628 CHAPTER 14 Psychiatry Compulsory hospitalization Compulsory detention of patients in the UK requires the patient to be both: \200 Suffering from a mental disorder (mental illness or handicap). \200 Re quiring emergency hospital admission to protect the health or safety of the patient or for the protection of others. Emergency detention under mental health legislation does not allow treatment for psychiatri c illness. Emergency treatment of psychiatric or physical illness is carried out under comm on law . In this situation, there must be an immediate threat to life or serious danger to the patient or others, if treatment is not given. For this reason, mental health legislatio n cannot be used to impose emergency treatment without patient consent. Note that ED patien ts are not legally inpatients until they go to a ward. Detention of psychiatric emergencies in the ED England and Wales Section 2 is used most com monly in the ED. It requires recommendations from 2 doctors to be accepted by an approved s ocial worker and allows detention for up to 28 days for assessment and treatment. Scotland The Mental Health (Care and Treatment) (Scotland) Act 2003 came into effect in 200 5 \200\224 see www.nes-mha.scot.nhs.uk/ . Part 5 of the Act enables a fully registered med ical practitioner to grant an emergency detention certi \201 cate that authorizes managers of a hospital to detain someone for 72hr. Before granting an emergency detention certi \201 cate, the medical practitioner also needs to consult and gain the consent of a mental health of \201 cer, unless impracticable. The patient is then examined by an approved medi cal practitioner (psychiatrist), who if not satis \201 ed that the relevant criteria are m et, cancels the certi \201 cate. Northern Ireland Mental Health (Northern Ireland) Order 1986, Part II. Article 4 \200\224 Admission for assessment of mental disorder. \200 Requires 2 or 3 doc tors including the responsible medical of \201 cer (RMO) \200\224 in charge of patient \200\231s treatment. Application by nearest relative or an approved social worker. \200 Lasts 7 days, renewabl e up to 14 days. \200 Lasts until discharge by RMO board or nearest relative or until det ained under article 12. Section 136 (England) This allows a police of \201 cer to detain someone in a public place when he/ she appears to be mentally disordered and is causing a disturbance. The police of \201 cer \200\231s responsibility is to take the detained person to a \200\230place of s afety \200\231 (usually a police station or psychiatric ward) where he/she is assessed by a psychiatrist and approved social worker. The Mental Health Act (Scotland) 2003 provides police of \201 cers in Scotland with simila r powers: a police constable may remove a person to a place of safety from a public place, if a mental disorder is suspected and it is also suspected that the person needs immediate care and treatment. 629 MENTAL CAPACITY ACT Mental Capacity Act The Mental Capacity Act 2005 (MCA) offers a comprehensive framework for decision-making on behalf of adults aged > 16 years lacking capacity to make decisions on their own behalf. It only applies in England and Wales. De \201 ning capacity A person lacks capacity if, when a decision needs to be made, they a re unable to make or communicate the decision because of an \200\230impairment or disturba nce of the mind or brain \200\231. There is a 2-stage test of capacity: \200 Is there an impairment of, or disturbance in the functioning of, the person \200\231s mind or brain? If so, Is the impairment or disturbance suf \201 cient that the person lacks the capacity to make that particular decision? Five statutory principles \200 Capacity must be assumed unless it is established to be la cking. \200 A person is not being treated as unable to make a decision unless all practic able steps to help him do so have been taken without success. \200 A person should not be treated as unable to make a decision merely because he makes an unwise decision. A decision made, or action performed, for or on behalf of a person who lacks capacity must be taken in his/her best interests. Before a decision is made or an action performed, consideration must be given to whether th e purpose for which it is needed can be as effec- tively achieved in a way that is less res trictive of the person \200\231s rights and freedom of action. Assessment of capacity A person lacks capacity if he/she fails: \200 To understand the in formation relevant to the decision. \200 To retain the information relevant to the decisi on. \200 To use or weigh the information. \200 To communicate the decision (by any mean s). Admission and treatment Patients can be admitted and treated under the Mental Capacity Act 2005 only if 6 qualifying safeguards are met: \200 The person is at least 18 years old. \200 The person has a mental disorder. \200 The person lacks capacity to decide whether to be in hospital or care home for the proposed treatment or care. The proposed deprivation of liberty is in the person \200\231s best interests and it is necessary and proportionate response to the risk of harm. The person is not subject, or potentially subject, to speci \201 ed provisions of the Mental Health Act in a way that makes them ineligible. There is no advance decision, or decision of an attorney or deputy which makes the proposed deprivation of liberty impossible. In other circumstances, consider using the Mental Health Act 1983 to admit mentally disorde red patient who lack capacity to consent. 630 Chapter 15 Chapter 00 Pediatric emergencies Pediatric problems also covered elsewhere in this book: b Consent 28 b Poisoning 179 b Incu bation periods of infectious diseases 220 b Childhood infectious diseases 222 b Meningitis 224 b Gastroenteritis/food poisoning 226 b Infestations 230 b Analgesia in speci \201 c si tuations 280 b Nasal diamorphine 281 b Local anesthesia in children 287 b Sedation 309 b In structions after minor head injury 367 b Tetanus prophylaxis 410 b Earache 550 b Sore throa t 554 The pediatric environment Primary assessment and resuscitation of the sick child Standard i mmunization schedule Venous access and venepuncture Intra-osseous infusion Resuscitation of the newborn Cardiopulmonary resuscitation of the newborn Pediatric basic life support Chok ing from a foreign body Anaphylaxis in children Pediatric advanced life support Pediatric a dvanced life support notes Children with abnormal heart rates or rhythms Sudden infant deat h syndrome (SIDS) Problems of neonates and infants Skin problems in infants The febrile chi ld Purpuric rashes 632 634 636 638 640 642 644 646 648 650 652 654 656 658 660 662 663 664 631 Chapter 15 Pediatric emergencies Meningococcal disease How to perform a lumbar puncture Skin lesions in multisystem disease Pediatric ENT problems Stridor: upper respiratory infections Severe acute asthma in childre n Acute bronchiolitis Whooping coughND TBND and cystic \201 brosis Pneumonia Fits, febril e convulsions, and funny turns Status epilepticus Diabetic ketoacidosis Urinary tract infec tion (UTI) Renal failure Haematuria Poisoning in children Prevention of pediatric poisoning Abdominal pain in children Inguinal and scrotal swellings Foreskin problems and zip entrap ment The limping child The painful hip Osteochondritis Major pediatric trauma Injury preven tion Resuscitation of the injured child Considerations in pediatric trauma Head injuries in children Pediatric fractures and dislocations Approach to limb injuries in children Pediat ric upper limb injuries Pediatric lower limb injuries Child abuse Presentation of child abu se Management of child abuse 666 670 672 674 676 678 682 684 685 686 688 690 691 692 694 695 696 697 698 700 702 704 706 708 710 711 712 714 716 718 720 722 726 728 730 734 632 CHAPTER 15 Pediatric emergencies The pediatric environment Dealing with children Children are not little adults. They differ from adults anatomically, physi- ologically, emotionally, and in the spectrum of pathologi cal conditions to which they are susceptible. It is natural for those hospital staff who ha ve not previously dealed with children to be slightly apprehensive about treating them, par ticularly when they are distressed or seriously unwell. Be guided by more experienced staff , who are often adept at dealing with children as patients (and very often as parents as we ll). Such staff are particularly good at recognizing children who are seriously unwell \200\224 listen carefully to what they have to say. There is no substitute for expe- rience , but practical courses aimed at managing emergencies in children (eg Advanced Pediatric Li fe Support (APLS)) are highly recommended. These courses deservedly devote much time to the recognition of seriously ill or injured children, according to whether or not they are phy siologically deranged. Consider each child according to expected \200\230normal \200\231 p hysiological values (see Table 15.1 ). Children do not always respond in the same way to illness as adults. They are particularly likely to be frightened of doctors, nurses, and hospitals. Do not waste the opportunity to make important observations (respi- ratory rate, pattern, and effort, behavior, conscious l evel, color, and parental interaction). Spend time talking to children to reassure them and win their con \201 dence before starting any examination or performing any procedure (unl ess, of course, they require emergency resuscitation). Lowering yourself to their physical level will make you less intimidating. Involve the parents from the start (see below). Wher e appropriate, allow children to relax and play with toys. Play therapists can be particula rly helpful providing distraction during procedures. Dealing with parents Parents are patients too. They are likely to be understandably upset a nd worried. Take time to explain to the parents exactly what is happening to their children at all stages. Obtain appropriate consent, but do not delay life-saving measures. For the sake of both parents and children, try to allow parents to remain with their children as mu ch as possible. This is especially important during resuscitation where an experienced memb er of the nursing staff should be allocated to look after and explain to parents what is ha ppening. If the presence of the parents is impeding the progress of the resuscitation, gent ly ask them to leave. Analgesia Differences between adults and children do not diminish the need to provide adequ ate analgesia for children. Reassurance is often an important component, but be honest and do not be tempted to tell to a child that a painful procedure (eg emergency insertion of an intravenous (IV) cannula) will not produce any pain or discomfort \200\224 this will simp ly cause the child to lose con \201 dence. 633 THE pediatric ENVIRONMENT Weight estimation All children should be weighed when they require treatment in the ED. Thi s is as important as the vital signs in children. In an emergency, use a Broselow tape or o ne of the formulas for estimating children \200\231s weight. The following formula estimate s a child \200\231s weight based upon age (between 1 and 10 years): weight in kg = (age in years + 4) \227 2 so a 6-year old child will weigh: (6 + 4) \227 2 = 20kg This formula often underestimates the weight of many children in the UK or other developed countries but it may overestimate the weight of children from other regions. A formula usin g mid-arm circumference (MAC) has been developed in Asia 1 and is: weight in kg = (mid-arm circumference in cm \200\223 10) \227 3 so a child with a 15cm MAC will weigh: (15 \200\223 10) \227 3 = 15kg. Drug doses Do not estimate \200\230rough doses \200\231 of drugs for children based on kno wledge of adult doses. Instead, use the weight and age of a child, together with a referenc e source (eg BNF for Children http://bnfc.org/bnfc ) to determine the appropriate dose. Preparation for resuscitation Find out where the pediatric resuscitation equipment is kept and how it works. Learn the pediatric resuscitation guidelines and practice basic life supp ort (BLS) and other procedures on manikins. Ask your local resuscitation of \201 cer for h elp with training. Knowledge of normal (expected) physiology at various ages will help you to evaluate sick children in the ED. Table 15.1 Normal (expected) physiological values at different ages * Age (years) Respiratory rate Heart rate Systolic BP <1 30 \200\22340 110 \200\223160 70 \200\22390 1 \200\2232 25 \200\22335 100 \200\223150 80 \200\22395 2 \200\2235 25 \200\22330 95 \200\223140 80 \200\223100 5 \200\22312 20 \200\22325 80120 90 \200\223110 > 12 15 \200\22320 60 \200\223100 100 \200\223120 Expected systolic BP = 80 + (age in years \227 2) mmHg. * Adapted from APLS. 1 Cattermole GN et al . Mid-arm circumference can be used to estimate children s weights . Resuscitation . 2010 . Available at: http://dx.doi.org/10.1016/j.resuscitation.2010.05.015 . PMID: 20619953 . 634 CHAPTER 15 Pediatric emergencies Primary assessment and resuscitation of the sick child Caring for a sick child is a dauntin g task. Get experienced help early; call for senior ED, pediatric, and ICU/PICU help if you are alerted that a sick or injured child is being brought to the ED. Perform a primary assessment of Airway, Breathing, Circulation, and Disability to identify and treat life-threatening problems as they are found in order to maintain vital functions before disease speci \201 c therapies are started. Early recognition and treatment is esse ntial to avoid cardio- respiratory arrest with its poor outcome. Airway Assess patency by looking, feeling, and listening. Resuscitate: if there is no air movement, perform chin lift or jaw thrust. If there is stil l no evidence of air movement, give rescue breaths using an appropriately-sized bag-valve-m ask device. If the child is breathing, listen for stridor, and look for recession. Breathing Assess the effort of breathing by measuring the respiratory rate, looking for int ercostal recession and accessory muscle use, and listen for gasping, stridor, wheeze, and g runting. Assess the ef \201 cacy of breathing by looking for chest expansion, auscultation of the c hest, and measuring SpO 2 . Assess the effects of respiratory failure by assessing mental s tatus and by measuring the heart rate (increases with hypoxia, but bradycardia is a pre-ter minal sign) and examining skin color (hypoxia causes pallor, cyanosis is a late sign). Redu ced breathing effort may indicate exhaustion (a pre-terminal sign), cerebral depression, or neuromuscular disease. Resuscitate : give high \202 ow O 2 to any child with respiratory dif \201 culty or hypoxia. If respiration is inadequate, support with basic airway care a nd bag valve mask ventilation and get senior ED/ICU/PICU help to provide a de \201 nitive airway (tracheal intubation and IPPV). Circulation Assess heart rate (bradycardia is a late sign of cardiovascular failure) pulse volume, capillary re \201 ll, BP (hypotension is a pre-terminal sign), skin tem- perature. Look for the effects of circulatory failure: tachypnoea, mottled cold skin, poor urine out put, agitation, and drowsiness. Resuscitate: give high \202 ow oxygen (O 2 ) to all shock ed patients. Gain IV/IO access, take blood samples and give 20mL/kg of crystalloid. Re-asse ss and repeat if necessary. 635 PRIMARY ASSESSMENT AND RESUSCITATION OF THE SICK CHILD Disability Any problem with \200\230ABC \200\231 can affect \200\230D \200\231. Assess conscious level. Initially, categorize according to AVPU scale: A \200\224 Alert V \200\224 responds to Voice P \200\224 responds to Pain U \200\224 Unresponsive Check pupil size, reaction and equality. Assess GCS (or children \200\231s equivalent \200 \224 see b Head injuries in children, p.716) and posture ( \202 oppy, decerebrate, decorti cate, etc.). Check BMG. Resuscitate: a child who does not respond to voice has an urgent need to secure the airway. Treat hypoglycaemia and \201 ts, and get senior help urgently. After initial evaluation and intervention, a more detailed approach to iden- tify speci \201 c problems should follow. Re-assess ABCD frequently to assess progress and detect dete rioration. Undertake a secondary assessment by obtaining a full history (from parents, para medics, teachers and witnesses) and undertaking a detailed physical examination. 636 CHAPTER 15 Pediatric emergencies Standard immunization schedule The UK Department of Health actively encourages immunization for children according to the standard schedule shown below. 1 The recom- mended timing of the early immunizations is a compromise between trying to protect children whilst they are at most risk and delaying it until immunization is likely to be most effective. Children w ho have completed a course of immunization against a particular disease are obviously less likely to present with that disease. Unfortunately, a signi \201 cant proportion of childr en are still not receiving standard vaccines (Table 15.2 ). Carefully enquire exactly which immunizations the child has received (information is often available from the child \200 \231s GP or health visitor). Failure to follow the recommended schedule may result in the c hild presenting with an otherwise unusual disease. Table 15.2 Standard childhood vaccines Age Vaccine 2 months Diphtheria, tetanus, pertussis, polio, Hib, pneumococcal 3 months Diphtheria, tetanus, pertussis, polio, Hib, meningitis C 4 months Diphtheria, tetanus, pertussis, polio, Hib, pneumococcal, meningitis C 12 months Hib, meningitis C 13 months Measles, mumps, rubella, (MMR), pneumococcal 3 \200\2235 years Diphtheria, tetanus, pertussis, polio, MMR 13 \200\22318 years Tetanus, diphtheria, polio May also be given in infancy, if appropriate. The Hib vaccine Haemophilus in \202 uenzae , a small Gram \200\223ve bacillus, has been r esponsible for the deaths of many young children. Type b has been implicated most frequentl y in serious pediatric disease, causing meningitis, pneumonia, cellulitis, and most, partic ularly, acute epiglottitis. The Haemophilus B ( \200\230Hib \200\231) vaccine has dramatica lly reduced the incidence of epiglottitis. Pneumococcal vaccine This was introduced as routine in the UK in 2006. 1 Department of Health . Immunization against infectious disease - The Green Book . HMSO, London , 2007 . Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publication s/ PublicationsPolicyAndGuidance/DH_079917 . See also: BNFC . 637 STANDARD IMMUNIZATION SCHEDULE Reactions to immunizations Vaccination is frequently wrongly blamed for symptoms caused by incidental viral illness. However, mild reactions, such as swelling and ery- thema at the i njection site, are relatively common following administration of a variety of immunizations . These respond to symptomatic treatment and an expectant approach. Severe anaphylactic rea ctions, involving airway obstruction or circulatory collapse are uncommon, but require prom pt and aggressive treatment ( b Anaphylaxis, p.42). Immunization in other countries If a child who normally lives outside the UK attends the ED , enquire carefully about their vaccination history. Likewise, if you are working outside t he UK, make sure you know the local immunization schedule as this can have a signi \201 ca nt impact on the type of communicable disease seen, particularly in children. Immunization in the ED If a child attending the ED has not been immunized against diphtheri a, tetanus, and pertussis and needs tetanus immunization, give the \200\230triple vaccine \200\231 (DPT) to avoid repeated injections. Inform the GP about any immunizations given. Table 15.3 Pediatric milestones 1 (after allowance for preterm delivery) 2 months Eyes follow movement. Smiles and makes noises when talked to 3 months Holds object placed in hand 3 \200\2234 months Turns head to sound 6 months Sits on \202 oor with hands forwards for support Transfers object from one hand to the other 9 \200\22310 months Crawls 12 months Walks with one hand held; says 2 or 3 words with meaning 13 months Walks unaided 18 months Makes tower of 2 or 3 bricks 21 \200\22324 months Joins 2 or 3 words together to make sentence 2 years Can build a tower of 6 or 7 bricks 2 years Knows full name and gender; can stand on tiptoes 1 See: Illingworth RS. The Normal Child . 10th edn. Churchill Livingstone, Edinburgh, 1991. 638 CHAPTER 15 Pediatric emergencies Venous access and venepuncture Venepuncture Needles frighten children. Topical anesthetic c ream (eg tetracaine \200\224 b p.288) is useful whenever the need for blood sampling is no t urgent. 4 % tetracaine (Ametop , amethocaine) anesthetizes the skin and d pain, but sh ould be applied for 30min before venepuncture and for 45min before can- nulation. Identify prominent veins at 2 separate sites, apply cream and cover with an adhesive \201 lm dress ing, then let the child play. As in adults, if an IV cannula is inserted, it should be possible to obtain samples of bloo d via this: even if aspiration fails, blood will often drip out. The amount of blood sample d depends upon the size of the child and laboratory requirements, remembering that total bl ood volume is only 80mL/kg. Check requirements and obtain the appropriate bottles before at tempting venepuncture. Neonates FBC and U&E can be performed on capillary samples obtained from heel pricks. Ask a n assistant to hold the foot and ankle \201 rmly to encourage venous engorgement, then sm ear white soft paraf \201 n on the heel and prick it with a lancet. Collect drops of blood into prepared capillary sample tubes. Toddlers and infants Aspirate via a 23G butter \202 y needle in the hand or forearm. This allows the needle to stay in the vein, despite the child moving. Samples of 1mL are usually required. Older children Use a 21G butter \202 y needle. IV cannulae The route chosen to obtain venous access will depend upon the available veins a nd urgency of the problem. First attempt to insert an IV cannula percutaneously into an upp er limb vein. Once inserted, \202 ush the cannula, then secure it with adhesive tape, a s plint, and bandage. In general, the fol- lowing sizes of cannulae are appropriate: \200 2 4G (orange/yellow) : neonates and infants. \200 22G (blue) : toddlers and small children. \200 20G (pink) or 18G (green) : older children. Smaller cannulae are designed so the ne edle does not protrude much beyond the end of the cannula. This means that once a \200\230 \202 ashback \200\231 is obtained, the tip of the cannula may already be within the vein: advancing the needle further may puncture the other side of the vein and exit it. If attem pts to insert a cannula into the hand or arm fail, it may be possible to use veins in the f eet, ankle, or in the scalp (useful in neonates, but \201 rst ensure that the intended ta rget is not the super \201 cial temporal artery). In an emergency, allow a maximum of 90se c and if still unsuccessful then gain intra-osseous access ( b p.640), which is quick, easy , and reliable. Other venous access routes (eg central, femoral) require specialist trainin g, are time-consuming and are associated with signi \201 cant complications (see opposite) . Give \202 uids by infusion pump or pediatric infusion set to avoid over-transfusion. 639 VENOUS ACCESS AND VENEPUNCTURE Other routes of venous access Femoral lines The femoral vein lies medial to the artery in t he groin. It allows rapid venous access to be obtained and is particularly useful in cardia c arrest where physical constraints (eg several resuscitating staff) restrict access to the neck. Complications include sepsis (use strict aseptic technique), i risk of thrombosis an d damage to other structures including the hip joint. External jugular vein cannulation is an option in children in whom spinal injury is not a c oncern. Place the child 15 \200\22330 head down and turn the neck to one side. The vein runs super \201 cially and caudally over the sternocleidomastoid at the junction of its mi ddle and lower third. Ask an assistant to compress the vein distally to distend and immobil ize it. Central venous access The techniques (and complications) are similar to those in adults ( b p.56), except that smaller equipment is needed. The safe insertion of central lines in chi ldren requires considerable experience and training, and often requires ultrasound guidance , which is sometimes unavailable in a resuscitation situation. Other routes are usually mor e appropriate during resuscitation. \200\230Cut downs \200\231 (eg long saphenous vein at the ankle) may be performed during r esuscitation, but can be time-consuming. In infants, the long saphenous vein is located hal f a \201 nger breadth superior and anterior to the medial malleolus. For children it is o ne \201 nger breadth superior and anterior to the medial malleolus. Umbilical venous acce ss can useful in newborn resuscitation ( b p.645). 640 CHAPTER 15 Pediatric emergencies Intra-osseous infusion If urgent venous access is required, but not obtained within 90sec b y per- cutaneous venous puncture, strongly consider using the intra-osseous route. Fluid an d drugs given into the medullary cavity of long bones rapidly reach the central venous circ ulation. Gaining intra-osseous access is reasonably easy and can be performed quickly. It i s particularly useful in young children, but may be used in all ages, including adults. Indications include major burns and trauma, cardiac arrest, and septic shock. Contraindications include infection or fracture at (or proximal to) the insertion site, ips ilateral vascular injuries, multiple unsuccessful attempts, osteogenesis imperfecta, osteop etrosis. Equipment Intra-osseous needles are usually of 16 \200\22318G and have a central metal styl et attached to a handle. A battery powered mechanical driver (EZ-IO) with pediatric or adul t intra-osseous needles is available and can be used to insert the needle to a speci \201 c depth, possibly reducing complications such as compartment syndrome. It can be used in ch ildren weighing more than 3kg. Site of insertion First choice is the proximal tibia 2.5cm below the tibial tuberosity on t he \202 at anteromedial surface (thus avoiding the epiphyseal growth plate). If this rout e is not available, because of local infection or trauma, use the distal tibia (proximal to the medial malleolus), distal femur (3cm above the lateral lower femoral condyle on the an terolateral surface), or the anterolateral proximal humerus at the greater tuberosity (Fig. 15.1 ). Manual intra-osseous needle insertion technique \200 Support the limb on a pad or blanket . \200 Sterilize the skin and use an aseptic technique. A small skin incision may be needed. Firmly grasp the handle and use a twisting motion to advance the needle and stylet through the cortex of the bone. (Note that some intra- osseous needles are designed with a thread a nd so require a rotatory, not an oscillatory, action). Aim at 90 to the bone surface, or slightly away from the epiphyseal growth plate. Stop w hen the slight \200\230give \200\231 of the medullary cavity is felt. \200 Remove the st ylet and try to con \201 rm correct placement by aspirating bone marrow (use this to check BMG or cross-match). If aspiration is not possible, the needle may still be correctly positioned: attach a prime d 3-way tap with extension set and \202 ush the needle and 3-way tap with 10mL of 0.9 % s aline, and ensure that there is no swelling of the surrounding soft tissues. Although connecting it to IV tubing and a pressurized infusion bag may work, it is often mu ch more effective in children to give drugs and \202 uid by boluses using 20mL syringes a nd the 3-way tap). If necessary, immobilize with a plaster of Paris (POP) backslab applied carefully to the posterior leg (eg for transportation to a PICU). 641 INTRA-OSSEOUS INFUSION Mechanical intra-osseous needle insertion technique \200 Support the limb on a pad or bla nket. \200 Use a 15mm needle for patients weighing 3 \200\22339kg; a 25mm needle for pati ents more than 39kg; and a 45mm needle for obese adult patients. \200 Identify the insert ion point and place the needle, loaded into the mechanical driver (drill), at the insertion point. Insert the needle, perpendicular to the skin, up to the 5mm line. \200 Remove the driver and stylet, attach a primed 3-way tap with extension set and \202 ush the needle and 3-way tap with 10mL of 0.9 % saline. Attach the giving set and secure as for manually inserted intra-osseous needles. Use the blood taken from an intra-osseous needle for BMG or cross matching, but not for FBC (automated blood counters may give spurious results). If using an intra-osseous needle in responsive patients, in \201 ltrate 1 % lidocaine into the skin before insertion, and cons ider administering 1 \200\2232mL of 2 % lidocaine slowly into the needle before beginning t he infusion to minimize pain (maximum 3mg/kg lidocaine in children). Complications of intra-osseous access \200 Extravasation of \202 uid and compartment sy ndrome. \200 Infection (cellulitis or osteomyelitis). \200 Iatrogenic fracture. \200 Fat or bone micro-emboli. \200 Fractures and/or epiphyseal growth plate injury. Intra-oss eous needles must be removed within 24hr to minimize the risk of infection and other compli cations. Conventional IV access should be secured as soon as possible after intra-osseous n eedle insertion. Fig. 15.1 Tibial intra-osseous access. 642 CHAPTER 15 Pediatric emergencies Resuscitation of the newborn Neonatal resuscitation is usually undertaken by pediatricians, but unexpected deliveries require other personnel to initiate resuscitation. Fortunately, most newborn babies do not need resuscitation. The discomfort of being born into a hostile environment provides the major initial stimulus to breathe. Ideally, any baby requiring res uscitation should be treated in a warm room with an overhead heater. Call urgently for expe rienced help. Approach (see Fig. 15.2 ) Make sure the cord is securely clamped and then dry the baby, rem ove the wet towels and wrap the baby in dry towels. Very preterm babies (<28 weeks) should be wrapped in food grade plastic as rapidly as possible without drying. Assess color, tone, breathing by chest movement (auscultation at birth is unreliable), and heart rate (best as sessed by steth- oscope placed over the apex). Repeat assessments every 30sec during resusc itation. Traditionally, an Apgar score (ranging from 0 \200\22310, based upon assessment of heart rate, respirations, muscle tone, re \202 ex irrita- bility, and color) at 1 and 5mi n is calculated, and used to assess newborn babies. However, do not delay resuscitation to calculate the score. A healthy baby will have good tone, will cry within a few seconds of delivery and have a he art rate of 120 \200\223150/min, and will become rapidly pink during the \201 rst 90sec. Less healthy babies will have poorer tone, slower heart rates, and may not establish adequa te respiration by 90 \200\223120sec. The most sick will be pale, \202 oppy, apneic, and b radycardic. Airway Open the airway by placing the baby \200\231s head in the neutral position (with the neck neither \202 exed nor extended). Because of the large occiput, this will require a towel under the shoulders of the baby. Avoid hyper- extension of the neck as this can occlu de the pharyngeal airway. Very \202 oppy babies may also need either chin lift or jaw thr ust. Remove visible meconium or secretions using a pediatric Yankauer sucker. Breathing If the baby is not breathing adequately by 90sec, give 5 in \202 ation breaths ( pressures of 30cm water for 2 \200\2233sec). Ventilate a term baby with air, but use oxygen for premature and/or hypoxic neonates. If the heart rate increases, this indicates success ful ventilation of the lungs. If the baby is apnoeic, continue ventilation at 30 \200\22340 breaths/min until self-ventilating. If the heart rate does not increase, then the most lik ely cause is that the lungs have not been in \202 ated. Recheck head position and consider a jaw thrust and longer in \202 ation time. If the airway is obstructed, consider an orop haryngeal airway, laryngoscopy and suction. Repeat the 5 in \202 ation breaths. If the hea rt rate remains <60/min or absent despite good chest movement, start chest compressions. 643 RESUSCITATION OF THE NEWBORN Dry the baby Remove any wet towels and cover Start the clock or note the time Birth AT 30 s Assess (tone), breathing and heart rate ALL If gasping or not breathing: Open the airway Give 5 inflation breaths Consider SpO2 monitor ing STAGES 60 s Re-assess If no increase in heart rate look for chest movement ASK: If chest not moving: Recheck head position Consider 2-person airway control and other airwa y maneuvers Repeat inflation breaths Consider SpO2 monitoring Look for a response Acceptable* pre-ductal SpO2 2 min 60% 3 min 70% 4 min 80% 5 min 85% 10 min 90% If no increase in heart rate look for chest movement DO When the chest is moving: If heart rate is not detectable or slow (<60 min \200\2231) Start chest compressions 3 compressions to each breath YOU NEED Reassess heart rate every 30s If heart rate is not detectable or slow (<60 min \200\2231) c onsider venous access and drugs HELP? Fig. 15.2 Algorithm for newborn life support. From Resuscitation Council (UK). Newborn Life Support , 2010. See www.resus.org.uk 644 CHAPTER 15 Pediatric emergencies Cardiopulmonary resuscitation of the newborn Chest compression (only to be started after su ccessful lung in \202 ation). Grip the chest in both hands in such a way that two thumbs can press on the lower third of the sternum, (just below the intermammary line) with the \201 ngers over the spine at the back (Fig. 15.3 ). Aim for a rate of 100/min, and to depress the antero-posterior (AP) dia meter of the chest by a third. Use a chest compression to in \202 ation ratio of 3:1 . Using encircling fingers Fig. 15.3 Method of CPR in the newborn. Tracheal intubation Treat continuing apnoea with tracheal intubation using a 3mm tube (2.5m m in premature babies). Precede intubation by pre-oxygenation with bag valve mask ventilati on for 30sec. Drugs Only use drugs if there is no signi \201 cant cardiac output despite effective lung in \202 ation and chest compression. Give drugs intravenously via an umbilical vein cathet er or intra-osseous needle. \200 Give adrenaline 10mcg/kg (0.1mL/kg of 1 in 10 000 if the re is no initial response. If this is ineffective the dose may be increased to 30 mcg/kg (0 .3mL/kg of 1 in 10 000). Give sodium bicarbonate 1 \200\2232mmol/kg (2 \200\2234mL of 4.2 % solution/kg) when there is no cardiac output despite all resuscitative efforts or in profound or unresponsive brady cardia. Hypoglycaemia is a potential problem for all newborns and BMG is unreliable when reading <5 mmol/L. Take blood sample to con \201 rm and treat immediately with a bolus of 2.5mL/kg of 10 % glucose. 645 CARDIOPULMONARY RESUSCITATION OF THE NEWBORN Suspect hypovolaemia if : very pale baby, pulseless electrical activity (PEA), history of a ntepartum hemorrhage, placenta praevia, or vasa praevia, or unclamped cord. Give 10mL/kg 0. 9 % saline followed by O \200\223ve blood, repeated as necessary. Atropine and calcium have no role in newborn resuscitation. Venous access \200\224 the umbilical vein The easiest and fastest method of obtaining veno us access in the newborn is to cannulate the umbilical vein. Identify the umbilical vein in the cut umbilical stump: it is the single large dilated vessel adjacent to the two constri cted arteries (Fig. 15.4 ). Prepare a 5F gauge catheter with 0.9 % saline and insert it 5cm into the umbilical vein. Suture and secure in place. Vein Arteries Fig. 15.4 Diagram of a cross-section of the umbilicus. If there are no signs of life after 10min of continuous and adequate resuscitation efforts, then discontinuation of resuscitation may be justi \201 ed; involve senior ED and neonata l staff in this decision. Meconium aspiration In the presence of meconium, do not attempt to aspirate the nose and mo uth of meconium as the head presents. If a baby is delivered with thick meconium and is unr esponsive at birth (absent or inadequate respiration, heart rate <100/min or hypotonia), pe rform laryngoscopy and clear meco- nium under direct vision using a wide bore catheter. Aim to intubate the larynx and apply suction to the tracheal tube which is then withdrawn. However, if intubation cannot be achieved immediately, clear the orophyarynx and start bag- valve-mask in \202 ation. If while attempting to clear the airway the heart rate falls <60 /min, stop airway clearance, give in \202 ation breaths and start ventilating the baby wit h a bag-valve-mask device. If meconium staining is present, but the infant is vigorous at birth, no special treatment is required immediately, but the infant should be closely observed. 646 CHAPTER 15 Pediatric emergencies Pediatric basic life support Follow the algorithm (Fig. 15.5 ). Note that the approach to c hoking is considered on b p.648. Evaluate responsiveness Check the child \200\231s responsi veness \200\224 gently stimulate and ask loudly \200\230are you alright? \200\231 Do not shake if you suspect cervical spine injury. If the child does not respond, shout for help get someone to go for assistance. Open airway Open the airway by head tilt and chin lift. Desirable degrees of tilt are neutr al <1 year and \200\230snif \201 ng the morning air \200\231 > 1 year. Do not press on th e soft tissues under the chin as this may block the airway. If it is still dif \201 cult t o open the airway, try a jaw thrust. If there is any suspicion that there may have been a n eck injury, instruct a second rescuer to manually immo- bilize it, and use either chin lift or jaw thrust alone. If this is unsuccessful, add the smallest amount of head tilt needed to open the airway. Check breathing Whilst keeping the airway open, look listen and feel for breathing for 10se c. If the child is not breathing or is making infrequent irregular breaths, carefully remov e any obvious obstruction, give 5 initial rescue breaths (with the rescuer taking a breath between each rescue breath). Rescue breaths For children > 1 year , whilst maintaining head tilt and chin lift, give bre aths mouth to mouth, pinching off the nose. Blow steadily for 1 \200\2231.5sec watching for the chest to rise. Take your mouth away, watch the chest fall and repeat this sequence 5 t imes. For the infant (<1 year) ensure the neutral position of the head and apply chin lift. Give mouth to mouth and nose breaths, ensuring a good seal. Blow steadily for 1 \200\2231. 5sec watching for chest rise. Take your mouth away, watch the chest fall and repeat this se quence 5 times. Dif \201 culty achieving an effective breath suggests airway obstruction. Open the mouth and remove visible obstruction (no blind \201 nger sweep), ensure appropri ate head tilt/chin lift and neck position. Try a jaw thrust if head tilt/chin lift has not worked. Try up to 5 times to give effective breaths. If still unsuccessful, move to chest c ompression.