JC115 (Paediatrics) - Childhood Medical Emergencies Flashcards
3 anatomical differences in a child’s respiratory system + implications on resuscitation
CNS receptors/ effectors in neonates has Biphasic response (tachypnea, bradypnea) to hypoxia
- Always give high levels of supplemental oxygen
Cartilaginous thorax, more horizontal ribs: chest stability and strength relies on diaphragm
- Less respiratory reserve
- Allow position of comfort/ sniffing position
Low number of alveoli, high airway resistance
- Common airway obstruction
Physiological differences in cardiovascular system between adults and children
Children:
- Small absolute blood volume: Low stroke volume and cardiac out depends on HR
- CVS response to fluid is similar to adults after 2 months old (CVP measurement in baby under 2 months is inaccurate)
- Pulmonary vasculature more reactive: easily go into pulmonary hypertension and hypoxia
- Variable catecholamine response
Ddx non-hypovolemic shock in children
Initial treatment
Pneumothorax
Pericardial effusion, myocardial dysfunction
Adrenal insufficiency
Intestinal ischemia, sepsis
Pulmonary artery hypertension, coarctation of aorta
Tx:
titrated fluid to 40 mL/kg
Physiological differences in metabolic function between children and adults
Children:
- Lower urine output
- Greater insensible water loss and heat loss (larger surface area to weight)
- Hypoglycemia more common, need higher glucose infusion
- Sodium control is not as refined: Hypo-, hypernatremia
Define the normal urine output for children
Neonate 2ml/kg/hr
Child 1ml/kg/hr
Outline P/E for paediatric medical emergencies
- What to examine in General, Neurological, Respiratory, CVS P/E
General examination:
Skin perfusion: color, warmth, capillary refill (normally <3s)
Hydration (skin turgor, mucosa; dehydrated if depressed anterior fontanelle)
Fever
Neurological:
Alertness, response to stimuli
Irritability, restlessness
Seizures and abnormal muscle activity
Respiratory:
Tachypnea, bradypnea
Expiratory grunting (significant respiratory distress)
Obligate nose breathing (<6mo), nasal flaring)
Compensated shock:
Tachycardia, BP may be normal,
Skin vasoconstriction/ mottling (marked with spots/ smears of color)
Long capillary refill (>4s)
Clinical grading system for paediatric medical emergencies
Paediatric Early Warning Score (PEWS):
Grades Behavior, Cardiovascular and Respiratory metrics
Cumulative score dictates management
Score reference (may vary between institutions): 0-4: (stable) continue 4hrly assessment 5-6: more frequent assessment; notify doctor >7: critical frequent assessment q30min; immediately notify doctor
Features of critical paediatric emergency on PEWS
Behavior:
Lethargic/ confused
Reduced response to pain
Respiratory:
Respiratory rate 5 /min below normal parameters
Sternal recession/ tracheal tug/ grunting
50% FiO2
>8L/min respiration
Cardiovascular
Grey and mottled/ Capillary refill >5s
Tachycardia (30bpm above normal rate) or Bradycardia
Differentiate IHCA and OHCA Chains of survival
IHCA (In-Hospital Cardiac Arrest):
surveillance and prevention»_space; recognition and activation of emergency response system»_space; immediate high-quality CPR»_space; rapid defibrillation»_space; advanced life support
OHCA (Out-Hospital Cardiac Arrest):
Out-Hospital Cardiac Arrest: recognition and activation of emergency response system»_space; immediate high-quality CPR»_space; rapid defibrillation»_space; ambulance**»_space; advanced life support
Ambulance is the only difference between IHCA and OHCA
Resuscitation procedures for Unwitnessed collapse in children/ infants
International Liaison Committee on Resuscitation (ILCOR):
Unwitnessed collapse in children/ infants:
1. Give 2 minutes of CPR (vs. adults: get AED first)
- Leave the victim to activate the emergency response system and get the AED
- Return to the child/ infant and resume CPR
- Use the AED as soon as it is available
Phases of Cardiac pulmonary resuscitation (CPR)
Phase 1 – basic CPR for maintaining oxygenation and circulation:
Airway
Breathing
Circulation
Phase 2 – advance life support for restoration of spontaneous circulation
Fibrillation
Drugs
ECG
Phase 3 – prolonged life support for managing multiple organ failure
brain resuscitation
Gauging: cause of arrest; assess condition
Intensive care support
Describe bystander CPR resuscitation techniques for adults
e.g compression frequency, depth…
Circulation = most important, Recommend Compression Only for untrained lay rescuer
- Compression frequency recommended at 100-120/min
- Compression depth: 5-6cm for adult
- Chest recoils:
Avoid leaning on the chest between compression for better recoils
Provide a relatively negative intrathoracic pressure for better venous return - Avoid compression interruption for >10s
- first ventilation after 30 compressions
Describe resuscitation for unwitnessed collapse, witnessed cardiac arrest
Unwitnessed collapse:
- 2 mins CPR, search for AED, then resume CPR (cf AED first in adults)
- Ventilation with advanced airway: 1 breath every 6 seconds (cf 1 ventilation every 30 compressions)
- Ventilation with bag-mask ventilation if possible
Witnessed cardiac arrest:
- Energy for SVT cardioversion revised to 1 J/kg
Hypothermia therapy for paediatrics use
- Indication
- Function
- Specific temperatures
Indication:
- both in-hospital and out-of-hospital cardiac arrest
- children who remain comatose after cardiac arrest
Function:
keep core temperatures within a certain range to reduce tissue metabolic rate and ischemic damage
Temps:
Option 1: maintain 32-34oC, followed by 36-37.5oC
Option 2: maintain 36-37.5oC
Treatment options for paediatric in-hospital cardiac arrest
- Conventional paediatric CPR
- Extracorporeal CPR: Cardiopulmonary bypass to maintain organ perfusion during cardiac arrest
- Indication: witness cardiac arrest or post-operative cardiac arrest in hospita;
- Improve response to cardiac arrest
- May increase risk of CNS complications
Differences in CPR for children compared to adults
Phase 2 and 3 CPR:
- Avoid compression interruptions >10s
- More monitoring support than adults (continuous end-tidal CO2, pulse oximetry…etc)
- Cautious use of hypothermia therapy for post-cardiac arrest
- Cautious use of fluid replacement in sepsis
- Use epinephrine for failed CPR (same as adults, no longer recommend vasopressin)
Neonatal resuscitation
Anatomical differences in upper respiratory tract and implication on respiratory resuscitation
Anatomical difference:
Airway smaller, shorter than adult - prone to airway obstruction
Larynx funnel-shaped, narrowest at cricoid cartilage, more superior and anterior (cf adult: more cylindrical, narrowest at vocal cord) - less functional lung capacity
Tongue and epiglottis relatively large - central airway obstruction
Resuscitation:
- Commonly use non-cuffed*** endotracheal tube
- Laryngeal mask is acceptable alternative
Neonatal resuscitation
- Procedures to avoid/ not recommended
- Time limit for start ventilation
- Monitoring methods
Procedures to avoid:
- Do not suction non-vigorous infants with meconium-stained liquor
- No recommended to do cord milking for preterm babies
- Do not delay ventilation
Time limit: 60s to start ventilation
Monitoring: SpO2, ECG, exhaled CO2 to confirm endotracheal tube placement
Neonatal resuscitation
Route of administration of drugs
Intraosseous route:
- Useful for volume bolus and effective delivery of medication
- Site: usually anterior tibial
- Technique: same as bone marrow puncture
Equipment required for resuscitation of acute epiglottitis in paediatrics
Prepare equipment: Bag and mask Laryngoscope ET tubes just 1 size smaller than recommended Percutaneous tracheostomy set
Resuscitation steps for acute epiglottitis in paediatric
General:
Monitor vital sign
No throat examination (stimulate laryngeal spasm and respiratory arrest)
Transport patient in sitting position (not horizontal) for intubation
Treatment:
- Oxygen supplement
- Antibiotics
- Supportive: fluid, hydration, humidify air, sedation and ET tube care
- Treat post-obstructive pulmonary oedema, ET tube care
- Extubation (18-24 hours later): fever subsiding and condition improve, or ET tube is leaking air
Status epilepticus (SE)
- Clinical definition
- Timing to start intervention
Definition:
3 seizures without awakening; or
Continuous motor seizure activity for >30 minutes
Timing:
Start treatment in Prolonged seizures of >5 minutes:
Systemic complications a/w Status epilepticus
Hypotension Hypoxia Acidosis High fever Arrhythmia Atelectasis Cerebral hemorrhage and ischemia
Pre-hospital treatment of Early convulsive Status Epilepticus
Emergency management and seizure control
0-5 min:
Supportive (semi-prone position, O2 suppl etc)
Prepare anti-epileptic medications
6-30min – first line anti-epileptic medications, Repeat bolus after 5-10min if necessary Diazepam – rectal **** Alternatives: Lorazepam Midazolam – buccal/ intranasal
Management of convulsive status epilepticus (after 30 mins to 1 hour)
Additional anti- epileptic drugs to Diazepam
Investigations for underlying causes, e.g. brain malformation, infections, poisoning, overdose etc.
Second line treatment if not responsive:
- IV Phenytoin (1st choice)
- IV Phenobarbital
- Buccal Midazolam
- Levetiracetam (Keppra)
- Thiopentone/ pentobarbitone infusion
- Propofol / other anaesthetic agents
- Sodium valproate
Management of refractory status epilepticus
Refractory SE (unresponsive to 2 anti- epileptic drugs), ongoing >60 mins
ICU admission
aggressive drug therapy control,
ventilatory / haemodynamic support
Side effects of second line anti-epileptic drugs for Status epilepticus
- Phenytoin (1 st choice): hypotension,strong alkaline, arrhythmia
- Phenobarbital: hypotension, respiratory suppression
- Thiopentone/ pentobarbitone infusion: Need ventilator support and more haemodynamic disturbance
