PEDIATRIC EMERGENCIES

Cardiopulmonary resuscitation

   Cardiopulmonary arrest is the final common pathway for many life threatening diseases e.g.: sepsis, infections, aspiration of foreign body, trauma, shock, upper and lower respiratory diseases, metabolic causes, cardiac causes especially dysrhythmias and near drowning.

  The physician must know early signs of distress before activation of the emergency medical system. These signs include:

1- Respiratory distress: tachypnea, retraction, nasal flaring, cyanosis, stridor or wheezes.

2- Poor perfusion: capillary refill time >3 seconds, cool and mottled skin, tachycardia and decrease urine output.

3- Blood pressure: hypotension.

4- Mental status changes: confusion and coma. 

Basic life support (BLS)

I- Determine responsiveness: the level of responsiveness is determined by gently shaking, tapping or shouting at the patient. If no response but the patient is breathing or struggling to breathe, call for assistance.

II- Airway opening: establishment and maintenance of a patent airway and support of adequate ventilation are the most important components of BLS. This is usually accomplished by the head tilt-chin lift maneuver by using one hand to tilt the head and extending the neck while the index finger of the rescuer’s other hand lifts the mandible outward by lifting on the chin (Fig. 18-1). If neck injury is suspected, head tilt should be avoided and the airway opened by a jaw thrust (Fig.18-2) while the cervical spine is completely immobilized. If the child is conscious and demonstrates spontaneous but labored respiratory efforts, the child should be transported to an advanced life support facility as rapidly as possible.

 

 

 

 

Fig. 18-1 Head tilt maneuver                Fig. 18-2 Jaw thrust-spin stabilization maneuver

III- Breathing establishment:  after the airway is opened, the rescuer must determine if the

child is breathing. The rescuer looks for a rise and fall of the chest and abdomen, listens for exhaled air, and feels for exhaled airflow at the mouth.

1- If there is chest rise and exhaled air is felt, the patient is ventilated.

2- If the chest rises, but without exhalation, the patient is not ventilated and rescue breathing should be provided while patient airway is maintained by a chin lift or jaw thrust. The rescue breathing at a rate of 20 breath/minute is maintained by one of 3 methods:

   a- By mouth - to- mouth (Fig. 18-3).

   b- By mouth to mask ventilation.

   c- Bag-valve mask ventilation with l00% O₂.

                            

Fig. 18-3 Rescue breathing in a child

3- If the child received the correct volume of air for each breath, the chest will rise. 

4- If the chest does not rise, either the airway is obstructed or more breath volume and pressure is needed, reposition of the head and try ventilation again.

5- If unsuccessful, there is airway obstruction. So, you must clear the airways.

  Airway obstruction is suspected when there is any combination of ineffective cough, nasal flaring, tachypnea, retraction, stridor and/ or central cyanosis.

Methods of relieving the airway obstruction:

In infants: by backblows four times and chest thrusts four times (Fig. 18-4).

In older child: by using manual thrust for 6 times (Fig. 18-5).

 

 Fig. 18- 4 Back blows and chest thrusts   Fig. 18-5 Abdominal thrusts with victim lying

6- If after these procedures ventilation is not restored, endotracheal intubation (ETI) is indicated. For proper intubation oropharyngeal suctioning, nasogastric suctioning and preoxygenation for 3-4 minutes must be done. Proper intubation is suggested by equal breath sounds and symmetrical chest movements. Monitoring for intubation is done by pulse oximetry for O₂  saturation.

IV- Circulation Support

1- Assess brachial or femoral pulse: if absent, start chest compression.

2- Chest compression entails rhythmic compressions of the chest that circulate oxygen containing blood to the vital organs (heart, lungs, and brain) until advanced life support can be provided. Chest compressions must always be accompanied by ventilation (Fig.18-6,18-7).

Table 18-1 Technique of chest compression.

	Method	Hand position	Sternal depression	No./min
Infant Toddler Child	Encircle the chest or use 2 fingers One hand Two hands	One finger width below the intramammary line Lower 1/3 of the sternum Lower 1/3 of the sternum	0.5- 1 inch 1- 1.5 inch 1.5 -2 inches	100 80-100 80-100

Fig. 18-6 Cardiac compression in infants               Fig. 18-7 Chest compression in child

3-  Venous access for administration of fluids and medications:

a- Children < 5 years old: the preferred venous access site is to the largest most accessible veins that does not require the interruption of resuscitation, e.g. femoral vein, median cubital vein or the saphenous vein. If this failed after 90 seconds, try the intraosseous line at the proximal end of the tibia, if this failed try the saphenous vein cut down or the central line.

b- Children > 5 years: try to get peripheral line if failed after 90 seconds, try a central line or cut down.

4- O₂ is given immediately.

5- Medications.

a- Epinephrine for cardiac arrest: 0.01 mg/kg of 1/10,000 solution IV or 0.1 ml/kg from the same solution by endotracheal tube or 0.1 mg/Kg /minute by continuous drip and increase gradually to 1mg/Kg/minute.

b- Dopamine: see shock

c- Atropine to increase heart rate in cases of bradycardia (0.02 mg/kg).

d- Sodium bicarbonate is indicated in cases with metabolic acidosis, hyperkalemia; 1mEq/kg followed by 0.5 mEq/kg every ten minutes till correction of acidosis.

Petroleum compounds

Examples: kerosene, petrol

 · Ingestion can cause encephalopathy.

Treatment: symptomatic

- Do not induce vomiting or give activated charcoal as inhalation can cause respiratory distress with hypoxaemia due to pulmonary oedema and lipoid pneumonia.

Scorpion sting

Symptoms are the result of depolarization of nerves and muscles as a consequence of the effects on Na⁺and K⁺ ion channels. It may stimulate sympathetic and /or parasympathetic nervous system

Clinical picture

· The severity of the disease is more in younger children.

· Temperature: hypothermia or hyperthermia.

· Eyes: lacrimation, mydriasis, blurred vision, nystagmus and temporary blindness.            

· Cardiovascular signs: hypotension, hypertension, arrhythmia or reversible cardiomyopathy.

· Respiratory system: stridor, wheezes, dyspnea, pulmonary edema and respiratory failure.

· Neurological features: local pain, hyperthesia, agitation, seizures, coma, intracerebral   hemorrhage, hallucination and autonomic nervous system manifestations.

· Gastrointestinal manifestations: vomiting, dysphagia, gastric dilatation and pancreatitis.

· Genitourinary: priapism, urgency, polyuria and renal failure.

· Hematological: coagulopathy and gross bleeding.

· Endocrinal features: hyperglycemia may be due to inhibition of insulin release.

Management

1- Monitoring for blood pressure, heart rate, temperature, urine volume and blood gases.

2- All cases should receive bed rest and pain relief.

3- Antivenin, 2-5 ml IM.

4- Propranolol for tachycardia, 0.0l-0.l mg/kg/dose IV over ten minutes, maximum dose 1mg /dose.

5- Seizure control: phenytoin (15-20 mg/kg IV) at a rate of 0.5-1.5 mg/kg/ minute in refractory cases.

6- Non-cardiogenic pulmonary edema: mechanical ventilator to maintain PaO₂ >50 mm Hg.  Morphia is contraindicated.

7- Hypotension: should be treated by IV fluid. Dopamine 2-5 µg/kg/minute or norepinephrine 0.l-0.2 µg/kg/minute.

8- Hypertension: should be treated by sublingual nifedipine (0.25-0.5 mg/kg) with prazosine    (0.l mg/ kg/ 24 hour divided every 6 hours).

9- Muscle spasm: should be treated by l0 ml of l0% calcium gluconate IV slowly or 5-l0 mg diazepam/4-6 hours for the first 8-l2 hours.

Snake bite

   Snake bite should be considered in any severe pain or swelling of a limb and in any unexplained illness presenting with bleeding or abnormal neurological signs.

Clinical manifestations

General signs: include shock, vomiting and headache.

● Examine the site of the bite for signs such as local necrosis, bleeding or tender local lymph node enlargement.

Specific signs: depend on the venom and its effects. These include:

● Shock

● Local swelling that may gradually extend up the bitten limb.

● Bleeding: from gums, wounds or intracranial.

● Signs of neurotoxicity: respiratory difficulty or paralysis (ptosis, bulbar palsy limb weakness).

● Signs of muscle breakdown: muscle pains and black urine.

● Check haemoglobin, (where possible, blood clotting should be assessed).

Treatment:

First aid

- Antivenom is given if available.

- Splint the limb to reduce movement and absorption of venom. If the bite was likely to have come from a snake with neurotoxic venom, apply a firm bandage to affected limb from fingers or toes to proximal of site of bite.

- Clean the wound.

- Avoid cutting the wound or applying tourniquet.

Hospital care

1- Treatment of shock and respiratory arrest: paralysis of respiratory muscles can last for days which may requires intubation and mechanical ventilation.

2- Antivenom if was not given.

- Give polyvalent antivenom if the species is not known.

- The dose for children is the same as for adults.

- Dilute the antivenom in 2-3 volumes of 0.9% saline and give intravenously slowly over 1 hour.

- Monitor closely for anaphylaxis or other serious adverse reactions. If itching /urticarial rash, restlessness, fever, cough or difficult breathing develop, then stop antivenom and give epineptirine 0.01 ml/kg of 1/1000 ' or 0.1 ml/kg of l/10.000 solution subcutaneously or chlorpheniramine 250 micrograms/kg.

- When the child is stable, re-start antivenom infusion slowly.

- More antivenom should be given after 6 hours if there is recurrence of blood incoagulability, or after 1-2 hr if the patient is continuing to bleed or has deteriorating neurotoxic or cardiovascular signs.

- If there is no response to antivenom infusion this should be repeated.

3-  Other treatment

- Seek surgical opinion if there is severe swelling in a limb, it is pulseless or painful or there is local necrosis.

4- Supportive care

   - Give fluids orally or by nasogastric tube according to daily requirements.

   - Provide adequate pain relief.

   - Evaluate the limb if swollen.

   - Give antitetanus prophylaxis.

Drowning and near-drowning

● Childhood submersion is a common cause of injury and fatality. Within a few minutes, hypoxia and ischemia can rapidly lead to irreversible multisystem injury and often to death.

● Death within 24 hours of submersion is termed drowning, which may be immediate or may follow resuscitation.

● Survival more than 24 hours is termed near-drowning regardless of whether the victim later dies or recovers.

Pathophysiology:

Once submersion occurs, all organs and tissues are at risk for hypoxia.

● In a short period, hypoxia can lead to cardiac arrest.

● The severity of injury is directly proportionate to the duration of hypoxia and ischemia.

● Pulmonary aspiration can further exacerbate hypoxia and subsequent respiratory failure.

● Some victims may develop hypothermia which is usually detrimental if not rapidly corrected.

● In some cases, arrhythmia is responsible for cardiac arrest and death.

Clinical manifestations:

 The clinical course and outcome of the victims are primarily determined by the circumstances of the incident, the duration of submersion and the speed and effectiveness of resuscitative efforts.

 Two groups may be identified based on responsiveness at the scene.

- Children who require minimal amounts of resuscitation at the scene commonly have good outcomes and experience a low incidence of complications. These victims quickly regain spontaneous respiration and typically regain consciousness rapidly.

- Children who require aggressive or prolonged resuscitation and have a high risk of multi-organ system complications, major neurologic morbidity or death.   

Treatment:

Initial management requires coordinated and experienced pre hospital care.

Initial resuscitation must focus on rapidly restoring oxygenation, ventilation and adequate circulation.

● The cervical spine should be protected in anyone with potential traumatic neck injury; the neck should be in a neutral position and protected with a well-fitting cervical collar.

● If the victim has ineffective respiration or apnea, ventilatory support must be initiated immediately (see cardiopulmonary resuscitation):

  - Mouth-to mouth or mouth-to nose breathing by trained person

  - O₂ should be administered to all victims.

  - Positive pressure bag-mask ventilation with oxygen should be given

  - If apnea, cyanosis and hypoventilation persist, trained personnel should perform endotrachal tube intubation.

     - I.V fluid and cardioactive medications are required to improve circulation

Hospital-Based evaluation:

All pediatric submersion victims should be hospitalized or observed for at least 6-12 hr for serial monitoring of vital signs, chest examination and neurologic assessment    

Management of body temperature:

   Attention to core body temperature in the field, during transport and in the hospital is very important. Core temperature is best measured at the tympanic membrane, which correlates to brain temperature. Rectal, oral and axillary temperature determinations are often inadequate

Rewarming measures include: the provision of dry warm blankets, a warm environment, the damp clothes removed and the skin dried.

Respiratory cardiovascular management: (see cardiopulmonary resuscitation)

Neurologic management: in comatose victims, the possibility of irreversible CNS injury is a major concern.

   ● The most effective neurologic intensive care measures after drowning are rapid restoration   and maintenance of adequate oxygenation

   ● Seizures should be treated. 

Prognosis: 

Overall about 80% of pediatric submersion victims survive and 92% of survivors have a complete recovery.