Emergencies Flashcards
what is the fluid bolus given in Sepsis?
balanced isotonic crystalloid OR saline 0.9%
septic shock in child
A_E assessment
airway - patent?
B- breathing- high flow o2
C- HR,CRT, BP, cap refill, femoral pulse; circulatory shock/BP here
establish VBG
establish IV/IO access
give fluid resus here
D- avpu / glucose
E- rash / temp
Sepsis - initial resus
what fluid?
what is the dose?
how long / what time over?
aim? better perfusion
no crackles at lung bases
or hepatomegaly
- means kid is not fluid overloaded
10mL kg balanced crystalloid IV BOLUS over 5-10 mins
reassess
if fluid overloads - sepsis?
stop bolus start inotropic support
-adrenaline infusion
initial resus principles - sepsis
SEEK HELP
1) fluid bolus - 10ml
2)inotrope - consider
3)correct hypoglycaemia/hypocalcaemia
4)abx broad spec
4)seek ID help
5) call anaesthetist / call picu
Sepsis -
signs of fluid refractory shock
how to manage
refractory shock is despite fluid resus there is persistent hypotension
IV/IO
inotrope infusion
adrenaline 0.05-0.3mcg kg
noradrenaline - 0.05mcg
DKA criteria?
ketosis - urinary or in plasma >3mmol/l
acidosis- <7.3
blood glucose - >11mmol/l
DKA -Resus
A-E
Airway: patent?
B: High flow O2 via non rebreathe mask - 94-98%
C: IV access, take VBG, monitor ECG, identify shock
pulse,HR,RR,BP,Cap refill, femoral pulse
D: raised ICP signs
rising BP with bradycardia
headache
confusion
E: Rash, AVPU, temperature
CALL FOR SENIOR SUPPORT
Fluid resus in acutely unwell DKA presentation
there are no signs of shock
what is the fluid bolus?
fluid bolus 10mL kg of ISOTONIC crystalloid or 0.9% NACL over 60 mins
Fluid resus in acutely unwell DKA presentation
SIGNS OF SHOCK
what is the fluid bolus?
10ml over 5-10 mins and reassess
can repeat to maximum of 40ml
fluid can be either crystalloid / 0.9% sodium chloride !!
inform PICU
DKA - if there are signs of raised ICP?
3% mannitol or sodium chloride
call for senior support asap / PICU / anaesathist
DKA - principles of treating
1) Fluid replacement with 40mmol potassium chloride
> unless potassium >5.5
2) Next is insulin to stop ketoacidosis
BUT insulin drives potassium into cells = hypokalaemia - this can cause fatal arrhythmia. So monitor and that is why you give fluid replacement with potassium in DKA paeds
3) Monitor electrolytes / ECG / neurological signs
How to correct fluid deficit in DKA?
over 48 hours
1) find out Fluid Requirement
2) find out fluid deficit
what is the estimated fluid deficit in DKA?
Mild DKA - 5% fluid deficit
Moderate DKA - 7% Fluid Deficit
Severe DKA - 10% Fluid Deficit
how is DKA defined as mild / moderate / severe
to then be able to get the estimated fluid deficit?
pH 7.2-7.9 is MILD
pH 7.1-7.19 is MODERATE
pH <7.1 is SEVERE
in mild DKA - 5% fluid deficit
in moderate 7% fluid deficit
in severe 10% fluid deficit
Maintenance fluid calculation?
if a kid weighed 25kg?
First 10kg add 100ml/kg
Next 11-20kg add 50ml/kg
20-75 add 20ml/kg
1) for first 10kg that 1000ml
2)Next 10kg is 500ml
3) last 5kg is 100ml
1600ml/ per day over 24 hours
1)Fluid deficit is calculated?
2)if 5% dehydrated 10kg child?
3) if no sign of shock in patient with DKA what do you do to the initial bolus given?
1) % dehydration x weight (kg) x10
in ML
2) 5% x 10 x 10
=500ml
3) Subtract initial fluid bolus from
fluid deficit
so in this patient if they were given 10ml/kg
500-100ml = 400ml is the fluid deficit
when is insulin started in DKA?
how is it given?
1-2 hours after IV fluids give insulin infusion
0.05-0.1 units /kg/hour
when is glucose given in DKA?
once blood glucose is LESS THAN 14mmol/l add 5% glucose
what are the 2 most serious DKA complication that occur in treatment?
Cerebral oedema:
Neuro observations
Watch for signs of raised ICP
Mannitol can be used for managing this but at this point- seek senior support urgently
Hypokalaemia:
cardiac dysfunction
monitor with ECG,
give 40mmol/l KCL with IV fluids
keep monitoring
Acute Asthma
Life threatening
signs?
Unable to talk
Silent chest
PEFR <33%
O2 sats <92% on air
cyanosis
hypotension
how to manage life threatening Asthma presentation
A-E
Seek / call for senior support - PICU
O2 High flow non rebreathe mask aim for 94-98%
Nebulised salbutamol 2.5-5mg every 20 mins
Ipratropium bromide 250mcg
Review
Oral steroids - 20mg prednisolone / 30-40mg if older than 5 years
IV magnesium bolus
Consider
Repeat / IV steroid if vomiting
Early single IV bolus of salbutamol
Aminophylline if unresponsive child
Anaphylaxis
A-E approach
Diagnose:
Airway/Breathing /Circulation problem
skin changes
Call for help
Position - Either lie down / sit to make breathing easier
Give IM adrenaline
High flow O2
pulse, ECG, BP
repeat IM adrenaline after 5 mins
IV fluid bolus
Adrenaline in anaphylaxis
> 12 years of age
6-12 years of age
6 months to 6 years
<6 month
IM anterolateral aspect of thigh
500 micrograms - 0.5mL
300 micrograms - 0.3mL
150 micrograms - 0.15mL
100-150 micrograms - 0.1-0.15mL
Neonatal resus
chest not moving
heart rate 50
at birth delay cord clamp
1) Dry baby- start clock
2) 30 seconds: Assess tone, breathing and heart rate
3) 60 seconds: open airway and 5 breaths
4)Reassess
5) No chest movement then
consider 2 person airway control
repeat inflation breaths
consider intubation / laryngeal mask
Neonatal resus
chest moving
heart rate 50
at birth delay cord clamp
1) Dry baby- start clock
2) 30 seconds: Assess tone, breathing and heart rate
3) 60 seconds: open airway and 5 breaths
4)Reassess
5) slow heart rate <60 min, ventilate for 60 seconds
6) Reassess and start chest compressions (3:1)
ventilate
7) reassess heart rate every 30 seconds
