CHAPTER 6 Poisoning and substance abuse 474 Methanol Description Commonly found in antifreeze, it is also consumed deliberately and acc identally in contaminated alcohol. Methods of abuse Oral. Clinical features Initial symptoms (under two hours) resemble ethanol intoxication: - Drows iness - Confusion - Irritability. After a latent period of 6 \200\22330 hours or longer, di zziness, drowsiness, abdominal pain, diarrhea, coma, and fits may follow. Hypoglycaemia may occur. Ocular effects may also occur up to 24 hours after ingestion. These include blurred vision with opacities within the visual fields, impaired acuity, and impaired papillary response t o light. Permanent blindness may follow. The minimum fatal dose of methanol in an adult is 60ml. Immediate management - Monitor: ECG, pulse, BP, and pulse oximetry - Check BM stix - Evacua te to hospital for further management. If evacuation to hospital is likely to be prolonged or delayed, 2.5ml/kg 40% proof spirit (whisky, gin, vodka, etc) should be given orally. Fur ther doses may be necessary after arrival in hospital. Activated charcoal does not absorb a lcohols. Diazemuls for fitting. SUBSTANCE ABUSE1 475 Opiates Description Synthetic and naturally occurring narcotic analgesics. The most com- mo nly abused opioid is heroin (diamorphine). Methods of abuse Oral, intravenous, smoking. Clinical features The classic features are: - Pinpoint pupils - Respiratory depression or a rrest - Reduced conscious level or coma. Signs of intravenous drug abuse (needle track mark s, thrombosed veins, skin puncture marks) may also be present. Symptoms of severe poisoning may also include: Pulmonary oedema (non-cardiogenic) - Hypotension - Hypothermia - Fits \200\224more common w ith dextropropoxyphene. Immediate management - Monitor: pulse, BP, respiratory rate, pulse oximetry - Ensure a pate nt protected airway and support respiration if required (bag-valve-mask is usually appropriate). Naloxone is a specific antidote for opiates. The dose is 0.4mg (400 g) \200\2242mg repeate d at intervals as required to a maximum of 10mg. If naloxone is given to exclude opiates as a cause of loss of consciousness, a dose of 10mg should be given. Children: intravenous 10 g/kg, subsequent dose of 100 g/kg if no response Naloxone is short-acting. As a result, when long-acting opiates are being reversed, repeate d doses may be needed. Drug abusers may leave the scene after a first dose only to collapse as the naloxone wears off. In order to reduce the likelihood off this, either the opiate c an be re- versed only enough to ensure adequacy of respiration before arrival in hospital, or a similar dose to the intravenous one given above may be given INTRAMUSCULARLY in additi on. Complete opioid reversal may precipitate an acute withdrawal syndrome. Activated charcoal may be given within one hour of poisoning if naloxone is not available A ND transfer to hospital is likely to be delayed or prolonged. Opiate-induced fits may respond to naloxone. If this fails, diazemuls should be used. CHAPTER 6 Poisoning and substance abuse 476 Phencyclidine Description A psychedelic agent. Methods of abuse Oral ingestion. Clinical features - Anxiety - Paraesthesia, decreased sensitivity to pain, synaesthesia - N ystagmus, ataxia, dysarthria - Disorientation - Hallucinations - Rigidity and catatonic mov ements - Fitting - Coma - Tachycardia, hyper/hypotension - Respiratory impairment or arrest . Immediate management - The patient should be assessed in a quiet environment - Monitor: pul se, BP, pulse oximetry, respiratory rate - Urgent transfer to hospital. SUBSTANCE ABUSE1 477 Volatile solvents Description The most commonly abused solvents are toluene, butane and xyl ene in such fluids as cleaning fluids, adhesives, typewriter correction fluid, lighter flui d, and glues. Methods of abuse Inhalation, often from a soaked rag or in a plastic bag. Clinical features Clinical effects occur within a few minutes: - Euphoria - Ataxia and dizz iness leading to falling and injury - Nausea and vomiting - Hallucinations - Respiratory an d eye irritation - Rash around the nose - Drowsiness - Headache - Double vision - Chest tig htness. Serious side-effects include confusion, drowsiness and coma, fits, arrhy- thmias, a nd pulmonary oedema. Sudden death is most likely to be due to arrhythmia but asphyxiation ( when the bag is placed over the head) or aspiration of vomit may also occur. The acute \200\230high \200\231 is likely to last less than 1 hour. Drowsiness may last many hours. Immediate management - Monitor: pulse, BP, ECG, and pulse oximetry - Establish and maintain a patent airway - Evacuate to hospital for further management. Note Butane is inhaled from a plastic bag and produces respiratory depression, coma, hypote nsion, and arrythmias. Supportive treatment only is required. CHAPTER 6 Poisoning and substance abuse 478 Common street names for drugs of abuse A Acid (blotter acid) Angel dust Amphetamine LSD or ecstasy Phencyclidine Bart (Simpson) Base Bazooka Beast Bennies Bhang Big O Blow Boy Brown stuff Bullet Bush Ecstasy Cocaine free base Cocaine LSD Amphetamines Cannabis Opium Cocaine Heroin Opium Amyl nitrate Cannabis C Candy Cake Charlie Chinese (rock) Coke Crap Crystal Cube juice Cocaine Cocaine Cocaine Cocaine Heroin Cocaine Heroin Amphetamine Morphine Dennis the menace Dexies Dike Disco biscuits Doll (dollies) Dome (dome dots) Dope Dose Dots Downers Dreamer Dust Dynamite Ecstasy Amphetamine Dipipanone (opiate) Ecstasy Methadone LSD Cannabis Cocaine LSD Barbitur ates Morphine Cocaine/opium Cocaine E Embalming fluid Ecstasy Phencyclidine Flake Freebase Cocaine Cocaine free base SUBSTANCE ABUSE1 479 Ganja Gas Ghost Glass Glue Grass Cannabis Volatile solvents LSD Amphetamines Solvents Cannabis H Hard stuff Happy dust Harry Hash Hash oil Hashish Hit Hocus Homegrown Horse(shit) Heroin Cocaine Morphine Heroin Cannabis resin Cannabis oil Cannabis resin Cocaine Morphine Cannabis Heroin Ice Amphetamine or cocaine Jam Joint Joy sticks Junk Cocaine Cannabis Cannabis Heroin Kitkat Ketamine L Lady Leaf LSD Cocaine Cocaine M Magic dust Marijuana Mary Jane Meth Microdot Monkey Morphine or ecstasy (MDMA) Hallucinogens Cannabis Cannabis Amphetamine LSD Morphine Noise Heroin Paki (black) Poppers Pot Purple haze Cannabis Amyl nitrate Cannabis LSD Reefer Resin Roaches Rock Cannabis Cannabis Cannabis Heroin CHAPTER 6 Poisoning and substance abuse 480 Shit Shrooms Skunk Smack Smoke Snort Speed Spliff Stuff Sulfate Cannabis Hallucinogenic fungi Cannabis Cocaine or heroin Cannabis Cannabis Amphetamines Can nabis Heroin Amphetamine Tea Cannabis Uppers Stimulants Vitamin K Ketamine Weed White dove White lightening Whizz Cannabis Ecstasy LSD Amphetamine XTC Ecstasy Chapter 7 481 Acute psychiatric emergencies Psychiatric emergencies 482 Psychiatric conditions 484 Legal and ethical issues 490 Managin g the violent patient 492 CHAPTER 7 Acute psychiatric emergencies 482 Psychiatric emergencies True psychiatric emergencies needing urgent resolution are relative ly rare. When they do occur, they require sensitivity and the formulation of a careful mana gement plan. Referral to hospital may not be the most appropriate option and the patient ma y already be known to the psychi- atric services. Nevertheless, a key component of the mana gement of psychiatric emergencies is the identification of the small number of patients who present a risk either to their own health or to the safety of those who are attempting to help them. As a result of this risk, the law which applies to psychiatric patients is diffe rent to that which applies to those who do not suffer from mental illness, and a vital part of the cor- rect management of these patients is a knowledge and understanding of the Ment al Health Act. Patient assessment \200\224mental state examination It is obviously impossible to carry out a full mental state examination in many pre-hospital situations. It is possible, however, to gain enough information to allow sensible management decisions to be made using a simpli fied system of assessment. The key features of a psychiatric history are: Presenting complaint - Past psychiatric history - Past medical history - Medication - Drug and alcohol use - Social situation and family history (including psychiatric history). The presenting complaint can be considered under the following headings: - Appearance and behav ior - Speech form (rate, quantity, and coherence) and content - Mood (depressed, manic, lab ile, inappropriate) - Beliefs and thoughts Passivity \200\224direction or manipulation of thought and thought content by an other agent Phobias - Worries - Obsessions - Suicidal/homicidal thoughts Delusions (false fixed unshakeable beliefs) - Hallucinations - Cognition (orientation, conc entration, memory) - Insight. Patient assessment \200\224physical examination A physical examination should be carried ou t wherever possible in order to exclude or confirm an underlying organic cause for the pres enting complaint (see box). PSYCHIATRIC EMERGENCIES1 483 Suicide risk Assessment of suicide risk is notoriously difficult and the pre-hospital docto r must ere on the side of caution. It is important not to be misled by the comments of othe rs who may underplay the significance of events. In addition, parasuicidal actions may have a fatal outcome due to igno- rance of the consequences on the patient \200\231s part. This is particularly the case in drug ingestions. In general, the more violent the method attem pted by the patient, the greater the intent to die. Suicidal risk fac- tors are listed in t he box below. Any patient who appears to be demonstrating a significant risk of a further completed suici de attempt should be taken to the local A&E department or mental health facility, depending on local services and protocols. When there is a perceived significant risk that a patient will take their own life, but the y are not obviously detainable under the Mental Health Act, it is permissible under common law to restrain them pending formal psychiatric assessment. More common organic causes of psychiatric illness Hypoglycaemia - Infection - Cardiac failure - Alcohol abuse (delirium tremens) - Substance abuse - Subdural haematoma. Risk factors for a successful suicide attempt Mental health issues - Present or previous psychiatric illness, especially depression - Per sonality disorder - Previous suicide attempt or self harm - Suicidal thoughts - Family hist ory of suicide. Physical health issues - Chronic physical illness. Demographic and social factors - Male sex - Age >40 - Single, unmarried, divorced - Unemplo yed - Problem drinking. Other - Recent life crisis. CHAPTER 7 Acute psychiatric emergencies 484 Psychiatric conditions Psychosis Presentation Psychotic patients demonstrate disordered thi nking and behavior. These symptoms may or may not be sufficiently characteristic to assign a diagnostic label such as schizophrenia. Psychotic symptoms may also complicate depression (depressive delusions are usually consistent with the mood of the patient; non-congruous d elusions are a feature of schizophrenia). Delusions Delusions are firmly held, unshakeable beliefs that are not consistent with the p atient \200\231s social, religious, and cultural background. Delusions may be paranoid, con trolling, or persecutory, but the patient may also believe themselves to be equipped with s pecial abilities or a particular mission. The patient may be deluded that they are being wa tched or bugged or that television programs or newspapers contain messages of signifi- canc e to them. Somatic delusions are those attached to the patient \200\231s bodily function or appearance. Hallucinations Hallucinations are false perceptions which can occur in any sensory modality . Auditory hallucinations are most common; visual hallucinations are characteristic of deli rium (an organic cause) and tactile hallucinations may occur secondary to drug abuse. Delus ional explanations may be formed for hallucinatory experiences and some hallucinations may lead the patient to specific courses of action. Both delusions and hallucinations (classica lly olfactory) may occur in temporal lobe epilepsy. Behavioral abnormalities Behavioral abnormalities in psychosis may vary from the threatenin g and aggressive to the withdrawn and uncommunicative. Speech may be unin- telligible and a ccompanied by wild gesturing, swearing, and antisocial behavior. The patient may be preoccu pied with responding to his delu- sions or hallucinations. In some, relatively rare cases, the patient may be at risk of harming themselves or others. Management The most important aspect of the management of a psychotic patient is control of their behavior. The best way to achieve this is by a calm empathic approach. There is no v alue in attempting to reason a psychotic patient out of their delusional beliefs, and this is only likely to inflame an already difficult situation. It is essential that a risk assessment is made and that appropriate assistance is sought, if necessary. Otherwise, an approach based on inap- propriate force a nd aggression must be avoided since it is unlikely to be helpful and may compound the delus ional beliefs of the patient. When sedation is required, the most appropriate for pre-hospital use is probably haloperidol (2 \200\22310mg intramuscularly). PSYCHIATRIC CONDITIONS1 485 Depression Presentation The characteristic features of depression are: - Misery - Lethargy and lack of motivation - Disturbed sleep - Disturbed appetite - Low self esteem - Lack of l ibido - Anxiety - Guilt - Self neglect - Suicidal thoughts. Risk factors for depression are given in the box below. Risk factors for depression Low social class - Single status - Family history - Unemployment - Urban environment - Medi cal and psychiatric co-morbidity - Drug and alcohol abuse - Loss of the patient \200\231s m other before age 11 - Those who are confined to the home (women) - Three or more young chil dren (women) - Lack of social support (women) Management The most important aspects of management are a patient approach and a sympatheti c ear. An assessment of suicide risk factors should be per- formed (p.483) and appropriate referral made to the psychiatric services. This may involve direct referral to A&E or, rare ly, detention under com- mon law or the Mental Health Act, pending formal psychiatric asses sment. CHAPTER 7 Acute psychiatric emergencies 486 Mania Presentation The characteristic presenting symptoms of mania are: - Overactivity - Di stractability - Agitation - Irritability - Impulsive behavior. Manic behavior may also be f lamboyant, provocative, violent, or sex- ually disinhibited. The patient may also suffer de lusions and hallucinations. Management The most important aspect of management is a calm rational approach. On occasion , physical restraint may be necessary but should only be used when there is no alternative. Adequate numbers of personnel must be available. If medication is necessary, haloperidol o r a benzodiazepine should be used. PSYCHIATRIC CONDITIONS1 487 Anxiety disorders Presentation The characteristic symptoms of anxiety are: Physical - Tachycardia/palpitation - Dry mouth - Sweating - Breathlessness - Flushing - Tre mor - Urinary frequency - Nausea and diarrhea Hyperventilation syndrome may occur with dysp noea, carpopedal spasm and perioral tingling. Psychological - Fear - Apprehension - Loss of patience/irritability - Insomnia. Management The main treatment aim is reassurance. Hyperventilation is treated by getting th e patient to breathe in and out of a paper bag until the symp- toms resolve. This should be done in the sitting position whilst the patient takes slow shallow breaths. Referral for l onger-term management is likely to be necessary. CHAPTER 7 Acute psychiatric emergencies 488 Personality disorders Patients with personality disorder can be extremely difficult to mana ge. They often appear hostile and impatient and do not easily interact with those attemptin g to care for them. Indeed, such patients seem to have a remarkable ability to antagonize c arers, with the inevitable consequence that their management is often suboptimal. Unfortunately, these patients are at a significantly increased risk of suc- cessful suicide despite often long histories of previous non-fatal self harm. It is vital, therefore, that an objective approach is taken and a formal assessment carried out. Any suicidal ideation must be taken seriously and appropriate referral to the psychiatric services made. This page intentionally left blank CHAPTER 7 Acute psychiatric emergencies 490 Legal and ethical issues The Mental Health Act 1983 The Mental Health Act 1983 states the l aw governing the management of patients with mental illness. The sections that are most lik ely to be used by pre-hospital care practitioners are sections 2,3,4, 135, and 136. Section 2 Admission for assessment Section 2 concerns admission for assessment and is usual ly applied when there is no previous history of diagnosed mental disorder or the patient is not known to the local psychiatric services. Admission must be neces- sary for assessment of the patient \200\231s condition, in their best interests, and required for the safety of others. Section 2 is valid for 28 days. Application is made by an approved social worker or (less commonly) the nearest relative and recommenda- tion for admission is by two doctors, one of whom must be approved under the Mental Health Act (Section 12) and is usually a consultant psychiatrist. An approved social worker can be contacted via the lo cal social services department. At the end of the 28-day period, the patient must be discharged or converted to Section 3. Patients admitted under Section 2 may request a mental health tribunal review after 14 days . Section 3 Admission for treatment Section 3 is intended to provide for compulsory admission for the treat- ment of a mental illness. Application is by an approved social worker and r ecommendation must be made by two doctors, of whom one must be approved under the Act (as f or Section 2). Admission is for 60 days. To be eligible for Section 3, the patient must suffer from mental illness, mental impairmen t or severe mental impairment, or psychopathic disor- der which is sufficiently serious to require treatment in hospital. Alterna- tively, detention in hospital must be necessary for the safety of others. Once an application has been made, it is considered to be in force. Section 4 Emergency admission for assessment Section 4 covers emergency admission, which ca n be recommended by any doctor (who does not have to be approved under the Act). Applica- t ion is made by an approved social worker or nearest relative. Section 4 can only be used in an emergency when Section 2 cannot be used due to the unavailability of staff. The duratio n of admission permitted under section 4 is 72 hours (before conversion to Section 2 is nec essary). Section 135 Removal to a place of safety (via a magistrate) Under Section 135, a social wor ker may apply to a magistrate for a warrant to remove a patient to a place of safety if he believes that the patient \200\231s mental illness means that the patient is unable to care for himself or he considers that the patient is being neglected or mistreated. Section 135 allows entry into the patient \200\231s home. The maximum duration for which the patient c an be held under Section 135 is 72 hours. LEGAL AND ETHICAL ISSUES1 491 Section 136 Removal to a place of safety (by the police) Section 136 allows the removal of a mentally ill person to a place of safety by a police officer in an emergency situation wh en it is not possible to involve a social worker or approved doctor. The patient must be in need of care or control in their own best interests or in the interests of others. The pla ce of safety is usually the nearest hospital or police station. The patient can be detained for a maximum of 72 hours pending assessment and transfer to a more appropriate section of the Act. Table 7.1 Relevant sections of the Mental Health Act 1983 Grounds Application by Medical recommendation Maximum duration Mental disorder, 28 days Approved social worker or nearest relative Two doctors, one approved under the Act As above As above 6 months Mental illness, psychopathic disorder, mental impairment, severe mental impairment As above Any doctor 72 hours Mental disorder (urgent need to admit) Mental disorder Magistrate N/A 72 hours Mental disorder Police officer N/A 72 hours CHAPTER 7 Acute psychiatric emergencies 492 Managing the violent patient The key to the successful management of the violent or potenti ally violent patient is risk assessment. Some important risk factors for violent behavior a re shown in the box. An awareness of these allows prepara- tion before a crisis occurs. The following management points may be helpful: DO - Keep a sideways posture relative to the patient; avoid \200\230aggressive \200\231 eye contact Keep your hands visible - Talk calmly and allow the patient to speak - Try to identify the cause of the aggression and deal with it - Have an escape plan. DO NOT - Interview the patient alone - Interview the patient in an environment in which you could be trapped - Fidget or look at your watch - Make promises that cannot be kept - Be c ritical. MANAGING THE VIOLENT PATIENT1 493 Risk factors for violent behavior Psychiatric - Psychopathic personality - \200\230Command \200\231 hallucinations (to harm others) - Delusional beliefs of persecution - Mania - Dementia. Psychological - Anxiety or fear about personal safety - Anger or conflict (with inability t o manage it) - Inability to cope. Organic - Learning disability - Drugs or alcohol - Delirium - Brain injury or disease.* Demographic - Young male - Previous history of violence - Group pressure/tolerance of viole nt behavior. Including head injury, frontal lobe damage, meningitis, epilepsy, and encephalitis This page intentionally left blank Chapter 8 495 Pediatrics Taking a pediatric history 496 Identification and management of the seriously III or injure d Child 500 Recognition of ABC problems 502 Management of ABC emergencies 506 Pediatric emergencies 510 Pediatric life support 524 Trauma in children 532 Analgesia 542 Consent 546 Child abuse 54 8 Triage 550 Pediatric trauma score 552 CHAPTER 8 Pediatrics 496 Taking a pediatric history The essential components of a pediatric history are: - History o f the presenting complaint - Previous medical history - Social and family history. Immediate assessment and attention to life-threatening problems pre- cedes a full history. However, even in a crisis, obtaining an AMPLE history takes only a short time and can provi de vital information: A M P L E Allergies Medicines Past medical history Last food and drink Events leading to current prob lem Allergies Allergic reactions to medicines and food in children are becoming increasingly co mmon, especially allergy to nuts. Parents of children with known severe allergies often car ry an adrenaline self-administration device (Epipen ). Medicines Regularly prescribed medication gives vital information about the child \200\231s active medical problems and underlying health issues. Past medical history The past medical history may provide crucial information, such as the presence of congenital cardiovascular or neurological problems and recurrent illnesses incl uding asthma or diabetes. Last food and drink Recent food and drink is a risk for regurgitation, especially for child ren with an altered level of consciousness. Vomiting occurs quite frequently in children wi th minor injuries and febrile illnesses. Events leading up to the current problem The mechanism of injury or details of current medi cal problems help in predicting patterns of injury or determining the medical diagnosis. As pects of the history should include: Information from the scene The position of vehicles, vehicle deformity, and the position in which the child was found all provide vital clues to potential injuries. In the case of me dical illnesses or domestic accidents, the state of the home and the well-being of siblings may give useful clues to the current problem. The pre-hospital carer is in the unique posi tion to know the home environ- ment and the possibility of physical abuse. TAKING A pediatric HISTORY1 497 Information from carers Children are usually accompanied by a parent, relative, family frie nd, or teacher. Carers, nursery nurses, and school teachers will often know about a child \200\231s medical illnesses, medication, and social circumstances. Information from witnesses Information from witnesses may provide valuable details regardin g the mechanism of injury. Was the child run over? Were they projected over the bonnet? Wer e they hit by another vehicle? Were they unconscious? The child \200\231s own history Communicating with a child can be difficult. Questions shou ld be pitched appropriately for the child \200\231s age. Language and intellect may be barr iers to understanding. Equally, a child may respond more appropriately to its parent or car er rather than to a stranger. ABCDE Direct questioning logically follows an ABCDE sequence: Airway - How long has the child had problems? - Could the child have inhaled a foreign body ? - Has the child been distressed? - Has the child been drooling? (consider epiglottitis) - Has the child been eating/drinking normally? Breathing Has the child: - Had the problem before? - Been responding normally? - Been distr essed? If there is a known respiratory problem, has the child: - Ever required steroids? - Ever been admitted to hospital with a similar problem before? - Ever been admitted to an in tensive care unit with breathing problems? - Had a cough, cold, ear infection, or sore thro at? Circulation - When did the problem start? - Does the child have any heart problems? - Does the child have a rash? - Has the child had diarrhea or vomiting? - Has the child been respo nding normally? Disability - When did the problem start? - Has the child been responding normally? - Does t he child have a rash? - Has the parent or carer noted any agitation or drowsiness? - Has th e child had a head injury? CHAPTER 8 Pediatrics 498 The following questions may be helpful in particular circumstances: In the case of fitting: - Has the child ever had fits before? - Was the child unwell before the fit? - Has the child had a raised temperature? - Did the child have a tonic/clonic rea ction? - How long did it last? In all cases of unconsciousness/diabetes: - Is the child known to be diabetic? (check a BM stix ) - If so, has the child had their normal insulin? - Has the child been eating and dr inking normally? - Has the child been behaving normally? Environment - In what position is the child most comfortable? - Is the child too hot or too cold? Important questions in neonates and infants: - Has the child had a raised temperature or be en shivering? - Has the child had a reduction or increased urine output (dry or wet nappies)? Is the child sleepy? Are there any symptoms of child abuse? - Non-accidental injury - Emotional neglect - Neglec t - Sexual abuse - Organized or ritual abuse. Features suggestive of non-accidental injury include: - Inappropriate delay in seeking help after significant injury - Previous history of frequent injuries - Mechanism of injury not appropriate - Vague or no history of trauma - Different explanations for cause of injury - Different history from the child - Inconsistent history for the child \200\231s chronologi cal age - Inappropriate response to carers and parents. Patient handover The child should be handed over to medical staff using the Mechanisms, Inj uries, Symptoms, Treatment (MIST) system. This page intentionally left blank CHAPTER 8 Pediatrics 500 Identification and management of the seriously ill or injured child The optimal management of the critically injured or ill child requires the accurate assessment, recognition, and t reatment of immediately life- threatening and urgent problems. The approach to the ill or i njured child follows the ABCDE system. Diagnosis is of secondary importance to the life-sav ing procedures. Assessment of the child demands a full under- standing of the important ana tomical and physical differences between children and adults. Weight Weight varies with age. The most rapid growth occurs within the first year (average birth weight 3.5kg, average weight at age 1, 10kg). The rate of growth then slows prior to the pubertal growth spurt and finishes when the epiphyseal growth plates fuse. Weight can be estimated between 1 \200\22310 years of age using the formula: Weight (kg) = (2 x age in years) + 8 Drug dosage calculation is related to the child \200\231s body weight. Appropriate aide mem oires in the form of tables or tapes are available to assist in calculating weight, equipme nt sizes, and drug dosage and should be checked prior to any pediatric drug administration. Vital signs Heart rate Heart rate varies with age from 120 \200\223140 beats per minute in the newborn to that of 60 \200\22370 beats per minute in a healthy adolescent. IDENTIFICATION AND MANAGEMENT1 501 Identification and management Age (years) Respiratory rate (breaths/minute) Pulse rate (beats/minute) Under 1 30 \200\22340 110 \200\223160 1 \200\2235 25 \200\22330 95 \200\223140 6 \200\22312 20 \200\22325 80 \200\223120 Fig. 8.1 Normal pediatric vital signs. The most common cause of bradycardia in children is hypoxia. Tachycardia may be due to pain , anxiety, or physiological compensation to maintain vital organ perfusion. Blood pressure Blood pressure varies with age and can be calculated using the formula: Syst olic blood pressure (mmHg) = 80 + (age in years \227 \227 \227 \227 2) Blood pressure can be difficult to measure in pre-hospital care. Children have very robust compensation mechanisms and only become hypotensive as a pre-terminal event. A hypotensive child is at serious risk of cardiovascular collapse as the compensatory mechanisms fail rap idly once hypotension is established. Respiratory rate Respiratory rate varies with age. It should be noted that infants are obli gatory nasal breathers. Conditions such as acute bronchiolitis risk airway blockade. Infant s use the diaphragm as the main muscle of ventila- tion. The child may exhaust easily. In a ddition, large amounts of air can be trapped in the stomach restricting movement of the dia phragm. The use of accessory muscles of ventilation, intercostal recession, and tracheal tu g are all features of respiratory distress. CHAPTER 8 Pediatrics 502 Recognition of ABC problems The child responds to trauma and acute illness by physiological compensation. When this is exhausted, decompensation follows, which if untreated will lead to death. Ventricular fibrillation is uncommon in children, the most frequent arrest rhyth m being asystole precipitated by hypoxia and acidosis. The prognosis for cardiac arrest is appalling. Therefore, the emphasis must be on its prevention. Airway - The airway should be checked for obstruction from foreign objects and vomit. Blind finger sweeps should not be undertaken. Upper airway obstruction may produce choking due to foreign bodies or airway narrowing due to croup, epiglotitis, or thermal injury. - The child may exhibit s tridor or a barking cough due to airway narrowing. Breathing - An increased respiratory rate in the child at rest may be due to an airway or c irculation problem as well as a breathing problem. Increased use of the muscles of ventilation and accessory muscles is a sign of ventilatory distress. Effective breathing is demonstrated by adequate symmetrical chest movements and equal breath sounds on auscultation. Wheeze or grunting respiration may be apparent. A silent chest (for example, in asthma) is a bad prognostic sign indicating inadequate ventilation and imp ending respiratory arrest. Circulatory assessment A systematic assessment of the heart rate, skin color, temperature, capillary refill, and central and peripheral pulses should be performed. - Tachycardia may be due to many factors including pain and anxiety. It is also seen as part of the cardiovas cular response to infection and hypovolaemia. Bradycardia is a sign of cardiovascular decompensation. - Comparative volumes of the centra l and peripheral pulses will give an indication of peripheral circulatory shut down. Capillary refill is assessed by pressing the skin for 5 seconds, then counting the time for the skin color to return on the release of the pressure. A figure les s than 2 seconds is normal. Prolongation in the absence of a limb injury with circulatory c ompromise or hypothermia indicates circulatory compromise. Altered mental state leads to confusion, aggression, and obtundation. - Respiratory rate in creases due to hypoxia and progressive metabolic acidosis. Pre-terminal features include skin mottling and cyanosis. RECOGNITION OF ABC PROBLEMS1 503 Signs of respiratory illness - Tachypnoea - Use of accessory muscles - Wheezing or grunting respiration - Silent chest - Tachycardia - Bardycardia (pre-terminal event) - Skin pallor - Cyanosis - Decreasing level of consciousness. Disability The level of consciousness should be assessed using the AVPU system: A V P U Alert response to Voice response to Pain only Unresponsive A central painful stimulus such as pressing over the supra-orbital ridge is preferred. Peri pheral stimulation may not produce a response in the presence of a spinal cord injury. A ch ild who is a P or U responder is at risk of airway compromise due to the loss of protective airway reflexes. The child \200\231s posture should be recorded, for example, decerebrate (arms extended) or decorticate (arms flexed). Abnormal stiffness and floppiness should be recorded. Pupils sh ould be observed for size, shape, and reactivity. Unilateral dilatation in the presence of a head injury suggests an intracranial collection. Sinus bradycardia and an elevated blood pressure suggest raised intracranial pressure. Monitoring Vital signs must be observed including: - Pulse rate - Respiratory rate - Glasgo w Coma Scale (GCS) - Oxygen saturation - ECG trace - BM stix - End tidal CO2 (if intubate d). In the event of any deterioration, the primary survey should be repeated. All children with significant ABC problems should be regarded as having a time-critical emergency. CHAPTER 8 Pediatrics 504 The Glasgow Coma Scale voice component requires adaptation in younger children (see Fig. 8.2) Response elicited Score BEST EYE OPENING RESPONSE Open spontaneously React to speech React to pain No response 4 3 2 1 BEST MOTOR RESPONSE Moves normally and spontaneously or obeys commands Localizes pain Withd raws in response to pain Flexes abnormally to pain (decorticate movements) Extends abnormal ly to pain (decerebrate movements) No response 6 5 4 3 2 1 BEST \200\234VERBAL \200\235 RESPONSE Smiles, follows sounds and objects, interacts Cries consolably or interacts inappropriately Cries with inconsistent relief or moans Cries incon solably or is irritable No response 5 4 3 2 1 Fig. 8.2 Pediatric Glasgow Coma Scale. This page intentionally left blank CHAPTER 8 Pediatrics 506 Management of ABC emergencies Airway - Manual maneuvers including chin lift or jaw thrust. The head should be maintained in the neutral position in neonates and the \200\230sniffing the morning air \200\231 position in older children. (see Figs 8.3 and 8.4). - Inline stab ilization of the cervical spine is necessary in trauma. - Aspiration of any vomit or secret ion. - Removal of foreign bodies under direct vision \200\224DO NOT perform a finger sweep. Oropharyngeal airway insertion if there is no gag reflex present. - Consideration of Bag \200\223Value \200\223Mask (BVM) venlilatory support. - Consideration of endotracheal intub ation or needle cricothyroidotomy as appropriate (consider surgical cricothyroidotomy if child over 12 years of age). Notes An oropharyngeal airway, if used, must be inserted following the contour of the tongu e and is best inserted using a tongue depressor (unlike in the adult where the airway is in serted upside down and then rotated). In a child, this procedure may damage the soft tissue s. The airway may induce wretching and vomiting. An appropriately sized nasopharyngeal airway may be used to support the airway and must be inserted carefully, following lubrication, to avoid damage to the nostrils and the adenoids . Endotracheal intubation should only be undertaken by trained, competent practitioners. All except completely unresponsive children will require drug-assisted rapid sequence induction to facilitate intubation. In the majority of cases, the airway can be opened as above and ventilation achieved using a 1- or 2- person bag-valve-mask technique until arrival at hosp ital. When all attempts to open the airway are unsuccessful, a needle crico- thyroidotomy may be performed. This will usually maintain life for a short period of time. The patient requires rapid transportation to hospital for a definitive airway. MANAGEMENT OF ABC EMERGENCIES1 507 Fig. 8.3 Manual airway maneuvers 1: Chin lift. The airway should be opened by chin lift and head tilt in the absence of trauma. Two fingers placed on the jaw prominence and lifting s lightly, extend the neck into the \200\230sniffing the morning air position \200\231. In i nfants, neck extension should be avoided. The child \200\231s face should remain parallel t o the surface on which they are lying. The soft tissues of the neck are easily compressed r isking airway obstruction. Blind finger sweeps should be avoided because of the risk of for cing a foreign body further into the airway. (Reprinted with permission from Greaves I et a l. (1995) Handbook of immediate care. Balliere Tindall). Fig. 8.4 Manual airway maneuvers 2: Jaw thrust. If cervical spine trauma is suspected (base d on mechanism of injury, pain in the neck, or neurological signs and symptoms), a jaw thru st maneuver should be undertaken. Two fingers are placed behind the angle of both sides of the jaw, gently pulling the jaw forward without tilting the head. Manual inline stabilizati on should be maintained and an appropriate cervical collar applied. In non-co-operative pat ients, reassurance, particularly from parents and friends, may facilitate treatment. In the combative child, the best approach is to attempt to maintain manual inline stabilization. (Reprinted with permission from Greaves I et al. (1995) Handbook of immediate care. Ballier e Tindall). CHAPTER 8 Pediatrics 508 Breathing - Ensure adequate oxygenation by using a trauma mask (a face mask with a non-rebreathe valve and an oxygen reservoir) to which oxygen, distributed at 15 litres per minute, is attached. COPD is not a problem in children and, therefore, there is no concern about giving high-flow oxygen. If the child remains hypoxic despite supplementary oxygen, consider bag-valve-mask assisted ventilation. Avoid over-ventilation as this will precipitate gastric distention and a high risk of regurgitation. Circulation - High-flow oxygen should be administered to all patients with significant blood loss. Vascular access should be achieved by inserting the largest possible cannula into the biggest available vein. Intraosseous access should be the access of choice in the collapsed and/or hypovolaemic younger child, although it is effective in all age gr oups.