logging in or signing up Paediatric Emergencies samarsen Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2526 Category: Science & Tech.. License: All Rights Reserved Like it (3) Dislike it (0) Added: February 16, 2010 This Presentation is Public Favorites: 4 Presentation Description No description available. Comments Posting comment... By: mohdamir (8 month(s) ago) Impressive and very good Presentation. please send the presentation as attachment to the following E.Mail:: mohdamir@omantel.net.om Saving..... Post Reply Close Saving..... Edit Comment Close By: rajeshiloveu (14 month(s) ago) hello sir, ur presentation is very impressive and effective, plz send this on my following email id. rajeshmscnursing@gmail.com, thank u sir Saving..... Post Reply Close Saving..... Edit Comment Close By: sushee (15 month(s) ago) plse send me the copy of this presentation.my email is sushee2005@yahoo.co.in.or me 2 download this ppt.thanks. Saving..... Post Reply Close Saving..... Edit Comment Close By: leigh_zali (20 month(s) ago) Good presentation Dr Sen. Would you mind emailing me a copy of this presentation please to leigh_zali@yahoo.com Thanks! Saving..... Post Reply Close Saving..... Edit Comment Close By: rup1esh (22 month(s) ago) Nice presentation,Dr Sen.Can be used 2 teach UG students,if u allow me 2 download the content.Thanks Saving..... Post Reply Close By: samarsen (22 month(s) ago) Please send me an email at samarsen@yahoo.co.uk and I will send you a copy of the presentation. Thanks for your comments. Sam Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript PAEDIATRIC EMERGENCIES : PAEDIATRIC EMERGENCIES Dr. Samarnath Sen MD,DCH,MRCPCH PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 2 PAEDIATRIC EMERGENCIES 1. COMA 2. SHOCK 2. UPPER AND LOWER AIRWAY OBSTRUCTION Croup and Epiglottitis, Foreign Body Asthma, Bronchiolitis, Chest infection 3. CARDIAC EMERGENCIES Heart Failure Supraventricular Tachycardia PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 3 PAEDIATRIC EMERGENCIES 4. INFECTIONS Meningitis Encephalitis Endocarditis 5. SEIZURES Status Epilepticus Febrile fits Non febrile fits Increased intracranial pressure PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 4 PAEDIATRIC EMERGENCIES 6. RENAL Hypertension Haematuria UTI Nephrosis HUS 8. PAINS Chest pain Abdominal pain Sickle Cell Crises PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 5 PAEDIATRIC EMERGENCIES 9. ENVIRONMENTAL Burns, Smoke inhalation Near Drowning Poisoning Hypothermia, heat stress Anaphylaxis Head injury and RTA NAI and SA EMERGENCIES IN BABIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 6 EMERGENCIES IN BABIES Excessive crying Not feeding Cyanosis Apnoea Jaundice Fitting Diarrhoea Vomiting Fever Bleeding COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 7 COMA State of unresponsiveness due to diffuse lesions of hemispheres / brain stem Structural lesions bleeding, tumour, abscess, hydrocephalus Non-structural lesions (95%) seizures, drugs / poisons infection (meningitis, encephalitis, HUS) metabolic (hypoglycaemia, DKA, Reye) renal failure, hepatic coma endocrine (Addisonian crisis) COMA: ASSESSMENT AND DIAGNOSIS : 2/16/2010 SHO INDUCTION/DR.S.SEN 8 COMA: ASSESSMENT AND DIAGNOSIS Rapid History and General Examination Skin ( trauma, petechiae, bleeding) Sutures in infant and neck stiffness, systemic, AF CNS examination GCS, Gag Reflex, Blinking Pupils, Reaction, EOM Palsy, Fundi, Dolls Eye Motor- Posture, Tone, Symmetry / Lateralizing signs Reflexes- DTR, Plantars Pain, Grimace, Flexion, Extension, None Assess level of Central Dysfunction BPA CHILDREN’S COMA SCORE (15) : 2/16/2010 SHO INDUCTION/DR.S.SEN 9 BPA CHILDREN’S COMA SCORE (15) Eyes: 4 spont. open 3 verbal command 2 pain 1 no response Motor:6 obeys verbal 5 localizes pain 4 withdraws from pain 3 abn. flexion to pain 2 extends to pain(decer) 1 no response Best verbal response: 5 orientated smiles, follows 4 disorientated consolable crying inappropriate interaction 3 inappropriate words sometimes consolable moaning 2 incomprehensible sounds inconsolable, irritable 1 no response MANAGEMENT OF COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 10 MANAGEMENT OF COMA Always emergency - get Registrar/Consultant Airways - check, suction, ventilation if needed Breathing - ensure adequacy: RR, BS,saturation Give high flow oxygen, if breathing Ventilate with bag and mask Intubate with Anaesthetist, if breathing inadequate / GCS 8 / herniation syndromes Circulation - monitor BP, CRT, PR IV access: 2 venous and arterial lines INVESTIGATIONS IN COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 11 INVESTIGATIONS IN COMA FBC, U+E, LFT, BC, Blood gases, Glucose, NH3, toxic screen, lactate, amino acids, ammonia, Virus studies, PCR Chest X-ray, EEG CT scan (has limited value), LP only with neurosurgical support TREATMENT OF COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 12 TREATMENT OF COMA Treat Shock - Restore and control BP Treat The Treatable Maintain BS with 10% dextrose 5mls/kg PRN Restricted fluid (document type & rate) Mannitol, if increased intracranial pressure Consider Cefotaxime, Acyclovir, Erythromycin Consider Flumazenil, Naloxone, Anticonvulsant May require transfer to PICU SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 13 SHOCK Failure of circulation of oxygen to tissues resulting in lactic acidosis, cellular dysfunction and cell death 1. Hypovolaemic shock due to loss of blood or fluid 2. Distributive (septic) shock: maldistribution of blood 3. Obstructive shock: reduced vascular size 4. Cardiogenic shock: primary heart problem HYPOVOLAEMIC SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 14 HYPOVOLAEMIC SHOCK Haemorrhagic loss: trauma, gastrointestinal bleed, Coagulopathy Fluid and electrolytes: gastroenteritis, diabetic ketoacidosis, polyuric states, mineralocorticoid deficiency Plasma/ protein loss: burns, peritonitis, bowel obstruction/ necrosis SEPTIC (DISTRIBUTIVE) SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 15 SEPTIC (DISTRIBUTIVE) SHOCK Maldistribution of blood within organs due to abnormal peripheral function Sepsis: Gram negative bacteria, Meningococcus Neurogenic shock Drugs: antihypertensives, barbiturates Anaphylaxis OBSTRUCTIVE SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 16 Reduced vascular size and limited blood flow due to intrinsic or extrinsic factors Pericardial tamponade Tension pneumothorax Pulmonary embolism OBSTRUCTIVE SHOCK CARDIOGENIC SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 17 CARDIOGENIC SHOCK Primary heart problem with inadequate cardiac output and inadequate tissue perfusion SVT, bradycardia, ventricular tachycardia Myocarditis Hypoplastic left heart Left sided outflow obstruction Critical aortic stenosis and coarctation of aorta ASSESSMENT OF SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 18 ASSESSMENT OF SHOCK Full history and physical examination Classic signs: tachycardia, tachypnoea, oliguria (anuria), weak pulse, mottled extremities, hypotension Children can compensate for hypoperfusion states Hypotension is a late sign of decompensated shock EARLY AND LATE SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 19 EARLY AND LATE SHOCK Tachycardia  bradycardia, dysrhythmia tachypnoea  severe tachypnoea and gasping low pulse pressure  hypotension cool extremities, decreased CR  absent peripheral pulses dry mucosa  mild oliguria  severe oliguria  anuria restlessness / agitation  unconsciousness GENERAL MANAGEMENT OF SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 20 GENERAL MANAGEMENT OF SHOCK MONITOR: HR, BP, BP (CVP), O2 SaO2, fluid balance AIRWAY, BREATHING, CIRCULATION Reverse hypoxia and acidosis Control bleeding with direct pressure Obtain intravenous (arterial) access INVESTIGATIONS: FBC, U+ E, Osm, LFT,BG, BC, clotting, BG MSU, X-ray, ECG, Brain scan TRANSFER TO ITU: no response to Dopamine 2-20ugm/kg/min signs of organ failure SPECIFIC MANAGEMENT OF SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 21 SPECIFIC MANAGEMENT OF SHOCK Hypovolaemia: rapid volume replacement Septic shock: antibiotics and inotropes Cardiogenic shock: minimal volume support Inotropes (Dopamine, Dobutamine)-low BP+ high HR Chronotropes (Isoproterenol or Epinephrine)-if low BP + bradycardia or normal heart rate Obstructive shock: drainage Anaphylaxis: oxygen, adrenalin, hydrocortisone RESPIRATORY EMERGENCIES : RESPIRATORY EMERGENCIES Upper Airway Obstruction Asthma ASTHMA ASSESSMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 23 ASTHMA ASSESSMENT ASTHMA TREATMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 24 ASTHMA TREATMENT Nebulisers: Salbutamol: 2.5/5mg Atrovent 125/250 micrograms Steroids: Prednisolone 2mg/kg/day (max 40) Hydrocortisone: 4mg/kg 6 hourly Aminophylline(in HDU): - loading dose: 5mg/kg maint. 1mg/kg/hour (max 20mg/kg/day) IV Salbutamol – 1-2 micrograms/kg/min SYMPTOMS OF CROUP : 2/16/2010 SHO INDUCTION/DR.S.SEN 25 SYMPTOMS OF CROUP Babies and toddlers (rarely school children) Coughing (barking) Mild fever Inspiratory stridor (=croup) Intercostal, suprasternal or subcostal recession Use of accessory muscle Differential Diagnosis of viral or spasmodic croup: Epiglottitis, Bacterial tracheitis, Laryngeal foreign body, Retropharyngeal abscess, Infectious mononucleosis, Angioneurotic oedema, Diphtheria CROUP - ASSESSMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 26 CROUP - ASSESSMENT Mild croup: Stridor only when crying / agitated no hypoxia and comfortable Moderate croup: Stridor at rest recession and tachypnoea, but no hypoxia Severe croup: Stridor all the time recession and tachypnoea, tachycardia decreased breath sounds HYPOXIA- MONITOR SATURATION NO INVESTIGATIONS, PLEASE CROUP - MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 27 CROUP - MANAGEMENT Mild croup: Comfortable, stridor only when crying No treatment, reassure and discharge with advice to return Moderate - severe croup: Stridor at rest, recession and tachypnoea, Hypoxia, stridor, tachycardia, decreased breath sounds Keep calm and nurse in warm room, in upright position Oxygen if oxygen saturations <92% Budesonide (Pulmicort) 2mg nebulised Dexamethasone (single dose) 0.15mg/kg Adrenaline (1:1000) 0.5mls nebulised with 5mls saline repeat 0.5mls/kg (max. dose 5mls) CROUP - CRITERIA FOR ADMISSION : 2/16/2010 SHO INDUCTION/DR.S.SEN 28 CROUP - CRITERIA FOR ADMISSION Stridor at rest Transport or phone difficulties Great distance from hospital Concerns over degree of supervision of the child Parental anxiety Timing of presentation Recent onset and course felt to be progressive. NO IMPROVEMENT FOR 4 HOURS AFTER NEDULISED ADRENALINE (ICU admission, if remains hypoxic with deteriorating respiratory distress after 2 doses) EPIGLOTTITIS : 2/16/2010 SHO INDUCTION/DR.S.SEN 29 EPIGLOTTITIS Toxic child, fever, drooling, can't swallow, can't talk, no cough. Advice to GP and ambulance staff: any child with severe stridor should be transported sitting on parent's lap with mask oxygen. Paediatrician should be waiting to receive the child. Inform ENT Consultant. Admission is automatic. This is a very serious condition. Monitoring of vital signs frequently (<4 hourly) No investigations (except urine Haemophilus ag) EPIGLOTTITIS - MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 30 EPIGLOTTITIS - MANAGEMENT Treatment before intubation: none. Adrenaline is not helpful and may irritate glottis. Steroids is of no use. 5-10% of children may be managed without intubation: if they arrive in the morning if they can still just talk and swallow if the physician is experienced there is facility for close observation on ICU Indication for intubation: the child is getting tired out despite adrenaline or with falling saturation. In ICU: bloods and iv 50 mg/kg Cefotaxime MENINGOCOCCUS INFECTION CLINICAL SIGNS : 2/16/2010 SHO INDUCTION/DR.S.SEN 31 MENINGOCOCCUS INFECTION CLINICAL SIGNS Suspect in any child with sudden onset of fever with headache, vomiting, stiff neck or pain in neck, petechial rash ( non blanching) Other features include photophobia, drowsiness or confusion and signs of meningism A rapidly evolving red macular rash may precede the typical petechial rash MENINGOCOCCAL INFECTION MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 32 MENINGOCOCCAL INFECTION MANAGEMENT Patients with meningococcal infection should be rapidly assessed in resuscitation room Monitor HR, BP, O2 saturation, respiratory rate Act on A.B.C. of resuscitation if required Further management depends on general condition MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Relatively Well Child : 2/16/2010 SHO INDUCTION/DR.S.SEN 33 MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Relatively Well Child Insert 2 iv lines and collect blood for investigations (clotting screen, venous gas, PCR, serum) Immediately start iv Ceftriaxone 80 mg/kg (repeat dose in 12 hours, cont. 7 days) Assess Glasgow Meningococcal Scoring Admit MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTIONUnstable Child : 2/16/2010 SHO INDUCTION/DR.S.SEN 34 MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTIONUnstable Child Inform, Anaesthetist and PICU Give oxygen via face mask (6 litres), intubate Site 2 iv lines and collect blood samples, Start IV Ceftriaxone 80mg /kg immediately Treat shock vigorously, use 4.5% HAS/) 0.9% SALINE 20mls/kg over 10-30 mins (up to 60-80mls/kg may be required) Give Dopamine 2.5ug-5ug/kg/min, if impaired perfusion has not responded to initial measures Glasgow Meningococcal Score and temperature hourly MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION: Early selection for transfer to PICU : 2/16/2010 SHO INDUCTION/DR.S.SEN 35 MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION: Early selection for transfer to PICU Refractory hypotension Deteriorating sensorium / coma Meningococcal score of 8 or more (30 % mortality) Rapid clinical progress of rash within 12 hrs (extensive/ necrotic skin lesion) Metabolic acidosis pH < 7.3 CHILDREN’S COMA SCORE (15) : 2/16/2010 SHO INDUCTION/DR.S.SEN 36 CHILDREN’S COMA SCORE (15) Eyes: 4 spont. open 3 verbal command 2 pain 1 no response Motor:6 obeys verbal 5 localizes pain 4 withdraws from pain 3 abn. flexion to pain 2 extends to pain (decer) 1 no response Best verbal response: 5 orientated smiles, follows 4 disorientated consolable crying inappropriate interaction 3 inappropriate words sometimes consolable moaning 2 incomprehensible sounds inconsolable, irritable 1 no response STATUS EPILEPTICUS - MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 37 STATUS EPILEPTICUS - MANAGEMENT Monitor vital signs (watch apnoea and hypotension) Give O2 100% by mask If not breathing: bag + mask / ventilate if required Investigations: BM , U & E, Ca, BG, FBC, C+S, toxic screen Always admission Use minimum doses to control seizures DRUGS IN STATUS EPILEPTICUS : 2/16/2010 SHO INDUCTION/DR.S.SEN 38 DRUGS IN STATUS EPILEPTICUS MIDAZOLAM (im, oral, nasal, rectal) iv 50-100-200 ugm/kg/dose (12-18yrs 300ugm/kg) LORAZEPAM (im, oral, rectal) iv 50-100 ugm/kg/dose (12-18yrs 4mg) PARALDEHYDE (im abscess, iv CSF peak 20-60 mins) rectal 0.4 ml/kg + equal volume of Arachnis oil PHENYTOIN (cardiac monitor: HR and BP) 20 mg/kg iv in normal saline over 10-20 mins may repeat 20 mg/kg (do not use in febrile status) COMPARISON OF DRUGS FOR STATUS : 2/16/2010 SHO INDUCTION/DR.S.SEN 39 COMPARISON OF DRUGS FOR STATUS NON-FEBRILE CONVULSION : 2/16/2010 SHO INDUCTION/DR.S.SEN 40 NON-FEBRILE CONVULSION The younger the child, the more likely is an underlying disorder (lower threshold for investigation < 1 yr) intracranial space occupying lesions hypertensive encephalopathy metabolic disturbance (hypoglycaemia, hypocalcaemia) inborn errors of metabolism congenital and inherited disorders (TS) History (prenatal and natal) and examination Monitoring (pulse oximetry) NON-FEBRILE CONVULSION: INVESTIGATIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 41 NON-FEBRILE CONVULSION: INVESTIGATIONS Blood for glucose, FBC, Na+K+Ca+P+Mg, Toxicology, pH Septic screen, incl.CXR Babies:TORCH, PCV / Clotting screen, urine metabolic screen, reducing substances MRI /CT / Brain US EEG 2-3 weeks after fit, except suspected infantile spasms JITTERY OR FITTING BABY? : 2/16/2010 SHO INDUCTION/DR.S.SEN 42 JITTERY OR FITTING BABY? FITTING BABIES: MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 43 FITTING BABIES: MANAGEMENT Urgent treatment is indicated because repeated seizures may result in brain injury: hypoventilation and apnoea, hypercapnia and hypoxemia leading to IVH Intubation Glucose if hypoglycaemia is present: 2 ml/kg (200 mg/kg) 10% dextrose iv and maintainance on 8 mg/kg/min PRN Phenobarbital iv loading dose of 20 mg/kg in 10 minutes Phenytoin iv loading dose of 20 mg/kg (monitoring) FEBRILE FIT - ASSESSMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 44 FEBRILE FIT - ASSESSMENT Accurate history of event Any preceding illness, including fever Funny turns, rigors, jerking with fever? Breath-holding attacks? Careful examination presence of fever? evidence of URTI, otitis or tonsillitis, MENINGITIS, GE, septic arthritis, UTI? SIMPLE FEBRILE CONVULSIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 45 SIMPLE FEBRILE CONVULSIONS At age of 6 months-5 years Generalized Loss of consciousness No focal features No serious perinatal problems, previous illness or head injuries Short lasting (< 20 minutes) FEBRILE FIT- INVESTIGATIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 46 FEBRILE FIT- INVESTIGATIONS > 1 year old If recovered from fit, can rely on clinical REVIEW If obvious source of infection, investigate as appropriate If no obvious source, do MSU and continue REVIEW If child is getting worse, do LP <1 year old: Much lower threshold for full investigations, including LP, blood cultures, CXR, MSU If the child is ill, especially one with signs of meningitis start iv antibiotics immediately (cultures) FEBRILE FIT - TREATMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 47 FEBRILE FIT - TREATMENT FEVER: take off clothes, give paracetamol, use fan FITS: rectal Diazepam 2.5 mg < 1 year and 5 mg > 1 year/ Buccal Midazolam INFECTION: antibiotics if not for viral URTI ADVICE TO PARENTS (fact sheet) PROLONGED FIT: Lorazepam 100 micrograms/kg Paraldehyde PR 0.4 ml/kg + equal volume of arachnis oil IM 1 ml/yr (maximum 10 ml)10 mins Phenytoin IV (cardiac monitor!) 10 mg/Kg slowly DKA - SYMPTOMS : 2/16/2010 SHO INDUCTION/DR.S.SEN 48 DKA - SYMPTOMS High blood glucose >16mmol/l Significant dehydration >5% Acidotic pH < 7.3 and bicarbonate < 15 Heavy ketonuria Impaired level of consciousness CLINICAL ASSESSMENT OF HYDRATION : 2/16/2010 SHO INDUCTION/DR.S.SEN 49 CLINICAL ASSESSMENT OF HYDRATION Deficit should not be overestimated with traditional 5,10,15%! (Mismanagement might start here!) Alert: mild 3% dehydration (only oral rehydration) Thirsty, lethargic: moderate 6% dehydration (iv rehydration) Drowsy or comatose child with low or unrecordable blood pressure has severe 10% dehydration, requiring immediately 20ml/kg 4.5% plasma (given in 15-60 mins, depending on BP) Slide 50: 2/16/2010 SHO INDUCTION/DR.S.SEN 50 DKA - INITIAL INVESTIGATIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 51 DKA - INITIAL INVESTIGATIONS Blood: glucose (BM is usually lower), FBC, culture, pH and bicarbonate U+ E+ osmolality Urine: glucose and ketones, C+ S Arterial or capillary blood gases if venous pH<7.0 CXR Calculate osmolality: 2(Na+K) + glu + urea DKA - IMMEDIATE MONITORING : 2/16/2010 SHO INDUCTION/DR.S.SEN 52 DKA - IMMEDIATE MONITORING Vital signs: RR, HR, BP. temp Body weight (estimate on 50th centile, last clinic weight) Blood glucose hourly until acidosis resolved U+E 6 hourly, urine ketones and glucose 2-4 hourly Fluid flow-chart (input, output, ongoing losses (aspirate) Oxygen saturation Neurological observation to detect cerebral oedema DKA - IMMEDIATE MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 53 DKA - IMMEDIATE MANAGEMENT ESTABLISH IV ACCESS: give initially 10-20ml/kg plasma or 4.5% albumin over one hour or within 15-30 mins to restore BP give normal 0.9% saline until BG is >15 mmol/l PASS NGT AND/OR BLADDER CATHETER if the child is unconscious, not passing urine, vomiting or presenting with abdominal distension CONSIDER IV ANTIBIOTICS DKA REHYDRATIONWhat do you want to give? : 2/16/2010 SHO INDUCTION/DR.S.SEN 54 DKA REHYDRATIONWhat do you want to give? Albumin 4.5% for the start if BP is low (10-20 ml/ kg) Normal, isotonic 0.9% saline without potassium until blood glucose >15mmol/l 4% dextrose / 0.18% saline with 20 mmol /500ml potassium, when blood glucose <15 mmol/l if serum potassium is <6 mmol/l and urine output is present Bicarbonate supplementation rarely if ph < 7.1 give half of the calculated dose (1/3 x wt x BE) DKA - REHYDRATIONHow much do you want to give? : 2/16/2010 SHO INDUCTION/DR.S.SEN 55 DKA - REHYDRATIONHow much do you want to give? Estimate the degree of dehydration on the clinical signs Calculate expected weight on 50th centile Calculate total loss and required volume of total rehydration: deficit + added daily maintenance Maximum fluid is limited to 4.0 litre / m2 / 24hrs Mild dehydration: oral 30ml/kg deficit + daily maintainance Moderate: iv 60 ml/kg fluid deficit + daily maintainance Severe dehydration: 20ml/kg plasma in 15-30-60 mins, followed by iv 100ml/kg deficit + daily maintainance DKA - VOLUME OF REHYDRATION : 2/16/2010 SHO INDUCTION/DR.S.SEN 56 DKA - VOLUME OF REHYDRATION DURATION OF REHYDRATION : 2/16/2010 SHO INDUCTION/DR.S.SEN 57 DURATION OF REHYDRATION Depending on osmolality: over 24 hrs if normosmolality (280 mosm) over 36 hrs if hyperosmolality > 340 over 48 hrs if hyperosmolality > 400 Reassess fluid requirement 4 hourly and add any accumulated negative balance (urine loss, vomiting, gastric aspirate etc) Treat cerebral oedema immediately with reduction of rate of fluid administration and with iv mannitol 0.25 -1.0gm/kg/dose over 30 mins DKA - INSULIN TREATMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 58 DKA - INSULIN TREATMENT Aim: slow reduction of hyperglycaemia (2.5mmol/hr) and maintainance of normoglycaemia (4-8 mmol/l) Initial dose of intravenous insulin infusion: 0.1unit / kg / hr of soluble Humulin S or Actrapid (use 50 units/50 ml saline) NEVER GIVE SC STAT DOSE! Reduce iv insulin infusion to 0.05 unit/kg/hr, when blood glucose falls to 10-15 mmol /l Increase to 0.15unit/kg/hr if acidosis persists (pH < 7.0) Replace iv sliding scale with sc insulin ASAP Slide 59: 2/16/2010 SHO INDUCTION/DR.S.SEN 59 Slide 60: 2/16/2010 SHO INDUCTION/DR.S.SEN 60 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Paediatric Emergencies samarsen Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2526 Category: Science & Tech.. License: All Rights Reserved Like it (3) Dislike it (0) Added: February 16, 2010 This Presentation is Public Favorites: 4 Presentation Description No description available. Comments Posting comment... By: mohdamir (8 month(s) ago) Impressive and very good Presentation. please send the presentation as attachment to the following E.Mail:: mohdamir@omantel.net.om Saving..... Post Reply Close Saving..... Edit Comment Close By: rajeshiloveu (14 month(s) ago) hello sir, ur presentation is very impressive and effective, plz send this on my following email id. rajeshmscnursing@gmail.com, thank u sir Saving..... Post Reply Close Saving..... Edit Comment Close By: sushee (15 month(s) ago) plse send me the copy of this presentation.my email is sushee2005@yahoo.co.in.or me 2 download this ppt.thanks. Saving..... Post Reply Close Saving..... Edit Comment Close By: leigh_zali (20 month(s) ago) Good presentation Dr Sen. Would you mind emailing me a copy of this presentation please to leigh_zali@yahoo.com Thanks! Saving..... Post Reply Close Saving..... Edit Comment Close By: rup1esh (22 month(s) ago) Nice presentation,Dr Sen.Can be used 2 teach UG students,if u allow me 2 download the content.Thanks Saving..... Post Reply Close By: samarsen (22 month(s) ago) Please send me an email at samarsen@yahoo.co.uk and I will send you a copy of the presentation. Thanks for your comments. Sam Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript PAEDIATRIC EMERGENCIES : PAEDIATRIC EMERGENCIES Dr. Samarnath Sen MD,DCH,MRCPCH PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 2 PAEDIATRIC EMERGENCIES 1. COMA 2. SHOCK 2. UPPER AND LOWER AIRWAY OBSTRUCTION Croup and Epiglottitis, Foreign Body Asthma, Bronchiolitis, Chest infection 3. CARDIAC EMERGENCIES Heart Failure Supraventricular Tachycardia PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 3 PAEDIATRIC EMERGENCIES 4. INFECTIONS Meningitis Encephalitis Endocarditis 5. SEIZURES Status Epilepticus Febrile fits Non febrile fits Increased intracranial pressure PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 4 PAEDIATRIC EMERGENCIES 6. RENAL Hypertension Haematuria UTI Nephrosis HUS 8. PAINS Chest pain Abdominal pain Sickle Cell Crises PAEDIATRIC EMERGENCIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 5 PAEDIATRIC EMERGENCIES 9. ENVIRONMENTAL Burns, Smoke inhalation Near Drowning Poisoning Hypothermia, heat stress Anaphylaxis Head injury and RTA NAI and SA EMERGENCIES IN BABIES : 2/16/2010 SHO INDUCTION/DR.S.SEN 6 EMERGENCIES IN BABIES Excessive crying Not feeding Cyanosis Apnoea Jaundice Fitting Diarrhoea Vomiting Fever Bleeding COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 7 COMA State of unresponsiveness due to diffuse lesions of hemispheres / brain stem Structural lesions bleeding, tumour, abscess, hydrocephalus Non-structural lesions (95%) seizures, drugs / poisons infection (meningitis, encephalitis, HUS) metabolic (hypoglycaemia, DKA, Reye) renal failure, hepatic coma endocrine (Addisonian crisis) COMA: ASSESSMENT AND DIAGNOSIS : 2/16/2010 SHO INDUCTION/DR.S.SEN 8 COMA: ASSESSMENT AND DIAGNOSIS Rapid History and General Examination Skin ( trauma, petechiae, bleeding) Sutures in infant and neck stiffness, systemic, AF CNS examination GCS, Gag Reflex, Blinking Pupils, Reaction, EOM Palsy, Fundi, Dolls Eye Motor- Posture, Tone, Symmetry / Lateralizing signs Reflexes- DTR, Plantars Pain, Grimace, Flexion, Extension, None Assess level of Central Dysfunction BPA CHILDREN’S COMA SCORE (15) : 2/16/2010 SHO INDUCTION/DR.S.SEN 9 BPA CHILDREN’S COMA SCORE (15) Eyes: 4 spont. open 3 verbal command 2 pain 1 no response Motor:6 obeys verbal 5 localizes pain 4 withdraws from pain 3 abn. flexion to pain 2 extends to pain(decer) 1 no response Best verbal response: 5 orientated smiles, follows 4 disorientated consolable crying inappropriate interaction 3 inappropriate words sometimes consolable moaning 2 incomprehensible sounds inconsolable, irritable 1 no response MANAGEMENT OF COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 10 MANAGEMENT OF COMA Always emergency - get Registrar/Consultant Airways - check, suction, ventilation if needed Breathing - ensure adequacy: RR, BS,saturation Give high flow oxygen, if breathing Ventilate with bag and mask Intubate with Anaesthetist, if breathing inadequate / GCS 8 / herniation syndromes Circulation - monitor BP, CRT, PR IV access: 2 venous and arterial lines INVESTIGATIONS IN COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 11 INVESTIGATIONS IN COMA FBC, U+E, LFT, BC, Blood gases, Glucose, NH3, toxic screen, lactate, amino acids, ammonia, Virus studies, PCR Chest X-ray, EEG CT scan (has limited value), LP only with neurosurgical support TREATMENT OF COMA : 2/16/2010 SHO INDUCTION/DR.S.SEN 12 TREATMENT OF COMA Treat Shock - Restore and control BP Treat The Treatable Maintain BS with 10% dextrose 5mls/kg PRN Restricted fluid (document type & rate) Mannitol, if increased intracranial pressure Consider Cefotaxime, Acyclovir, Erythromycin Consider Flumazenil, Naloxone, Anticonvulsant May require transfer to PICU SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 13 SHOCK Failure of circulation of oxygen to tissues resulting in lactic acidosis, cellular dysfunction and cell death 1. Hypovolaemic shock due to loss of blood or fluid 2. Distributive (septic) shock: maldistribution of blood 3. Obstructive shock: reduced vascular size 4. Cardiogenic shock: primary heart problem HYPOVOLAEMIC SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 14 HYPOVOLAEMIC SHOCK Haemorrhagic loss: trauma, gastrointestinal bleed, Coagulopathy Fluid and electrolytes: gastroenteritis, diabetic ketoacidosis, polyuric states, mineralocorticoid deficiency Plasma/ protein loss: burns, peritonitis, bowel obstruction/ necrosis SEPTIC (DISTRIBUTIVE) SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 15 SEPTIC (DISTRIBUTIVE) SHOCK Maldistribution of blood within organs due to abnormal peripheral function Sepsis: Gram negative bacteria, Meningococcus Neurogenic shock Drugs: antihypertensives, barbiturates Anaphylaxis OBSTRUCTIVE SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 16 Reduced vascular size and limited blood flow due to intrinsic or extrinsic factors Pericardial tamponade Tension pneumothorax Pulmonary embolism OBSTRUCTIVE SHOCK CARDIOGENIC SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 17 CARDIOGENIC SHOCK Primary heart problem with inadequate cardiac output and inadequate tissue perfusion SVT, bradycardia, ventricular tachycardia Myocarditis Hypoplastic left heart Left sided outflow obstruction Critical aortic stenosis and coarctation of aorta ASSESSMENT OF SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 18 ASSESSMENT OF SHOCK Full history and physical examination Classic signs: tachycardia, tachypnoea, oliguria (anuria), weak pulse, mottled extremities, hypotension Children can compensate for hypoperfusion states Hypotension is a late sign of decompensated shock EARLY AND LATE SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 19 EARLY AND LATE SHOCK Tachycardia  bradycardia, dysrhythmia tachypnoea  severe tachypnoea and gasping low pulse pressure  hypotension cool extremities, decreased CR  absent peripheral pulses dry mucosa  mild oliguria  severe oliguria  anuria restlessness / agitation  unconsciousness GENERAL MANAGEMENT OF SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 20 GENERAL MANAGEMENT OF SHOCK MONITOR: HR, BP, BP (CVP), O2 SaO2, fluid balance AIRWAY, BREATHING, CIRCULATION Reverse hypoxia and acidosis Control bleeding with direct pressure Obtain intravenous (arterial) access INVESTIGATIONS: FBC, U+ E, Osm, LFT,BG, BC, clotting, BG MSU, X-ray, ECG, Brain scan TRANSFER TO ITU: no response to Dopamine 2-20ugm/kg/min signs of organ failure SPECIFIC MANAGEMENT OF SHOCK : 2/16/2010 SHO INDUCTION/DR.S.SEN 21 SPECIFIC MANAGEMENT OF SHOCK Hypovolaemia: rapid volume replacement Septic shock: antibiotics and inotropes Cardiogenic shock: minimal volume support Inotropes (Dopamine, Dobutamine)-low BP+ high HR Chronotropes (Isoproterenol or Epinephrine)-if low BP + bradycardia or normal heart rate Obstructive shock: drainage Anaphylaxis: oxygen, adrenalin, hydrocortisone RESPIRATORY EMERGENCIES : RESPIRATORY EMERGENCIES Upper Airway Obstruction Asthma ASTHMA ASSESSMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 23 ASTHMA ASSESSMENT ASTHMA TREATMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 24 ASTHMA TREATMENT Nebulisers: Salbutamol: 2.5/5mg Atrovent 125/250 micrograms Steroids: Prednisolone 2mg/kg/day (max 40) Hydrocortisone: 4mg/kg 6 hourly Aminophylline(in HDU): - loading dose: 5mg/kg maint. 1mg/kg/hour (max 20mg/kg/day) IV Salbutamol – 1-2 micrograms/kg/min SYMPTOMS OF CROUP : 2/16/2010 SHO INDUCTION/DR.S.SEN 25 SYMPTOMS OF CROUP Babies and toddlers (rarely school children) Coughing (barking) Mild fever Inspiratory stridor (=croup) Intercostal, suprasternal or subcostal recession Use of accessory muscle Differential Diagnosis of viral or spasmodic croup: Epiglottitis, Bacterial tracheitis, Laryngeal foreign body, Retropharyngeal abscess, Infectious mononucleosis, Angioneurotic oedema, Diphtheria CROUP - ASSESSMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 26 CROUP - ASSESSMENT Mild croup: Stridor only when crying / agitated no hypoxia and comfortable Moderate croup: Stridor at rest recession and tachypnoea, but no hypoxia Severe croup: Stridor all the time recession and tachypnoea, tachycardia decreased breath sounds HYPOXIA- MONITOR SATURATION NO INVESTIGATIONS, PLEASE CROUP - MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 27 CROUP - MANAGEMENT Mild croup: Comfortable, stridor only when crying No treatment, reassure and discharge with advice to return Moderate - severe croup: Stridor at rest, recession and tachypnoea, Hypoxia, stridor, tachycardia, decreased breath sounds Keep calm and nurse in warm room, in upright position Oxygen if oxygen saturations <92% Budesonide (Pulmicort) 2mg nebulised Dexamethasone (single dose) 0.15mg/kg Adrenaline (1:1000) 0.5mls nebulised with 5mls saline repeat 0.5mls/kg (max. dose 5mls) CROUP - CRITERIA FOR ADMISSION : 2/16/2010 SHO INDUCTION/DR.S.SEN 28 CROUP - CRITERIA FOR ADMISSION Stridor at rest Transport or phone difficulties Great distance from hospital Concerns over degree of supervision of the child Parental anxiety Timing of presentation Recent onset and course felt to be progressive. NO IMPROVEMENT FOR 4 HOURS AFTER NEDULISED ADRENALINE (ICU admission, if remains hypoxic with deteriorating respiratory distress after 2 doses) EPIGLOTTITIS : 2/16/2010 SHO INDUCTION/DR.S.SEN 29 EPIGLOTTITIS Toxic child, fever, drooling, can't swallow, can't talk, no cough. Advice to GP and ambulance staff: any child with severe stridor should be transported sitting on parent's lap with mask oxygen. Paediatrician should be waiting to receive the child. Inform ENT Consultant. Admission is automatic. This is a very serious condition. Monitoring of vital signs frequently (<4 hourly) No investigations (except urine Haemophilus ag) EPIGLOTTITIS - MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 30 EPIGLOTTITIS - MANAGEMENT Treatment before intubation: none. Adrenaline is not helpful and may irritate glottis. Steroids is of no use. 5-10% of children may be managed without intubation: if they arrive in the morning if they can still just talk and swallow if the physician is experienced there is facility for close observation on ICU Indication for intubation: the child is getting tired out despite adrenaline or with falling saturation. In ICU: bloods and iv 50 mg/kg Cefotaxime MENINGOCOCCUS INFECTION CLINICAL SIGNS : 2/16/2010 SHO INDUCTION/DR.S.SEN 31 MENINGOCOCCUS INFECTION CLINICAL SIGNS Suspect in any child with sudden onset of fever with headache, vomiting, stiff neck or pain in neck, petechial rash ( non blanching) Other features include photophobia, drowsiness or confusion and signs of meningism A rapidly evolving red macular rash may precede the typical petechial rash MENINGOCOCCAL INFECTION MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 32 MENINGOCOCCAL INFECTION MANAGEMENT Patients with meningococcal infection should be rapidly assessed in resuscitation room Monitor HR, BP, O2 saturation, respiratory rate Act on A.B.C. of resuscitation if required Further management depends on general condition MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Relatively Well Child : 2/16/2010 SHO INDUCTION/DR.S.SEN 33 MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Relatively Well Child Insert 2 iv lines and collect blood for investigations (clotting screen, venous gas, PCR, serum) Immediately start iv Ceftriaxone 80 mg/kg (repeat dose in 12 hours, cont. 7 days) Assess Glasgow Meningococcal Scoring Admit MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTIONUnstable Child : 2/16/2010 SHO INDUCTION/DR.S.SEN 34 MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTIONUnstable Child Inform, Anaesthetist and PICU Give oxygen via face mask (6 litres), intubate Site 2 iv lines and collect blood samples, Start IV Ceftriaxone 80mg /kg immediately Treat shock vigorously, use 4.5% HAS/) 0.9% SALINE 20mls/kg over 10-30 mins (up to 60-80mls/kg may be required) Give Dopamine 2.5ug-5ug/kg/min, if impaired perfusion has not responded to initial measures Glasgow Meningococcal Score and temperature hourly MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION: Early selection for transfer to PICU : 2/16/2010 SHO INDUCTION/DR.S.SEN 35 MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION: Early selection for transfer to PICU Refractory hypotension Deteriorating sensorium / coma Meningococcal score of 8 or more (30 % mortality) Rapid clinical progress of rash within 12 hrs (extensive/ necrotic skin lesion) Metabolic acidosis pH < 7.3 CHILDREN’S COMA SCORE (15) : 2/16/2010 SHO INDUCTION/DR.S.SEN 36 CHILDREN’S COMA SCORE (15) Eyes: 4 spont. open 3 verbal command 2 pain 1 no response Motor:6 obeys verbal 5 localizes pain 4 withdraws from pain 3 abn. flexion to pain 2 extends to pain (decer) 1 no response Best verbal response: 5 orientated smiles, follows 4 disorientated consolable crying inappropriate interaction 3 inappropriate words sometimes consolable moaning 2 incomprehensible sounds inconsolable, irritable 1 no response STATUS EPILEPTICUS - MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 37 STATUS EPILEPTICUS - MANAGEMENT Monitor vital signs (watch apnoea and hypotension) Give O2 100% by mask If not breathing: bag + mask / ventilate if required Investigations: BM , U & E, Ca, BG, FBC, C+S, toxic screen Always admission Use minimum doses to control seizures DRUGS IN STATUS EPILEPTICUS : 2/16/2010 SHO INDUCTION/DR.S.SEN 38 DRUGS IN STATUS EPILEPTICUS MIDAZOLAM (im, oral, nasal, rectal) iv 50-100-200 ugm/kg/dose (12-18yrs 300ugm/kg) LORAZEPAM (im, oral, rectal) iv 50-100 ugm/kg/dose (12-18yrs 4mg) PARALDEHYDE (im abscess, iv CSF peak 20-60 mins) rectal 0.4 ml/kg + equal volume of Arachnis oil PHENYTOIN (cardiac monitor: HR and BP) 20 mg/kg iv in normal saline over 10-20 mins may repeat 20 mg/kg (do not use in febrile status) COMPARISON OF DRUGS FOR STATUS : 2/16/2010 SHO INDUCTION/DR.S.SEN 39 COMPARISON OF DRUGS FOR STATUS NON-FEBRILE CONVULSION : 2/16/2010 SHO INDUCTION/DR.S.SEN 40 NON-FEBRILE CONVULSION The younger the child, the more likely is an underlying disorder (lower threshold for investigation < 1 yr) intracranial space occupying lesions hypertensive encephalopathy metabolic disturbance (hypoglycaemia, hypocalcaemia) inborn errors of metabolism congenital and inherited disorders (TS) History (prenatal and natal) and examination Monitoring (pulse oximetry) NON-FEBRILE CONVULSION: INVESTIGATIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 41 NON-FEBRILE CONVULSION: INVESTIGATIONS Blood for glucose, FBC, Na+K+Ca+P+Mg, Toxicology, pH Septic screen, incl.CXR Babies:TORCH, PCV / Clotting screen, urine metabolic screen, reducing substances MRI /CT / Brain US EEG 2-3 weeks after fit, except suspected infantile spasms JITTERY OR FITTING BABY? : 2/16/2010 SHO INDUCTION/DR.S.SEN 42 JITTERY OR FITTING BABY? FITTING BABIES: MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 43 FITTING BABIES: MANAGEMENT Urgent treatment is indicated because repeated seizures may result in brain injury: hypoventilation and apnoea, hypercapnia and hypoxemia leading to IVH Intubation Glucose if hypoglycaemia is present: 2 ml/kg (200 mg/kg) 10% dextrose iv and maintainance on 8 mg/kg/min PRN Phenobarbital iv loading dose of 20 mg/kg in 10 minutes Phenytoin iv loading dose of 20 mg/kg (monitoring) FEBRILE FIT - ASSESSMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 44 FEBRILE FIT - ASSESSMENT Accurate history of event Any preceding illness, including fever Funny turns, rigors, jerking with fever? Breath-holding attacks? Careful examination presence of fever? evidence of URTI, otitis or tonsillitis, MENINGITIS, GE, septic arthritis, UTI? SIMPLE FEBRILE CONVULSIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 45 SIMPLE FEBRILE CONVULSIONS At age of 6 months-5 years Generalized Loss of consciousness No focal features No serious perinatal problems, previous illness or head injuries Short lasting (< 20 minutes) FEBRILE FIT- INVESTIGATIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 46 FEBRILE FIT- INVESTIGATIONS > 1 year old If recovered from fit, can rely on clinical REVIEW If obvious source of infection, investigate as appropriate If no obvious source, do MSU and continue REVIEW If child is getting worse, do LP <1 year old: Much lower threshold for full investigations, including LP, blood cultures, CXR, MSU If the child is ill, especially one with signs of meningitis start iv antibiotics immediately (cultures) FEBRILE FIT - TREATMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 47 FEBRILE FIT - TREATMENT FEVER: take off clothes, give paracetamol, use fan FITS: rectal Diazepam 2.5 mg < 1 year and 5 mg > 1 year/ Buccal Midazolam INFECTION: antibiotics if not for viral URTI ADVICE TO PARENTS (fact sheet) PROLONGED FIT: Lorazepam 100 micrograms/kg Paraldehyde PR 0.4 ml/kg + equal volume of arachnis oil IM 1 ml/yr (maximum 10 ml)10 mins Phenytoin IV (cardiac monitor!) 10 mg/Kg slowly DKA - SYMPTOMS : 2/16/2010 SHO INDUCTION/DR.S.SEN 48 DKA - SYMPTOMS High blood glucose >16mmol/l Significant dehydration >5% Acidotic pH < 7.3 and bicarbonate < 15 Heavy ketonuria Impaired level of consciousness CLINICAL ASSESSMENT OF HYDRATION : 2/16/2010 SHO INDUCTION/DR.S.SEN 49 CLINICAL ASSESSMENT OF HYDRATION Deficit should not be overestimated with traditional 5,10,15%! (Mismanagement might start here!) Alert: mild 3% dehydration (only oral rehydration) Thirsty, lethargic: moderate 6% dehydration (iv rehydration) Drowsy or comatose child with low or unrecordable blood pressure has severe 10% dehydration, requiring immediately 20ml/kg 4.5% plasma (given in 15-60 mins, depending on BP) Slide 50: 2/16/2010 SHO INDUCTION/DR.S.SEN 50 DKA - INITIAL INVESTIGATIONS : 2/16/2010 SHO INDUCTION/DR.S.SEN 51 DKA - INITIAL INVESTIGATIONS Blood: glucose (BM is usually lower), FBC, culture, pH and bicarbonate U+ E+ osmolality Urine: glucose and ketones, C+ S Arterial or capillary blood gases if venous pH<7.0 CXR Calculate osmolality: 2(Na+K) + glu + urea DKA - IMMEDIATE MONITORING : 2/16/2010 SHO INDUCTION/DR.S.SEN 52 DKA - IMMEDIATE MONITORING Vital signs: RR, HR, BP. temp Body weight (estimate on 50th centile, last clinic weight) Blood glucose hourly until acidosis resolved U+E 6 hourly, urine ketones and glucose 2-4 hourly Fluid flow-chart (input, output, ongoing losses (aspirate) Oxygen saturation Neurological observation to detect cerebral oedema DKA - IMMEDIATE MANAGEMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 53 DKA - IMMEDIATE MANAGEMENT ESTABLISH IV ACCESS: give initially 10-20ml/kg plasma or 4.5% albumin over one hour or within 15-30 mins to restore BP give normal 0.9% saline until BG is >15 mmol/l PASS NGT AND/OR BLADDER CATHETER if the child is unconscious, not passing urine, vomiting or presenting with abdominal distension CONSIDER IV ANTIBIOTICS DKA REHYDRATIONWhat do you want to give? : 2/16/2010 SHO INDUCTION/DR.S.SEN 54 DKA REHYDRATIONWhat do you want to give? Albumin 4.5% for the start if BP is low (10-20 ml/ kg) Normal, isotonic 0.9% saline without potassium until blood glucose >15mmol/l 4% dextrose / 0.18% saline with 20 mmol /500ml potassium, when blood glucose <15 mmol/l if serum potassium is <6 mmol/l and urine output is present Bicarbonate supplementation rarely if ph < 7.1 give half of the calculated dose (1/3 x wt x BE) DKA - REHYDRATIONHow much do you want to give? : 2/16/2010 SHO INDUCTION/DR.S.SEN 55 DKA - REHYDRATIONHow much do you want to give? Estimate the degree of dehydration on the clinical signs Calculate expected weight on 50th centile Calculate total loss and required volume of total rehydration: deficit + added daily maintenance Maximum fluid is limited to 4.0 litre / m2 / 24hrs Mild dehydration: oral 30ml/kg deficit + daily maintainance Moderate: iv 60 ml/kg fluid deficit + daily maintainance Severe dehydration: 20ml/kg plasma in 15-30-60 mins, followed by iv 100ml/kg deficit + daily maintainance DKA - VOLUME OF REHYDRATION : 2/16/2010 SHO INDUCTION/DR.S.SEN 56 DKA - VOLUME OF REHYDRATION DURATION OF REHYDRATION : 2/16/2010 SHO INDUCTION/DR.S.SEN 57 DURATION OF REHYDRATION Depending on osmolality: over 24 hrs if normosmolality (280 mosm) over 36 hrs if hyperosmolality > 340 over 48 hrs if hyperosmolality > 400 Reassess fluid requirement 4 hourly and add any accumulated negative balance (urine loss, vomiting, gastric aspirate etc) Treat cerebral oedema immediately with reduction of rate of fluid administration and with iv mannitol 0.25 -1.0gm/kg/dose over 30 mins DKA - INSULIN TREATMENT : 2/16/2010 SHO INDUCTION/DR.S.SEN 58 DKA - INSULIN TREATMENT Aim: slow reduction of hyperglycaemia (2.5mmol/hr) and maintainance of normoglycaemia (4-8 mmol/l) Initial dose of intravenous insulin infusion: 0.1unit / kg / hr of soluble Humulin S or Actrapid (use 50 units/50 ml saline) NEVER GIVE SC STAT DOSE! Reduce iv insulin infusion to 0.05 unit/kg/hr, when blood glucose falls to 10-15 mmol /l Increase to 0.15unit/kg/hr if acidosis persists (pH < 7.0) Replace iv sliding scale with sc insulin ASAP Slide 59: 2/16/2010 SHO INDUCTION/DR.S.SEN 59 Slide 60: 2/16/2010 SHO INDUCTION/DR.S.SEN 60