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Ammar Rahman
Pediatric Emergency
Aids
Seizure (Fit)
It is a common presentation in pediatrics emergencies , presented as
repetitive limbs movements , upward deviation of eye ball , sometimes
apnea or focal limb movement (focal fit) .
Management :
1-A (airway protection : put the patient in the lateral position , fluid
suction by sucker if there is mouth secretion).
2-B (breathing exam because the fit may cause apnea, so resuscitate and
give O2 as needed ).
Give the patient I.V diazepam (valium) 0.1 - 0.3 mg/kg diluted with distal
water slowly , if there is no response , the dose may be repeated up to
three times .
If there is no benefit with luminal, give phenytoin bolus dose (the same
as luminal).
Any case of fit you should find the underlying cause as possible .
Dr.Ammar Rahman
DDX :
4- Idiopathic (epilepsy).
Hypoglycemia
Any lethargy or decrease in consciousness level, you should exclude
hypoglycemia.
but the level of glucose may be higher than this and the patient is
clinically deteriorated, so the clinical picture is more important which
includes:
Shakiness
Nervousness or anxiety
Sweating, chills and clamminess
Irritability or impatience
Confusion, including delirium
Rapid/fast heartbeat
Lightheadedness or dizziness
Hunger and nausea
Sleepiness
Dr.Ammar Rahman
Blurred/impaired vision
Tingling or numbness in the lips or tongue
Headaches
Weakness or fatigue
Anger, stubbornness, or sadness
Lack of coordination
Nightmares or crying out during sleep
Seizures
Unconsciousness and may be apnea
Possible causes:
1- Diabetic patient:
Too much medication; for instance, too much insulin or oral diabetes
medication.
Medication mistakes. All families will, at some point, give the wrong
kind of insulin for a meal or at bedtime.
Inaccurate blood-glucose readings.
A missed meal.
A delayed meal.
Too little food eaten, as compared to the amount of insulin taken.
More exercise than usual.
Diarrhea or vomiting.
Injury, illness, infection, or emotional stress.
Other medical problems sometimes seen in people with type 1 diabetes,
such as celiac disease or an adrenal problem.
Notes:
Keep in your mind (in pediatric age group ) hypertonic (50% dextrose) is
diluted with fluid before administered , because direct IV
administration of hypertonic dextrose (50%) may cause cerebral
oedema or rebound hypoglycaemia.
Example:
Fever
Normal body Temperature (36.5 – 37.5 ) C .
Treatment:
2- Cold sponges (not very cold water) apply them in the forehead, axilla,
between thighs and abdomen).
DDx:
Dyspnea
Dyspnea: is difficulty to take spontaneous breathing,the patient
presentation is variable according to the severity of the case, may be
presented with or without cyanosis (central, peripheral, or both) ,
irritability , jitteriness or fit due to hypoxia , decrease of consciousness
level , coma or apnea in severe cases .
Management:
1-Iniatially in any case of dyspnea check the airway patency and take
quick history (it's very important to ask about documented disease).
1-Asthmatic exacerbation.
3-Bronchioliatis.
Dr.Ammar Rahman
4-Croup.
6-Pulmonary embolism.
Asthmatic exacerbation
Presented with dyspnea , cough and wheezy chest , treated by :
1-O2
2-Ventolin nebulizer (1/2cc diluted with 2cc N/S) , you can repeat it 6
hourly as required or every 20 minutes in severe cases .
Chest infection or
pneumonia
The patient presented with dyspnea , baronial breath , and fever .
Treated by :
1-O2
3-Antibiotics
4-Ventolin nebulizer : (1/2cc diluted with 2cc N/S) , you can repeat it 6
hourly as required or every 20 minutes in sever cases .
Bronchiolitis
Its seasonal infection occurs mostly in infants during the winter
(November and December), involves the bronchioles. The patient
presented with dyspnea, fever , cough or sneezing . On examination, the
patient may be presented with hypoxia , wheezy chest and acidic
breathing due to respiratory acidosis. Chest x-ray in severe cases may
show air bronchogram (atelectasis) in severe cases . Treated by :
1-O2
3-Antibiotics.
Dr.Ammar Rahman
4-Ventolin nebulizer: (1/2cc diluted with 2cc N/S) , you can repeat it 6
hourly as required or every 20 minutes in sever cases .
Croup
(Laryngeotrachiobronchitis)
Its acute condition characterized by croupy cough with may be
associated with inspiratory stridor and voice hoarseness due to varying
degree of laryngeal obstruction. The causes may be mechanical
(laryngeal web , tracheal or laryngeal malacia , laryngeal stenosis ,
foreign body ) or inflammatory (parainfluenza , haemophilus influenza ,
acute diaphragmatic laryngitis .. ect) or other causes like congenital
goiter . Treated by:
2-O2
5-In case of sever laryngeal obstruction, the patient may need tracheal
intubation and RCU admission.
Dr.Ammar Rahman
Pulmonary oedema
The patient presented with dyspnea , chest crepitation . Ask about
chronic diseases. It's could be heart failure , congenital heart disease ,
renal failure ,nephrotic syndrome , hepatic failure , hypoproteinaemia ,
inflammatory causes like lung CA or metastasis ) . Treated by :
1-Sitting upright position and swing the legs down to reduce the venous
preload .
1-O2
Pulmonary embolism
The patient presented with sudden dyspnea , chest pain , cyanosis
(central or peripheral or both) , hypotension , tachypnea , hypoxia ,
congested JVP and shock in severe cases . The patient usually has history
of long bone fracture, bedridden, DVT , thrombophilia , congenital heart
disease , family history of thrombotic disease or thromboembolic
phenomena . Send the patient for ECG (sinus tachycardia), the criteria of
S1Q3T3 may present in ECG. The definitive diagnosis is obtained by CT
pulmonary angiography (filling defect) .
1-High flow O2
Surgical causes:
pneumothorax , haemothorax , haemopneumothrax , pleural effusion
, foreign body inhalation , CO toxicity (burn) , trauma , lung contusion ,
tumor ..ect).
DKA
It's precipitated by stress (infection , psychological , insulin dose
error , trauma or vomiting) . Clinical presentation (vomiting,
abdominal or legs pain , dehydration , acidic breathe, fever,
irritability.. ect)
Lab investigations :RBS (elevated) , GUE (ketones and glucose
in urine), S.electrolytes (K , Na , HCO3 ) and CBC.
Management :
Fluid replacement : give the patient bolus dose of fluid (shoot),
(N/S) 20cc/kg during one hour for any suspected DKA (don’t wait
for lab investigations results). Then calculate the fluid that the
patient needs per hour via this equation:
But roughly and for safety add 1cc of Kcl for each 100cc of fluid
(for example when the fluid requirement is 150cc/hr add 1.5cc
kcl /hr , when the fluid requirement is 50cc/hr add 0.5cc kcl/hr
….ect) . The potassium should be administered slowly to avoid
Dr.Ammar Rahman
Gastroenteritis
Clinical presentation: diarrhea, vomiting, fever, dehydration, perhaps
abdominal cramp.
Treatment:
2- Flagyl (metronidazole) vial : 7.5 mg/kg (W.T + 1/2 W.T = dose in cc)
4-Fluid:
UTI
Presentation : dysurea , haematuria , vomiting , fever , sometimes crying
during urination (infants) .
Treatment :
3-Fluid .
4-Analgesia .
Tonsillitis
Presentation: Fever, malaise, vomiting, odynophagia, palpable neck
lymph nodes .
Treatment:
1-Antiobiotics.
Snake bite
1-Check the vital signs of the patient (risk of shock).
4-Antivinin (polyvalent snake): give 4 – 6 vials infused in one hour (in 250
cc N/S) , be careful from allergic reaction . Try to give it early as possible
(DON’T DELAY MORE THAN 6 HOURS).
5- Send the patient for CBC (platelets), PT, and PTT (risk of DIC).
Scorpion sting
1-Check the vital signs of the patient (risk of shock).
Dog bite
1-Check the vital signs.
3-DON’T SUTURE THE BITE WOUND, because this may accelerate the
migration of rabies virus via the nerves to CNS.
Common neonatal
presentations
General protocol for admission to neonatal unites:
2-Continous O2
5-Fluid:
1st day: 60 cc/kg/24 hrs (for term neonate), 70 cc/kg/24 hrs (for
preterm neonate).
Neonatal Apnea
Apnea: failure to take spontaneous breathing for 10 seconds or long
enough to produce cyanosis and bradycardia .
DDX :
Management:
-Check A B C ..ect
-Check RBS
Respiratory Distress
Syndrome
Also known as hyaline membrane disease occurs almost exclusively in
premature infants, in which hyaline membrane and atelectasis found by
biopsy.
Neonatal jaundice
Jaundice means yellow discoloration of sclera and skin , it occurs
when serum bilirubin is 3 mg/dl or more .
Management :
1-History taking : ask about duration , activity , feeding , any
family history of hemolytic diseases , Rh and ABO incompatibility,
fever , Cephalohematoma ,color of urine and stool, any attacks of
irritability , jitteriness or fit , lethargy and family history of
jaundice.
4-DDX :
#Jaundice in the 1st day of life :
1-Rh incompatibility or ABO incompatibility.
2-Antenatal infection (STORCH-EB).
5-Congenitla infection .
6-Metabolic (galactocemia ).
7-Inspissated bile syndrome.
8-Crigler –Najjar syndrome.