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Emergencies
Christa
Yee L
Yeon
Assessment of a Child
Effort of Breathing
Appearance
Pediatric
Assessment
Triangle
Circulation to Skin
Appearance
TICLS
The
irritable/inconsolable child
consciousness.
Effort of Breathing
Listen:
Visual signs
Altered tone of
voice/Stridor= Upper
airway obstruction
Grunting = hypoxia/
lower airway obstruction
Head
bobbing/tripoding:
abnormal positions
Retractions: increased
effort of to move air into
lungs
Nasal flaring: effort to
increase ventilationand
oxygenation = hypoxia
Circulation of Skin
Primary Survey
Airway
Breathing
Circulation
Airway
Abnormal
Breathing
Rapid
Circulation
Children
Shock
Shock
Hypovole
mic Shock
Cardiogeni
c Shock
Distributiv
e Shock
Traumatic
Shock
Neurogeni
c Shock
Anaphylac
tic Shock
Septicemic
Shock
Hypovolemic shock
Loss
of blood (external/internal)
Loss of plasma (burns)
Loss of fluids (vomiting, diarrhea,
sweating)
Traumatic shock: associated with
neurogenic shock; severe pain
inhibits vasomotor center
Cardiogenic Shock
Failure
Obstructive Shock
Obstruction
heart
Pulmonary embolism
Cardiac tamponade
Tension pneumothorax
Distributive Shock
Due
Cushings Reflex
Cerebral
Cushing Reflex
Raised
ICP>MAP
Cerebral
Ischaemia
Sympathetic
activation
Heart rate
increased +
peripheral
vasoconstrictio
n
Reflex
bradycardia
Parasympatheti
c response to
reduce heart
rate
Cerebral
perfusion
maintained +
baroreceptor
reflex activated
Systemic Blood
Pressure
increased
Second Stage
High ICP,
brainstem
distortion
Third Stage
Abnormal
breathing/
apnea
First Stage
Triage
System
Triage
Secondary
Triage
Definitive
Triage
Triage Zones
Red
Zone; T1
Life threatening (ABCD problems)
Limb threatening
Time Critical (Thrombolytic Therapy)
Yellow Zone; T2
May progress to life/limb threatening
conditions or morbidity if not treated in 30
mins.
Relief of severe pain
In a trolley
Green Zone; G1, G2, G3, G4
G1, Fast-track
Senior
Green Zone
G2
Patients requiring initial management or
G4
Patients who can be seen outpatient
RM 50
Resuscitation
Focused
on correcting identified
abnormalities in oxygenation and
perfusion and preventing further
deterioration.
Oxygen supplementation: improve
oxygen saturation
Circulation: fluid bolus with isotonic
crystalloids (normal saline, lactated
Ringer solution) 10-20 mL/kg.
Vasoactive
substances:
Vasoactive
substances:
DISCLAIMER
The following case scenario was taken
from
http://www.hawaii.edu/medicine/pedi
atrics/pedtext/s18c03.html
Case 1
An ambulance brings a 15 month old boy
to A&E with a seizure a/w fever. He has
been in good health except for a high
fever that developed today to about 39.440.0 C.
His mother gave him a small dose of
acetaminophen. About 20 minutes ago
when the mother was checking up on her
child, she noticed shaking of the arms and
legs and his eyes had a blank stare. This
went on for what seemed like 5 minutes.
Physical Examination
Vital signs:
T: 39.8 C
PR: 165 bpm
RR: 30 bpm
BP: 90/60 mmHg
O2 sat 100% on RA.
He
Questions
1. At what ages do febrile seizures occur? How
common is this problem?
2. What are the differences between simple and
complex febrile seizures? Why is it important to
know this distinction (think of recurrence risk of
febrile seizures, development of epilepsy, and
work-up)?
3. A febrile seizure is a diagnosis of exclusion. What
other diagnoses should be considered in a child
with fever and seizures?
4. Who should be strongly considered to receive a
lumbar puncture?
Question 1
The
Question 2
Febrile seizures can be divided into two
Complex
Generalized seizure
Focal seizure
Question 3
DDX
Differential
Infection
Trauma
Metabolic
Others
Example
meningitis/ encephalitis
UTI
brain lesion (in head trauma,
intracranial bleed)
shaken baby syndrome
hypoglycemia
hypocalcemia / hypomagnesemia
hypo- or hypernatremia
poisons/toxins/drugs
hypoxic ischemic insult
Question 4
Must
Question 5
Indications:
1. To exclude intracranial pathology
especially infection
2. Fear of recurrent fits
3. To investigate and treat the cause
of fever besides meningitis or
encephalitis
4. To allay parental anxiety, especially
if they are staying far from the
hospital
Question 6
Disadvantages:
1. Lethargy
2. Drowsiness
3. Ataxia
4. Masking of CNS infection
Question 7
Prognosis
in remain
febrile seizures
Febrile
seizures
a benign
Febrile
convulsions are benign events with
condition
excellent prognosis
3-4% of population have febrile convulsions
30% recurrence after 1st attack
48% recurrence after 2nd attack
2-7 % develop subsequent afebrile seizure or
epilepsy
no evidence of permanent neurological
deficits following febrile convulsions or even
febrile status epilepticus
no deaths were reported from simple febrile
convulsion
Control fever:
1. Take off clothing and tepid sponging
2. Antipyretic i.e. syrup or rectal
Paracetamol 15mg/kg 6 hourly
*antipyretic is indicated for patients
comfort, but has not been shown to
reduce the recurrence rate of febrile
convulsion.
Question
a)
b)
c)
d)
e)
SCENARIO 2
A
Differential diagnosis
Dengue
Acute
URTI
fever
gastroenteritis
Look
MILD
MODERATE
SEVERE
BODY WEIGHT
LOSS
GENERAL
APPEARANCE
<5%
5-10%
>10%
THIRST
THIRSTY,RESTLESS
OR LETHARGIC
DROWSY,COLD,SWE
ATING
TEARS
PRESENT
REDUCED/ABSENT
ABSENT
TISSUE
ELASTICITY
MUCOUS
MEMBRANE
CAPILLARY REFILL
TIME
BLOOD PRESSURE
PRESENT
REDUCED/ABSENT
ABSENT
DRY
DRY
VERY DRY
NORMAL
PROLONGED(>2s)
NORMAL
NORMAL/PROLONGE
D
NORMAL/LOW
URINARY OUTPUT
REDUCED
REDUCED
PULSE RATE
NORMAL
RAPID
EYES
GROSSLY SUNKEN
ANTERIOR
FRONTANELLE
FLAT
VERY SUNKEN
SUNKEN
LOW/UNRECORDABL
E
MARKED OLIGURIA
RAPID,WEAK,MAY
IMPALPABLE
Investigations
Full
blood count
- WCC : high indicate bacterial infection
:low indicate dengue fever
-platelet :low dengue fever
-haematocrit : high dengue fever ( can also be low
after hydration)
BUSE
- to see the hydration status and any electrolyte
imbalance
Liver function test
- AST / ALT increase in dengue fever
ABG , coagulation profile
Dengue serology
Management (dengue
fever)
Whether
Febrile
phase
rest
antipyretic
no aspirin (why?)
no antibiotic is necessary
ORS / IV therapy
food should be given according to
appetite
Platelet <100000 & rise in Hct of 20%
-significant plasma loss & indicates
the need for IV fluid therapy
If
QUIZ
Dengue
ANSWER
A)
Scenario 3
A 3 year old Malay boy presents to ED
by his parents with 2 days history of
coughing. He has low grade fever, rapid
breathing and audible wheeze.
DDx
Common
Uncommon
History
44 breaths/min (Tachypnoea)
HR:
SpO2:
90% (Low)
Temperature:
37.8 C (Low-grade)
Physical Examination
General
Respiratory
Absence
Other
Investigation
O2
saturation -90%
Peak Expiratory Flow Rate(PEFR) not done as the child is under 5y/o
CXR and blood investigationsnotroutinely indicated
Monitor electrolyte (hypoK is
complication of 2-agonist)
Management
Pharmacological method:
Reassure the child and parents
Give oxygen via mask
Short-acting 2-agonist(SABA),
salbutamol via nebulizer
Oral steroid, Prednisolone 1-2mg/kg
(14 mg) is started and continues
SABA (patients weight: 7kg)
Non-pharmacological method:
Educate the parents and child about
importance of compliance to inhaler,
allergen avoidance, smoking cessation as
well as Influenza and pneumococcal
vaccination.
Quizzes
(True/False with
negative marking)
1)
2)
3)
4)
5)
Answers
1)
2)
3)
4)
5)
SCENARIO 4
2
DDX
Cardiac
HISTORY
SVD,
no complications
NKD/FA
No significant past medical history
Not on any medication
Family history negative
VITAL SIGNS
Temperature:
SpO2
PR
RR
BP
:
:
:
:
36 C
92%
240 bpm
48 bpm
normotensive
PHYSICAL
EXAMINATIONS
General appearance : pale, irritable, alert,
mild mottling, no cyanosis
A : patent
B :clear breath sounds, no retractions
C : strong pulses, CRT<2 sec
S1, S2 heard, no gallop rhythm/murmur
No evidence of trauma
No hepatosplenomegaly
INVESTIGATION
ECG
MANAGEMENT
NON-PHARMACOLOGICAL
PHARMALOGICAL
Acute : Adenosine
Chronic : Digoxin, B-blocker
Quizzes
Answers
Case Scenario 5
-A 5-month-old infant arrives at the emergency center
strapped to a backboard with a cervical collar in place.
-The father was holding him in his lap in the front passenger
seat of their car when the driver lost control and crashed.
The child was ejected from the car through the windshield.
-He loss conscious after the accident. He had a self-limited,
2-minute generalized tonic-clonic seizure when transfer to
the hospital.
*ref: Eugene CT, Robert JY, Rebecca GG, et al. Case Files: Pediatrics. The McGraw- Hill
Companies, Inc. 3rd edition, 2009. pg321-328.
Approach:
Rapid primary survey
Resuscitation
Detailed secondary
survey
Definitive care
Indication
for intubation:
airway trauma)
Inadequate oxygenation with
spontaneous respiration (SpO2<90% or
rising pCO2)
Profound shock
Anticipatory: in trauma, overdose,
congestive heart failure, asthma, COPD,
smoke inhalation injury
Breathing
Look for chest movement, colour,
nasal flaring
Listen for breath sound
Feel for tracheal shift, chest wall for
crepitus, flail segment, sucking chest
wounds
His SpO2 improved to 95% after
intubation.
Symmetry breath sounds and
Circulation
Pulse rate= 180 bpm
Respi rate= 50 bpm
BP= 90/70
CRT = 5 sec
Is he in shock?
Yes. Compensated shock
Apply pressure to stop bleeding
Insert two large venous cannulae or
intraosseous infusion in the tibia
What to give?
Crystalloid (20 ml/kg)
Disability
GCS = 6
He has several facial and scalp lacerations.
His anterior fontanelle is bulging, his sutures are
slightly separated
What is the most likely etiology for this childs
altered mental status?
Simple cerebral concussion or increased
intracranial pressure due to subdural hematomas
This child is younger than 1 year, and subdural
hematomas are more common in this age group;
epidural hematomas are more common in older
children.
Seizures are more common with subdural
Eyes
Open spontaneously
Open spontaneously
Verbal command
React to speech
Pain
Motor
Verbal
React to pain
Score
No response
No response
Obeys
Spontaneous
Localises pain
Localises pain
Withdraw
Withdraw
Abnormal flexion
Abnormal flexion
Abnormal extension
Abnormal extension
No response
No response
Inappropriate words
Incomprehensive words
Moans to pain
Exposure
Remove all clothing
Assess entire body for injury
Logroll to examine the back
Digital rectal examination
Avoid hypothermia
2. Detailed secondary
survey
History
SAMPLE
Sign and symptom LOC and seizures
Allergy
Medication
Past medical history
Last meal
Events related to injury - ejected
through the windshield
Physical examination
Head to toe
Pupils left sided dilated non-reactive
pupils
Funduscopic examination reveals bilateral
retinal hemorrhages.
FAST (Focused assessment with
sonography for trauma) reveals no
abnormalities
Fracture of left humerus
What will you order?
CT-brain, X-Ray (C-spine, chest, pelvis, left
humerus)
CT- brain
Left
sided
subdural
haematoma
Note the high
signal intensity
of acute blood
and the (mild)
midline shift of
the ventricles.
3. Definitive care
Signs of ICP
Deteriorating
LOC
Deteriorating
respiratory
pattern
Cushing
reflex (high
BP, low HR)
Lateralizing
CNS signs
Seizures
Nausea and
vomitting,
headache
Treatment of
ICP
Elevated
head of bed
Mannitol
Hyperventilati
on
Paralyzing /
sedating
agent
Disposition
Neurosurgical
ICU
Answer
A 17-year-old adolescent female is brought to the hospital after a motor
vehicle crash. She and her boyfriend had been drinking beer and were on
their way home when she lost control of the car and hit the side wall of
the local police station. She reportedly had a brief loss of consciousness
but currently is oriented to name, place, and time. She responds
appropriately to your questions. While waiting for her cervical spine
series, she vomits and lapses into unconsciousness. She becomes
bradycardic and develops irregular respirations. Which of the following
brain injuries is most likely in this case?
A. Subdural hemorrhage
B. Epidural hemorrhage
C. Intraventricular hemorrhage
D. Post-traumatic epilepsy
E. Concussion
Overview
Paediatric
Assessment Triangle:
Appearance, Breathing, Circulation
Primary Survey (ABCD)
Triage System (T1,T2,T3)
Resuscitation:
Airway: advanced airway
Breathing: Supplementary Oxygen
Circulations: Bolus fluids, Types of shock