Emergency care in children

Pavlyshyn Halyna Andriyivna

Ternopil state medical university

Learning Objectives

1. Essentials of pediatric intensive care of seizures

2. Essentials of pediatric intensive care respiratory disease

3. Essentials of pediatric intensive care of anaphylaxis

Definition of Child Care

Children requiring emergency care have unique and special needs.

This is especially so for those with serious and life-threatening emergencies.

It is an illness or injury that may threaten a child’s life

Learning Objectives

Essentials of pediatric

intensive care of seizures

Convulsions or seizures

are when a person's body shakes rapidly and uncontrollably.

During convulsions, the person's

muscles contract and relax

repeatedly.

• are the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain.

Seizure ClassificationsGeneralized Partial

Complex Simple

Involves BOTH hemispheres of the brain

May have aura No impaired consciousness

Always involves loss of consciousness

Involves motor* or autonomic# symptoms with altered level of consciousness

Can involve motor,* autonomic# or somatosensory+ symptoms

Types: Tonic or clonic movements or combination (grand mal) Absence (petit mal) Myoclonic Atonic (e.g., drop attacks) Infantile spasms

May generalize May generalize

Types of symptoms:1) Motor* - head/eye deviation, jerking, stiffening2) Autonomic# - pupils dilatation, drooling, pallor, change in heart rate or respiratory rate3) Somatosensory+ - smells, alteration of perception

A Seizure Is:

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Simple Febrile Seizure (SFS) Unprovoked Seizures (UnS) Status Epilepticus (SE)

Seizure activity cannot be interrupted with verbal or physical stimulation

Seizure activity cannot be interrupted with verbal or physical stimulation

Febrile Seizure are the most common seizure

disorder in childhood, affecting 2 - 5% of children between

the ages of 6 months and 5 years

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Febrile Seizure is a seizure accompanied by a fever

Caused by the increase in the body temperature greater than 100.4F or 38C

Threshold of temperature which may trigger seizures is unique to each individual

Can occur within the first 24 hours of an illness Can be the first sign of illness in 25 - 50% of

patients 9

Febrile Seizures Are benign condition

Repetitive non-purposeful movements Staring Lip-smacking Falling down without cause Stiffening of any or all extremities Rhythmic shaking of any or all extremities May be either simple or complex type seizure

Seizure accompanied by fever (before, during or after) WITHOUT ANY

Central nervous system infection Metabolic disturbance

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Febrile Seizure: ED Assessment

Baseline assessment

Vital signs (including temperature) Assess A, B, C, D’s Begin passive cooling measures Remove clothing/coverings

Damp towels Consider giving antipyretic if not previously administered

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Oxygen, oral airway. Suction.

Avoid hypoxia!

Consider bag-valve mask ventilation. Consider intubation

IV/IO access. Treat hypotension, but NOT hypertension

Disability

AA

BB

CC

Assess A, B, C, D’s airway, breathing, circulation,

neurological status = Disability

DD

First Unprovoked Seizure:

Partial seizure Generalized onset, tonic-clonic seizure Tonic seizure

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Remember: this is a seizure that occurs without an immediate precipitating event

(fever, trauma or infection).

Remember: this is a seizure that occurs without an immediate precipitating event

(fever, trauma or infection).

First Unprovoked Seizure: Diagnostic Testing

Laboratory tests are based on individual clinical circumstances and may include: CBC with differential Blood glucose Electrolytes Calcium, magnesium, phosphorous Urine drug/toxicology screen EEG MRI, CT Scan

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Lumbar puncture is only indicated if there are other symptoms that suggest

a diagnosis of meningitis.

Lumbar puncture is only indicated if there are other symptoms that suggest

a diagnosis of meningitis.

Status Epilepticus

Seizures that persist without interruption for more than 5 minutes

Two or more sequential seizures without full recovery of consciousness between seizures

This is a life threatening emergency that requires immediate treatment.

This is a life threatening emergency that requires immediate treatment.

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Family education should include instruction to protect the child during the

Seizure

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Instruct parent/caregivers to prevent injury during a seizure :

Position child while seizing in a side-lying position

Protect head from injury Loosen tight clothing about the neck Prevent injury from falls Reassure child during event Do not place anything

in the child’s mouth

1. Protect from potentiallyharmful objects.2. Cushion head.

3. Turn on side and keepairway clear4. Observe & time events

5. NOTHING in the mouth6. Don’t grab, don’t hold down 7. Speak softly & calmly8. Protect from hazards

First Aid: Seizure

Anticonvulsants

Rapid acting

Plus Long acting

Anticonvulsants - Rapid acting Benzodiazepines

Lorazepam 0.1 mg/kg i.v. over 1-2 min Diazepam 0.2 mg/kg i.v. over 1-2 min

In children, rectal diazepam gel - Diastat – the only FDA approved product for non-medical

professional administration

Anticonvulsants - Long acting

Phenytoin 20 mg/kg i.v. over 20 min

Onset 10-30 min May cause hypotension, dysrhythmia

Phenobarbital 20 mg/kg i.v. over 10 - 15 min Onset 15-30 min May cause hypotension, respiratory depression

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Learning Objectives

Essentials of pediatric intensive care respiratory disease

Learning Objectives

Respiratory illnesses that occur in children and necessitate intensive care can be divided intoupper and lower respiratory obstruction.

Upper airway obstructionAcute causes (infective) of

upper airway obstruction

Croup Epiglottitis Bacterial tracheitis Foreign bodyDiphtheria Acute tonsillitis Infectious mononucleosis Retropharyngeal abscess Trauma

Upper airway obstruction‘Congenital’ (non-acute) causes of

upper airway obstruction Choanal atresia or stenosis Laryngomalacia Laryngeal webs, stenosis, cleft, cyst Tracheomalacia Vascular ring Bronchomalacia Sub-glottic stenosis Laryngeal papillomata Intra-thoracic tumours

• Larynx is located on level the 3-4th (neck) vertebrae; •Vocal and mucous membranes are rich blood vessels and lymphatic tissue, prone to inflammation, swelling, due to babies suffering from laryngitis (viral croup), airway obstruction, inspiratory dyspnea;

Upper respiratory tract in children

•The larynx of a child is funnel-shaped, cartilage soft;

Upper respiratory tract in children

• The most narrow point is a mucous membrane on level the cartilage larynx until the age of 8-10 years

Normal Laryngomalacia

Upper respiratory tract in children

Croup

Croup

is the most common acute upper airway obstruction

is seen predominately in children between

6 months and 3 years of age Etiology - the primary etiologic agents are parainfluenza influenza viruses,respiratory syncytial virusadenovirus

CroupLaryngitis,

laryngotracheitis

Inflammation involving the vocal

cords and structures inferior to the cords;Is manifested by "barking" cough, inspiratory stridor (a high-pitched

sound produced by an obstruction of the trachea or larynx that can be heard during inspiration and/or expiration),

some degree of respiratory distress.

Croup Syndromes

Signs and Symptoms

“Barky” cough, Inspiratory stridor Hoarseness Nasal drainage, coryza (catarrh). Low-grade fever Intercostal, suprasternal, infrasternal

retractions. RR - slightly increased A frontal X-ray of the neck shows a

characteristic narrowing of the trachea, called the STEEPLE sign

The steeple sign on X-ray of a child with croup

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Symptoms are characteristically worse at night.

Agitation and crying greatly aggravate the symptoms and signs.

The child may prefer to sit up in bed or be held upright.

Hoarse voice, coryza, a slightly increased respiratory rate.

Hypoxia and low oxygen saturation

The child who is hypoxic, cyanotic, pale or obtunded needs immediate airway management.

Croup

Croup score Mild croup, 0–3; moderate croup, 4–6;

severe croup, 7–10

Score 0 1 2Breath sounds Normal Harsh, wheeze Delayed

Stridor None InspiratoryInspiratory and

expiratory

Cough None Hoarse cry Bark

Recession/flaring

NoneFlaring,

suprasternal recession

Flaring, suprasternal,

intercostal recession

Cyanosis None In air In oxygen 40%

A scoring system for croup is useful in assessing severity

TreatmentCroup Syndrome

includes humidification of respiratory gases, oxygen, steroids and nebulized epinephrine;

The treatment of croup includes nebulized racemic epinephrine, systemic or nebulized corticosteriods, fluids, rest and comforting measures.

Epinephrine is a short-acting bronchodilator. It also decreases congestion in the airway, thus reducing tissue edema.

Treatmentcroup syndrome

Nebulized epinephrine is used for children with hypoxia who have some degree of respiratory distress.

Corticosteroids, which may be systemic or nebulized, are indicated for mild to severe croup.

The anti-inflammatory

action of these medications reduces airway edema.

Treatmentcroup syndrome

Epiglottitis

Epiglottitis is bacterial infection of the epiglottis and supraglottic structures

H. influenzae type b (Hib)

Acute Epiglottitis

Stridor inspiratory Sore throat, painful swallowing Drooling, Hoarse, muffled voice High fever Dysphagia Suprasternal, substernal

retractions Position of head and neck - to sit

leaning forwards, mouth open and with tongue and jaw protruding in order to open the airway.

On X-ray - the thumb-print sign is a finding that suggests the diagnosis of epiglottitis

Diagnosis

Croup Gradual onset Late night seal-bark cough Low-grade fever Inspiratory stridor Hoarse voice Other signs and symptoms depending on degree of

distress

Epiglottitis Sudden onset Muffled cough (not a prominent

finding) High fever Inspiratory stridor Dysphagia Sore throat Drooling (sometimes noted) Tripod position (facilitates air

movement)

Acute Epiglottitis

Establishing an airway by nasotracheal intubation or by tracheostomy is indicated in patients with epiglottitis, regardless of the degree of apparent respiratory distress, because as many as 6% of children with epiglottitis without an artificial airway die, compared with <1% of those with an artificial airway.

Children with acute epiglottitis are

intubated for 2-3 days + antibiotics therapy.

Foreign body aspiration

A foreign body above the vocal cords can cause complete obstruction of the upper airway, stridor, a change or loss of voice;

Small objects - seeds, nuts, toy parts, buttons, pebbles Sudden onset of cough Choking or gagging or wheezing Stridor, high pitched wheezing Cyanosis

An aspirated foreign body (coin)

Foreign body aspirationPartial

Blockagecoughingaccessory

muscle usenasal flaringwheezing

Complete BlockageComplete Blockage- no soundno sound- no cryno cry- stridorstridor- cyanosiscyanosis- loss of loss of

consciousnessconsciousness

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Foreign bodies

Atelectasis of right apex Note the coil and the

endotracheal tube just above it

Explaining the difficulties in placing the tube

• Bronchoscope under sedation may be necessary to remove object or surgery.

The peculiarities of the bronchi in children

In young children the bronchi are relatively wide,

The right bronchus is a straight continuation of the trachea,

The muscle and elastic fibers are undeveloped, The bronchi are well blood supplied, The lobules and segmental bronchus are

narrow.

Anatomy and physiology Several anatomical and physiological features of

the respiratory system in infants (age <1 yr) and young children make them susceptible to airway obstruction.

The upper and lower airways are small, prone to occlusion by secretions and susceptible to oedema and swelling.

A small decrease in the radius of the airway results

in a marked increase in resistance to airflow and the work of breathing (Poiseuille's law);

The support components of the airway are less developed and more compliant than in the adult.

Bronchiolitis – acute inflammation in the mucosa of small bronchi

and bronchioles, predominantly in young children with the concomitant obstruction of respiratory ways

Dry cough, nonproductive Dyspnea (breathlessness) Noisy breathing Moaning breathing with prolonged expiration Retractions Ban-box sound - on percussion Bronchial breathing with prolonged

expiration, wheezing, diffuse crackles;

Clinical case 6 months patient

Complaints: Increased body temperature to 38 °C Irritability Dry cough Dyspnea (breathlessness)

Anamnesis morbi (present history)

Acute onset Disease has begun from cough, sneezing, high

temperature up to 38 °C, then has appeared noisy breathing, cough, which have increased gradually;

He became ill in 36 hours after contact with an ill mother;

Treatment started at home (antibiotic by mouth, mucolitic, decongestant);

Condition of patient remained the same, and he was admitted to the hospital;

Anamnesis vitae (past history)

Infant was born from 1st pregnancy, 1st

delivery Birth weight was 3100 g Neonatal period – without complication Breastfeeding In age of 2 month he had acute viral

infection Vaccination: BCG, DPT+IPV+Hib (1st

and 2nd)

Physical examination at hospitalization:• General condition was moderate due to dyspnea syndrom; • Skin was pale with perioral cyanosis and acrocyanosis

Nasal breathing was impaired because of nasal congestion

Cough was nonproductive, moderate retractions, moaning breathing with prolonged expiration were present

Physical examination at hospitalization:

On percussion – ban-box sound, On auscultation – harsh breathing with prolonged

expiration, numerous moist diffuse rales and crepitation

RR - 68 per min HR - 148 beats per min

Video

Laboratory data

CBC (complete blood count) Er – 3,68 х1012/l, Hb – 92 g/l, Le – 5,4х109/l,

eosinophyls – 1%, bands – 2%, polymorphonuclear cells – 39%, lymphocytes – 56%, monocytes – 2%, ESR - 2 mm per h

Rapid immuno-chromatographic test for determination of RSV - positive

X-ray chest

Clinical diagnosis:

RS-infection:

Acute bronchiolitis. RI II degree.

DIAGNOSTIC CRITERIA OF ACUTE BRONCHIOLITIS

1. Deterioration of the general patient's condition with the symptoms of rhinitis, nasopharyngitis, the catarrhal symptoms.

2. The body temperature in most cases is normal. 3. The pronounced respiratory failure, the expiratory

dyspnea, the cyanosis of nasolabial triangle. 4. The symptoms of the bronchial obstruction

(enlargement of anterioposterior chest size, the horizontal positions of the ribs, the prolapse of the diaphragm).

5. Percussion: tympanic percussion sounds.

DIAGNOSTIC CRITERIA OF ACUTE BRONCHIOLITIS

6. Auscultation: bronchial breath sounds, the extended expiration, the moist small bubbling rales, the wheezes in expiration.

7. In chest X-ray, the lung pattern is enhanced, the transparence of the lungs increases due to the obturation emphysema, the bronchial pattern is also enhanced.

What is Asthma?

Disease of chronic inflammatory disorder of the airways

Characterized by: Airway inflammation Airflow obstruction Airway

hyperresponsiveness

DEFINITION Asthma is a disorder defined by its clinical,

physiological and pathological characteristics

The predominant feature of the clinical history is episodic shortness of breath,

particularly at night, often accompanied by cough.

Wheezing defined on auscultation of the chest is the most common physical

finding.

DEFINITION Asthma is a disorder defined by its clinical,

physiological and pathological characteristics

The main physiological feature of asthma is episodic airway obstruction.

The dominant pathological feature is airway inflammation (limits airflow from

bronchospasm, mucosal edema, mucus plugs)

recurring episodes of wheezing breasthlessness chest tightness cough particularly at night or in the early morning.

Asthma causes

Wheezing

Wheezes are musical adventitious lung sounds

Diagnosis of asthma

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Cough Episodic wheezing, recurrent wheeze Shortness of breath, episodic breathlessness Chest tightness, hyperinflated chest, Use of accessory muscles and intercostals

recession

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Peak expiratory flow (PEF)

Measurements of lung function

The Peak Flow Meter

The Peak Flow The Peak Flow MeterMeter

Acute severe asthmatic episode (status asthmaticus)

Correction of significant hypoxemia with supplemental

oxygen: In severe cases, alveolar hypoventilation requires

mechanically assisted ventilation. Use repeated or continuous administration of an inhaled

beta2-agonist (Albuterol, Ventolin) Early administration of systemic corticosteroids (oral

prednisone or IV methylprednisolone) is suggested in children with absent effect from inhaled beta2-agonists.

Bronchodilator, beta2-agonists (Sympathomimetics)

Short acting beta agonists – SABAAlbuterol, Ventolin, Salbutamol, Proventil,Terbutaline,

Long-acting – Sereven, Foradil, Formoterol, Salmeterol

Learning Objectives

Essentials of pediatric

intensive care of Anaphylaxis

Case

A child with bee sting came to ED

He has Facial Edema, wheezing

Anaphylaxis is a severe, systemic allergic reaction

multisystem involvement, including the skin, airway, vascular system, and GI

Severe cases may result in complete obstruction of the airway, cardiovascular collapse, and death

Etiology

Pharmacologic agents Antibiotics (especially parenteral

penicillins and other ß-lactams), aspirin and nonsteroidal anti-inflammatory

drugs intravenous (IV) contrast agents are the

most frequent medications associated with life-threatening anaphylaxis.

Stinging insects

ants, bees, hornets, wasps, and yellow jackets.

Foods

Peanuts, seafood, and wheat are the foods most frequently associated with life-threatening anaphylaxis.

Paraesthesia, flushing, facial swellingGeneralised itching – hands and feet

Shock

Cardiac arrest

Cardiac anaphylaxis

Clinical Signs

Symptoms Peripheral vasodilation

vascular permeablility (edema)

Bronchospasm Cardiac arrhythmias Smooth muscle contractions

Laryngeal Angioedema

Signs and Symptoms Serious upper airway (laryngeal) edema, lower

airway edema (asthma), or both may develop, causing stridor and wheezing.

Bronchospasm and laryngospasm (wheezing and breathing difficulty)

Rhinitis

Cardiovascular collapse - rapid weak pulse together with fall in blood pressure

Gastrointestinal signs and symptoms of anaphylaxis include abdominal pain, vomiting, and diarrhea

Guidelines for ED Treatment

Suspicion of severe anaphylaxis ABC

1e line : Adrenaline + Fluid resuscitation: crystalloïds or saline 0.9%, adult 500 ml to1000 ml, children 20ml/Kg

Jasmeet S. Resuscitation 2008;77:157-169.

A U T H O R S ’ C O N C L U S I O N S Implications for practice

We found no relevant evidence for adrenaline use in the treatment of anaphylaxis. We are, therefore, unable to make any new recommendations based on the findings of this review. Guidelines on the management of anaphylaxis need to be more explicit about the basis of their recommendations regarding the use of adrenaline.

Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock (Review)Sheikh A, Shehata YA, Brown SGA, Simons FERThis is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 10http://www.thecochranelibrary.com

Adrenaline I.M

Adrenaline IM: dilution 1/1000

- Adult : 500 microgramms (0,5ml)- Child > 12 years: 500 microgrammes

(0,5ml)- Child 6 to 12 years: 300 microgrammes

(0,3ml)- Child < 6 years: 150 microgrammes

(0,15ml)

Jasmeet S. Resuscitation 2008;77:157-169.

An EpiPen

Self-injected epinephrine

Self-injected epinephrine

Self-injected epinephrine

Adrenaline I.V Intravenous adrenaline has been associated with fatal

cardiac arrythmias and myocardial infarction, these cases have been associated with too rapid injection, undiluted doses, or excessive doses (Fischer, 1995; Pumphrey, 2000; Brown, 2001; Montanaro and Bardana, 2002).

To minimise these adverse effects, the use of intravenous adrenaline is now recommended at a dilution of 1:10,000 (Project Team of the Resuscitation council, UK, 2005).

Second line treatment

Histamine antagonists

Dexchlorpheniramine=against itching Corticosteroids

Hydrocortisone - Methylprednisolone=prevent recurrent anaphylaxis

Jasmeet S. Resuscitation 2008;77:157-169.

A U T H O R S ’ C O N C L U S I O N S Implications for practice

We found no relevant evidence for the use of glucocorticoids in the treatment of an acute episode of anaphylaxis. We are, therefore, unable to make any new recommendations based on the findings of this review. While we do not necessarily suggest that anaphylaxis guidelines no longer recommend glucocorticoids, these guidelines need to be more explicit about the basis of their recommendations regarding the use of these agents (Alrasbi M, Sheikh A. Comparison of international guidelines for the emergency medical management of anaphylaxis. Allergy 2007; 62:838–41.).

Glucocorticoids for the treatment of anaphylaxis (Review)Choo KJL, Simons FER, Sheikh A

This This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 10http://www.thecochranelibrary.com

Management of Anaphylactic Shock

Position:Oxygen. Epinephrine.Antihistamines. H2 blockers. Inhaled b-adrenergic agents.

Management of the Anaphylactic shock

Position: in a position of comfort. If hypotension is present, elevate the legs until replacement fluids and vasopressors restore the blood pressure

Oxygen. Administer oxygen at high flow rates. Epinephrine. Administer epinephrine to all patients with clinical

signs of shock, airway swelling, or definite breathing difficulty. Antihistamines. Administer antihistamines slowly IV or IM. Inhaled b-adrenergic agents. Provide inhaled albuterol if

bronchospasm is a major feature. If hypotension is present administer parenteral epinephrine before inhaled albuterol to prevent a possible further decrease in blood pressure.

Corticosteroids. Infuse high-dose IV corticosteroids slowly or administer IM after severe attacks. The beneficial effects are delayed at least 4 to 6 hours

Thank You