Breathing If the baby is not breathing adequately by 90sec, give 5 in \202 ation breaths ( pressures of 30cm water for 2 \200\2233sec). Ventilate a term baby with air, but use oxygen for premature and/or hypoxic neonates. If the heart rate increases, this indicates success ful ventilation of the lungs. If the baby is apnoeic, continue ventilation at 30 \200\22340 breaths/min until self-ventilating. If the heart rate does not increase, then the most lik ely cause is that the lungs have not been in \202 ated. Recheck head position and consider a jaw thrust and longer in \202 ation time. If the airway is obstructed, consider an orop haryngeal airway, laryngoscopy and suction. Repeat the 5 in \202 ation breaths. If the hea rt rate remains <60/min or absent despite good chest movement, start chest compressions. 643 RESUSCITATION OF THE NEWBORN Dry the baby Remove any wet towels and cover Start the clock or note the time Birth AT 30 s Assess (tone), breathing and heart rate ALL If gasping or not breathing: Open the airway Give 5 inflation breaths Consider SpO2 monitor ing STAGES 60 s Re-assess If no increase in heart rate look for chest movement ASK: If chest not moving: Recheck head position Consider 2-person airway control and other airwa y maneuvers Repeat inflation breaths Consider SpO2 monitoring Look for a response Acceptable* pre-ductal SpO2 2 min 60% 3 min 70% 4 min 80% 5 min 85% 10 min 90% If no increase in heart rate look for chest movement DO When the chest is moving: If heart rate is not detectable or slow (<60 min \200\2231) Start chest compressions 3 compressions to each breath YOU NEED Reassess heart rate every 30s If heart rate is not detectable or slow (<60 min \200\2231) c onsider venous access and drugs HELP? Fig. 15.2 Algorithm for newborn life support. From Resuscitation Council (UK). Newborn Life Support , 2010. See www.resus.org.uk 644 CHAPTER 15 Pediatric emergencies Cardiopulmonary resuscitation of the newborn Chest compression (only to be started after su ccessful lung in \202 ation). Grip the chest in both hands in such a way that two thumbs can press on the lower third of the sternum, (just below the intermammary line) with the \201 ngers over the spine at the back (Fig. 15.3 ). Aim for a rate of 100/min, and to depress the antero-posterior (AP) dia meter of the chest by a third. Use a chest compression to in \202 ation ratio of 3:1 . Using encircling fingers Fig. 15.3 Method of CPR in the newborn. Tracheal intubation Treat continuing apnoea with tracheal intubation using a 3mm tube (2.5m m in premature babies). Precede intubation by pre-oxygenation with bag valve mask ventilati on for 30sec. Drugs Only use drugs if there is no signi \201 cant cardiac output despite effective lung in \202 ation and chest compression. Give drugs intravenously via an umbilical vein cathet er or intra-osseous needle. \200 Give adrenaline 10mcg/kg (0.1mL/kg of 1 in 10 000 if the re is no initial response. If this is ineffective the dose may be increased to 30 mcg/kg (0 .3mL/kg of 1 in 10 000). Give sodium bicarbonate 1 \200\2232mmol/kg (2 \200\2234mL of 4.2 % solution/kg) when there is no cardiac output despite all resuscitative efforts or in profound or unresponsive brady cardia. Hypoglycaemia is a potential problem for all newborns and BMG is unreliable when reading <5 mmol/L. Take blood sample to con \201 rm and treat immediately with a bolus of 2.5mL/kg of 10 % glucose. 645 CARDIOPULMONARY RESUSCITATION OF THE NEWBORN Suspect hypovolaemia if : very pale baby, pulseless electrical activity (PEA), history of a ntepartum hemorrhage, placenta praevia, or vasa praevia, or unclamped cord. Give 10mL/kg 0. 9 % saline followed by O \200\223ve blood, repeated as necessary. Atropine and calcium have no role in newborn resuscitation. Venous access \200\224 the umbilical vein The easiest and fastest method of obtaining veno us access in the newborn is to cannulate the umbilical vein. Identify the umbilical vein in the cut umbilical stump: it is the single large dilated vessel adjacent to the two constri cted arteries (Fig. 15.4 ). Prepare a 5F gauge catheter with 0.9 % saline and insert it 5cm into the umbilical vein. Suture and secure in place. Vein Arteries Fig. 15.4 Diagram of a cross-section of the umbilicus. If there are no signs of life after 10min of continuous and adequate resuscitation efforts, then discontinuation of resuscitation may be justi \201 ed; involve senior ED and neonata l staff in this decision. Meconium aspiration In the presence of meconium, do not attempt to aspirate the nose and mo uth of meconium as the head presents. If a baby is delivered with thick meconium and is unr esponsive at birth (absent or inadequate respiration, heart rate <100/min or hypotonia), pe rform laryngoscopy and clear meco- nium under direct vision using a wide bore catheter. Aim to intubate the larynx and apply suction to the tracheal tube which is then withdrawn. However, if intubation cannot be achieved immediately, clear the orophyarynx and start bag- valve-mask in \202 ation. If while attempting to clear the airway the heart rate falls <60 /min, stop airway clearance, give in \202 ation breaths and start ventilating the baby wit h a bag-valve-mask device. If meconium staining is present, but the infant is vigorous at birth, no special treatment is required immediately, but the infant should be closely observed. 646 CHAPTER 15 Pediatric emergencies Pediatric basic life support Follow the algorithm (Fig. 15.5 ). Note that the approach to c hoking is considered on b p.648. Evaluate responsiveness Check the child \200\231s responsi veness \200\224 gently stimulate and ask loudly \200\230are you alright? \200\231 Do not shake if you suspect cervical spine injury. If the child does not respond, shout for help get someone to go for assistance. Open airway Open the airway by head tilt and chin lift. Desirable degrees of tilt are neutr al <1 year and \200\230snif \201 ng the morning air \200\231 > 1 year. Do not press on th e soft tissues under the chin as this may block the airway. If it is still dif \201 cult t o open the airway, try a jaw thrust. If there is any suspicion that there may have been a n eck injury, instruct a second rescuer to manually immo- bilize it, and use either chin lift or jaw thrust alone. If this is unsuccessful, add the smallest amount of head tilt needed to open the airway. Check breathing Whilst keeping the airway open, look listen and feel for breathing for 10se c. If the child is not breathing or is making infrequent irregular breaths, carefully remov e any obvious obstruction, give 5 initial rescue breaths (with the rescuer taking a breath between each rescue breath). Rescue breaths For children > 1 year , whilst maintaining head tilt and chin lift, give bre aths mouth to mouth, pinching off the nose. Blow steadily for 1 \200\2231.5sec watching for the chest to rise. Take your mouth away, watch the chest fall and repeat this sequence 5 t imes. For the infant (<1 year) ensure the neutral position of the head and apply chin lift. Give mouth to mouth and nose breaths, ensuring a good seal. Blow steadily for 1 \200\2231. 5sec watching for chest rise. Take your mouth away, watch the chest fall and repeat this se quence 5 times. Dif \201 culty achieving an effective breath suggests airway obstruction. Open the mouth and remove visible obstruction (no blind \201 nger sweep), ensure appropri ate head tilt/chin lift and neck position. Try a jaw thrust if head tilt/chin lift has not worked. Try up to 5 times to give effective breaths. If still unsuccessful, move to chest c ompression. Check pulse Over the next 10sec check for signs of life: any movement, coughing or normal b reathing and check for a pulse (use carotid for > 1yr and brachial for those <1 year). If t here are no signs of life and/or no pulse or pulse <60/min with poor perfusion or you are u nsure: start chest compression. Chest compression For infants , perform chest compressions (100 \200\223120/min) by placing both thumbs \202 at side by side on the lower third of the sternum with the tips pointin g towards the infant \200\231s head. Encircle the rib cage with tips of \201 ngers suppor ting the infant \200\231s back. Press down with thumbs at least one third of the depth of t he chest. In children > 1 year using the heel of one hand, compress the lower half of the s ternum by at least one-third of the depth of the chest at a rate of 100 \200\223120/min. Us e two hands if necessary to achieve the depth required. 647 pediatric BASIC LIFE SUPPORT Unresponsive? Shout for help Open airway Not breathing normally? 5 rescue breaths No signs of life? 15 chest compressions 2 rescue breaths 15 compressions Call resuscitation team Fig. 15.5 Pediatric basic life support (healthcare professionals with a duty to respond). R esuscitation Council (UK). Pediatric basic life support , 2010. See www.resus.org.uk 648 CHAPTER 15 Pediatric emergencies Choking from a foreign body Despite preventative measures (eg making pen tops with holes in them), children continue to die each year from airway obstruction due to FB impaction. FB aspiration produces a sudden onset airway problem and must be distinguished from other caus es of airway obstruction (epiglot- titis, bacterial tracheitis see b Stridor: upper respira tory tract infections, p.677), which may be worsened by the basic measures described below. The majority of choking events in children are witnessed and occur during play or whilst ea ting. FB airway obstruction is characterized by sudden onset of respiratory distress associ ated with coughing, gagging or stridor with no other signs of illness. If the child is coug hing effectively (fully responsive, loud cough, able to take a breath before coughing, cryi ng or verbal response to questions), encourage coughing and observe for the cough becoming ineffective. Conscious, but ineffective cough If conscious with an ineffective cough, give 5 back blows. In the infant, support in a head downwards prone position and in the child aim for a head down or forward leaning position. Deliver 5 sharp back blows with the heel of one hand cent rally between the shoulder blades. If ineffective, turn to supine position and give 5 chest thrusts to infants (using the same landmarks as for cardiopulmonary resuscitation (CPR), b ut thrusts are sharper and delivered at a slower rate) and abdominal thrusts to children > 1 year. Perform abdominal thrusts from behind the child, placing your \201 st between the umbilicus and xiphisternum, and grasping it with your other hand, then pulling sharply inw ards and upwards \200\224 repeat up to 5 times. Following chest or abdominal thrusts, if the object has not been expelled and the victim is still conscious then repeat the sequence of back blows and chest (for infant) or abdominal (for children) thrusts. Do not use abdominal thrusts for infants. Unconscious from foreign body airway obstruction If a child with FB airway obstruction is o r becomes unconscious, place him on a \202 at surface, then open the mouth and look for a ny obvious object. If one is seen, use a single \201 nger sweep to remove it. It may be p ossible to remove the FB with Magill \200\231s forceps under direct laryngoscopy. Do not at tempt blind or repeated \201 nger sweeps. Open the airway and attempt 5 rescue breaths. I f a breath does not make the chest rise, reposition the head before making the next attempt . If there is no response whilst attempting the 5 rescue breaths, proceed to chest compress ion with ventilation using a ratio of 15:2. Each time the airway is opened, check for a for eign body and if visible, try to remove it (Fig. 15.6 ). If it appears that the obstruction has been relieved, open and check the airway. If the chi ld is not breathing, deliver rescue breaths. If initial measures prove unsuccessful and the child is hypoxic, oxygenate via a surgical airway until senior help arrives. Perform needl e cricothyroidotomy in children aged <12 years, surgical cricothyroidotomy in older childre n ( b Airway obstruction: surgical airway, p.326). 649 CHOKING FROM A FOREIGN BODY Assess severity Ineffective cough Effective cough Unconscious Conscious Encourage cough 5 back blows 5 thrusts (chest for infant) (abdominal for child >1 year) Continue to check for deterioration to ineffective cough or until obstruction relieved Open airway 5 breaths Start CPR Fig. 15.6 Pediatric foreign body airway obstruction treatment. Resuscitation Council (UK). Pediatric FB airway obstruction , 2010. See www.resus.org.uk 650 CHAPTER 15 Pediatric emergencies Anaphylaxis in children The background, causes and pathophysiology of anaphylaxis in childr en is similar to that in adults \200\224 see b p.42. Treat according to the 2008 UK Resusc itation Council algorithm, shown in Fig. 15.7 . After initial treatment, admit the child fo r observation in case of a delayed or biphasic reaction. Anaphylactic reaction? Airway, Breathing, Circulation, Disability, Exposure Diagnosis - look for: Acute onset of illness \200 Life-threatening airway and/or breathing and/or circulation p roblems1 \200 And usually skin changes Call for help \200 Lie patient flat \200 Raise patient \200\231s legs Adrenaline2 When skills and equipment available: Establish airway \200 High flow oxygen \200 IV fluid challenge3 \200 Chlorphenamine4 \200 Hydrocortisone5 Monitor: \200 Pulse oximetry \200 ECG \200 Blood pressure 1 Life-threatening problems: Airway: Swelling, hoarseness, stridor Breathing: Rapid breathi ng, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion Circulation: Pale, clammy, low blood pressure, faintness, drowsy/coma 2 Adrenaline (give IM unless experienced with IV adrenaline) IM doses of 1:1000 adrenaline (repeat after 5 min if no better) \200 Adult: 500 micrograms IM (0.5 mL) \200 Child mor e than 12 years: 500 micrograms IM (0.5 mL) \200 Child 6 \200\22312 years: 300 micrograms IM (0.3 mL) \200 Child less than 6 years: 150 micrograms IM (0.15 mL) Adrenaline IV to b e given only by experienced specialists Titrate: Adults 50 micrograms; Children 1 microgram /kg 3 IV fluid challenge: Adult - 500 \200\2231000 mL Child - crystalloid 20 mL/kg Stop IV colloid if this might be the cause of anaphylaxis 4 Chlorphenamine (IM or slow IV) 10 mg 5 mg 2.5 mg 250 micrograms/kg 5 Hydrocortisone (IM or slow IV) 200 mg 100 mg 50 mg 25 mg Adult or child more than 12 years Child 6 \200\22312 years Child 6 months to 6 years Child less than 6months Fig. 15.7 UK Resuscitation Council algorithm 2008. 1 See http://www.resus.org.uk/pages/reaction.pdf for details. Notes are shown opposite . 651 ANAPHYLAXIS IN CHILDREN Notes for anaphylaxis algorithm opposite 1 Intramuscular (IM) adrenaline is the agent of ch oice in anaphylaxis and should be administered without delay. 2 If profound shock is judged immediately life-threatening, consider giving a slow bolus of 1mcg/kg of intravenous (IV) adrenaline as a 1 in 100,000 solution (= 10micrograms/mL solut ion). This is hazardous and is recom- mended only for experienced specialists who can also obtain IV access without delay. Note that a different dilution of adrenaline is required fo r IM compared to IV use. Adrenaline can also be given via the IO route in the same dose as the IV route. 3 An inhaled B 2 -agonist such as salbutamol may be used as an adjunctive measure if bronch ospasm is severe and does not respond rapidly to other treatment. 4 For children who have been prescribed an EpiPen , 150 mcg can be given instead of 120 mcg, and 300 mcg can be given instead of 250 mcg or 500 mcg. 5 Crystalloid may be safer than a colloid. 6 Do not use the subcutaneous route for adrenali ne. It has no role in anaphylaxis because its absorption is appreciably slower than IM adre naline. Consider taking blood samples for mast cell tryptase testing as soon as possible after star ting treatment if the cause is thought to be venom- related, drug-related or idiopathic (se e www.nice.org.uk/cg134): \200 A sample as soon as possible after emergency treatment has started. \200 A second sample ideally within 1 \200\2232 hours (but no later than 4 hour s) from the onset of symptoms. 652 CHAPTER 15 Pediatric emergencies Pediatric advanced life support Overall, cardiac arrest in children has a worse outcome tha n in adults, because the underlying causes are different. However, the situation is likely to be far from hopeless if a child arrests within the ED or other areas of the hospital. Ef fective immediate resuscitation is important to minimize hypoxic organ damage. Early recogn ition of the child presenting with impending cardio-respiratory arrest may allow prompt int ervention and prevent secondary cardiac arrest (Fig. 15.8 ). Follow the guidelines shown op posite. Establish BLS ( b p.646) and use a ratio of 15:2 while ventilating with a bag-valve -mask. Aim for tracheal intubation by a highly skilled operator as soon as possible, then v entilate at a rate of 10 \200\22312/min with compressions uninterrupted at 100 \200\223120/ min. Non-shockable rhythm: PEA and asystole Give BLS with high concentration O 2 . Give adrenali ne IV/IO 10mcg/kg (0.1mL/kg of 1 in 10,000). If no other access is present, consider giving 100mcg/kg adrenaline via the trachea, but this is the least satisfactory route. Give IV/IO adrenaline every 3 \200\2235min (every other loop). As in adults ( b p.51), PEA may re \202 ect a correctable underlying cause. In particular, exclude tension pneumothorax and co nsider hypovolaemia. Hemorrhage, septic shock, and dehydration are implicated relatively fr equently, so consider an initial IV \202 uid bolus of 20mL/kg 0.9 % saline early in the r esuscitation. Follow this with further IV \202 uid/blood if hypovolaemia is still present or suspected. If circulation returns, ventilate at 12 \200\22320breaths/min to achieve a n ormal pCO 2 and monitor ETCO 2 to con \201 rm correct tracheal tube placement. Shockable rhythm: VF/pulseless VT VF is uncommon in children, but is more likely in witness ed and sudden collapse. It occasionally occurs in children with congenital heart disease, h ypothermia or electrolyte disturbance. Follow the \200\230VF/VT \200\231 treatment algorit hm shown opposite. Give one shock of 4J/kg if using a manual de \201 brillator. These ener gy levels are appropriate for both monophasic and biphasic de \201 brillators. When select ing the energy level to use during de \201 brillation, if the de \201 brillator can only deliver certain predetermined \200\230stepped \200\231 shocks, choose the nearest higher \200\230step \200\231 to that required. Pads or paddles for children should be 8 \200\22312 cm in size and 4.5cm for infants. Resume CPR immediately without reassessing rhythm or feel ing for a pulse. Continue CPR for 2min and if still in VF/VT, give a second shock and resum e CPR immediately for 2min. Consider reversible causes. If still in VF/VT at this time, giv e a third shock. Give adrenaline 10 mcg/kg and amiodarone 5mg/kg (diluted in 5 % glucose) o nce chest compressions have restarted and give a fourth shock after 2min CPR. Continue givi ng shocks every 2min and adrenaline immediately before every other shock (ie every 3 \200 \2235min), until a return of spontaneous circulation. Amiodarone 5mg/kg can be repeated onc e after the \201 fth shock. Uninterrupted good quality CPR is vital \200\224 only interr upt chest compressions and ventilation for de \201 brillation. See b Pediatric advanced li fe support notes, p.654. 653 pediatric ADVANCED LIFE SUPPORT Unresponsive? Not breathing or only occasional gasps CPR (5 initial breaths then 15:2) Attach defibrillator/monitor Minimize interruptions Call resuscitation team (1 min CPR first, if alone) Assess rhythm Shockable (VF/Pulseless VT) Non-Shockable (PEA/Asystole) Return of spontaneous circulation 1 Shock 4J/kg Immediate post cardiac arrest treatment \200 Use ABCDE approach \200 Controlled oxygena tion and ventilation \200 Investigations \200 Treat precipitating cause \200 Temperat ure control \200 Therapeutic hypothermia? Immediately resume CPR for 2 min Minimize interruptions Immediately resume CPR for 2 min Minimize interruptions During CPR \200 Ensure high-quality CPR: rate, depth, recoil \200 Plan actions before i nterrupting CPR \200 Give oxygen \200 Vascular access (intravenous, intraosseous) \200 Give adrenaline every 3 \200\2235 min \200 Consider advanced airway and capnography \200 Continuous chest compressions when advanced airway in place \200 Correct reversible causes Reversible causes Hypoxia \200 Hypovolaemia \200 Hypo-/hyperkalaemia/metabolic \200 Hypothermia Tension pneumothorax \200 Toxins \200 Tamponade - cardiac \200 Thromboembolism Fig. 15.8 Pediatric advanced life support. Resuscitation Council (UK). Pediatric advanced l ife support guidelines , 2010. Available at: www.resus.org.uk 654 CHAPTER 15 Pediatric emergencies Pediatric advanced life support notes Airway O 2 Give high \202 ow oxygen (use a well- \201 tting mask with a reservoir). Suction Use a rigid suction catheter to aspirate pharyng eal contents. Oropharyngeal airway An airway may help when ventilating with a bag valve mask device while personnel and equipment are prepared for tracheal intubation. Size the airway by matching its length to the distance between the central incisor teeth and the angle of the mandible. Use a tongue depressor or laryngoscope to displace the large tongue and insert the airway the \200\230right way up \200\231 in order to avoid trauma to the palate. Bag-valve-mask v entilation Attach high \202 ow O 2 to a self-in \202 ating bag-valve- mask device. Use a 500mL (up to age 1 year) or 1600mL bag ( > 1 year). Tracheal intubation This method of securing the airway requires experience and practice. Ca ll for senior help. Always use a capnograph. Follow the same technique as that described fo r adults ( b p.324), except: \200 Use a straight-bladed laryngoscope in infants (<1 year) . \200 Use correct size of endotracheal (ET) tubes in children, either cuffed or uncuffed. Correct size of ET tube: internal diameter (mm) = (age in years/4) + 4 If intubation is not achieved within 30sec, ventilate with high \202 ow O 2 via bag-valve-mask. Consider a re scue airway, such as a laryngeal mask. Equipment sizes, drugs, and doses Become familiar with and use the Broselow tape. See Box 1 5.1 for key formulas Venous access First attempt to secure peripheral venous access. If thi s is not obtained within 90sec, attempt intra-osseous access ( b p.640). High dose adrenali ne is not recommended and may be harmful. Consider it only in exceptional circumstances. At ropine 20mcg/kg (minimum dose 100mcg, max 600 mcg) may be used for patients with bradycardi a related to increased vagal tone. There is no evidence of ef \201 cacy for atropine. Magn esium for polymorphic VT or documented hypomagnesaemia \200\224 give 25 \200\22350mg/kg ov er several min to a max of 2g. Calcium chloride (0.2mL/kg of 10 % solution) is given for hy pocalcaemia, hyperkalaemia and clinically severe overdose of calcium channel blocking drugs . Do not give in the same IV/IO line as bicarbonate. Sodium bicarbonate is not recommended routinely, but consider it in prolonged arrest, hyperkalaemia, and arrhythmias associated w ith tricyclic antidepressant overdose. The dose is 1 \200\2232mL/kg of 8.4 % solution IV/IO . Ensure adequate \202 ushing after giving it. Avoid mixing with other agents (it inactiv ates adrenaline and precipitates out calcium). Glucose Treat hypoglycaemia with IV glucose (0.5g/kg). IV \202 uids Give a 20mL/kg IV normal saline bolus where cardiac arrest is sec ondary to hypovolaemia or sepsis. is indicated 655 pediatric ADVANCED LIFE SUPPORT NOTES Discontinuing resuscitation Resuscitation efforts are unlikely to be successful if there is no return of spontaneous circulation at any time after 30min of life support and in the ab sence of recurring or refractory VF/VT. Prolong resuscitation for patients who are hypother mic or who may have been poisoned. Pediatric resuscitation chart (Fig. 15.9 ) 50 60 80 100 120 140 150 Length cm 14 12 10 8 6 ) s r a e y ( 4 2 1 e g A 9 months 6 months 3 months Weight 5 10 20 30 40 50 kg Fig. 15.9 Box 15.1 Key resuscitation formulas Assume birth weight of 3.5kg, reaching 10kg by the end of the \201 rst year Weight in kg = (age in years + 4) x 2 {works for ages 1 \200\22310 years} Tracheal tube internal diamete r in mm = (age/4) + 4 Tracheal tube length (oral) in cm = (age/2) + 12 Laryngeal mask sizes for children: \200 Size 1 for weight up to 5kg. \200 Size 1.5 for weight 5 \200\22310k g. \200 Size 2 for weight 10 \200\22320kg. \200 Size 2.5 for weight > 20kg. IV \202 u id challenge 20mL/kg De \201 brillation for VF/pulseless VT = 4J/kg Drug doses \200 Glucose in hypoglycaemia : 5mL/kg of 10 % (2.5mL in neonates). \200 Adr enaline IV in cardiac arrest : 0.1mL/kg of 1 in 10,000. \200 Lorazepam IV for seizures : 0.1mg/kg. \200 Diazepam PR for seizures : 0.5mg/kg. \200 Midazolam buccal for seizures : 0.5mg/kg. \200 Phenytoin IVI for continuing seizures : 18mg/kg IVI over 30min. \200 M orphine for pain : IV 0.1 \200\2230.2mg/kg (titrated according to pain). 656 CHAPTER 15 Pediatric emergencies Children with abnormal heart rates or rhythms Background Arrhythmias are uncommon: obtain e xpert advice at an early stage. Children may present with poor feeding, heart failure, shoc k or palpita- tions. Sinus tachycardia may be as fast as 220/min in infants and 180/min in children. Consider undiagnosed congenital heart disease in infants. Bradycardia Heart rates of <60/min are usually pre-terminal events in response to pro- foun d hypoxia and ischaemia, but can be due to i ICP or poisoning. Treat the underlying cause a nd if the child is shocked and <60/min start CPR, give O 2 and ventilate as necessary. Give IV 20mL/kg \202 uid bolus. If this is ineffective, give adrenaline 10mcg/kg IV. If the bradycardia is due to vagal stimulation (eg tracheal intubation or tracheal suctioni ng), give atropine 20mcg/kg (minimum dose 100mcg, max 600mcg). Ventricular tachycardia in children Until proved otherwise, initially consider wide complex tachycardia in children to be VT. \200 Causes of VT: hyperkalaemia, long QT syndrome. Tr icyclic poisoning (p192) often produces a tachycardia and wide QRS resembling VT. \200 Ch ildren with VT and who are clinically shocked but conscious require urgent anesthesia follo wed by synchronized shocks starting at 1J/kg (followed if necessary by 2J/kg). If the child is not clinically shocked , involve a (pediatric) cardiologist and consider amiodarone 5mg/kg IVI over 60 min. Torsades de pointes is treated with magnesium sulfate IVI 25 \200\22350mg/kg (up to a maximum of 2g); seek expert guidance. SVT in children Distinguish SVT from sinus tachycardia (where heart rate is <200/min, P wav es are upright in ECG leads I and AVF, there is beat to beat variation in rate, and history consistent with shock). If clinically shocked , but responsive, obtain expert help to give synchronized shocks (sta rting at 1J/kg, increasing if unsuccessful to 2J/kg) under anesthesia. If there is any dela y, try adenosine IV as outlined for haemodynamically stable patients. In the absence of clinical evidence of shock , try vagal stimulation : immersion of the fac e in iced water, or Valsalva maneuver or unilateral carotid massage. If this is unsuccessfu l, give adenosine 100mcg/kg rapid IV followed by a saline \202 ush, followed if still uns uccessful by further dose(s) at 200mcg/kg, then 300mcg/kg. If this fails, seek expert help and consider IV amiodarone. This page intentionally left blank 658 CHAPTER 15 Pediatric emergencies Sudden infant death syndrome (SIDS) SIDS (also called SUDI \200\224sudden unexplained death in infancy; previously known as \200\230cot death \200\231 or \200\230crib death \200 \231) is decreasing in incidence, but each death is a tragedy. A senior doctor (consultant) should manage distressed parents (and staff). It remains a leading cause of infant death ( 1 in 2000 live births), 90 % occurring between 1 and 6 months of age. Most hospitals now ha ve detailed SUDIC (Sudden Unexpected Death in Infancy and Childhood) protocols, which shoul d be followed in this situation. De \201 nition Sudden death in infancy with no cause identi \201 ed after autopsy. Etiology Although the etiology is unknown, a variety of theories have been proposed, includ ing prone sleeping position, airway obstruction, apnoea, viral illness, and overheating. Risk factors Passive smoking, males, winter months, sleeping prone, premature babies, twins , apnoeic spells in \201 rst week of life, lower socio-economic groups, maternal illicit drug abuse in pregnancy, sibling with SIDS. Prevention \200 Avoid overheating (aim for ambient T of 16 \200\22320 C). \200 Av oid duvets and excess bedding in infancy. \200 Place infant \200\231s feet at cot end to prevent migration under blankets. \200 Sleep supine (unless Pierre \200\223Robin, scolios is, or oesophageal re \202 ux). \200 Consider apnoea alarm. \200 Avoid infant sharing bed with parent. Approach \200 Take the infant into the resuscitation room and continue resuscitation as f or cardiac arrest unless there is post-mortem staining or rigidity. Call the ED consultant and consultant pediatrician. \200 Ensure that a named senior nurse stays with the parents. \200 Immediately death is declared, prepare yourself, then infor m the parents in the presence of the senior nurse. Use the techniques described in b Breaki ng bad news, p.24. Refer to the child throughout by their \201 rst name. Some hospitals have dedicated bereavement counselors \200\224 involve them early. Allow the parents to see and hold the baby, and suggest that they keep a lock of their hair. Take digital or polaroid photographs of the baby: give them to the parents and \201 le copies in the notes. Explain further procedures (eg autopsy) to the parents and provide written information eg \200\230A guide to the post mortem examination proce- dure involving a baby or child \200 \231 (DoH ref 29768/A). Offer to request a minister of religion and involve a social worker. \200 Careful documen tation including general appearance, state of nutrition, weight, rectal temperature (T ) , marks from procedures, rashes, any visible injuries, and appearance of the retinae. Inform GP to arrange to visit parents and discuss whether to suppress lactation with bromocriptine if mother is breast-feeding. 659 SUDDEN INFANT DEATH SYNDROME (SIDS) Retain clothes and bedding (stored in a paper bag, not polythene) and inform police and cor oner (Procurator Fiscal in Scotland) in all cases. \200 Ensure blood, urine, and skin spe cimens will be obtained (looking for infection and inborn errors of metabolism). Arrange a further appointment for the parents with the same consultant pediatrician. Suggest the Foundation for the Study of Infant Deaths, which has various lea \202 ets and a \200\230Cot Death Helpline \200\231 (Telephone 0870 787 0554). Advise about preventative measures for siblings. If the baby was a twin, recommend admissio n of the surviving twin with the mother for monitoring and investigation. Cancel any hospital outpatient appointments and vaccination appointments for the child. Inform the parents that the police will visit them as a matter of course. \200 Finally, c onsider yourself and your colleagues. Staff have feelings too All staff involved with the child and family (ambulance staff, poli ce, GP, nurses and doctors \200\224 including you) will be traumatized by the experience. Those who are themselves parents with young children may be particularly distressed. At the very least, a debrie \201 ng session over a cup of coffee will be required. \200\230Near miss sudden infant death syndrome \200\231 (apparently life- threatening even t) Refer to the pediatrician for admission and monitoring any infant whose parents report a n apparently life-threatening event ( \200\230ALTE \200\231): apnoea, color change, tone ch ange, cyanosis, choking, gagging. The patient may appear well at the time of presentation. Liaise with the pediatric team and take blood (to include FBC, U&E, glucose, calcium, magne sium, phosphate) and admit for apnoea monitoring. The differential diagnosis includes arrhythmias and congenital heart disease, child abuse, gastro-oesophageal re \202 ux, meningitis and sepsis, seizures and metabolic disorders. In 50 % of cases, no cause is found. Despite parental anxiety, short apnoeic episodes (<15sec ) may, in fact, be entirely normal. Theophylline, home monitoring devices, and counseling h ave all been used for infants believed to be at risk. 660 CHAPTER 15 Pediatric emergencies Problems of neonates and infants Neonatal cephalhaematoma This haematoma results from birth trauma and overlies a single skull bone (usually parietal). It resolves spontaneously: do not attempt to aspirate. Umbilical cord sepsis The dried cord separates at 1 week. If the stump develops signs of in fection (becoming moist and red), refer to the pediatrician. Breast swelling Neonatal breasts commonly swell, due to exposure to maternal hormones. Occa sionally, these breasts lactate ( \200\230witch \200\231s milk \200\231) and very occasiona lly become infected, requiring parenteral antibiotics. Neonatal jaundice Jaundice within 24hr of birth is highly abnormal. Neonates who develop ja undice after 24hr mostly have \200\230physiological jaundice \200\231 (typically in the \201 rst week, especially premature babies) or \200\230breast milk jaundice \200\231 (typi cally in second week: self-limiting, breast feeding can usually continue). Refer all patien ts to exclude serious underlying disorders: Rhesus haemolytic incompatibility; congenital s pherocytosis; glucose-6- disease; ABO phosphate dehydrogenase (G-6-PD) de \201 ciency; CMV infection; hypothy- roidism; biliary atresia. The pediatrician will check: serum bilirubin (including ratio of conjugated: unconjugated), FBC; blood \201 lm; U&E; LFTs; direct ant iglobulin test; TFTs; and infection screen. Neonatal conjunctivitis A watery/sticky eye in the \201 rst few days of life may be due t o an unopened tear duct, or occasionally to gonococcal or chlamydial infection acquired fro m the mother \200\231s genital tract. Therefore, take a swab for Gram staining for gonococc i and culture for chlamydia. Refer the baby and mother if organisms are demonstrated, other wise arrange GP follow-up. Sepsis Potentially life-threatening sepsis (eg meningitis) may present in a non- speci \201 c manner in infants (this is especially true of neonates). Classic presen- tations are replaced by: feeding problems, irritability, drowsiness, jaundice, hypotonia, poor weight gain, petechiae or skin rash, apnoea, bradycardia, and cyanotic episodes. Neonates at i ris k are those with low birth weight, those previously ventilated and those with congenital ab normalities. Treatment Give O 2 and IV \202 uids (20mL/kg). Refer for admission and urgen t investigation: BMG, urine culture, FBC, blood cultures, TORCH screen (Toxoplasma, Rubella , CMV, Herpes), CXR, abdominal X-ray (if necrotizing enterocolitis suspected), LP. Commence \200\230blind \200\231 antibiotics (see BNFC ). 661 PROBLEMS OF NEONATES AND INFANTS Crying babies It is quite normal for babies to cry. The amount of crying varies enormously, as does the ability of parents to cope with it. With more acute onset of irritability and crying exclude an acute cause (eg otitis media, incarcerated hernia, testicular torsion, in tussusception, fractured limb), before reassuring and counseling the parents. Parents who a re driven to despair may bene \201 t from a self-help group (eg CRY-SIS 020 7404 5011 www. cry-sis.com ) or follow-up with a pediatrician. Feeding dif \201 culties Parents bring their babies to the ED with a variety of feeding pr oblems. The underlying causes vary widely and range from acute life-threatening sepsis to c hronic parental anxiety or overfeeding. Obtain a careful feeding history and watch the baby feed. Babies normally require at least 15mL of milk/kg/day at day 1, increasing to (cid:12 4) 150mL/kg/day by day 7. Plot weight, height, and head circumference on centile charts. Ta ke weight loss or failure to satisfactorily gain weight seriously \200\224 it may be due t o a signi \201 cant underlying disorder (eg pyloric stenosis). Remember that newborn babie s lose up to 10 % of their birth weight in the \201 rst week, but should regain it by 2 w eeks. Arrange for the health visitor to advise. Refer chronic feeding problems to GP or ped iatrician. Bilious vomiting Occasionally neonates and infants present with bilious vomiting, a sign of serious pathology. The most important differential diagnosis is intestinal malrotation (vo lvulus) secondary to peritoneal bands, which requires emergency laparotomy to avoid total s mall bowel infarction ( b Abdominal pain in children, p.698). Consult a pediatric surgeon u rgently. Other differential diagnoses include an obstructed hernia, Hirschsprung \200\231s disease or sepsis. Metabolic diseases (inborn errors of metabolism) Occasionally neonates present to the ED da ys after birth with coma or seizures with no obvious cause (infection, trauma, hypoglycaemi a, etc.). These infants may have an inborn error of metabolism (e.g. maple syrup urine dise ase, urea cycle disorders, and hyperammonaemia) and they require urgent specialist pediatri c care, often at a tertiary children \200\231s hospital. If an older child presents to the ED with a previously diagnosed metabolic disease, seek expert advice by referring to the pe diatricians early. Remember the parents will know more about the disease than you. Treatmen t Give O 2 and IV \202 uids (20mL/kg) and treat hypoglycaemia, and sepsis. Refer for admi ssion and urgent investigation by a pediatrician. Emergency treatment protocols for this ch allenging group of patients are available at the British Inherited Metabolic Disease Group website ( http:// www.bimdg.org.uk/protocols/documents.asp?o=1&tid=1 ). 662 CHAPTER 15 Pediatric emergencies Skin problems in infants Minor skin problems are common in infants. The combination of a sk in rash and an ill infant should arouse suspicion of serious illness (eg b Meningococcal di sease, p.666) and prompt urgent referral. Do not discharge an infant with an undiagnosed ra sh \200\224 obtain an expert opinion. Neonates Multiple tiny white papules ( milia ) seen on the face of neonates are super- \201 cial epidermal inclusion cysts. Erythematous lesions with central white vesicles are c ommon in the \201 rst days of life \200\224 erythema toxicum ( \200\230neonatal urticari a \200\231). Both are harmless and disappear spontaneously within days. Peeling skin Peeling skin is a common feature of post-mature babies and should be dis- ting uished from scalded skin syndrome and Kawasaki disease ( b p.672). Scalded skin syndrome ( \200\230toxic epidermal necrolysis \200\231) This staphylococcal in fection results in red peeling skin, sometimes with blistering. Refer for admission and IV antibiotics.