOGY
 Compensation
 Decompensation
 CLINICAL MANIFESTATION
Age Type of epileptic state Features

Neo- Neonatal epileptic state - subtle, tonic, clonic,

nates myoclonic, apneic,
fragmentary
Neonatal syndromes epileptic
 early infantile epileptic - tonic
encephalopathy - erratic, myoclonic
 neonatal myoclonic - clonic
encephalopathy
 benign familial neonatal seizures
Infant & Febrile epileptic state - convulsive or hemiconvulsive
Child (tonic-clonic)
Infantile spasms (west syndromes) - salaam attacks
State in childhood myoclonic - myoclonic + absence
syndromes - complex partial seizures
State in benign partial epilepsy
Child & Adult Tonic-clonic epileptic state - tonic-clonic, subtle
Absence epileptic state - absence
Continue partially epileptic - simple partial
Myoclonic epileptic state in coma - myoclonic
Myoclonic epileptic state syndromes - myoclonic
Complex partial epileptic state - complex partial
Epileptic state in mental retardation - atypical absence, tonic, minor
motor
 TREATMENT
 Initial treatment (stabilization)
 Position
 ABC
 Vital signs monitoring
 Blood glucose & electrolyte
 Anticonvulsan
 Benzodiazepine ( diazepam, midazolam)
 Phenytoin
 Phenobarbital
 Cardiorespiratory & EEG monitoring
 Refracted treatment
 Barbiturate (Phenobarbital, thiopental)
 Propofol & midazolam
INTUSSUSCEPTION
 DEFINITION

A condition where a section of intestine

telescope into its self (proximal segment
telescope into distal segment of intestine).
PATHOFISIOLOGY
Intussusceptions
CLINICAL MANIFESTATION

 Colic
 Vomiting
 Bloody stool , currant jelly stool & terry stool
 Sausage-shaped mass
 Pseudoportio
 DIAGNOSIS
 Clinical manifestation
 Radiology assessment:
 Doughnut sign

 Target sign

 Cupping sign
TREATMENT
 Radiology reduction
 Surgery
DIAPHRAGMATIC
HERNIA
 DEFINITION

An abnormal opening in the diaphragm that

allow part of abdominal organs to migrate into
the chest cavity.
 ETIOLOGY

 Improper fusion of the canal of

pleuroperitoneal
 Medicines
 Abnormal development of thoracic mysencime
CLINICAL MANIFESTATION
 Dyspnea
 Tachypnea
 Cyanosis
 Asymmetry of the chest wall
 Tachycardia
 Scapoid abdomen
 Breath sound loosing at defect side
 DIAGNOSIS

 Clinical manifestation
 Radiology examination
 TREATMENT

 Oxygen (ET), position, stop oral intake

 Surgery