Emergency care in children

1. Emergency care in children Pavlyshyn Halyna Andriyivna Ternopil state medical university

2. Learning Objectives • Essentials of pediatric intensive care of seizures • Essentials of pediatric intensive care respiratory disease • Essentials of pediatric intensive care of anaphylaxis

3. Definition of Child Care • Children requiring emergency care have unique and special needs. • This is especially so for those with serious and life-threatening emergencies. • It is an illness or injury that may threaten a child’s life

4. Learning Objectives Essentials of pediatric intensive care of seizures

5. Convulsions or seizures • are the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. • are when a person's body shakes rapidly and uncontrollably. • During convulsions, the person's muscles contract and relax repeatedly.

6. Seizure Classifications Types of symptoms: 1) Motor* - head/eye deviation, jerking, stiffening 2) Autonomic# - pupils dilatation, drooling, pallor, change in heart rate or respiratory rate 3) Somatosensory+ - smells, alteration of perception

7. A Seizure Is: • Simple Febrile Seizure (SFS) • Unprovoked Seizures (UnS) • Status Epilepticus (SE) Seizure activity cannot be interrupted with verbal or physical stimulation

8. FebrileSeizure • are the most common seizure disorder in childhood, • affecting 2 - 5% of children between the ages of 6 months and 5 years

9. FebrileSeizureis a seizure accompanied by a fever • Caused by the increase in the body temperature greater than 100.4F or 38C • Threshold of temperature which may trigger seizures is unique to each individual • Can occur within the first 24 hours of an illness • Can be the first sign of illness in 25 - 50% of patients

10. Febrile Seizures • Are benign condition • Repetitive non-purposeful movements • Staring • Lip-smacking • Falling down without cause • Stiffening of any or all extremities • Rhythmic shaking of any or all extremities • May be either simple or complex type seizure • Seizure accompanied by fever (before, during or after) WITHOUT ANY • Central nervous system infection • Metabolic disturbance

11. Febrile Seizure: ED Assessment • Baseline assessment • Vital signs (including temperature) • Assess A, B, C, D’s • Begin passive cooling measures • Remove clothing/coverings • Damp towels • Consider giving antipyretic if not previously administered

12. Assess A, B, C, D’s • airway, breathing, circulation, • neurological status = Disability A Oxygen, oral airway. Suction. Avoid hypoxia! Consider bag-valve mask ventilation. Consider intubation IV/IO access. Treat hypotension, but NOT hypertension Disability B C D

13. First Unprovoked Seizure: • Partial seizure • Generalized onset, tonic-clonic seizure • Tonic seizure Remember: this is a seizure that occurs without an immediate precipitating event (fever, trauma or infection).

14. First Unprovoked Seizure: Diagnostic Testing Laboratory tests are based on individual clinical circumstances and may include: • CBC with differential • Blood glucose • Electrolytes • Calcium, magnesium, phosphorous • Urine drug/toxicology screen • EEG • MRI, CT Scan Lumbar puncture is only indicated if there are other symptoms that suggest a diagnosis of meningitis.

15. Status Epilepticus • Seizures that persist without interruption for more than 5 minutes • Two or more sequential seizures without full recovery of consciousness between seizures This is a life threatening emergency that requires immediate treatment.

16. Family education should include instruction to protect the child during theSeizure • Instruct parent/caregivers to prevent injury during a seizure : • Position child while seizing in a side-lying position • Protect head from injury • Loosen tight clothing about the neck • Prevent injury from falls • Reassure child during event • Do not place anything in the child’s mouth

17. First Aid: Seizure 1. Protect from potentially harmful objects. 2. Cushion head. 3. Turn on side and keep airway clear 4. Observe & time events 5. NOTHING in the mouth 6. Don’t grab, don’t hold down 7. Speak softly & calmly 8. Protect from hazards

18. Anticonvulsants • Rapid acting Plus • Long acting

19. Anticonvulsants - Rapid acting • Benzodiazepines • Lorazepam 0.1 mg/kg i.v. over 1-2 min • Diazepam 0.2 mg/kg i.v. over 1-2 min • In children, rectal diazepam gel - Diastat • – the only FDA approved product for non-medical professional administration

20. Phenytoin 20 mg/kg i.v. over 20 min Onset 10-30 min May cause hypotension, dysrhythmia Anticonvulsants - Long acting • Phenobarbital • 20 mg/kg i.v. over 10 - 15 min • Onset 15-30 min • May cause hypotension, respiratory depression

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23. Learning Objectives Essentials of pediatric intensive care respiratory disease

24. Learning Objectives Respiratory illnesses that occur in children and necessitate intensive care can be divided into upper and lower respiratory obstruction.

25. Upper airway obstruction Acute causes (infective) of upper airway obstruction • Croup • Epiglottitis • Bacterial tracheitis • Foreign body • Diphtheria • Acute tonsillitis • Infectious mononucleosis • Retropharyngeal abscess • Trauma

26. Upper airway obstruction ‘Congenital’ (non-acute) causes of upper airway obstruction • Choanal atresia or stenosis • Laryngomalacia • Laryngeal webs, stenosis, cleft, cyst • Tracheomalacia • Vascular ring • Bronchomalacia • Sub-glottic stenosis • Laryngeal papillomata • Intra-thoracic tumours

27. Upper respiratory tract in children • Larynx is located on level the 3-4th (neck) vertebrae; • Vocal and mucous membranes are rich blood vessels and lymphatic tissue, prone to inflammation, swelling, due to babies suffering from laryngitis (viralcroup), airwayobstruction,inspiratorydyspnea;

28. Upper respiratory tract in children • The larynx of a child is funnel-shaped, cartilage soft; • The most narrow point is a mucous membrane on level the cartilage larynx until the age of 8-10 years

29. Upper respiratory tract in children Laryngomalacia Normal Croup

30. Croup is the most common acute upper airway obstruction • is seen predominately in children between 6 months and 3 years of age • Etiology - the primary etiologic agents are • parainfluenza • influenza viruses, • respiratory syncytial virus • adenovirus

31. CroupLaryngitis, laryngotracheitis • Inflammation involving the vocal cords and structures inferior to the cords; • Is manifested by "barking" cough, • inspiratorystridor(a high-pitched sound produced by an obstruction of the trachea or larynx that can be heard during inspiration and/or expiration), • some degree of respiratory distress.

32. CroupSyndromes SignsandSymptoms • “Barky” cough, • Inspiratorystridor • Hoarseness • Nasaldrainage, coryza (catarrh). • Low-gradefever • Intercostal, suprasternal, infrasternal retractions. • RR - slightly increased • A frontal X-ray of the neck shows a characteristic narrowing of the trachea, called the STEEPLE sign The steeple sign on X-ray of a child with croup

33. Croup • Symptoms are characteristically worse at night. • Agitation and crying greatly aggravate the symptoms and signs. • The child may prefer to sit up in bed or be held upright. • Hoarse voice, coryza, a slightly increased respiratory rate. • Hypoxia and low oxygen saturation • The child who is hypoxic, cyanotic, pale or obtunded needs immediate airway management.

34. CroupscoreMildcroup, 0–3; moderatecroup, 4–6; severecroup, 7–10 A scoringsystemforcroupisusefulinassessingseverity

35. TreatmentCroupSyndrome includes humidification of respiratory gases, oxygen, steroids and nebulized epinephrine;

36. Treatmentcroupsyndrome • The treatment of croup includes nebulized racemic epinephrine, systemic or nebulized corticosteriods, fluids, rest and comforting measures. • Epinephrine is a short-acting bronchodilator. It also decreases congestion in the airway, thus reducing tissue edema. • Nebulized epinephrine is used for children with hypoxia who have some degree of respiratory distress.

37. Treatmentcroupsyndrome • Corticosteroids, which may be systemic or nebulized, are indicated for mild to severe croup. • The anti-inflammatory action of these medications reduces airway edema.

38. Epiglottitis is bacterial infection of the epiglottis and supraglottic structures H. influenzae type b (Hib) Epiglottitis

39. AcuteEpiglottitis • Stridor inspiratory • Sore throat, painful swallowing • Drooling, • Hoarse, muffled voice • Highfever • Dysphagia • Suprasternal, substernal retractions • Position of head and neck - to sit leaning forwards, mouth open and with tongue and jaw protruding in order to open the airway.

40. On X-ray - the thumb-print sign is a finding that suggests the diagnosis of epiglottitis

41. Diagnosis Croup • Gradual onset • Late night seal-bark cough • Low-grade fever • Inspiratorystridor • Hoarse voice • Other signs and symptoms • depending on degree of distress Epiglottitis • Sudden onset • Muffled cough (not a prominent finding) • High fever • Inspiratory stridor • Dysphagia • Sore throat • Drooling (sometimes noted) • Tripod position (facilitates air movement)

42. AcuteEpiglottitis • Establishing an airway by nasotracheal intubation or by tracheostomy is indicated in patients with epiglottitis, regardless of the degree of apparent respiratory distress, because as many as 6% of children with epiglottitis without an artificial airway die, compared with <1% of those with an artificial airway. • Children with acute epiglottitis are intubated for 2-3 days + antibiotics therapy.

43. Foreign body aspiration • Small objects - seeds, nuts, toy parts, buttons, pebbles • Sudden onset of cough • Choking or gagging or wheezing • Stridor, high pitched wheezing • Cyanosis A foreignbodyabovethevocalcordscancausecompleteobstructionoftheupperairway, stridor, a changeorlossofvoice; An aspirated foreign body (coin)

44. Foreign body aspiration • Complete Blockage • no sound • no cry • stridor • cyanosis • loss of consciousness • Partial Blockage • coughing • accessory muscle use • nasal flaring • wheezing

45. Foreign bodies • Atelectasis of right apex • Note the coil and the endotracheal tube just above it • Explaining the difficulties in placing the tube • Bronchoscope under sedation may be necessary to remove object or surgery.

46. The peculiarities of the bronchi in children • In young children the bronchi are relatively wide, • The right bronchus is a straight continuation of the trachea, • The muscle and elastic fibers are undeveloped, • The bronchi are well blood supplied, • The lobules and segmental bronchus are narrow.

47. Anatomyandphysiology • Several anatomical and physiological features of the respiratory system in infants (age <1 yr) and young children make them susceptible to airway obstruction. • The upper and lower airways are small, prone to occlusion by secretions and susceptible to oedema and swelling. • A small decrease in the radius of the airway results in a marked increase in resistance to airflow and the work of breathing (Poiseuille's law); • The support components of the airway are less developed and more compliant than in the adult.

48. Bronchiolitis– acute inflammation in the mucosa of small bronchi and bronchioles, predominantly in young children with the concomitant obstruction of respiratory ways • Dry cough, nonproductive • Dyspnea (breathlessness) • Noisy breathing • Moaning breathing with prolonged expiration • Retractions • Ban-box sound - on percussion • Bronchial breathing with prolonged expiration, wheezing, diffuse crackles;

49. Clinical case 6 months patient Complaints: • Increased body temperature to 38 °C • Irritability • Dry cough • Dyspnea (breathlessness)

50. Anamnesis morbi (present history) • Acute onset • Disease has begun from cough, sneezing, high temperature up to 38 °C, then has appeared noisy breathing, cough, which have increased gradually; • He became ill in 36 hours after contact with an ill mother; • Treatment started at home (antibiotic by mouth, mucolitic, decongestant); • Condition of patient remained the same, and he was admitted to the hospital;