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 and contact - Attempt/verify: IV/IO access airway and oxygen - Give uniterrupted 1 Shock 4 J/kg or AED (attenuated as appropriate) compressions when trachea intubated - Give adrenaline every 3 \200\2235 min - Consider: ami odarone, atopine, magnesium I Immediately resume CPR 15:2 for 2 min Immediately resume CPR 15:2 for 2 min Reversible Causes Hypoxia Hypovolaemia Hypo/hyperkalaemia/metabolic Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thromboembolism Fig. 8.7 Pediatric advanced life support: cardiac arrest protocol. Reprinted with permissio n from the Resuscitation Council (UK) (2005) Resuscitation guidelines. CHAPTER 8 Pediatrics 532 Trauma in children Trauma is the leading cause of death in children over one year of age an d 50% of deaths occur immediately or within the first few minutes following the accident. A s in adults, untreated hypoxia and hypovolaemia are the common causes of death. Trauma affe cts children differently, not just physically but also psychologically. Always look for a child at the scene of a road traffic collision if there is a childseat or toys in the car. Children can be ejected from the vehicle or be impacted under the seats. Anatomy and physiology - Children are smaller than adults, therefore more areas may be inju red. - Increased elasticity of the skeleton leads to a greater risk of internal organ damage in the absence of bony fractures. Patterns of injury are different (for example, a bumper may strike a child \200\231s abdomen or pelvis, rather than the lower limb as in an adult). - Appropriat e sized equipment is needed to manage trauma in children. - An aide-m moire, pocket book, chart, or tape should be used to determine equipment sizes (for example, endotracheal tubes ) and drug dosages (see Fig. 8.8). Psychology It is important to: - Be as reassuring as possible - Adopt a caring attitude - E xplain to the child what you are doing, especially if it is going to be painful Involve a parent, carer, or friend to give additional reassurance. TRAUMA IN CHILDREN1 533 Pediatric resuscitation chart Endotracheal tube Length (cm) Internal diameter (mm) 60 70 80 100 120 140 150 160 50 Length (cm) 14 12 18 \200\22321 7.5 \200\2238.0 10 18 7.0 ) s r a e y ( 8 17 6.5 6 16 6.0 e g A 4 15 5.5 2 18 months 1 9 months 6 months 3 months 14 5.0 13 4.5 4.0 3.5 3.0 \200\2233.5 12 0 5 10 20 30 40 50 10 Weight (kg) Adrenaline (ml of 1/10000) intravenous or endotracheal 0.5 1 2 3 44 5 Atropine (mg) intravenous or endotracheal 0.1 0.2 0.4 0.6 0.6 0.6 Bicarbonate (ml of 8.4%) intravenous 5 10 20 30 40 50 Calcium chloride (mmol)* intravenous 11 2 4 6 8 10 intravenous per rectum 1.25 2.5 2.5 5 5 10 7.5 \200\223 10 \200\223 10 \200\223 Diazepam (mg) Glucose (ml of 50%) intravenous 10 20 40 60 80 100 Lignocaine (mg) intravenous or endotracheal Salbutamol ( g) intravenous 5 10 20 30 40 50 25 50 100 150 200 250 Initial DC defibrillation (J) 10 20 40 60 80 100 Initial fluid infusion in hypovolaemic shock (ml) 50 100 200 300 400 500 Fig. 8.8 Oakley resuscitation chart. Reproduced with thanks to Peter Oakley. CHAPTER 8 Pediatrics 534 Scene assessment Scene safety is the first priority (self, scene, patient). Appropriate per - sonal protective equipment (PPE) is essential. Adequate resources and expertise should be mobilized early. It is vital to read the wreckage care- fully and to look for evidence of a child occupant who could have been ejected or hidden within the wreckage or be trapped or hidden by adult casualties. Patient assessment Assessment always follows the ABCDE system. Airway Assessment and management of the airway in children is considered on pp.524 \200\223 6. Notes It must be remembered that the cranium in a small baby is proportionately large and t ends to tilt forwards, obstructing the airway. The important differences between a child and an adult which need consideration include: - A large cranium - Compressible soft tissues - A large tongue - A m ore anterior larynx - A floppy epiglottis. The airway is narrowest at the cricoid ring. The size (internal diameter) of the tube is calculated using the formula age 4 + 4 Internal diameter ETT = The length of the tube is calculated using the formula age 2 Length of the tube = + 12 Cervical spine control The spine should be immobilized based on the mechanism of injury and is mandatory in all unconscious trauma victims. This is in the conventional manner with ma nual inline stabilization or a semi-rigid collar, side blocks, and tape. Notes Adult spinal boards are unsuitable for small children. Consider an alternative, for e xample, immobilization in a box splint (small baby) or a vacuum splint. A neutral neck posi tion must be maintained. Flexion of the neck risks airway obstruction in small babies. Collars may be ill-fitting and, if not properly applied, can produce airway compromise due to pressure on soft tissues in the neck. Inline manual stabilization should be considered a s an option for providing the safest means of ensuring safe spinal care. TRAUMA IN CHILDREN1 535 An infant already in a car seat who is at risk of having incurred a spinal injury should be transported to hospital in the seat using a blanket roll and tape to immobilize the cervic al spine. Breathing Children have pliable ribs and flexible rib cages making fractures rare. Therefor e, if rib fractures are clinically present, this implies serious internal damage due to ene rgy dissipation. Signs of respiratory distress include: Increased respiratory rate - The use of accessory muscles - Intercostal and subcostal reces sion - Grunting respiration - Head bobbing - Late features include cyanosis and an altered level of consciousness. Children with i respiratory distress have both an oxygenation and v entilation problem. Assisted ventilation using a bag-valve-mask system is essential because the depth of inspiration may be insufficient due to the fast rate. (See Fig. 8.1, p.501, f or normal respiratory rates in children.) Immediately life-threatening conditions should be identified and treated : - Airway obstruction - Tension pneumothorax - Open pneumothorax - Massive haemoth orax Flail chest and cardiac tamponade are extremely rare in children. Table 8.3 Clinical signs of the four life-threatening conditions Position of the trachea in relation to the side of injury Chest wall movement on the side of injury Percussion note on the side of injury Breath sounds on the side of injury Flail chest Central Decreased Paradoxical movements Decreased with pain on palpation Central/away Normal/ Decreased Decreased Massive haemothorax decreased Central Decreased Increased Decreased Open pneumothorax Away Decreased Increased Decreased Tension pneumothorax CHAPTER 8 Pediatrics 536 Management Flail chest A rare injury in children because of the pliability of the chest wal l. If present, it implies two or more rib fractures, fractured in two or more places. Flail chest is associated with underlying lung contusion. The classical clinical feature is para doxical breathing. Pre-hospital treatment includes manual splintage and analgesia. Consider assisted ventilation if significant respiratory compromise. Haemothorax Clinical features include both hypoxia and hypovolaemia. Management includes in travenous access and judicious fluid replacement. There is usually no indication for insert ing a chest drain in the pre-hospital environment; it may worsen an already difficult situa tion. Open pneumothorax Air moves preferentially through the hole in the chest wall if it is grea ter than of the transverse diameter of the trachea. The hole should be sealed with an As cherman chest seal or three-sided dressing and the patient regularly reassessed for develop ing tension pneumothorax. Tension pneumothorax The management is immediate needle thoracocentesis. A chest drain will be required and is usually inserted at a later stage in hospital. Deteriora- tion in a ven tilated child may be due to the development of a tension pneumothorax. Circulation The essential clinical indicators of the degree of shock include: - Pulse rate - Capillary refill time - Skin color - Peripheral temperature - Respiratory rate - Mental s tatus. Systolic blood pressure is maintained until late in hypovolaemic shock and, therefor e, hypotension should be regarded as a pre-terminal event. The degree of volume loss can be determined by collating the physical signs (see Table 8.4). Shock Shock is defined as the inadequate delivery of oxygen to the t issues. The classification of shock is the same as in adults. Several types of shock may co exist, for example, septic shock may coexist with hypovolaemia from diarrhea, distributive shock due to capillary leak, and cardiogenic shock due to toxins. Children differ from adults in the following way: Children with a healthy cardiovascular system compensate very efficiently. Hypotension should be regarded as a pre-terminal event. Children vasoconstrict very effectively and can develop a tachycardia in excess of 200bpm before the blood pressure falls. Children under 2 years of age are unable to compensate effectively for hypovolaemia because they have a fixed cardiacvolume. TRAUMA IN CHILDREN1 537 Types of shock \200\224see box Hypotension is a pre-terminal event. In pre-hospital care, i t may be difficult to determine. Problems include the range of physiological values based o n age, lack of an appropriately sized cuff, and difficulty of measurement in distressed non -co-operative children. Fortunately, the other signs of hypovolaemia will be apparent long before the blood pressure drops. Children rarely show signs of shock until 25% of the circu latory volume is lost. Causes of shock Hypovolaemic - Blood loss - Heat loss - Burns - Diarrhea - Diabetic ketoacidosis. Obstructi ve - Cardiac tamponade - Tension pneumothorax. Neurogenic - Spinal cord injury. Cardiogenic - Cardiac contusion - Congenital heart disease - Myocarditis. Distributive - Anaphylaxis - Capillary leak. Table 8.4 Physical signs of shock Less than 25% 25 \200\22340% >40% Heart rate Tachycardia + Tachycardia ++ Tachycardia +++ or bradycardia Blood pressure Normal Falling Normal or reduced Pulse volume Reduced + Reduced ++ Normal or reduced Increased+ Increased ++ Capillary refill time Normal or increased Skin Cool, pale Cold, mottled Cold, pale Increased + Increased ++ Respiratory rate Profound respiratory distress Mental status Lethargic Mild aggression Responds to pain only CHAPTER 8 Pediatrics 538 Treatment Shock due to blood loss: - Arrest external bleeding - Administer high-flow oxygen - Splint fractures - Elevate the legs - Obtain intravenous or intraosseous access - Replac e fluids at 20ml per kg of warmed normal saline. Weight can be estimated using the formula: Weight (kg) = (2 x age in years) + 8 Avoid Hartmann \200\231s solution (contains lactate and potassium) in the treatment of shoc k in children Disability Head injury is the most common cause of death in children. The level of consciou sness is assessed using the AVPU system: A V P U Alert Verbally responsive responds to Pain only Unresponsive Pupillary size, reactivity, and equality should be determined. Unilateral pupillary dilatat ion suggests focal pathology. Bilateral pupillary dilatation may be due to brain injury, hy poxia, or hypovolaemia. Abnormal posture should be noted, for example, decerebrate \200 \230extensor \200\231 or decorticate (flexor). The pre-hospital carer can do nothing about the primary injury. However, preventing seconda ry brain injury (correcting hypoxia and hypovolaemia) improves outcome and survivability. High-flow oxygen via a non-rebreathe mask and reservoir bag at Inadequate breathing can be 15l/minute should be administered. supported by BVM ventilation. Judicious fluid replacemen t should be given to support the circulation but should on no account delay transfer to def initive care. Exposure and the environment The child should be exposed, if necessary, to ensure adequate clinical examination after which the patient should be covered and kept warm depending on t he time of year and environment. - Many children become hypothermic because of prolonged ex posure to facilitate examination and clinical procedures. The ambulance should be kept warm and the doors open for a minimum time to reduce heat loss. Pre-hospital fluids, if given, should be warmed. TRAUMA IN CHILDREN1 539 Secondary survey This should only be undertaken once the primary survey has been completed and all problems identified have been addressed. For most children, especially those with m ultiple injuries, this will be undertaken in hospital. The secondary survey is a head-to-toe examination and may be undertaken in the ambulance en route to hospital \200\224in a warm environment. In practice, the pre-hospital secondary s urvey should take no more than five minutes. Important features to note include: Head - Scalp for bleeding, lacerations, and boggy swelling - Ears for evidence of blood/ CS F in the external auditory meatus (sug- gestive of a middle cranial fossa fracture) Nose for blood or CSF loss - Face for bruising, swelling, wounds, deformity, and dental tra uma. Neck - For bruising, tenderness, wounds, deformity, and bony tenderness - Neck veins (diste nsion suggests cardiac tamponade or tension pneumothorax). Chest - Chest wall for bruising (including pattern brusing), wounds, swelling, and symmetrical movements, bony tenderness, or fractures Percussion for altered resonance. The abdomen and pelvis - Abdominal wall for bruising, grazes, swelling, tenderness, guardin g, rigidity, and rebound tenderness. Extremities Examine for the presence of fractures (indicated by swelling, tenderness, defor mity, lack of function, and (rarely) neurovascular deficit). Assess the distal capillary re fill which should be the same as a non-injured limb. Compound fractures should be cleaned, dressed, and splinted. Analgesia should be provided if possible. Trained personnel may stra ighten/reduce fractures. Monitoring Careful monitoring should be maintained throughout the child \200\231s care and especially during transportation to hospital. CHAPTER 8 Pediatrics 540 Burns Minor scalds and burns are relatively common in children. Fortunately, the majority d o not represent any significant threat to life. They do, however, cause great distress to t he child and its parents. The relative proportions of different body areas vary with age and an adult burns chart or the \200\230rule of nines \200\231 do not apply. Fig. 8.10 can be used to estimate burns a rea in children. The principles of burn management are: Stopping the burning process - Airway assessment and management - Removal of clothes - Cool ing (the burn, not the child) - Analgesia. TRAUMA IN CHILDREN1 541 CHART FOR ESTIMATING SEVERITY OF BURN WOUND NAME AGE WARD NUMBER DATE ADMISSION WEIGHT LUND AND BROWDER CHARTS IGNORE SIMPLE ERYTHEMA A A 1 partial thickness loss (PTL) Full thickness loss (FTL) 2 2 2 2 13 13 1 1 1 1 % PTL FTL REGION HEAD NECK ANT.TRUNK POST.TRUNK RIGHT ARM LEFT ARM BUTTOCKS GENITALIA RIGHT LEG LEFT LEG TOTAL BURN 1 1 1 1 2 2 1 B B B B C C C C 1 1 1 1 RELATIVE PERCENTAGE OF BODY SURFACE AREA AFFECTED BY GROWTH AREA A= OF HEAD B= OF ONE T HIGH C= OF ONE LEG AGE 0 9 2 2 10 5 4 3 15 4 4 3 5 6 4 2 ADULT 3 4 3 1 8 3 2 Fig. 8.9 Calculating burns area in children. Reprinted with permission from Greaves I et al . (UK) (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 8 Pediatrics 542 Analgesia Children require analgesia just as adults do. In time-critical injury, how- ever, delays on scene to provide analgesia should not occur. The degree of pain may be monitored using a 1 \200\22310 pain ladder, but this depends on the child being able to understand w hat is being asked and to be able to communicate. In young children, pain may be manifested by agitation and crying. Pain management may be achieved using pharmacological and non-pha rmacological measures. Non-pharmacological pain management Distraction - Give them something to do. Reassurance - Positive reassurance from a parent/carer or friend of the patient. Environment - Friendly, sympathetic, and, ideally, single-person contact - Address the chil d by their name. Immobilization - Use simple splintage. Pharmacological pain management Therapeutic options include: Mild pain - Oral paracetamol - Oral ibuprofen. Moderate pain - Non-steroidal anti-inflammatory drugs, for example, diclofenac given orally or rectally Oral or nasal morphine. Severe pain - Intravenous morphine - Ketamine - Entonox (can provide short-term effective a nalgesia but requires patient co-operation for effective administration and is, therefore, unsuitable for young children). Analgesic doses for children are given opposite. Local analgesic infiltration may, occasionally, be of value in the management of pain in children. ANALGESIA1 543 Pediatric doses Adrenaline INTRAMUSCULAR for anaphylaxis - Under 6 months: 50 g, 0.05ml, 1 in 1000 - 6 mon ths \200\2236 years: 120 g, 0.12ml, 1 in 1000 - 6 \200\22312 years: 250 g, 0.25ml, 1 in 1 000 - 12 years and over: 500 g, 0.5ml, 1 in 1000. Atropine 20 g/kg, maximum 600 g Benzyl penicillin - Under 1: 300mg - 1 \200\2239 years: 600mg - 10 years and over: adult do se. Chlorpheniramine - 1 month \200\2231 year: 250 g/kg - 1 \200\22312 years: 200 g/kg or 1 \200\2235 years: 2.5 \200\2235mg - 6 \200\22312 years: 5 \200\22310mg. Diazepam - Rectal \200\224children over 10kg, 500 g/kg, maximum 20mg - Intravenous \200 \224300 \200\223400 g/kg or 1mg per year of age. Glucagon - Under 8 years (or under 25kg): 500 g - Over 8 years (or over 25kg): 1mg. Hydrocortisone - Up to 1 year: 25mg - 1 \200\2235 years: 50mg - 6 \200\22312 years: 100mg. Ibuprofen - 3 \200\2236 months: 50mg (body weight over 5kg) - 6 months \200\2231 year: 50mg - 1 \200\2233 years: 100mg - 4 \200\2236 years: 150mg - 7 \200\2239 years: 200mg - 10 \200 \22312 years: 300mg. CHAPTER 8 Pediatrics 544 Ketamine As adult doses, by weight (See p.331) Lignocaine Local anesthesia, 3mg/kg Methioni ne Child over six: 2.5g initially, followed by 3 further doses of 2.5g every 4 hours Child under six: 1g initially, followed by 3 further doses of 1g every 4 hours Midazolam (iv) - 6 months \200\2235 years: 50 \200\223100 g/kg initially - 6 \200\22312 years: 25 \200\22350 g/kg, further increments as required. Morphine - Up to 1 month: 37.5 \200\22375 g/kg - 1 \200\22312 months: 50 \200\223100 g/kg - 1 \200\2235 years: 1 \200\2232mg - 6 \200\22312 years: 2 \200\2235mg. Naloxone 10 g/kg, subsequent dose of 100 g/kg if no response Parace tamol Orally - Under 3 months: 10mg/kg (5mg/kg if jaundiced), on doctor \200\231s advice only 3 months \200\2231 year: 60 \200\223120mg - 1 \200\2235 years: 120 \200\223250mg - 6 \200 \22312 years: 250 \200\223500mg. These doses may be repeated every 4 \200\2236 hours, maxim um 4 doses in 24 hours Suppository - 1 \200\2235 years: 125 \200\223250mg - 6 \200\22312 ye ars: 250 \200\223500mg - Over 12 years: repeat dosing as above. Salbutamol (Over 18 months: 2.5mg as nebulized solution) under 18 months: 1.25 \200\2232.5m g as nebulized solution This page intentionally left blank CHAPTER 8 Pediatrics 546 Consent Always explain what you are proposing to do to a child. Gillick competent children below the age of 16 are capable of giving informed consent to treatment; they cannot refuse treatment against the wishes of a parent or guardian until they have reached the age of 18 . This page intentionally left blank CHAPTER 8 Pediatrics 548 Child abuse Child abuse may be defined as treatment by an adult or another child in a way t hat is unacceptable in a given culture at a given time. It includes: - Neglect - Physical i njury - Sexual abuse - Emotional neglect. Factors which alert the practitioner to the risk of child abuse include: Delay in seeking medical attention, especially if the injury is serious - Inconsistent hist ory to account for the injury - Varying history from witnesses - Injury pattern is inconsis tent with the history - Injury pattern is inappropriate to the developmental state of the c hild - Abnormal parental or carer attitude - Abnormal child/carer interface - Unusual patte rns of injury, for example, finger marks, burns, and bites. Under these circumstances, the first priority is to the child, who should be transported to hospital. Concern must be rais ed with hospital staff and this should be clearly documented. All health care professionals have a responsibility under the Children \200\231s Act 1989 t o protect children and should be aware of local procedures for child protection. This page intentionally left blank CHAPTER 8 Pediatrics 550 Triage The standard triage sieve used in adult practice presents problems as many children cannot walk. Therefore, triage is a complicated process. Age-specific triage sieves are giv en on p.604. This page intentionally left blank CHAPTER 8 Pediatrics 552 Pediatric trauma score A score of 8 or less on the pediatric trauma score is one way of ide ntifying a time-critical injury for which prompt transfer to a hospital is essential. The m echanism of injury, for example \200\230run over by a car \200\231 also correlates with th e severity of injuries. Table 8.5 Pediatric trauma score +2 +1 \200\223 1 Size >20kg 11 \200\22320kg <10kg Airway Normal Assisted mask Intubated, cricothyroidotomy, obstruction Conscious level Awake Decreased Unresponsive >90mmHg 51 \200\22390mmHg Systolic blood pressure <50mmHg or only central pulses Fractures None Single closed Open or multiple Skin Normal Contusion, abrasion, cut less than 7cm, not through fascia Tissue loss, knife or gun wounds Chapter 9 553 The hostile environment Hypothermia 554 Cold injury 558 Heat-related illness 560 Near drowning 564 Diving emergenci es 568 Electrocution injury 572 CHAPTER 9 The hostile environment 554 Hypothermia Body temperature is regulated through the hypothalamus which is activated by ch anges in blood and skin temperature. The hypothalamus adjusts heat production and loss. Alt hough hypothermia is defined as a core temperature of less than 35oC, medical attention is appropriately directed to any cold patient. It is better to prevent hypothermia than to hav e to try and treat it. Hypothermia is defined as a core temperature of less than 35oC Mechanisms The human body loses heat by: - Radiation: greatest when naked and erect - Condu ction: by contact with another surface such as water or wet clothing Evaporation: by insensible moisture loss and sweating, and from the respiratory tract Convection: largely dependant on wind velocity, it is increased by limb movement and shivering. Exacerbating factors - Air movement ( \200\230wind chill \200\231) - Moisture (humidity, ra in, or dampness). Predisposing factors - Extremes of age - Poverty - Inappropriate clothing in a harsh enviro nment - Nausea and vomiting - Trauma - Stress - Alcohol - Coincident medical illness (diabe tes mellitus, hypothyroidism). Physiological effects - Constriction of peripheral vessels (conserves heat but increases the risk of local cold injury) Shivering \200\224increases heat production - Deliberate activity \200\224increases heat pr oduction - Reduced energy reserves \200\224secondary to increased heat production - Increas ed oxygen consumption \200\224secondary to increased heat production Diuresis \200\224secondary to central redirection of blood. Increased oxygen consumption se condary to heat generation may lead to hypoxia and is the reason angina is more likely to o ccur in cold weather. Hypoxia may eventually restrict heat production, leading to loss of s hivering. Heat production may also be prevented by exhaustion or starvation as a result of lack of nutrient. HYPOTHERMIA1 555 Effects of exposure to cold temperatures Impaired co-ordination Central nervous system Behavioral changes Reduced visual acuity Decreased alertness Slowed reflexes More frequent errors Impaired sensory intrepretation Hallucinations Shivering Muscular Increased risk of muscular injury Lowered angina threshold Cardiovascular Hypertension Asthma Respiratory Loss of manual dexterity Peripheral nervous system Reduced skin sensation Diagnosis An approximate indication of likely symptoms and signs as the body temperature fa lls is given in Table 9.1. It may be difficult to achieve an accurate temperature in the pr e-hospital environment and it is essential to stress that the temperature at which any part icular clinical feature is seen will vary dramatically from patient to patient. Therefore: A patient who feels cold should be treated for hypothermia Management The key to good management is effective rewarming with prevention of further hea t loss. - Administer high-flow oxygen during rewarming - Monitor pulse and BP (warming is a ssociated with increasing peripheral blood flow with consequent hypotension if there is trauma) Remove and replace cold wet clothing when safe to do so (in a warm place, out of the wind) Warm the patient (see below); warm drinks (NO ALCOHOL) may be given if the patient is conscious Manage associated injuries \200\224used pre-warmed fluids - Keep the patient flat whenever possible and remove from the cold environment. Handle with care: do not precipitate VF! CHAPTER 9 The hostile environment 556 Table 9.1 The effects of hypothermia Temperature Clinical features 37 Normal oral temperature 36 Respiratory rate and pulse increase 35 Shivering maximal Slow thinking, dysarthria 34 Patient still capable of functioning; blood pressure normal 33 \200\22331 Retrograde amnesia; conscious level clouded; pupils dilated BP difficult to measure; shivering largely stopped 30 \200\22328 Loss of consciousness; bradycardia; bradypnoea; muscular rigidity; VF may supervene seconda ry to stimulation 27 No voluntary motion 26 Consciousness very rare 25 Spontaneous appearance of VF 24 \200\22321 Pulmonary oedema 23 Apnoea 18 Asystole Spontaneous rewarming The surface of the victim \200\231s head and body are insulated (norm ally with a space blanket but polythene sheeting is effective) to prevent further heat loss . The hands and feet are kept cool (hands by the patient \200\231s side) since warm hands a nd feet inhibit heat production. Shelter from the wind is a key component of management. Surface rewarming - Body-to-body rewarming rarely effective and may put both the victim and rescuer at further risk. Hot water immersion at 40*C (elbow hot \200\224only for conscious, shivering, uninjured victims). Once warmed, remove from water, lie down and wrap in blanket s. Skin rubbing is contraindicated and hot water bottles are best avoided. Young fit victims m ay be warmed rapidly. Following admission to hospital, warming can be continued by: HYPOTHERMIA1 557 Central rewarming These procedures can only be carried out after arrival in hospital: - Air way warming - Cardiopulmonary bypass - Haemodialysis - Peritoneal and pleural irrigation wi th warmed fluids Note Elderly patients with hypothermia should be warmed slowly and carefully. A temperature rise of more than about 0.5* per hour runs the risk of cerebral and pulmonary oedema in th ese patients. The most appropriate place for ongoing rewarming is an ITU. Cardiopulmonary resuscitation in hypothermia - Once commenced, CPR should be continued unti l the patient recovers, reaches hospital, and is handed over for continued care or the rescuer becomes ex hausted. Follow the normal cardiorespiratory arrest protocols. - Defibrillation is usually unsuccess ful in the presence of VF if the core temperature is below 30 degrees. Adrenaline and other drugs, including amiodarone, should not be used until the temperature is above 30 degrees. Always check for hypoglycaemia. REMEMBER to rule out other treatable causes of cardiac arrest CHAPTER 9 The hostile environment 558 Cold injury Frost nip Is a minor form of frost bite where the skin becomes white and numb. These changes are completely reversible on rewarming, leaving short- term pain and hyperaem ia. Frost bite - Commonly affects the finger, toes, nose, and ears. - Is worsened on thawing by reperfusion injury and may produce tissue necrosis. Appears white when frozen and becomes blue or purple on thawing and is associated with swelling and severe pain. Causes blistering followed by a thick carapace which blackens and eventually separates (some times after several months) leaving healthy tissue underneath. I n some cases, auto-amputation of digits occurs. Management The key features are: - Protection from the environment if possible - No attempt to rewarm until it can be sustained Active rewarming can be achieved by placing the limb i n circulating water at 40 C. This is extremely painful and requires strong analgesia. This page intentionally left blank CHAPTER 9 The hostile environment 560 Heat-related illness Temperature regulation Heat gain results from basal metabolic activity , muscular exertion, heat absorption, and the breakdown of food. Heat is lost through radia tion, evaporation (of sweat), convection, conduction, and loss of body waste. The hypothala mus (which responds to core temperature receptors) balances heat production and loss to mai ntain a body temperature set within precise limits. When core temperature rises above 40oC, enzyme systems begin to break down. Normally, this temperature range is between 36.3 and 3 7.1oC. In hot weather, there may be a temperature difference of up to 1oC between core and peripheral temperatures. Adaptation to heat Acclimatization to heat is largely complete in 7 \200\22312 days but may continue for several weeks. Sweating leads to loss of water and sodium. Decreased circulat ing blood volume results in decreased renal blood flow. As a result of this (and secondary to increased aldosterone secre- tion), there is reduced secretion of sodium in sweat and ur ine. This results in re-expansion of the extracellular space. Cutaneous blood flow increase s and cardiac output rises to maintain blood pressure despite vasodilatation. Once blood pr essure can no longer be maintained, peripheral vasoconstriction occurs which has the advers e effect of preventing heat loss. Other effects of heat include a lower threshold for sweat ing, anorexia, and loss of interest in activity (both of which result in reduced heat produ ction). Risk factors Increased heat production - Physical activity - Drugs (cocaine, PCP, ecstasy, amphetamines, LSD, tricyclics) - Medical conditions such as hyperthyroidism, acute febrile illness. Reduced heat loss - Inappropriate clothing - Alcohol - Old age - Poor condition - Obesity. Dehydration - Prolonged exertion - Diarrhea and vomiting - Diabetes - Mental impairment - D rugs (diuretics) and alcohol. HEAT-RELATED ILLNESS1 561 Minor heat illness Oedema Oedema of the hands, feet, and ankles occurs in the first few day s of heat exposure. No specific treatment is required, although elevation and compression s tockings are effective. The problem usually resolves spontaneously. Cramp Painful muscular contractions, especially of the thighs, calves, upper arms, and abdo men usually occur when large amounts of sweat have been replaced by large volumes of unsalt ed water. The cramps usually occur during or following exercise. Oral or intravenous admini stration of salt solution (N saline intravenous) is effective. The condition is more common in unacclimatized individuals.