PEDIATRIC EMERGENCIES
DR NOR AZLINA MOHAMMAD RASHID
1
AIM
TO RECOGNIZE PEDIATRICS EMERGENCY
SITUATION, PRIORITIZE IMMEDIATE MANAGEMENT,
FORMULATE AN IMMEDIATE PROVITIONAL
DIAGNOSIS AND OUTLINE INVESTIGATION AND
SECONDARY MANAGEMENT
2
OBJECTIVES
• CARDIOPULMONARY COLLAPSE
• HYPOVOLUMIC SHOCK
• FOREIGN BODY ASPIRATION
• DROWNING
• PARACETAMOL, SALICYLATE AND
ORGANOPHOSPHOROUS POISONING
• HYPOGLYCAEMIA
• KETOACIDOSIS
3
CARDIOPULMONARY ARREST
4
CARDIORESPIRATORY ARREST
Loss of normal circulation of the blood due to
failure of systole
Leading hypoxemia and thus, death
Commonly result from prolonged period of
hypoxia secondary to a respiratory arrest.
Heart failure Cerebral hypoperfusion
Hypoxemia If prolonged Unconscious
Apnoea Brain death Death
5
CARDIORESPIRATORY ARREST
CAUSE EXAMPLES
RESPIRATORY FAILURE • Respiratory distress
• Choking on foreign body or secretions
• Acute life threatening events
• Upper airway obstruction
• Severe exacerbation of bronchial asthma
RESPIRATORY DEPRESSION • Following general anesthesia
• Convulsions
• Raised ICP
• Poisoning
• Muscle weakness
CIRCULATORY FAILURE • Fluid loss
• Electrolyte imbalance
• Fluid misdistribution
• Cardiac disease and arythmias
6
CLINICAL FEATURES OF RESPIRATORY
DISTRESS
Pallor or cyanosis
Stridor, wheeze, cough, prolonged expiratory
phase
Excessive effort and work of breathing
Mental status (level of consciousness)
Hallmark are use of accessory muscles and
tachypnea
7
Assessment and management
Airway
Clear nasal, oropharynx passage and oral cavity
using suction catheter
If suspect foreign body inhalation, invert small
child and apply 5 back blows. Older child
Heimlich manoeuvre/use Magill’s forceps to
remove foreign object
Oroharyngeal airway
Endotracheal intubation/
CricothyrodotomyETT
8
Assessment and management
Breathing
ventilation/mouth to mouth ventilation
bag mask
9
Assessment and management (Cont’)
Circulation
Check pulse (brachial/radial/carotid)
If not felt, start cardiac compression with
alternate ventilation (30:2)
Continue until pulses are palpable
Collect urgent blood sample for blood glucose
testing at bedside.
Treat underlying problems.
Prepare for possibility of seizures
10
INVESTIGATION
Non-invasive : pulse oximetry measurement of
oxyhemoglobin
ABG/capillary blood sample
Blood test :FBC, electrolytes,glucose
CXR : severe pnuemonia/assess complications
(pulmonary edema/pnuemothorax)
11
Reassessment
Think of hypoxia, hypovolumia, hypothermia, hypoglycemia,
hypocalcemia if conditions do not improve despite
intervention.
12
SHOCK
13
Shock
It is the inability to provide sufficient
perfusion of oxygenated blood to tissues to
maintain organ function.
14
Type Description Example
Hypovolemic Reduced venous return leading to reduced cardiac AGE with dehydration, blood
output with hypo-perfusion of the body tissue loss, burns,
Cardiogenic Abnormal myocardial function causing reduced Congenital cardiac lesions,
myocardial contractility with reduced cardiac circulatory obstruction with
output cardiac failure, hypoxia-
ischemic injury, myocarditis
Septic Release of inflammatory mediators leading to Gram positive or negative
derangement in vasculature, with vasodilation, bacteria, viruses
increased vascular permeability, and platelet and
leukocyte aggregation. Also associated with release
of vasculotoxins leading to reduced cardiac output
and contractility
Anaphylatic Allergic reaction releases mediators resulting in Occur in response to any
derangement of vasculature with vasodilation, allergen, common causes are
increased vascular permeability, muscle insect stings, food and drug
contraction, bronchoconstriction, arrhythmias. allergies
15
Cardiac signs: Cool peripheries
CRT>2 sec
Pallor
Narrowed pulse pressure Respiratory signs: tachypnoea
Respiratory distress
Tachycardia
Oliguria
hypotension
CNS signs: restless
Anaphylactic: skin flushing Changes in sensorium
Generalised urticaria CLINICAL
FEATURES Confusion
Angio-oedema Stupor
Pallor coma
Cyanosis
Bronchospasm
Laryngeal obstruction
Rhinitis Septic shock signs: fever
Abdominal pain Lethargy
Vomiting Petechiae or bleeding tendencies
Seizures and coma Flushed skin
Bounding pulse
16 meningism
Hypovolemic shock
Most common cause of shock in children
It is distinguished from other causes of shock by
history and the absence of signs of heart failure,
or sepsis.
In addition to signs of sympathoadrenal activity
like tachycardia, vasoconstriction
Clinical features usually includes signs of
dehydration or pallor
17
Management principles
Children in shock must not be moved until adequate
circulatory volume has been established
Early recognition of shock whereby it may be reversible
Therapy directed at treating symptoms and signs,
minimizing cardiopulmonary work while ensuring
adequate cardiac output
Support of blood pressure, prevention of hypoxia vital
Close monitoring for effectiveness of shock resuscitation
While shock is being corrected, treat underlying
conditions.
18
How to treat hypovolemic shock
- Management priorities include infusion of fluids
and stopping the bleeding of fluid loss.
- Isotonic fluid such as normal saline or lactated
Ringer’s solution always a good choice
- If there is blood loss, isotonic crystalloids are
most often used but if does not show adequate
respond, colloids should be used.
19
DROWNING
20
DROWNING & NEAR DROWNING
Def: Death resulting from suffocation within 24
hours of submersion in water; near drowning
victims survive for at least 24 hours.
Most cases are of children below 5 years old
Occurs most commonly in bathtubs, pail
drowning and swimming pools.
Submerged child tries to Relief of laryngospasm Hypoxia and
breathe and aspirates leads to child aspirating Dysfunction in alveolar decrease in oxygen
water triggering large amounts of water capillary gas exchange delivery to vital
laryngospasm into the lungs tissues
21
HISTORY TAKING
Note the following:
Duration of submersion
Type and temperature of water
Time to institution of CPR
Time to first spontaneous breath
Any vomiting
22
CLINICAL MANIFESTATIONS
Patient may present with the following:
Tachypnea
Tachycardia
Decreased breath sounds
Hypoxic-ischaemic injury could lead to
cardiovascular collapse
Depression of cerebral function , altered mental
status
Hypothermia if drowning in cold bodies of water
23
PROGNOSIS
An early resuscitation is associated with
improved outcome.
Unfavourable prognostic markers (>3 of the
following):
Age younger than 3 years
Submersion of more than 5 minutes
Greater than 10 minute delay in resusciation efforts
Coma on admission to emergency department
pH less than 7.10
24
Management
Resuscitation of near-drowning victim – CPR
If victim is apnoeic, artificial ventilation started
and victim provided with supplemental oxygen
Assess haemodynamic status
If there is evidence of shock treat hypovolemia
with fluid
Establish condition of CNS
25
FOREIGN BODY ASPIRATION
26
Epidemiology
Into the tracheobronchial tree (common)
Young children (250, arterial pH 4 s, cool peripheries
2. Eyes: very sunken
3. Pulse: thready or absent, tacycardia
4. Tears: absent
5. Skin turgor: tenting
87
His blood pressure is recorded as
70/50mmHg
What is John’s clinical condition?
- Hypovolumic shock
88
Outline the principle of
management
1. Administer oxygen, initiate cardiorespiratory
monitoring and keep the child warm.
2. IV or IO access should be established.
3. Volume-expanding crystalloids (normal saline or
lactated Ringer’s should be given in a bolus of
20ml/kg as fast as possible and repeated after
reassessing the child if there are still signs of
inadequate perfussion.
89
SENARIO 6
Ali was diagnosed to have Insulin Dependant
Diabetes Mellitus since 4 years old.
He is found to be comatose by his school teacher.
What is your immediate action?
State 2 important differential diagnosis related to
his condition.
Outline the management
90
COMATOSE
Initial assessment
A: airway
B:Breathing
C: Circulation
D: Dextrostix
Neurology assessment using GCS
91
Differential diagnosis
Hypoglycemia (poor oral intake)
Diabetic ketoacidosis (Hyperglycemic attack)
92
93
Hypoglycemia management
Rapid administration of IV glucose (2mL/kg of
10% dextrose in water)
After the initial bolus of glucose, and infusion of
IV glucose should be established to provide
approximately 1.5 times the normal hepatic
glucose production rate (8-12 mg/kg/min in
infants, 6 -8mg /kg/min in children)
94