sign of ventilatory distress. Effective breathing is demonstrated by adequate symmetrical chest movements and equal breath sounds on auscultation. Wheeze or grunting respiration may be apparent. A silent chest (for example, in asthma) is a bad prognostic sign indicating inadequate ventilation and imp ending respiratory arrest. Circulatory assessment A systematic assessment of the heart rate, skin color, temperature, capillary refill, and central and peripheral pulses should be performed. - Tachycardia may be due to many factors including pain and anxiety. It is also seen as part of the cardiovas cular response to infection and hypovolaemia. Bradycardia is a sign of cardiovascular decompensation. - Comparative volumes of the centra l and peripheral pulses will give an indication of peripheral circulatory shut down. Capillary refill is assessed by pressing the skin for 5 seconds, then counting the time for the skin color to return on the release of the pressure. A figure les s than 2 seconds is normal. Prolongation in the absence of a limb injury with circulatory c ompromise or hypothermia indicates circulatory compromise. Altered mental state leads to confusion, aggression, and obtundation. - Respiratory rate in creases due to hypoxia and progressive metabolic acidosis. Pre-terminal features include skin mottling and cyanosis. RECOGNITION OF ABC PROBLEMS1 503 Signs of respiratory illness - Tachypnoea - Use of accessory muscles - Wheezing or grunting respiration - Silent chest - Tachycardia - Bardycardia (pre-terminal event) - Skin pallor - Cyanosis - Decreasing level of consciousness. Disability The level of consciousness should be assessed using the AVPU system: A V P U Alert response to Voice response to Pain only Unresponsive A central painful stimulus such as pressing over the supra-orbital ridge is preferred. Peri pheral stimulation may not produce a response in the presence of a spinal cord injury. A ch ild who is a P or U responder is at risk of airway compromise due to the loss of protective airway reflexes. The child \200\231s posture should be recorded, for example, decerebrate (arms extended) or decorticate (arms flexed). Abnormal stiffness and floppiness should be recorded. Pupils sh ould be observed for size, shape, and reactivity. Unilateral dilatation in the presence of a head injury suggests an intracranial collection. Sinus bradycardia and an elevated blood pressure suggest raised intracranial pressure. Monitoring Vital signs must be observed including: - Pulse rate - Respiratory rate - Glasgo w Coma Scale (GCS) - Oxygen saturation - ECG trace - BM stix - End tidal CO2 (if intubate d). In the event of any deterioration, the primary survey should be repeated. All children with significant ABC problems should be regarded as having a time-critical emergency. CHAPTER 8 Pediatrics 504 The Glasgow Coma Scale voice component requires adaptation in younger children (see Fig. 8.2) Response elicited Score BEST EYE OPENING RESPONSE Open spontaneously React to speech React to pain No response 4 3 2 1 BEST MOTOR RESPONSE Moves normally and spontaneously or obeys commands Localizes pain Withd raws in response to pain Flexes abnormally to pain (decorticate movements) Extends abnormal ly to pain (decerebrate movements) No response 6 5 4 3 2 1 BEST \200\234VERBAL \200\235 RESPONSE Smiles, follows sounds and objects, interacts Cries consolably or interacts inappropriately Cries with inconsistent relief or moans Cries incon solably or is irritable No response 5 4 3 2 1 Fig. 8.2 Pediatric Glasgow Coma Scale. This page intentionally left blank CHAPTER 8 Pediatrics 506 Management of ABC emergencies Airway - Manual maneuvers including chin lift or jaw thrust. The head should be maintained in the neutral position in neonates and the \200\230sniffing the morning air \200\231 position in older children. (see Figs 8.3 and 8.4). - Inline stab ilization of the cervical spine is necessary in trauma. - Aspiration of any vomit or secret ion. - Removal of foreign bodies under direct vision \200\224DO NOT perform a finger sweep. Oropharyngeal airway insertion if there is no gag reflex present. - Consideration of Bag \200\223Value \200\223Mask (BVM) venlilatory support. - Consideration of endotracheal intub ation or needle cricothyroidotomy as appropriate (consider surgical cricothyroidotomy if child over 12 years of age). Notes An oropharyngeal airway, if used, must be inserted following the contour of the tongu e and is best inserted using a tongue depressor (unlike in the adult where the airway is in serted upside down and then rotated). In a child, this procedure may damage the soft tissue s. The airway may induce wretching and vomiting. An appropriately sized nasopharyngeal airway may be used to support the airway and must be inserted carefully, following lubrication, to avoid damage to the nostrils and the adenoids . Endotracheal intubation should only be undertaken by trained, competent practitioners. All except completely unresponsive children will require drug-assisted rapid sequence induction to facilitate intubation. In the majority of cases, the airway can be opened as above and ventilation achieved using a 1- or 2- person bag-valve-mask technique until arrival at hosp ital. When all attempts to open the airway are unsuccessful, a needle crico- thyroidotomy may be performed. This will usually maintain life for a short period of time. The patient requires rapid transportation to hospital for a definitive airway. MANAGEMENT OF ABC EMERGENCIES1 507 Fig. 8.3 Manual airway maneuvers 1: Chin lift. The airway should be opened by chin lift and head tilt in the absence of trauma. Two fingers placed on the jaw prominence and lifting s lightly, extend the neck into the \200\230sniffing the morning air position \200\231. In i nfants, neck extension should be avoided. The child \200\231s face should remain parallel t o the surface on which they are lying. The soft tissues of the neck are easily compressed r isking airway obstruction. Blind finger sweeps should be avoided because of the risk of for cing a foreign body further into the airway. (Reprinted with permission from Greaves I et a l. (1995) Handbook of immediate care. Balliere Tindall). Fig. 8.4 Manual airway maneuvers 2: Jaw thrust. If cervical spine trauma is suspected (base d on mechanism of injury, pain in the neck, or neurological signs and symptoms), a jaw thru st maneuver should be undertaken. Two fingers are placed behind the angle of both sides of the jaw, gently pulling the jaw forward without tilting the head. Manual inline stabilizati on should be maintained and an appropriate cervical collar applied. In non-co-operative pat ients, reassurance, particularly from parents and friends, may facilitate treatment. In the combative child, the best approach is to attempt to maintain manual inline stabilization. (Reprinted with permission from Greaves I et al. (1995) Handbook of immediate care. Ballier e Tindall). CHAPTER 8 Pediatrics 508 Breathing - Ensure adequate oxygenation by using a trauma mask (a face mask with a non-rebreathe valve and an oxygen reservoir) to which oxygen, distributed at 15 litres per minute, is attached. COPD is not a problem in children and, therefore, there is no concern about giving high-flow oxygen. If the child remains hypoxic despite supplementary oxygen, consider bag-valve-mask assisted ventilation. Avoid over-ventilation as this will precipitate gastric distention and a high risk of regurgitation. Circulation - High-flow oxygen should be administered to all patients with significant blood loss. Vascular access should be achieved by inserting the largest possible cannula into the biggest available vein. Intraosseous access should be the access of choice in the collapsed and/or hypovolaemic younger child, although it is effective in all age gr oups. Transfer to hospital should not be delayed pending vascular access which should be undertaken en route. At the time of vascular access, blood should be taken for glucose estimation. The initial fluid bolus for a shocked child is 20ml per kg of warmed crystalloid. When usin g the intraosseous route, it is necessary to use a syringe and 3-way tap to achieve adequat e infusion. Disability - The management of disability relates to effective ABC management and the determination of a blood glucose level to exclude hypoglycaemia. Inadequate airway management (hypoxia), ineffective ventilation, and circulatory compromise (hypovolaemia) all contribute to significant secondary brain injury. Environment - Children are prone to hypothermia in view of their relatively large exposed body surface area (head in small babies) and their inability to maintain homeostasi s. Excessive cooling of burns in children invariably causes hypothermia. - The child knocked d own in the street should be covered appropriately to preserve body temperature. Conversely, the febrile child should have unnecessary clothes removed and should not be kept in an over-warm environment. This page intentionally left blank CHAPTER 8 Pediatrics 510 Pediatric emergencies Respiratory emergencies These are common, and whilst many produce mil d symptoms, they can be life-threatening. Children differ from adults in their ability to c ompen- sate for respiratory compromise by virtue of their different anatomy and physiology. Anatomical and physiological variations in infants and small children include: - Obligator y nasal breathing (in children younger than 6 months) - A short neck with a large head - An anterior larynx (the airway and breathing can be easily affected by neck position and external pressure) A large tongue (many children have large tonsils) - A smaller diameter airway which require s a lesser degree of swelling to cause obstruction A trachea narrowest at the cricoid ring - Mainly diaphragmatic breathing - A more compliant chest wall (retraction may compromise effective respiration) Loose primary dentition (age dependant). Diagnostic respiratory noises include - Stridor \200\224of sudden onset in an otherwise unf it child is suggestive of an acute foreign body infection; in an unwell child who appears t oxic and is drooling it suggests epiglotitis Harsh barking cough \200\224is suggestive of viral croup - Snoring noises \200\224suggest u pper airway obstruction (for example, from the tongue) in the unconscious child Bubbly noises \200\224suggest excessive secretions and an inability to clear the airway. Croup \200\224laryngotracheobronchitis Clinical features - Viral illness, more common in au tumn and spring - Initial history of cold, snuffles, mild pyrexia, and malaise - Followed b y typical harsh barking cough - Inspiratory stridor - Signs of respiratory distress includi ng increased respiratory rate, use of accessory muscles, nasal flaring, and wall recession mandate urgent hospital referra l. Treatment - The key to successful management is to aim for as little interference as possible, combined with regular monitoring Nebulized 1:1000 adrenaline in severe cases - Nebulized budesonide (2mg, for example as Pul micort Respules ) or oral dexamethasone (0.15mg/kg) may modify the illness within 45 minutes Mild cases can be managed at home; severe respiratory distress will require hospital admission pediatric EMERGENCIES1 511 Rarely, intubation may be necessary, but in the child who is becoming exhausted, this can usually wait for formal induction of anesthesia in hospital. Note The use of a nebulizer may worsen a child \200\231s distress rather than improve it (e specially in small children) and should be considered carefully if the child is stable and hospital transfer likely to be brief. If it is not possible to distinguish between croup and epiglottitis, admission is MANDATORY Epiglottitis Clinical features - Incidence is decreasing due to the use of haemophilus infl uenza B (HIB) vaccination Generally occurs in older children - Characterized by fever, stridor, (and if severe) drool ing, and later, an extended neck and an altered level of consciousness Usually no prodromal illness - Child appears pyrexial and toxic. Treatment - Do not examine or disturb the child - Keep the child comfortable, nursed on the parent \200\231s knee - Accompany the child to hospital - Collapse is usually due to airwa y obstruction in which case needle cricothyroidotomy is effective in achieving an airway as an emergency pending a definitive airway in hospital Treatment involves appropriate antibiotic therapy (usually a 3rd generation cephalosporin). Table 8.1 Distinguishing croup and epiglottitis Croup Epiglottitis Typical age <3 years 2 \200\2238 years Cause Viral (many different) Bacterial (H Influenza) Onset Slow Rapid Prodrome Usual Unusual Pyrexia (often >39oC) Toxicity Apyrexial Feeding Good Poor Cough Barking, harsh None Secretions Can swallow Drooling CHAPTER 8 Pediatrics 512 Bronchiolitis Clinical features - Commonly caused by the respiratory syncytial virus - Occu rs in children < 1year old - Premature and chronically unwell particularly at risk - Coryza precedes: - Cough - Increased respiratory rate - Wheeze - Intercostal recession Widespread crepitations - Hyperinflation of the chest - Mild pyrexia - Cyanosis if severe. Treatment - Appropriate positioning, sitting up \200\224for small children this can be achieved using a child safety seat Nebulized ipratropium bromide 125 g will reduce secretions - Antibiotics of no proven valu e - If severe respiratory distress, administer oxygen and transportation to hospital. pediatric EMERGENCIES1 513 Asthma Clinical features - Common medical emergency in childhood - Common association with atopy and wheeze in infancy - Diagnostic feature is expiratory stridor - May be classified as mild, moderate, severe, or life-threatening - Severity determined by clinical features, peak expiratory flow rate (PEFR) (children over 5), and pulse oximetry. Clinical classification Mild asthma - Minimal signs - Wheeze detected on auscultation only - Dry cough at night or after exercise is common - Heart rate and respiratory rate normal - PEFR greater than 75% of best or predicted value - Oxygen saturation above 95%. Moderate a sthma - Audible wheeze - PEFR 50 \200\22375% of best or predicted - Mild increase in heart and respiratory rate - Mild degree of intercostal recession and use of accessory muscles - Oxygen saturation above 90% - May have difficulty in completing long sentences. Severe asth ma - Inability to talk or feed - Respiratory rate greater than 50 breaths per minute (2 \200\22310 years) - Intercostal and sternal recession/use of accessory muscles - Heart rate greater than 140 beats per minute - Oxygen saturation less than 90% - PEFR 33 \200\22350% of best or predicted. Life-threatening asthma As for severe but with sinister additional signs including: - Exhau stion - Silent chest - Depressed conscious level - Central cyanosis and bradycardia precede cardiorespiratory arrest - Oxygen saturation < 85% - PEFR <33% predicted. Management Treatment should follow a stepped plan depending on the severity of the symptoms . Mild asthma - Usually managed in the community - Under parental guidance, 2 puffs from a metered dose inhaler delivering a beta 2 agonist, using a spacer if required Repeat beta 2 agonist if no response after 30mins - If symptoms remain, refer to hospital. CHAPTER 8 Pediatrics 514 Note Oral steroids (prednisolone 2mg per kg to a maximum of 40mg) can be considered if ther e is no response to 24 hours of regular (4 \200\2236hrly) inhaled bronchodilator therapy. Moderate asthma - Children will be mildly hypoxic and should be given high-flow oxygen pending other treatment Beta 2 agonist should be given through a nebulizer driven by oxygen - Oral steroids should be prescribed in all patients with moderate asthma (prednisolone 2mg per kg to a maximum of 40mg) - If no improvement after 30 minutes, repeat beta 2 agonist and transportation to hospital If transportation is delayed, repeat beta 2 agonist on a regular basis. Severe asthma - Requires urgent management and hospital transfer - Hypoxia should be treate d with high-flow oxygen - Salbutamol 2.5mg (<5years) or 5mg (>5 years), nebulized (driven b y 100% oxygen), repeated as required Oral steroids (prednisolone 2mg per kg to a maximum of 40mg) - If vomiting (or child unable to take tablets), prescribe intravenous hydrocortisone (2mg per kg) Nebulized ipratropium bromide (250 \200\223500 g) should be added after the beta 2 agonist Monitor carefully and frequently during transportation to hospital. Note In view of the potential problems with its use, intravenous aminophylline should only be used in hospital. Life-threatening asthma - As for severe asthma Also Consider Salbutamol 5 g/kg intravenously (if available) - Bag-valve-mask assisted ventilation - Adv anced airway measures Transportation urgently to hospital requesting appropriate medical personnel to be present on arrival. High pressures risk the development of a pneumothorax or regurgitation due to gastric dilat ation. Always consider pneumothorax or tension pneumothorax in acute deterioration of asthma. pediatric EMERGENCIES1 515 Pneumonia The range of causative organisms is wider in children than in adults. In the newb orn, common organisms include E coli (and other gram negatives), haemolytic streptococci, a nd Chlamydia trachomatis. Causes in infancy include viruses (most commonly, respiratory syn cytial virus \200\224RSV), Pneumoccocus, haemophilus, and, more rarely, Staphyloccocus aure us. Older children are more likely to be infected with bacteria including those listed abov e and Mycoplasma pneumonia. - Typically presents with pyrexia, cough (usually dry initially , then productive), and general malaise Similar physical signs to pneumonia in adults including: Tachycardia - Tachypnoea - Dullness to percussion - Crepitation. Signs may be difficult to elicit, especially in younger children, and a chest X-ray may be needed to localize pathology. Other symptoms which may occur in children include: - Neck st iffness - Abdominal pain. Patents with significant respiratory distress require hospital re ferral, otherwise administer a cephalosporin, penicillin, amoxycillin, or erythromycin. If there is any doubt about the diagnosis, hospital transfer for investigation is necessary. CHAPTER 8 Pediatrics 516 Inhaled foreign body This is a relatively rare condition and the most likely site of impact ion is the cricoid ring \200\224the narrowest part of a child \200\231s airway. Severe resp iratory distress due to complete obstruction occurs, which untreated will progress to coma and death. Treatment should follow the Resuscitation Council pediatric choking algorithm (see Fig. 8.5). If conscious: 5 back blows 5 thrusts chest for infant, abdominal for child >1year - If unsu ccessful, alternate back blows and thrusts - Between steps, the child \200\231s mouth shoul d be inspected for a displaced foreign body If unsuccessful, undertake a needle cricothyroidotomy. If unconscious: attempt 5 rescue breaths - Then start CPR (do not assess circulation) - Bet ween steps, the child \200\231s mouth should be inspected for a displaced foreign body If unsuccessful, undertake a needle cricothyroidotomy. The Heimlich maneuver should not be undertaken in children under 1 year old due to the risk of abdominal injury Assess severity Ineffective cough Effective cough Unconscious Conscious Encourage cough Open airway 5 breaths Start CPR 5 back blows 5 thrusts (chest for infant) (abdominal for child > 1) Continue to check for deterioration to ineffective cough or relief of obstruction Fig. 8.5 Pediatric choking algorithm. Reprinted with permission from the Resuscitation Coun cil (UK) (2005) Resuscitation guidelines. pediatric EMERGENCIES1 517 Convulsions Causes include: - Secondary to a febrile illness or are idiopathic in origin - Hypoxia - Hypoglycaemia - Poisoning - Intracranial infection or tumors - Failure to take or absorb medication in known epileptics. Febrile convulsions commonly occur between the ages of 6 months and 6 years and are normally of a short duration and stop spontaneously. Howev er, they cause intense distress to parents (particularly the first time). The majority of fits are grand mal seizures, although focal or unilateral fits can occur. S tatus epilepticus occurs when a fit has continued for 30 minutes or fits occur so frequentl y that the patient does not recover between them. Deaths occur due to hypoxia, airway obstr uction, and aspiration of vomit. Treatment Whatever the cause of the seizure, the treatment in the pre-hospital care situati on follows the ABC system: - Ensure the safety of the patient - Establish a patent protecte d airway - Do not place anything in the mouth or between the teeth if the jaw is clenched Administer high-flow oxygen, 10 \200\22315 litres per minute using a non re-breathe mask and a reservoir bag In the event of the child not breathing, commence bag-valve-mask ventilation In the case of fitting associated with a febrile illness, intravenous access is not usually necessary providing the fit has stopped; remove excess clothing to co ol the child In children who continue fitting, those with repeated fits, and those in status epilepticus: - Vascular access should be obtained (intraosseous access may be the route of choice) Intravenous diazemuls 0.2mg/kg should be given followed by a saline flush If intravenous access cannot be obtained, rectal diazepam should be given (5mg for children less than 5 years of age, 10mg in children more than 5 years of age) Blood sugar estimation should be undertaken and appropriate treatment given if indicated In all cases, except where the child is a known epileptic and their parents or carers are experienced in post-ictal care, the child should be transported to ho spital. Children with febrile convulsions should be transferred to hospital for investigation of th e cause of the fever. Pyrexia may be treated with rectal paracetamol (see p.357 for doses). CHAPTER 8 Pediatrics 518 Metabolic emergencies In children, the common metabolic emergencies invariably relate to th e diagnosis and treatment of diabetes. However, in the child less than 6 months of age, in- born errors of metabolism can present with fitting and unconsciousness. Hypoglycaemia Most cases of hypoglycaemia are due to excessive insulin administration which is normally accidental (but occasionally deliberate, especially in adolescents). The diagn osis should be made by the use of a BM Stix . Treatment - Mild/moderate hypoglycaemia (biz arre behavior or mild confusion): oral glucose or hypostop More severe cases (unable to protect their own airway, reduced conscious level or unconscio us): 2.5ml per kg of 10% dextrose intravenously over 5 \200\22310 minutes or intramuscular glucagon 500 g under 8 years (or under 25kg), 1mg over 8 years (or over 25kg). Hyperglycaemia This is most commonly associated with ketoacidosis. This may be the first pr esentation of diabetes and there may be a history of thirst, polydipsia, polyuria, and gene ral malaise. Associated symptoms include nausea, vomiting, and dehydration. Pre-hospital tr eatment will depend on the patient \200\231s clinical state. Depending on the time to hospi tal, rehydration may be commenced with normal saline, 20ml per kg given over 1 hour. Follow ing consultation with the receiving hospital, intramuscular insulin may be given at rate of 0.05 units per kg. pediatric EMERGENCIES1 519 The unconscious child Common causes of coma include: - Hypoxia - Hypoglycaemia/hyperglycaem ia - Post-ictal state - Drugs/poisoning - Alcohol - Trauma - Raised intracranial pressure i ncluding meningitis encephalitis, and blocked shunts in children with hydrocephalus Sepsis (including meningococcal). In all cases, assessment and treatment should follow the ABC system. Airway - Consider airway adjuncts or endotracheal intubation if necessary. Breathing - Administer high-flow oxygen 10 \200\22315 litres per minute with a non re-breathe mask and reservoir bag Consider 2-person bag-valve-mask assisted ventilation. Circulation - Assess and treat shock as necessary. Disability - Don \200\231t Ever Forget Glucose - If blood sugar is less than 4mmol/liter, g ive glucose 10%, 2.5ml per kg intravenously Assess pupils, look at focal signs; pinpoint pupils suggest opiate ingestion Consider and treat opiate overdose with naloxone, where appropriate. Exposure Look for evidence of a non-blanching rash suggestive of meningococcal septicaemia. If present or suspected, give benzylpenicillin (under 1, 300mg; 1 \200\2239 years, 600mg; 10 years and over, adult dose). Babies are sometimes described as being \200\230floppy \200\231 or children, inattentive o r listless. These are significant observations and, particularly in the case of the floppy child, indicate serious illness. Common causes of loss of consciousness in children Epilepsy/convulsions - Hypoglycaemia - Hypoxia (organ failure or any cause of shock includi ng trauma) - Hypercapnia - Hypothermia - Head injury - Meningitis/encephalitis - Metabolic - Poisoning. CHAPTER 8 Pediatrics 520 Diarrhea and vomiting Gastroenteritis is the leading cause of pediatric illness and death i n small babies. Vomiting may be a symptom of gastroenteritis or of other conditions includi ng pyloric stenosis (males approximately 6 weeks old), intussus- ception, intestinal obstru ction, urinary tract infections, meningitis, and febrile illnesses. Diarrhea is usually infective, though occasionally can be due to food intolerance. Children frequently present dehydrated. Treatment depends on the level of dehydration which can be assessed as less than 5% (mild), 5 \200\22310% (moderate), and greater than 10% (severe). Mild dehydration - Treat with oral rehydration solutions (balanced salt glucose solution) \200\224usually 75ml per kg over 4 \200\2236hours Consider using Dioralyte \204 or other proprietary rehydration solution if available. Moderate dehydration - May respond to oral rehydration - Alternatively, normal saline or Ri ngers lactate given intravenously at 20ml/kg in addition to normal requirements Consider transfer to hospital. Severe dehydration - Intravenous or intraosseous therapy - Normal saline or Ringers lacate 20ml/kg over 30 minutes (1hour in infants) Then 70ml/kg over 3 hours (5 hours in infants) - Transfer urgently to hospital. Table 8.2 Assessment of dehydration Mild Moderate Severe Drinking Normal Thirsty Poorly Skin pinch Normal Slow return Very slow return Eyes Normal Sunken Very sunken Mucous membranes Normal Dry Very dry Level of consciousness Normal Irritable Lethargic/coma pediatric EMERGENCIES1 521 Meningitis Meningitis is fortunately relatively rare. The mode of presentation varies based on the patient \200\231s age. Under 3 years Diagnosis in this age group requires a high index of suspicion since symptoms may be non-specific, (for example, not feeding and listlessness). Classical signs (neck st iffness, photophobia, headache, and vomiting) are often absent. Clinical features include: Distended fontanelles may be absent if the child is dehydrated - Pyrexia (however, the chil d may be afebrile) - Nausea - Poor feeding - Listlessness, drowsiness, or irritability - Co nvulsions - Apnoeic or cyanotic attacks - Nausea and vomiting. Older children The older the child, the more likely they will present with clinical feature s similar to adults including: - Neck stiffness - Headaches - Photophobia - Vomiting - Pyre xia - Rash (indicative of septicaemia). CHAPTER 8 Pediatrics 522 Meningococcal septicaemia Meningococcal septicaemia may present without signs and symptoms of meningitis. Similarly, meningococcal meningitis may present without evidence of septicae mia. The classical features of meningococcal septi- caemia include: - Non-blanching petechi al rash - The child may be unwell out of all proportion to the physical signs Pre-hospital treatment follows the ABC system: High-flow oxygen 10 \200\22315 litres per minute using a non-rebreathe mask and a reservoir bag Ventilatory support, if required - Intravenous access (peripheral vain or intraosseous) - B enzylpenicillin 1200mg over 10 years of age - 600mg between 1 and 9 years of age - 300mg in children less t han 1 year of age Consider intravenous fluid replacement 20ml/kg normal saline of ringer lactate given over 20 \200\22330minutes but DO NOT delay transfer Transfer urgently to hospital - A cephalosporin is usually given in hospital. Erythromycin is appropriate in penicillin allergy. In established meningo- coccal septicaemia, ensure th at the patient is genuinely penicillin allergic. If not, give penicillin. If genuine allerg y is present, transfer immediately to hospital for alternative therapy if this is not immed iately available. pediatric EMERGENCIES1 523 Poisoning Poisoning may be willful or accidental. Young children may ingest anything they c an get into their mouths and adolescents with psychological problems may take deliberate an d potentially serious overdoses. The possibility of poisoning should be considered in any c hild with unexplained illness. Management - Identify the poison if possible; send samples to A&E for identification \200\224do not send vomit samples Consider specific antidote if available \200\224see p.406 - Do not induce vomiting; do not give charcoal - Monitor ABC depending on clinical picture - Transfer to hospital for assess ment and monitoring. CHAPTER 8 Pediatrics 524 Pediatric life support Pathogenesis of cardiac arrest in children Children seldom suffer pr imary cardiac arrest which is commonly secondary to airway and breathing problems producing hypoxia, acidosis, and terminal bradycardia. Cardiac arrest, therefore, has a very poor ou tcome. However, sudden infant death syndrome (SIDS) and trauma are responsible for most pre -hospital deaths in children. The classical presentation is an unconscious, pulseless, apno eic child. Preventative measures include the recognition of the acutely unwell child, promp t intervention, and transfer to hospital. Pediatric respiratory arrest is an infrequent pre-hospital occurrence making skill retention difficult. Pediatric resuscitation Follows the same principles as in adults: - Establish an open airwa y - Achieve effective ventilation of the lungs - Achieve effective oxygenation of the blood and re-establish the circulation. Airway management Simple airway techniques - Head tilt and chin lift or jaw thrust in traum a - Use of airway adjuncts Oropharyngeal airways will overcome obstruction caused by the tongue. An airway that is too short will be ineffective and, if too long, may induce vomiting. Insertion should follow t he contour of the tongue using a tongue depressor. Nasopharyngeal airway may be used in semi-conscious casualties. Insertion involves lubricat ion of the tube, and gentle rotatory movements in a direction perpendicular to the face. Ca re is necessary to avoid trauma to the nares and adenoids. Oropharyngeal airway Correct size is measured from the center of the mouth to the angle of the jaw. Nasopharyngeal airway Correct size is measured from the tip of the nose to the tra gus. Notes Avoid overextension of the neck in infants and small children which will, in itself, cause airway obstruction. If a nasopharyngeal airway is not available, a shortened encuffed endotracheal tube can be used. pediatric LIFE SUPPORT1 525 Advanced airway techniques - The laryngeal mask airway (LMA) may have a role in pre-hospita l pediatric resuscitation, although it has not been formally evaluated. It must be remembered that the LMA does not properly protect the airway and that there is a risk of aspiration o f stomach contents. Tracheal intubation is the gold standard for securing and protecting the airway but require s specific training and skill retention. In selected patients, intubation may be facilitate d using rapid sequence induction of anesthesia. Specific equipment suitable for the child \200\231s age and size is essential. The internal diameter of the endotracheal tube can be calculated from the formula: age 4 Internal diameter = + 4 Neonates require a 3.0 or 3.5. It is essential to have available the size above and below t he predicted size. The appropriate length of the tube is calculated from the formula: age 2 Length (cm) = + 12 Uncut tubes are used to avoid the risk of the tube being too short. Pediatric tubes up to a size of 6mm are uncuffed and these should be used on children up to the age of 8 years to avoid damage to the cricoid ring. Intubation is achieved by: - Pre-oxygenating the child - Applying gentle cricoid pressure t o bring the larynx into view - Inserting the tube 2 \200\2234cm below the inlet or, alterna tively, until the mark on the tube is at the level of the cords Checking tube placement by Auscultation over the chest and stomach - Pulse oximetry using a pediatric probe - End tida l CO2 monitoring Securing the tube in place (noting its position at the lips). Attempts at intubation should take less than 30 seconds. If unsuccessful, the child should be re-oxygenated by bag-valve -mask ventilation before the process is repeated. The current evidence base suggests intubation in pre-hospital care is possible but confirms no added benefit over effective bag-valve-mask ventilation with or without airway adjuncts . Whilst RSI will secure the airway, the low frequency of performing this skill in children i n the pre-hospital scene requires a need of training, competence, and skill retention which is beyond most practitioners. The establishment of trained practitioners to deliver advanc ed airway care (RSI) should be considered for specific circumstances and remote areas, but the skill, otherwise, is likely to remain the remit of the specialist, usually an anestheti st. CHAPTER 8 Pediatrics 526 Needle and surgical cricothyroidotomy For children less than 12 years old needle cricothyro idotomy should be performed using a 14-gauge or 16-gauge cannulae with a Y connection and a n oxygen source delivering 5 to 10 litres per minute. In older children, a surgical cricoth yroidotomy may be appropriate using a small vertical skin incision, a horizontal incision t hrough the cricothyroid membrane, and a Spencer Wells or similar instrument to dilate the o pening to permit the insertion of a size 6 tracheostomy tube or similar sized cuffed ET tub e. pediatric LIFE SUPPORT1 527 UNRESPONSIVE ? Shout for help Open airway NOT BREATHING NORMALLY ? 5 rescue breaths STILL UNRESPONSIVE ? (no signs of a circulation) 15 chest compressions 2 rescue breaths Fig. 8.6 Pediatric basic life support algorithm. (Single rescues CPR is given at 30 compres sions to 2 ventilations; dual rescues CPR is given at 15 compressions to 2 ventilations \200\224up to the onset of puberty.) Reprinted with permissions from the Resuscitation Coun cil (UK) (2005) Resuscitation Guidelines. CHAPTER 8 Pediatrics 528 Breathing - If the child is spontaneously breathing, administer oxygen 10 \200\22315l/min via a face mask using a non re-breathe valve and an oxygen reservoir bag. If spontaneous respirations are absent or inadequate, consider mouth-to-mouth or, in young children, mouth-to-nose rescue breaths or use a pocket mask. Ventilation is best achieved using a bag-valve-mask technique with an oxygen reservoir. Notes The pediatric and infant reservoir bags have pressure valves at 20cm of H2O to protec t the patient \200\231s lungs. DO NOT overventilate \200\224use enough air to cause modest chest wall rise Circulation - Unless there is an obvious peripheral vein, consider intraosseous access 2 \200\2233cm below and medial to the tibial tuberosity. The use of a 3-way tap and syringe f acilitates infusion. The tracheal route can be used if iv an io access is not possible. - Normal saline is the r esuscitation fluid of choice given in a bolus of 20ml per kg. Notes Most drugs (except bretyllium) and fluids can be given by the intraosseous route. Marrow aspirate can be used to determine the hemoglobin, urea, and electrolytes and blood sugar. It can also be used for cross-matching. For endotracheal use, optimal drug doses are yet to be defined; effec- tiveness appears to be volume dependant . After resuscitation from cardiac arrest, fever should be treated aggressively Otherwise No attempt should be made to warm the child as a temperature of 32 \200\22334 con fers survival benefit pediatric LIFE SUPPORT1 529 Treatment algorithms (non-shockable rhythms) Asystole Asystole is the most common rhythm of cardiac arrest in infants and children and is usually secondary to hypoxia. In infants, br adycardia (less than 60bpm) does not produce adequate cardiac output to maintain life and s hould be treated in the same way as asystole (See algorithm). - Ensure that the rhythm is a systole (check gain and connections) - Administer adrenaline: initial dose, 10mcg per kg of 1:10,000 solution or 100 g per kg via an ET tube until another route is available - Followed by 3 \200\2235 minutes of CPR at a rate of 30 compressions to 2 ventilations to achieve 100 compressions per minute Administer repeat doses of adrenaline every 3 \200\2235 minutes: using 1:10,000 solution Repeat cycles of CPR - Attempt tracheal intubation and verify tube position - Monitor the p atient. Note Atropine no longer forms part of the asystole protocol but may be indicated in asystol e due to vagal overactivity (for example, following airway maneuvers). The dose is 20 g/kg (maximum 1mg in children, 2mg in adolescents). Electromechanical dissociation The most common cause of an absent pulse with ECG evidence o f organized cardiac activity in children is shock. In all cases of non-VF arrest, treatable causes must be identified: Four Hs - Hypoxia - Hypovolaemia - Hypothermia - Hyperkalaemia/hypokalaemia. Electrolyte ab normalities cannot be confirmed pre-hospital, but in patients where this is possible (for e xample, known calcium channel blockers or renal dialysis patients), treatment with calcium is appropriate. Four Ts - Tension pneumothorax - Tamponade - Toxic and thermal - Thromboembolism. CHAPTER 8 Pediatrics 530 VF or pulseless VT VF is less common in children but may occur secondary to electrocution, drug overdose/poisoning (especially tricyclic antidepressants), hypothermia, and heart dise ase (usually congenital). - Defibrillate ONCE at 4 joules per kilogram \200\224all further shocks are delivered at 4 joules per kilogram - 2 minutes CPR (30:2) without pulse check - Defibri llate ONCE at 4 joules per kilogram - Give adrenalin intravenously, 10 g per kg, if VT/VF persists - Defibrillate up to three times at 4 joules per kilogram - Give 100 g per kg (an d for all subsequent doses) - Repeat CPR - Repeat adrenaline every 3 \200\2235 minutes - In tubate as soon as possible after the first three shocks. In children, look for the underlyi ng cause of cardiac arrest \200\224for example, hypothermia, drugs (tryptizole overdosage). Notes Amiodarone is effective in VF/VT refractory to defibrillation. An AED may be used in children over 8 years, with an electrical output attenuator (50 \200\22370J). pediatric LIFE SUPPORT1 531 Unresponsive ? Commence BLS Oxygenate/ventilate Call Resuscitation Team CPR 15:2 Until defibrillator/monitor attached Assess rhythm Shockable (VF/puseless VT) Non-Shockable (PEA /Asystole During CPR: - Correct reversible causes* - Check electrode position