Pediatric Emergencies

General Concepts

Critically ill or injured child must be evaluated rapidly to minimize morbidity and mortality (time factor is very important). The patient is stabilized by administering: Basic life support (Airway + Breathing + Circulation) and Advanced life support measures (Drugs + ECG + Fluids). Once the patient is clinically stable the cause of the childs symptoms can be investigated and determined. Pediatric emergencies are of various types: respiratory, cardiac, neurological, and metabolic. Pinpointing the cause of various system failures may take considerable precious time, so treatment to stabilize a child physiologically should start immediately. Infants and children are more prone to suffer emergency situations due to many factors - Temperature instability. - High fluid content with liability to dehydration. - Small and narrow airway with large tongue. - Heart rate-dependent cardiac output. - Poor glycogen stores with possible hypoglycemia.

Emergency approach
1) Primary survey: aim to identify arrest and pre-arrest situations. 2) Cardiopulmonary resuscitation (CPR): * Basic life support A: Open, clear and maintain the airway. B: Maintain breathing by assisted ventilation (mouth to mouth, bag and mask). C: Maintain circulation by chest compressions and IV fluids. *Advanced life support (if basic support only failed) D: Drugs mainly adrenaline. E: ECG to determine type of arrhythmia. F: Defibrillation if needed. 3) Secondary survey: A head to toe examination to detect which system(s) is failing 4) Nonspecific system support as follows - Respiratory support Oxygen, suction, mechanical ventilation. - Cardiovascular support Oxygen, fluid resuscitation, inotropic drugs. - Neurological support A+B+C, control of convulsions and decrease intracranial pressure. - Metabolic support Keep hydration, temperature and organ function. 5) Specific treatment of the cause such as antibiotics for pneumonia.

Respiratory Emergencies
Importance: - No. 1 cause of pediatric hospital admissions. - No. 1 cause of death during first year of life except for congenital abnormalities. - Most pediatric cardiac arrest begins as respiratory failure or respiratory arrest. Definition of respiratory failure The loss of ability of the respiratory system to maintain adequate blood levels of CO2 and O2. Common causes of respiratory failure and distress 1. Croup. 2. Epiglottitis. 3. Foreign body aspiration. 4. Acute severe asthma. 5. Bronchiolitis. 5. Pneumonias.

Management of Respiratory Failure

1) Respiratory monitoring Clinical monitoring by following vital signs and organ functions. Arterial Blood gases. Pulse Oximetry (Measures arterial O2 saturation). 2) Respiratory support a) Oxygen Therapy (Oxygen is a Drug): * Indications and Dosage (Fio2): - Use as less FiO2 as possible for the shortest possible period to maintain adequate oxygenation. FiO2 is the fraction (concentration) of inspired O2. - Use 100% O2 in CPR, cyanosis, and convulsions. - Dose in system failure: * Respiratory failure (40 100%). * Cardiovascular failure (40%). *Neurological failure (40%). * Methods of Administration - Incubators. - Simple face mask. - Venturi mask. - Head box (oxyhood). - Nasal prongs and nasopharyngeal tubes. - Endotracheal tube. * Complications of oxygen therapy: - Eye toxicity. - Lung toxicity. - Oxygen dependence. b) Mechanical ventilation. c) Other aspects of support: * Inhalation therapy. * Suctioning and chest physiotherapy. 3) Specific Treatment of respiratory failure - Pneumonia (IV Antibiotics), asthma (bronchodilators), laryngitis (steroids). - Guilain-Barre syndrome (immunoglobulin), foreign body aspiration (bronchoscopy). 2

Circulatory Failure (Shock)

Definition and pathophysiology: - The function of the circulatory system is to maintain tissue perfusion. Shock is a state of circulatory dysfunction resulting in inadequate delivery of oxygen and nutrient delivery i.e. tissue hypoperfusion. - Normal circulatory function depends on 3 components: 1) Adequate blood volume (the fluid or the fuel). 2) Adequate cardiac function (the pump). 3) Adequate vascular tone (the pipes). - As children are heart rate dependent, tachycardia is the earliest and most important single sign when evaluating for shock. - Shock is not necessarily hypotension. It begins with a normal blood pressure (maintained by compensatory catecholamine release) and progress over time. - Early shock does occur without hypotension. So, hypotension is seen in late or established shock states after compensatory mechanisms are exhausted. - A high index of suspicion is needed and shock should be suspected and expected in all conditions that may lead to shock. - Early recognition and treatment of compensated shock is essential to prevent decompensated and irreversible stages so as to get good prognosis. Table . Causes of shock. Type of Shock Hypovolemic Examples Dehydration due to vomiting/diarrhea Trauma with severe hemorrhage Vasodilation secondary to anaphylaxis Cardiogenic Distributive Dissociative Viral myocarditis Postoperative cardiac patient with poor heart function Septic shock Carbon monoxide poisoning

Management of Shock 1. Monitoring of shock Clinical: HR, RR, BP, peripheral perfusion, urine output. Laboratory: Blood gases, electrolytes, blood sugar, cultures. Imaging: Chest x-ray, echocardiography. 2. Cardiovascular support: a. Oxygen therapy.

b. Preload augmentation by volume expansion or fluid resuscitation: - Crystalloid such as Ringers lactate or normal saline 20 ml/kg over 15 min, which can be repeated once or twice as needed especially in hypovolemic, distributive or septic shock. - Care is needed in treating cardiogenic shock with volume expansion, and better to be guided by careful monitoring of CVP. - Alternatives for volume expansion include colloids as albumin or plasma, and whole blood. - If failed preload augmentation, consider obstructive shock (CXR). c. Contractility augmentation: - If volume expansion failed or further volume is not safe, use inotropic drug support: Dopamine 5-15 mcg/kg/min, or dobutamine 5-20 mcg/kg/min or adrenaline 0.1-0.2 mcg/kg/min. d. Afterload reduction (Vasodilators): - Careful use of vasodilators needs adequate volume expansion and invasive monitoring to document elevated systemic vascular resistance. Examples include nitroprusside, nitroglycerin and angiotensin converting enzyme (ACE) inhibitors. e. Treatment of Arrhythmias: - Treatment of precipitating factors as hypoxia, acidosis. - Bradycardia: Atropine. - Supraventricular tachycardia: Adenosine or DC shock. 3) Multisystem support. 4) Specific treatment such as O2 and ventilation for respiratory failure and dialysis for renal failure.

Poisoning
Definition A poison is any substance which when introduced into the body or by local action injuries the health or produce death. Causes of poisoning: 1) Accidental: the vast majority of all cases, age: 1-5 yr, most ingestion occurs at home due to inadequate supervision. 2) Non-accidental: child abuse, in young children. 3) Suicidal: in adolescents. 4) Iatrogenic: drug overdosage. Diagnosis of poisoning (A) When to suspect poisoning: 1- Unexplained illness in a previously healthy child. 2- Abrupt and drastic manifestations. 3- Onset of illness related to working, ingestion, or playing with a poison. 4- Frank history of ingestion. 5- Family troubles and decreased supervision. (B) History and Physical examination: - For example odor, eye, skin, heart, lung and CNS manifestations. (C) Toxic Syndromes: For example nausea, vomiting, acute hepatic failure in paracetamol poisoning; and fever, red dry skin and mouth, mydriasis, urine retention and tachycardia in atropine poisoning. 4

General Treatment of Poisoning

The telephone is often the first contact in pediatric poisoning. Proper telephone management can reduce morbidity and prevent unwarranted or excessive treatment. Initial Telephone Contact Basic information obtained at the first telephone contact includes: the patient's name, age, weight, address, and telephone number; the agent and amount of agent ingested; the patient's present condition; and the time elapsed since ingestion or other exposure. Principles of Management A) Multisystem support, such as: - Respiratory depression: 02 and assisted ventilation. - Hypotension: IV fluids, plasma and inotropic drugs. - Convulsions: anticonvulsants. B) Prevention of further absorption G I T : ( within 60 minutes) (1) Induction of vomiting by syrup of ipecac or salt solution. (2) Gastric lavage if (1) fails or unconscious patient. (3) Activated charcoal (currently the most important and mainstay of treatment): for adsorbing material in stomach or gut (within 1 hour). It is ineffective with corrosives and hydrocarbons. (4) Catharsis: Magnesium sulphate. (5) Simple dilution by water or milk especially with corrosives and volatile substances, where emesis or lavage is contra-indicated. Others: Washing skin and eyes with water. Note: - Vomiting or lavage is contraindicated in the following conditions: a) Unconsciousness. b) Hydrocarbons and volatile agents. c) Corrosive agents. C) Enhancement of elimination by: - Forced alkaline diuresis e.g. salicylates and barbiturates. - Chelation e.g. lead and iron. - Dialysis if suitable: e.g. salicylates and barbiturates if other measures fail. D) Specific antidotes, if suitable; for: - Paracetamol : N acetyl-L-cysteine. - Atropine: Anticholinesterases. - Organophosphorus: Atropine. - Narcotics (opiates): Naloxone. - Iron: Desferroxamine.

Prevention
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Each year, children are accidentally poisoned by medicines, polishes, insecticides, drain cleaners, bleaches, household chemicals, and materials commonly stored in the garage. It is the responsibility of adults to make sure that children are not exposed to potentially toxic substances. Table. Poison prevention Poison safety "do's" and "don'ts" DO: 1. Ask for "safety-lock" tops on all prescription drugs. DON'T: 1. Don't store food and household cleaners together.

2. Keep cleaners, bug sprays, medicines, and 2. Don't take medicine in front of children; other harmful products out of the reach and children love to imitate "mommy" and sight of children. If possible, keep the products "daddy." locked up. 3. Store medicine in original containers. 3. Don't call medicine candy. 4. Read the label before taking medicine; don't 4. Don't take medicine that is not for you. take medicine that doesn't have a label. Never take medicine in the dark. 5. Follow the directions for all products. 5. Don't put gasoline, bug spray, antifreeze, or cleaning supplies in soft-drink bottles, cups, or bowls. Always keep them in their original containers.

Pain Management
Definition of pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Misconceptions about pediatric pain - Small infants do not have the neurologic capacity to experience pain. - Even if they feel pain, they are less sensitive to it than older children and adults. - They have no memory of pain, and so it has no lasting effect. - Side effects of analgesic medications particularly respiratory depression are more in children. - Concerns about addiction should limit use of narcotic analgesics. Clinical Assessment of Pain 1) Self-report: asking about character, location, duration, frequency, and intensity of pain. 2) Behavioral indicators such as vocalization (crying), facial expressions (The most reliable & consistent indicator, grimacing), Body movements (limb withdrawal). 3) Physiological indicators such as tachycardia, tachypnea and hypertension. 6

Types of pain - Minor procedures: Heal lancing, intravenous or arterial lines, lumbar punctures - Major procedures: Endotracheal intubation, chest tube insertion, mechanical ventilation - Perioperative: Minor surgery (as circumcision) and major surgery. - Disease-related: Intestinal obstruction, ICH, tissue injury such as laceration or burn. Management of Pain A) Non-pharmacologic pain relief (Safe and effective): - Numerous methods: * Distraction, Imagination (hypnotherapy), * Massage therapy (hold, touch, heat, vocal) * Oral sucrose and pacifiers - Mechanism of action: Blocking nociceptive transmission, activation of descending inhibitory pathways, Activation of arousal system (change attention) that modulate pain. - Useful as complementary strategies to pharmacologic methods to relieve pain. B) Pharmacologic treatment 1) Local anesthetics - Lidocaine 0.5 % (cutaneous infiltration) - TAC (tetracaine, epinephrine and cocaine) - EMLA 5% cream: Eutectic Mixture of Local Anesthetics: - Composition: 2.5 % lidocaine & 2.5 % prilocaine - Eutectic combination means a mixture of 2 solid phases that melt easily at low temperature than they do separately; hence they form a liquid at room temperature. - The combination increases the concentration of the drugs in the emulsion and is more effective than using both drugs. - Use: 30 90 min before procedure, under occlusive dressing. Dermal analgesia persists 1-2 hours after removal. 2) Non narcotic analgesics - Acetaminophen Replaced aspirin as the most widely used antipyretic and mild analgesic for children. Rectal acetaminophen should be used cautiously because of delayed and variable absorption. Dose: 10-15 mg/kg/dose 4-6 hourly PO. Daily dose should not exceed 90 mg/kg/day for children, 60 mg/kg/day for infants, 30 mg/kg/day for newborn. Excessive dose can lead to hepatic failure. - NSAIDs The most widely used analgesic and antipyretic. Used to treat mild pain or adjunct to reduce dose of opioids. Ibuprofen is associated with fewer side effects and better compliance. Side effects are rare and include GIT and renal troubles and impaired hemostasis. Selective cyclooxygenase (COX2) inhibitors are associated with less side effects. 7

No neonatal studies of effectiveness and safety of NSAID to reduce pain. 3) Narcotic analgesics Opioids are the mainstay of pharmacological pain treatment and are used for moderate and severe postoperative pain, procedural pain, sickle cell crisis pain, and cancer pain. May be administered as single or intermittent boluses or as continuous infusion. Continuous infusion permits more constant plasma levels and clinical effects than intermittent doses. To be used by persons : 1) Experienced in Airway management, 2) Knowledgeable in pharmacodynamics and pharmacokinetics of opioids, and 3) With facility of continuous cardio-respiratory monitoring available. Side effects : Constipation, nausea and vomiting, pruritis, and mild respiratory depression. Addiction refers to psychological craving with compulsive drug seeking behavior, is very rare in pediatrics and is not prevented by under dosing.

- Weak opioids as codeine: Indicated if acetaminophen or NSAIDs alone failed to control moderate pain. Oral codeine is the most common weak opioid used alone or in combination with acetaminophen. Tramadol is a synthetic analog of codeine and can be an used for mild to moderate pain (e.g. orthopedic surgery) for older children > 35 kg. - Morphine sulphate Morphine is the most commonly opioid used in NICU and PICU to provide pain relief to ventilated babies and postoperative pain. It is best given as a continuous infusion following a bolus to provide a steady state of pain relief and to avoid hypotension if multiple boluses are used. Infusion rates are 0.01 mg/kg/hr in young infants and 0.03 mg/kg/hr in older infants and children. It has a slower onset and longer duration compared with lipophilic opioids as fentanyl. - Fentanyl Fentanyl is 100 times more potent than morphine. Unlike morphine, fentanyl acts selectively at the mu receptor, leading to an improved side effects profile with less hypotension, negligible histamine release, less sedation, and less constipation. It is extremely lipophilic, with a rapid onset and short duration of action. It has no active metabolites and is safe in renal failure. Infusion rate is 1-2 g/kg/hr. IV boluses may be associated with glottic and chest wall rigidity. Two new formulations are available : oral transmucosal (rapid and brief) and transdermal (slow onset).

Practical Guidelines:
* Brief Procedural Pain A) Supportive 8

1. Non-pharmacologic methods e.g. imagery, relaxation, heat,..etc 2. Have the parents present if appropriate. B) Analgesia 1. Local anesthetics for simple procedures as venipuncture. 2. If severe pain is expected e.g. bone marrow aspiration, systemic agents are required. * Peri-operative Pain 1. Non-pharmacologic approaches. 2. Opioids for moderate-severe postoperative pain. 3. Added acetaminophen & NSAIDs can reduce the dose of opioids. 4. Pain control should be as quickly as possible (no delay). 5. Give optimal starting dose & subsequent doses according to response. 6. Avoid multiple small ineffective doses. 7. Treatment should not stop abruptly & a home plan should be arranged with the family. * Cancer Pain - Mild Pain : Non-opioid analgesic. - Moderate Pain : Non-opioid analgesic + Oral weak opioid. - Severe Pain : Strong opioid Non-opioid analgesic. * Migraine: - Preventive therapy by serotonin agonist; sumatriptan, B- blockers, calcium channel blockers and antidepressants. - Acute episodes can be treated by dihydroergotamine, ibuprofen, and acetaminophen. * Sickle cell anemia 1. Oral NSAIDs & oral opioids. 2. Ketorolac decrease dose of opioids and need of hospitalization. 3. For severe pain IV opioids infusions in hospital. 4. Acupuncture. 5. Antidepressants e.g. Amitriptylline. * Neuropathic Pain Described as burning or stabbing pain with skin hypersensitivity. It constitutes 35% of chronic pain, caused by peripheral nerve injuries, spinal cord injury, post-amputation and metabolic causes. Neuropathic pain responds poorly to opioids. Proper treatment includes : - Antidepressants e.g. amitriptyline. - Anticonvulsants e.g. carbamazepine & gabapentin. * Circumcision 1) Before Oral sucrose and acetaminophen 2) For the procedure dorsal penile nerve block or subcutaneous ring block. ? EMLA can be Used. 9

3) After Acetaminophen/6 hr for 24 hr.

Emergency Pediatric Drugs

Although careful attention to airway and breathing remains the mainstay of pediatric resuscitation, medications are often needed. Rapid delivery to the central circulation, which can be via peripheral IV catheter, is essential. If no IV or IO access is achievable, some drugs may be given by endotracheal tube. Emergency drugs that may be given by endotracheal tube are lidocaine, epinephrine, atropine, and naloxone.
Table . Emergency pediatric drugs. Drug Atropine Indications 1. Bradycardia, especially cardiac in origin 2. Vagally mediated bradycardia, eg, during laryngoscopy and intubation 3. Anticholinesterase poisoning 1. Metabolic acidosis 2. Hyperkalemia Dosage and Route - 0.010.02 mg/kg (minimum, 0.1 mg; maximum, 2 mg) IV, IO, ET. Comment - Epinephrine is the first-line drug in pediatrics for bradycardia caused by hypoxia or ischemia.

Bicarbonate

- 1 mEq/kg IV or IO; - By arterial blood gas: 0.3 x kg x base deficit. May repeat every 5 min. 1030 mg/kg slowly IV, preferably centrally, or IO with caution. Bradycardia and cardiac arrest: IV/IO: 0.01 mg/kg of 1:10,000 solution. - ET: 0.1 mg/kg of 1:1,000 solution. Anaphylaxis: - SC/IM: 0.01 mg/kg of 1:1000 solution. - Constant infusion by IV drip:0.11 mcg/kg/min. 0.1 mg/kg IV, I0, or ET; maximum dose, 2 mg. Repeat as needed.

- Infuse slowly. - Sodium bicarbonate will be effective only if the patient is adequately oxygenated, ventilated, and perfused. Potent tissue necrosis results if infiltration occurs. Use with caution.

Calcium 1. Documented chloride 10% hypocalcemia 2. Hyperkalemia, hypermagnesemia Epinephrine 1. Bradycardia, especially hypoxicischemic 2. Hypotension (by infusion) 3. Asystole 4. Pulseless electrical activity 5. Anaphylaxis

Epinephrine is the single most important drug in pediatric resuscitation. Adverse effects include increased myocardial oxygen consumption during resuscitation and worsened postarrest myocardial dysfunction.

Glucose Naloxone

1. Hypoglycemia 1. Opioid overdose

0.250.5 g/kg IV or IO. 24 mL/kg D10W, 12 mL/kg D25W. Side effects are few. Repeat as necessary, or give as constant infusion in opioid overdoses.

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D5W, 5% glucose in water; ET, endotracheally; IO, intraosseously; IV, intravenously; SC, subcutaneously.

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