Table 5.1 Contribution of different body parts to total body surface area at different ages Body part area/total body surface (%) at ages Body part <1yr 1 \200\22311yrs >11yrs Head 18 13 9 Trunk (front) 18 18 18 Trunk (back) 18 18 18 Arm 9 9 9 Leg 14 16 18 Genitalia 1 1 1 Symptoms Features of hypovolaemia, pain, and signs of inhalation injury may be present. 05_McClure_05.indd 66 11/15/2012 12:18:58 AM BURNS 67 Symptoms of inhalation in the lung \200 \200 \200 \200 \200 \200 \200 Tachypnoea. Stridor. Crackles. Wheeze. Cough. Respiratory distress. Black sputum. Other burn symptoms Brain \200 \200 \200 \200 \200 \200 Confusion. Dizziness. Headache. Restlessness. Coma. Seizures. Skin \200 \200 \200 Facial burns. Nasal burn. Cherry-red color. Etiology You should \201 nd out the following about the injury: \200 \200 \200 \200 Its mechanism. The duration of exposure. Environmental factors (closed or open space). Loss of consciousness during the accident. Investigations Minor burns There is no need for routine investigations in children with min or burns, i.e. burns that are: \200 \200 partial thickness and <5% body surface; full thickness and <2cm or 2 (unless hands, face, genitals, joints involved). Major burns \200 \200 \200 \200 Arterial blood gas. Carboxyhaemoglobin level. Blood count and cross-match. Blood urea, crea tinine, and electrolytes may be tested. Consider child protection issues! 05_McClure_05.indd 67 11/15/2012 12:18:58 AM CHAPTER 5 Emergency and high dependency care 68 Burns: treatment Initial treatment Follow a standard protocol \200 ABC: endotracheal intubation may be needed. Assume that there is carboxyhaemoglobin level a nd PaO2. Give humidi \201 ed 100% oxygen until results are available. Follow serial arteri al blood gasses and CXRs. Consider almonds, or if the accident is \201 re-related, or if there is metabolic acidosis with raised anion-gap. In infants with burns >10% of body surfa ce area, or children with >15% burns, consider an IV bolus of normal saline (10 \200\22320m L/kg). Further \202 uid resuscitation should be directed toward maintaining a urine outpu t of 0.5 \200\2232mL/kg/h. In patients with >25% burns use the Parkland \200\231s formula a s a guide to \202 uid therapy Box 5.3. if there is evidence of inhalation then pulmonary toilet with carbon monoxide poisoning and measure \200 cyanide exposure and poisoning if the breath smells of Box 5.3 Parkland \200\231s formula 0 \200\22324hr after burn Crystalloid \200 \200 4mL/kg per 1% burn Use 50% of this volume in the \201 rst 8hr 24 \200\22348hr after burn Crystalloid + colloid \200 \200 Use 50 \200\22375% of \202 uid requirements on day 1 Add albumin (1g/kg/day) to maintain serum level above 2g/dL Analgesia: pain must be treated. First ensure that ventilation, oxygenation, and perfusion are adequate. Use IV analgesics if required. injuries: do a secondary survey of associated traumatic injuries. Other Assess for cardiac and skeletal muscle injury in electrical accid ents. In chemical burn, wash and neutralize the chemical. Place a Pulse limitations in carb on monoxide poisoning. Eyes: antibiotics if required. Give tetanus \200 nasogastric tube (NGT) and urinary catheter. Follow outputs. oximetry and cardiac monitorin g are useful, but remember their examine the eyes for burn or abrasion, and treat with topical immunoprophylaxis if required. 05_McClure_05.indd 68 11/15/2012 12:18:59 AM BURNS: TREATMENT 69 05_McClure_05.indd 69 11/15/2012 12:18:59 AM CHAPTER 5 Emergency and high dependency care 70 Sepsis Sepsis is bacterial infection of the bloodstream accompanied by signs of systemic to xicity. In this section we will consider the recognition and spe- ci \201 c treatment for sepsis. Shock and respiratory failure are covered else- where in the chapter (see b pp.48, 54). Clinical assessment Clinically, there may be fever in the older child, but be aware that fe ver or hypothermia can be the presenting feature in the infant. Perfusion is usually poor a nd there may be evidence of shock and coagulopathy (i.e. petechiae or purpura). Investigations All organ systems may be involved in sepsis so it is important to perform th e following tests. Blood \200 \200 \200 \200 \200 \200 FBC with differential. Coagulation state. Serum electrolytes with urea and creatinine. Live r function tests. Arterial or capillary blood gas. In \202 ammatory markers (e.g. CRP and erythrocyte sedimentation rate (ESR)). Urine Urinalysis. Imaging \200 CXR. \200 Abdominal X-ray (AXR). Sepsis screen \200 Blood culture: that blood cultures may not be positive, so repeat when there is fever). Uri ne culture. Stool swab. CSF. Other cultures: catheters. bacteria (aerobic and anaerobic), virus, fungi. (Remember \200 \200 \200 respiratory; wound; and all ports of any indwelling Monitoring Ensure the ABCs. Then, the form and type of monitoring will be dictated by the p atient \200\231s condition. Start with: \200 \200 \200 \200 Continuous pulse oximetry. ECG monitoring. Intermittent BP monitoring. Hourly urine output. 05_McClure_05.indd 70 11/15/2012 12:18:59 AM SEPSIS 71 Therapy Antibiotics \200 When: trying to get a blood culture \201 rst. Should I do a lu mbar puncture? This can wait until you have stabilized the child \200\224you may even have to defer it if there is any coagulopathy. What: patient, as well as your local microbial \202 ora. In general, you can start with a third generation cephalosporin and use the follo wing antibiotics for speci \201 c groups of patients. do not delay the \201 rst dose because of tests, but it is worthwhile the choice of antibiotics you should use will depend on the Age <8 weeks Consider group B streptococcus \200\224ampicillin. Indwelling catheter Consider Staphylococcus aureus \200\224anti-staphylococcal cover that i s appro- priate in your institution. Intra-abdominal cause Consider gut anaerobes \200\224metronidazole, gentamicin. Immunosuppressed or oncological \200 \200 \200 Pseudomonas Fungi: Herpes, Varicella: : ceftazidime, gentamicin. amphotericin B. aciclovir. Cellulitis or fasciitis Consider group A streptococcus \200\224penicillin. 05_McClure_05.indd 71 11/15/2012 12:18:59 AM CHAPTER 5 Emergency and high dependency care 72 Altered level of consciousness See also b p.552. The brain can be injured in many ways. Its responses to injury, however, are uniform and include any combination of: \200 Altered l evel of consciousness (LOC). \200 Seizures or dystonia. \200 Impaired respiratory funct ion. \200 Loss of cardiovascular autoregulation. \200 Cerebral swelling. \200 SIADH. \200 Weakness. Take a note of: \200 When symptoms started, and their progression (gradual versus sudden). Possible ingestion or exposure to medication or toxins. Possible recent trauma, illness, or exposure to infectio n. History: seizures; diabetes; allergies; chronic illness. Family history/consanguinity. P revious altered LOC. \200 \200 \200 \200 Etiology Infectious causes \200 \200 \200 b pp.78 \200\22379, 720 \200\223721). Meningitis, encephalitis ( b p.719). Toxic shock ( Subdural empyema, cerebral abscess. Autoimmune Acute disseminated encephalomyelitis (ADEM) b p.520. Toxins See poisoning (b pp. 82 \200\22388). Neoplastic causes Brain tumors (b pp.662 \200\223665). Trauma \200 \200 concussion or contusion. Head injury: Hemorrhage: epidural; subdural; brain. Vascular causes \200 \200 AV malformation. Aneurysm, venous thrombosis. Metabolic causes \200 \200 \200 \200 \200 \200 \200 b p.96). Hypoglycaemia ( Diabetic ketoacidosis ( Electrolyte abnormalities. Inborn errors of metabol ism ( Hepatic encephalopathy. Hormonal abnormalities: Uraemic encephalopathy. b pp.98 \200\223101). b p.102). thyroid; adrenal; pituitary (b pp.424, 449). 05_McClure_05.indd 72 11/15/2012 12:18:59 AM ALTERED LEVEL OF CONSCIOUSNESS 73 Other \200 \200 \200 \200 \200 \200 \200 \200 Hypothermia. Hyperthermia. Seizures and post-ictal state ( Hypertension ( Hydrocephalus ( H ypoxia \200\223ischaemia. b p.714). Sepsis ( Intussusception ( b pp.506 \200\223507). b p.396). b p.535). b p.860). 05_McClure_05.indd 73 11/15/2012 12:18:59 AM CHAPTER 5 Emergency and high dependency care 74 Altered level of consciousness: clinical assessment Initial examination General examination can provide an explanation for the patient \200\231s state. General \200 signs: make a note of the adequacy and rate and depth of Vital respiration, the pulse rate and rhythm, BP, and body temperature. Medic-Alert that may indicate a longst anding medical problem. Skin: needle tracks. Breath: bracelet: search for a bracelet or tag, or other information examine for evidence of trauma, rash, petechiae, jaundice, and check for odors of alcohol, ketones, hydrocarbons, or toxins. Head and neck \200 if the anterior fontanelle is patent, a tense fontanelle indicates Head: raised ICP, whereas a sunken fontanelle suggests dehydration. Nose suggests basal sku ll fracture. and ears: leakage of blood or CSF; \200\230raccoon eyes \200\231 or Battle sign Pupils \200 \200 \200 Small Midsize Pinpoint commonly associated with opiates. Unequal the side of the dilated pu pil. Bilateral \201 xed dilated pupils: imply a poor prognosis, although similar pupils m ay be produced by mydriatics, barbiturate intoxication, and hypothermia. (2 \200\2233mm) reactive pupils: suggest metabolic cause of coma. (4 \200\2235mm) unreactive, midposition pupils: suggest midbrain lesion. (1 \200\2232mm) pu pils: indicate a pontine disorder, but are also pupils with one \201 xed and dilated: suggest a brain disorder on Fundi Examine for evidence of retinal hemorrhages and papilloedema. After the ABCs, a focused neurological assessment is needed (see Box 5.4). Look for evidenc e of increased ICP and potential site of intracranial lesion. Signs of raised ICP The signs of raised ICP include: \200 \200 \200 \200 \200 \200 Abnormal respiratory pattern. Unequal or unreactive pupils. Impaired or absent oculocephali c or oculovestibular responses. Systemic hypertension, bradycardia. Tense fontanelle. Abnor mal body posture or muscle \202 accidity. 05_McClure_05.indd 74 11/15/2012 12:18:59 AM ALTERED LEVEL OF CONSCIOUSNESS: CLINICAL ASSESSMENT 75 Box 5.4 Detailed neurological examination Pattern of respiration \200 Cheyne \200\223Stokes seen with metabolic disturbance, bilateral cerebral hemisphere dysfun ction, and insipient temporal lobe herniation Central with hypoxia \200\223ischaemia, hypog lycaemia, or lesion between low midbrain and midpons Ataxic respiration (irregular depth an d rate) can be caused by abnormality of the medulla and impending respiratory arrest Apneus tic breathing (gasping, respiratory arrest in inspiration) indicates pontine involvement (alternating apnoea and hyperpnoea) can be neurogenic hyperventilation (deep rapid respiration) can occur Eye movements \200 Roving disease Extra-ocular a supratentorial disorder Absence of intoxication Abnormality o f a destructive cerebral lesion and away from an irritative cerebral lesion. In a brainstem lesion the eyes are directed away from the side of the lesion Skew Ocular eye movements are seen in light coma without structural brain movements with coma suggests a metabolic disorder or movements suggests infratentorial disorder or drug of lateral gaze: the eyes are deviated toward the side \200 deviation is seen with posterior fossa lesions bobbing is seen in pontine lesions Lateral eye movement re \202 exes Lateral eye movements are mediated by brainstem structur es and re- quire an intact midbrain and pons. These are assessed clinically by: \200 re \202 ex (doll \200\231s eye): sudden turning of the head from one Oculocephalic side to the other normally causes conjugate deviation of the eyes in the direction opposite to tha t in which the head is turned. \200 Oculovestibular ear with the head held 30 above the horizontal normally causes conjugate deviation of the eyes toward the side of the irrigati on Do not test when the neck is unstable re \202 ex (cold caloric): cold water irrigated into the Motor function and posture \200 Decorticate legs in extension. This signi \201 es a lesion in the cerebral white matter, i nternal capsule, or thalamus Decerebrate are extended. Occurs with lesions from midbrain to midpons, and with bilateral anterior cerebral lesions. Can also be seen with metabolic abn ormalities, hypoxia \200\223ischaemia, or hypoglycaemia. rigidity: the arms are held in \202 exion and adduction, the rigidity: arms are extended and internally rotated. Legs 05_McClure_05.indd 75 11/15/2012 12:18:59 AM CHAPTER 5 Emergency and high dependency care 76 Altered level of consciousness: Glasgow coma scale As a summary of conscious state, the GCS score should be used (Tables 5.2 and 5.3). It is also a useful tool for monitoring changes . The full score is calculated from the sum of E + V + M. A score (cid:1)8 is used as a cri terion for endotracheal intubation in the head-injured. Table 5.2 Glasgow coma scale: scores for older children Response Score Eye opening (E) Spontaneous 4 To verbal stimuli 3 To pain 2 None 1 Best verbal (V) Orientated 5 Confused speech 4 Inappropriate words 3 Non-speci \201 c sounds 2 None 1 Best motor (M) Follows commands 6 Localizes pain 5 Withdraws to pain 4 Flexes to pain 3 Extends to pain 2 None 1 Reproduced from Teasdale G, Jennett B. (1974) Assessment of coma and impaired consciousness . A practical scale. Lancet Jul 13; 2(7872): 81 \200\2234, with kind permission from Elsevi er 05_McClure_05.indd 76 11/15/2012 12:18:59 AM ALTERED LEVEL OF CONSCIOUSNESS: GLASGOW COMA SCALE 77 Table 5.3 Glasgow coma scale: scores for infants Response Score Eye opening (E) Spontaneous 4 To speech 3 To pain 2 None 1 Best verbal (V) Coos and babbles 5 Irritable cries 4 Cries to pain 3 Moans to pain 2 None 1 Best motor (M) Normal 6 Withdraws to touch 5 Withdraws to pain 4 Abnormal \202 exion 3 Abnormal extension 2 None 1 Reproduced from Teasdale G, Jennett B. (1974) Assessment of coma and impaired consciousness . A practical scale. Lancet Jul 13; 2(7872): 81 \200\2234, with kind permission from Elsevi er 05_McClure_05.indd 77 11/15/2012 12:19:00 AM CHAPTER 5 Emergency and high dependency care 78 Altered level of consciousness: management Investigations Consider the following if the cause of the coma is unknown. Blood \200 \200 \200 FBC, clotting, and bleeding time. Glucose, electrolytes, urea, liver function tests, ammoni a, and lactate. Save two extra tubes of clotted blood for storage in the laboratory. Toxicology \200 \200 Urine, blood, gastric aspirate for ingestions. Serum lead and free erythrocyte protoporphyr in. Acid \200\223base Arterial blood gas. Microbiology Blood and urine cultures. Imaging \200 \200 Cranial CT scan. MRI particularly for posterior fossa or white matter lesions. Cranial imag ing should only be performed if the child is well enough to leave the emergency department, i.e. a full assessment has been undertaken, and the child is stable, or intubated if GCS<9 Electroencephalography Standard EEG. Lumbar puncture Defer LP until a CT scan has been obtained if there are signs of raised ICP or focal neurology, and until after intubation if GCS<9. Examine CSF for microscopy, cultu re, glucose, and protein (see also b pp.720 \200\223721). Meningitis \200 3 with a polymorphonuclear 20 \200\22320,000 white blood cells (WBC)/mm neutrophil leucocyte predominance. An elevated protein level >100mg/dL. Low glucose <2mmol/L (or <50% of plasma level). \200 Encephalitis \200 \200 3 with lymphocyte predominance. 20 \200\2231000cells/mm The presence of red blood cells (RBC) up to 500 cells/mm herpes sim plex virus (HSV) infection. CSF protein can be normal or mildly elevated. Glucose is usuall y normal (770% of plasma level). 3 suggests \200 Monitoring The form and type of monitoring will be dictated by the underlying cause of the patient \200\231s state. Generally, after initial evaluation, monitor hourly: \200 \200 Vital signs, pupil reaction, \202 uid balance. The GCS for neurological review \200\224in those with GCS 9 \200\22311 a gastric tube and urinary catheter may be needed. 05_McClure_05.indd 78 11/15/2012 12:19:00 AM ALTERED LEVEL OF CONSCIOUSNESS: MANAGEMENT 79 Treatment Follow a standard protocol \200 \200 ABC: Glucose: glucose (250 \200\223500mg/kg) should be given IV after a blood sample has be en taken for laboratory blood glucose testing. Speci \201 c the initial priority. whenever the cause of coma is not clearly obvious, 25% therapies should be considered (see Box 5.5). Box 5.5 Speci \201 c therapies See also b p.720 Meningitis \200 \200 Immediately begin the appropriate antibiotics (see Antibiotics, p.79) Dexamethasone (IV 150 micrograms/kg, qds for 4 days) if >3mths Encephalitis In the presence of a compatible clinical history, treat for HSV encepha- litis with aciclovir (IV 10mg/kg, tds for 10 \200\22314 days) Suspected raised ICP \200 \200 \200 \200 \200 (cid:1)8: rapid sequence endotracheal intubation GCS Ventilate to achieve normocapnia and n ormoxia Elevate the head of the bed to 30 Keep the head in the midline Mannitol (IV 0.25 \200\2231g/kg) and/or furosemide (IV 1mg/kg) SIADH secretion Limit the \202 uids to 67% maintenance Antibiotics Antimicrobial therapy is often given presumptively. The choice will de- pend on local epidemiology, public health, immunization, and antibiotic policy. In the comatose ch ild, consider the following. \200 <4 weeks: group B streptococcus, Gram \200\223ve bacteria, and Listeria Age monocytogenes: Recommend: ampicillin + aminoglycoside. Infants Streptococcus pneumoniae , Neisseria meningitides. Recommend: ampicillin + aminoglycoside/3rd generation cephalospor in. >3 Recommend: 3rd generation cephalosporin. 1 \200\2233 months: group B streptococcus, Gram-negative bacteria, months: Streptococcus pneumoniae, Neisseria meningitides. In the comatose older child where no CSF is available, a combination of antimicrobials to c over HSV, Streptococcus pneumoniae, and Mycoplasma pneumoniae infection is often prescribed . \200 \200 \200 Cefotaxime (IV 50mg/kg qds; maximum 12g/day). Erythromycin (IV 10mg/kg qds). Aciclovir (IV 10mg/kg, tds). 05_McClure_05.indd 79 11/15/2012 12:19:00 AM CHAPTER 5 Emergency and high dependency care 80 Status epilepticus Status epilepticus (StE) is a prolonged seizure lasting over 30min or re cur- rent seizures during which the patient does not fully regain consciousness within a 30 min period. However, in practical terms, once a child has been \201 tting for more than 5 min, the chances of the seizure lasting more than 30min are dramatically increased, and the refore the common practice is to start therapy at this point. The success of treatment depe nds on prompt recognition and treatment (see Box 5.6, also b p.505). Symptoms StE is classi \201 ed as convulsive (C) or non-convulsive (NC). NCStE is di- agno sed with electroencephalogram (EEG), and should be considered in the comatosed. Etiology The common causes of childhood StE include: \200 \200 \200 \200 \200 \200 \200 A regular occurrence in a child with a known/dif \201 cult epilepsy. Fever. Subtherapeutic anticonvulsant levels. Central nervous system (CNS) infections. Trauma. Poisoning. Metabol ic abnormalities. Note: in teenagers diagnosed with convulsive StE in the emergency depart- ment, who do not have a pre-existing disability, up to 50% will be having voluntary movements of psychologic al origin ( \200\230pseudoseizures \200\231). So con- sider whether it is de \201 nitely a genuine epileptic seizure. Investigations After emergency life-supporting therapies, useful diagnostic tests include: \200 Brain imaging: computerized tomography (CT), magnetic resonance imaging (MRI). EEG. Lumbar puncture* caution, see Blood: Arterial blood gas. Toxicology: Anticonvulsant levels in those on anticonvulsants. FBC and WBC differential. \200 \200 \200 \200 \200 \200 b pp.720 \200\223721; magnesium, electrolytes, calcium, glucose, and creatinine levels. blood and urine. Initial treatment Box 5.6 summarizes the treatments according to time after seizure begins. At any stage, if there is respiratory depression, intubate the trachea and support breathi ng. 05_McClure_05.indd 80 11/15/2012 12:19:00 AM STATUS EPILEPTICUS 81 Box 5.6 Anticonvulsants in status epilepticus 0 \200\2235min: ABC \200 Note time \200 Call for help \200 Consider whether it is a g enuine epileptic seizure \200 Check glucose \200 Establish IV access \200 Monitor vit al signs, especially pulse oximetry saturation \200 Give 100% oxygen via mask 5 \200\22315min: start anticonvulsants \200 \200 Use IV lorazepam (50 \200\223100micrograms/kg, up to 4mg) Rectal diazepam (0.5mg/kg, up to 10mg) or 15 \200\22320min: anticonvulsants If there is no response, repeat the dose of lorazepam or diazepam (if no IV access). Note if the child has been given a benzodiazepine already, e.g. paramed- ics, give only one dose. 15 \200\22335min: if seizure persists \200 \200 or Load with IV phenytoin (18mg/kg, at rate <1mg/kg/min) IV phenobarbital (18mg/kg, at rate <1 mg/kg/min) 45min: refractory seizure \200 \200 \200 \200 If seizures persist intensive care should be initiated Intubate the trachea and support bre athing Intensive care medications include midazolam and thiopentone EEG monitoring Once the seizure has stopped Whilst the child is convulsing there is a reasonable amount of oxygen perfusing the brain. Hence, the advice to parents that home oxygen is not indicated for the treatment of StE. However, once the convulsion ends, the child may have a respirat ory arrest. So this is the critical period for vigilance of ABC. Roll into the recovery pos ition, keep the oxygen run- ning, watch the SpO2, and other observations carefully. Do not transfer the child or perform potentially dangerous procedures, such as LP until the child has a GCS that is both improving and >9. 05_McClure_05.indd 81 11/15/2012 12:19:00 AM CHAPTER 5 Emergency and high dependency care 82 Poisoning The peak incidence of childhood accidental poisoning is between the ages of 2 and 3yrs. Most cases occur at home. In older children, accidental self- poisoning should be su spected as a possible suicide gesture. Etiology Parents usually know the name and often have a good idea of the amount of material ingested. Obtain the bottle or container of the ingestant. Get these details in the histor y. \200 \200 \200 Exact Preparation Probable maximum possible dose. Time Check name of the drug or chemical exposure. and concentration of the drug exposure. dose (by history) of drug ingested in mg/kg, as well as \200 since ingestion or exposure. the National Toxicology database. Symptoms and signs There are various signs and symptoms produced by poisoning. It is help- ful to consider the derangement in body systems and think of potential causes (see Box 5.7) . In addition, there are speci \201 c odors that may lead to diagnosis. Odors \200 \200 \200 \200 \200 \200 \200 Acetone. Alcohol. Bitter almonds (cyanide). Garlic (heavy metals). Oil of wintergreen (meth yl salicylates). Pears (chloral hydrate). Carrots (water hemlock). Diagnosis The likely type of poisoning may be indicated by its clinical effect (see Box 5.7 ). Bedside or laboratory tests should also be performed. \200 \200 \200 \200 \200 \200 \200 \200 \200 Urinary dip-tests and toxicology. Arterial blood gas. Blood glucose. Co-oximetry (carboxyha emoglobin level). Serum urea and electrolyte. Osmolar gap: [osmolality \200\223 (2 Drug le vels. ECG: X-rays: \227 Na) + urea + glucose]. 12-lead for assessment of rhythm and QT interval. abdomen to detect radio-opaque tablets (e.g. iron). 05_McClure_05.indd 82 11/15/2012 12:19:00 AM POISONING 83 Box 5.7 Clinical effect and causative drugs or poisons \200 Depressed cyclic antidepressants, alcohol, narcotics, nicotine Tachycardia Tachycardia anti depressants, hydralazine, iron, phenothiazine, theophylline and hypertension: clonidine erg otamine, ephedrine Bradycardia Bradycardia and hypotension: calcium-channel blockers, cloni dine, digoxin, narcotics, organophosphates, phentolamine, propranolol, sedatives Atrioventr icular channel blockers, clonidine, cyclic antidepressants, digoxin Ventricular \202 ecan ide, quinidine, procainamide), carbamazepine, chloral hydrate, chlorinated hydrocarbons, co caine, tricyclic antidepressants, digoxin, phenothiazine, theophylline Torsade antidepressa nts, lithium, phenothiazine, quinidine, sotalol with miosis: alcohol, barbiturates, bromide , chloral hydrate, Coma clonidine, ketamine, narcotics, organophosphates, phenothiazines Co ma with mydriasis: atropine, carbon monoxide, cyanide, cyclic antidepressants, glutethimide Hypoglycaemia: propranolol, salicylates Seizures: anticholinergic, antihistamines, camphor , carbon monoxide, chlorinated hydrocarbons, cocaine, cyanide, tricyclic antidepressants, i soniazid, ketamine, lead, lidocaine, meperidine, phenothiazine, phenylpropanolamine, propra nolol, theophylline anion gap (Na \200\223 [Cl + HCO3]) metabolic acidosis: alcohol, High carbon monoxide, cyanide, ethylene glycol, iron, isoniazid, methanol, salicylate, theophyll ine Low respiration: antipsychotics, carbamate pesticides, clonidine, \200 and hypertension: amphetamines, antihistamines, cocaine and hypotension: salbutamol, carbon monoxide, tricyclic \200 block: astemizole, -adrenergic antagonists, calcium- tachycardia: amphetamines, anti-arrhythmics (encainamide, de pointes: amantadine, antihistamines (astemizole), cyclic alcohols, insulin, oral hypoglycaemic agents, amphetamines, anticonvulsants (carbamazepine, phenytoin), anion gap: bromide, lithium, hypermagnesaemia, hypercalcaemia 05_McClure_05.indd 83 11/15/2012 12:19:00 AM CHAPTER 5 Emergency and high dependency care 84 Poisoning: management Initial treatment Follow a standard protocol for ABCD and seek advice from your regional or national poisons center. Gastrointestinal decontamination Avoid if a irway is unprotected. Otherwise consider the following. Activated charcoal \200 \200 or nasogastric: 1g/kg is used for substances that can be adsorbed. Oral Do not use when there is ileus, absent gag re \202 ex). Do not use after ingestion of alcohol, iron, boric acid, caustics, lithium, or electrolyte solutions. risk of aspiration (e.g. bowel obstruction, Gastric lavage \200 May be useful if the patient arrives within 1hr of ingestion (longer if salicylates or iron ). Do not use if there has been caustic or hydrocarbon ingestion. Do not use if co-ingestio n of sharp objects. The lavage is performed via a large bore gastric tube with normal salin e (15mL/kg/cycle, maximum 200mL/cycle) until the gastric contents are clear. \200 \200 Ipecacuanha \200 \200 \200 \200 \200 \200 \200 Useful within 30min of ingestion. (cid:2)6mths. Use 10mL for infants Use 15mL for children 1 \200\2232yrs. Use 30mL for child Do not use when there has been caustic ingestion. Do not use if the child has altered LOC or is at risk of seizures. After taking ipecacuanha the c hild should be placed in the prone or lateral position. (cid:2)12yrs. Bowel irrigation \200 25 \200\22340mL/kg/h Nasogastric polyethylene glycol solution (GoLYTELY for 4 \200\2236h r or until clear ef \202 uent) is useful after toxic iron, lithium, or lead ingestion. may be useful some hours after ingestion of enteric- GoLYTELY coated tablets (salicylates, calcium channel blockers, -blockers). Do not use in cases of coma when the airway is not protected. Do not use in cases of GI hemorrhage, obstruction, and ileus. \200 05_McClure_05.indd 84 11/15/2012 12:19:00 AM POISONING: MANAGEMENT 85 Enhanced elimination \200 Urinary alkalinization (pH 7 \200\2238) aids elimination of weak acids (salicylates, barbit urates). Use IV NaHCO \202 uids (1.5 \200\2232 times) with added NaHCO3. Beware of furthe r electrolyte disturbance. Haemodialysis is useful for low molecular weight substances that have low volume of distribution and low binding to plasma proteins (aspirin, theophylline, lithium, phenobarbitone, and alcohols). 3 (1 \200\2232mmol/kg) followed by increased maintenance \200 05_McClure_05.indd 85 11/15/2012 12:19:01 AM CHAPTER 5 Emergency and high dependency care 86 Poisoning: antidotes and substrates Antidotes and substrates are useful in only a minority of poisonings. Poison centers will provide exact advice. Antidotes and substrates Paracetamol (acetaminophen) \200 \200 Children taking >150mg/kg need assessment Take blood 4hr after ingestion and use nomogram. Give N-acetylcysteine if criteria are met. Check liver function tests (LFTs) and Internatio nal normalized ratio (INR) N-acetylcysteine: dose qds for 17 doses. IV used if GI bleeding. Repeat blood level at 24hr PO or NG loading 140mg/kg, then 70mg/kg/ Anticholinergics, antihistamines (diphenhydramine), plants (deadly nightshade, jimson weed, henbane), anti-Parkinsonian drugs, dilating eye drops, skeletal muscle relaxants \200 \200 Benzodiazepines: Physostigmine: central effects of agitation and seizures. Not for tricycli c antidepressant overdose, asthmatics, GI obstruction, genitourinary (GU) obstruction. Give slow IV 20micrograms/kg/dose (up to 500micrograms) over 5min. Repeat every 5min, but maxim um cumulative dose should be below 2mg. Have atropine available for cholinergic symptoms (0 .5mg for every mg of physostigmine). Response is rapid used for agitation and seizures (avoid phenytoin) useful for anticholinergic syndrome. It reverses Benzodiazepines: chlodiazepoxide, clonazepam, diazepam, temazepam \200 \200 If ABCs are stable there is little need to do more than observe . Reverses lethargy and com a. Not for tricyclic Flumazenil antidepressant or chloral hydrate overdose, or child with s eizure disorder on benzodiazepines. Give 10micrograms/kg over 1min (maximum 500micrograms/d ose, or 1mg overall). Response is rapid, but resedation may occur. May induce seizures -adrenergic antagonists: atenolol, esmolol, labetalol, propranolol \200 is useful for reversing bradycardia and hypotension. Give Glucagon 0.05 \200\2230.1mg/kg bolus, followed by 0.1mg/kg/h infusion Atropine hypotension persist after glucagon Cardiac pacing may be needed. If cardiac arrest occurs, massive dose s of adrenaline (epinephrine) may be required , isoprenaline, and amiodarone can be used if bradycardia or Calcium channel blockers: diltiazem, nifedipine, nimodipine, verapamil \200 Use hypotensi on unresponsive to \202 uids and calcium glucagon, amrinone, isoprenaline, atropine, and dopamine for 05_McClure_05.indd 86 11/15/2012 12:19:01 AM POISONING: ANTIDOTES AND SUBSTRATES 87 Give (100mg/kg of 10% solution) for hypotension and bradyarrhythmias Consider calcium chloride (20mg/kg of 10% solution) or calcium gluconate cardiac pacing Carbon monoxide (CO) \201 re; exhaust from fuel engines, furnaces, or burners; paint remo ver with methylene chloride \200 \200 \200 Ensure ABCs and give 100% oxygen Check COHb level Consider hyperbaric oxygen if COHb >40%, or if symptoms persist after 4h despite 100% oxygen Also consider cyanide toxicity if smoke inhalation Cyanide \200 \200 There are special kits for rescue that will be in Drugstore Sodium poisoning as well Sodium nitrate 3%: dose depends on Hb level, but do not give if CO thiosulphate 25%: dose depends on Hb level Digoxin \200 \200 \200 Measure serum drug level. Toxicity occurs with level >2ng/mL Check electrolytes, magnesium, thyroxine, and calcium Correct hypokalaemia (IV 0.5 \200\2231mmol/kg/dose as infusion 0.5m mol/kg/h over 2hr) If hyperkalaemic (>5mmol/L) give insulin, dextrose, sodium bicarbonate, and Kayexalate . Do not give calcium chloride or calcium gluconate because these potentiat e ventricular arrhythmias Digoxin-speci \201 c dysrhythmias, or supraventricular bradyarrh ythmias (if resistant to IV atropine 10 \200\22320micrograms/kg), hyperkalaemia, hypotensio n, heart block, and ingestion >4mg. Phenytoin may be used to improve AV conduction. Avoid q uinidine, procainamide, isoprenaline, or disopyramide if AV block present antibody (FAB fragments). Give for ventricular Ethylene glycol, methanol \200 Fomepizole 15mg/kg bd until levels (cid:1)20mg/dL): antidote for methanol and ethylene glyc ol. Indications: level (cid:2)20mg/dL, or high anion gap metabolic acidosis If not availabl e, use followed by infusion 100mg/kg/hr) Other agent: the case of methanol, also give folat e (50 \200\223100mg over 6hr) (loading 15mg/kg, then 10mg/kg bd for 4 doses, then ethanol (loading dose 0.6g/kg; load over 1hr pyridoxine 2mg/kg and thiamine 500micrograms/kg. In Iron \200 Measure serum concentration 2 \200\2236hr after ingestion. A level >350micrograms/dL is fre quently associated with systemic toxicity. If ingestion <20mg/kg no treatment needed Desfer rioxamine serious poisoning (i.e. based on symptoms, AXR, serum level >500micrograms/dL). C ontinue until symptoms have resolved : IV infusion 5 \200\22315mg/kg/hr in all cases of 05_McClure_05.indd 87 11/15/2012 12:19:01 AM CHAPTER 5 Emergency and high dependency care 88 Isoniazid For stopping seizure use pyridoxine (vitamin B6) 3 \200\2235g Lead \200 \200 (cid:2)70micrograms/dL Immediate intervention for blood level Oral chelation with dimercaptosuccinic acid (DMSA): kg/day divided every 8hr; next 14 days 20mg/kg/day divided every 12hr Parenteral chelation with British antilewisite (BAL): initial dose 75mg/ m2 deep IM; then 4hr later start CaNa2E DTA (1500mg/m2/day via continuous IV infusion for 48hr). If there is risk of cerebral oedem a, then give IM. BAL is continued simultaneously at 75mg/m2/dose IM 4-hourly for 48hr BAL i s suspended in peanut oil, and may cause haemolysis in patients with G6PD de \201 ciency \201 rst 5 days 30mg/ Methaemoglobinaemia: sulphonamides, quinines, phenacetin, nitrates, aniline dyes, naphthale ne \200 \200 Measure level and if >30% start treatment Methylene repeat dose (maximum total 7mg/kg) if s ymptoms present after 1hr Beware of methylene blue in G6PD de \201 ciency Consider hyperba ric oxygen or exchange transfusion if no response blue 1%: 1 \200\2232mg/kg (0.1 \200\2230.2mL/kg) IV over 5min. May \200 Narcotics: codeine, dextromethorphan, propoxyphene, pentazocine, butorphanol, methadone \200 Naloxone or via ETT 2mg (10micrograms/kg, if < 12yrs) inc to 100micrograms/ kg. Response is rapid and repeat doses or infusion can be used. useful for reversing coma caused by opiates. Give IV, IM, Organophosphates: pesticides \200 initial dose 20micrograms/kg (max 2mg) IV; then additional Atropine: doses if bronchorrhoea Pralidoxime: infusion for severe cases 25 \200\22350mg/kg/dose (up to 1g) IV; consider 10 \200\22315mg/kg/hr Phenothiazine \200 For extrapyramidal syndrome, IV over 5min. Also if life-threatening, IV (1 \200\2232 doses per day in children >3yrs) diphenhydramine: 1mg/kg/dose slow benzatropine 20 \200\22350micrograms/kg/dose 05_McClure_05.indd 88 11/15/2012 12:19:01 AM FLUID AND ELECTROLYTES 89 Fluid and electrolytes Normal \202 uid requirements All children with serious acute illne ss in hospital are given \202 uid and elec- trolyte solutions. It is important to match w hat you prescribe to what the child actually needs. There are a number of ways of calculati ng daily requirements, but the method we most commonly use is based on patient weight (see Box 5.8). Box 5.8 Calculating \202 uid and electrolyte requirements 24-hr \202 uid requirements \200 \200 \200 100mL/kg: +50mL/kg: +20mL/kg: for the \201 rst 10kg of weight for the second 10kg of weight for the remaining weight ab ove 20kg 24-hr electrolyte requirements \200 2 \200\2234mmol/kg \200 Sodium: Potassium: 1 \200\2232mmol/kg Normal \202 uid therapy is based on the above calculations. In the fasting pa- tient, the type of \202 uid given should contain dextrose (usually 5%), sodium chloride, and added potassium chloride. Outside the neonatal period we use 0.9% or 0.45% saline with dextrose a nd additives. Do not use plain 5% dextrose in water or 5% dextrose 0.18% saline. The volume of \202 uid admin- istered should be increased in dehydration (see b p.91), and restrict ed to 50 \200\22375% of the usual maintenance volume in cases of: \200 \200 \200 \200 b pp.92, 448). SIADH ( b p.53). Fluid overload ( b p.226). Congestive heart failure ( Renal failure with oliguria or anuria ( b pp.362 \200\223365). 05_McClure_05.indd 89 11/15/2012 12:19:01 AM CHAPTER 5 Emergency and high dependency care 90 Fluid and electrolytes: dehydration Dehydration can lead to shock, severe metabolic acidosi s, and death, par- ticularly in infants. Its severity can be assessed using change in weigh t or the following physical signs. Mild dehydration (0 \200\2235%) \200 \200 \200 \200 \200 \200 \200 \200 \200 Weight Skin Mucous Urine: Heart Blood Perfusion: Skin Consciousness: loss: 5% in infants and 3% in children. turgor: may be decreased. membranes: dry. may be low. rate: increased. pressure: normal. normal. color: pale. irritable. Moderate dehydration (5 \200\22310%) \200 \200 \200 \200 \200 \200 \200 \200 \200 Weight Skin Mucous Urine: Heart BP: Perfusion: Skin Consciousness: loss: 10% in infants and 6% in children. turgor: decreased. membranes: very dry. oliguric. rate: increased. may be normal. prolonged capillary re \201 ll (capillary re \201 ll time (CRT) > 2s). color: gray. lethargic. Severe dehydration (10 \200\22315%) \200 \200 \200 \200 \200 \200 \200 \200 \200 Weight Skin Mucous Urine: Heart Blood Perfusion: Skin Consciousness: loss: 15% in infants and 9% in children. turgor: poor with tenting. membranes: parched. anuric. rate: increased. pressure: decreased. prolonged CRT. color: mottled; blue or white. comatose. After you have assessed the degree of dehydration in your patient, two problems need to be addressed \200\224water and electrolyte losses. In practice, our treatment is aimed at corr ecting both the water and electrolyte losses (Table 5.4). 05_McClure_05.indd 90 11/15/2012 12:19:01 AM FLUID AND ELECTROLYTES: DEHYDRATION 91 Table 5.4 Water and electrolyte losses in 10% dehydration Losses in 10% dehydration H2O (mL/kg) Na (mmol/kg) K (mmol/kg) Cl (mmol/kg) Isotonic dehydration (Na, 130 \200\223150mmol/L) 100 \200\223120 8 \200\22310 8 \200\22310 8 \200\22310 Hyponatraemic dehydration (Na < 130mmol/L) 100 \200\223120 10 \200\22312 8 \200\2231 10 \200\22312 Hypernatraemic dehydration (Na > 150mmol/L) 100 \200\223120 2 \200\2234 0 \200\2234 2 \200\2236 Isotonic and hyponatraemic dehydration \200 \200 \200 \200 First assess the degree of dehydration (use weight change and signs). Calculate the \202 uid de \201 cit. FBC with differential. Serum electrolytes (Na, K, Ca) with urea, creatini ne, and glucose.