Jay Ped. Emergencies

8/8/2019 Jay Ped. Emergencies

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ObjectivesGroup reviews common pediatric illnesses and

emergencies such as fever acute gastroenteritis,hypoglycemia, hyperglycemia, diabetic

ketoacidosis, status epileptics, Septic shock,respiratory failure and pediatric surgical

emergencies.

Group identifies patient requiring emergencymanagement in relation to specific conditionsmentioned above.

Group discuss diagnosis requiring emergentevaluation and management in relation to specific

conditions mentioned above.


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A Pediatric Emergency care is the care

of children and

teens who are acutely ill or injured


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Objectives of Management of Pediatric

Emergencies

To preserve life

To promote health

To restore health

To alleviate sufferingTo prevent further complication

To decrease Mortality and Morbidity.

P

rovide Healthy citizen for nation


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Definition of Fever :

It is an elevation of body temperature abovenormal.


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Not a disease, its a sign of disease.

Severity is not indication of severity ofunderlying disease.

Fever

Emergency if:

>1040F in any child

>1010F in infant < 3months old


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Anatomical and Physiologic

Characteristics

-Increased metabolic rate

-Largebody surface

-Immature kidneys

-Rapid fluid loss


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Causes:

- Infection

- Inflammatory disease

- Dehydration

- Tumors- Disturbances in temperature

regulating center

- Extravasations of blood in tissue

- Effect of drugs or toxins


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Assessment:

1.Basic principles to be kept in mind

*Newborns temperature varies with environment*Degree of fever does not always reflect severityof the disease.

*Febrile seizures due to rapid rise in temperature

2. History

-physical examination

- laboratory test

3.Attempt to identify the pattern of fever


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Principlesof Management

- Monitor vitals

- Maintain hydration

- Prevent hypothermia

- Administration of antipyretic

- Dietary management


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Managementof fever- Use traditional cooling methods- Minimum clothing's

- Expose skin to air

- Reduce room temperature

- Increase air circulation

- Apply cool moist compress

- Tepid sponging

- -Cold sponging

Take care that temperature should not

increase more than set points.


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Diarrhea

Definition:

It is alteration in consistency and /or frequency of

stool resulting in a net loss of fluid and electrolyte

from the body.

According to W.H.O/ UNICEF :

Acute diarrhea is an attack of sudden onset ,

which lasts usually for three to seven days but

may lasts up to tento fourteen days caused byinfection of the bowel.


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Signs and Symptoms1History

- loose stool

- frequency and consistency, color ,mucus and blood

- vomiting, frequency, vomits nature

- fever

- altered sensorium

- oliguria

- tachypnea

- distention of abdomen


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2. Grades of dehydration

characteristics Mild - Gr.1 Moderate- Gr.2 Severe- Gr.3

% of loss of

fluid

Loss in

ml/kg.

General

appearance

Pulse

0.5%

50ml/kg

Thirsty

Normal

5-10%

50-100ml/kg.

Irritable/

Lethargic

Rapid /normal

>10%

>100ml/kg

Drowsy

Feeble/not

palpable


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Grades of dehydration cont

B.P. Normal decrease Unrecordable

Respiration Normal Normal /rapid Acidotic

Eyeballs Normal Soft Deeply

sunken

Anterior

fontanels

Normal Slightly

depressed

Markedly

depressed


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Grades of dehydration cont

Skin turgor Normal Normal todecrease

Completeloss

Mucous

membrane

Moist dry Very dry

Tears Present Reduced Absent

Urine

output

Normal Decreased Severe

oliguria to

anuria


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3.Investigation

stool Urine

blood


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AssessmentCollect information

- Normal body weight prior to illness

- Number and description of stool patientusually has each day, when well .

- The description of stool (fluidity ,volume,

color and the presence of blood or mucus)

- Fever, abdominal pain ,weight loss.

- Fluid intake

- Frequency of urination

- Degree of dehydration/skin turgor

- State of consciousness


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Principles of management

Correction and restoration of fluid

Useof drugs

Dieteticmanagement

Symptomatictreatment

Treatmentofcomplications

preventivemeasures


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Correction of dehydration

Grade 1-

ORS solution

Plenty oforal fluids and

Continuetobreast feed

Takethechild to health worker


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Treatment of grade 2

Hospital based treatment 100ml/kg ORS in 4hours.

Reassure the client and family members

Monitor vitals

Check skin turgorMaintain intake output

Observe the fluidity and frequency of stool

Maintain personal hygiene

Continue breast milk

Provide coconut water


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Treatment of grade 3-

I.V.Rehydration therapy (Ringer lactate )Shock

Unable to drink

Severely dehydrated


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Fluid management

Fluid till 10kg -100ml/kg/day10-20kg -50ml/kg/day

>20kg - add 20ml/kg/day

Sodium 3meq./kg/day

potassium 2meq./kg/day


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Status Epilepticus

Statusepilepticusis defined as

recurrentorcontinuousseizure

activity lasting longerthan 30minutes

in which the patient does not regain

baselinemental.


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Investigations

Specimen Investigation

Blood Complete blood count

Electrolyte, Glucose, Calcium, Magnesium,

Creatinine, Liver function test,Lactate , Arterial blood gas analysis

Anticonvulsant levels

CSF Biochemistry, Cytology, Bacteriology,viral studies

Urine Routine, microscopy, myoglobin

CT Scan/MRI Brain

EEG


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Management of Status Epilepticus

At: zero minutes

Initiategeneral systemicsupportofthe airway (insert nasal

airway orintubateif needed)Check blood pressure / Begin nasal oxygen / Monitor ECGand respiration./ Check temperature/ Obtain history.

Perform neurologicexamination.

Send sampleserum forevaluation ofelectrolytes,blood ureanitrogen,glucose level,completeblood cell count,toxic drugscreen, and anticonvulsant levels;check arterial blood gasvalues

.

StartIV linecontainingisotonicsaline at a low infusion rate.

Inject 50mLof 50 percentglucoseIV and 100mgofthiamineIV orIM.

Administer lorazepam (Ativan) at0.1to0.15 mg per kgIV (2

mg perminute);ifseizures persist, administer phenytoin at18mg per kgIV (150mg perminute, with an additional 7 mg


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Nursing Diagnosis

1.Risk for injury related to type of seizure

2.Risk for injury related to impaired

consciousness.

3.Interrupted family process related to

child with a chronic illness


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Status Asthmaticus

Severe attack of bronchial asthma with extensive

bronchial obstruction from the beginning or during the

course of episode


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Causes


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Signs and symptoms

Severe persistent dysponea

Respiratory rate over 30per/minute

Prolonged expiration [wheezing]

Hyperactivity of accessory muscles

Inability to speak without pauseCyanosis

Altered consciousness

Respiratory muscle fatigue

Pneumothorax


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MANAGEMENT

Humidified oxygen

Hydration

Correction of metabolic acidosis

Maintain electrolyte

Antibiotics


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Nursing management

Emotional support

Positioning

Assessment of respiratory status

Administration of oxygenAerosol therapy

Postural drainage

I.V. Medication

Restrict overeating

Provide rest


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Aspiration of foreign bodies


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Aspiration of foreign bodies occurs in infants and toddlers

between the of 6 months to 3years of age

Laryngeal

hoarseness of voice,

cough,

aphonia

hemoptysisdyspnea ,

wheezing &

inflammation

Tracheal

Cough ,

hoarseness, dyspnea

Bronchial

Cough, wheeze, blood streaked sputum

atelectasis ,

gagging cough


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Management

Removal of foreign body

Bronchoscopy

AntibioticsAbdominal thrust


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Poisoning

Definition:It is an ingestion or inhalation

of toxic substances which ,when taken into

the body or exposed to the body produce

serious and harmful effect on the body.


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Types of poisoning

- Corrosive poisoning

Acid and Alkali

Hydrocarbons

keroseneLamp oil

Turpentine

Paintthinner and remover

Over doseofmedicinee.g. aspirin,syrups

cleaning agents (phenol/Lysol)


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CONT.

Eyes should be flushed with water

Skin should be cleaned

Induce vomiting

Prevent aspiration

Hospital approach

- Removal of poison

- Observe for symptoms of complications- Emotional support to child & parents


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Non corrosive substance

Decreased amount or activity of substance in G.I.T.

- Gastric lavage

- Administration of charcoal

- Administration of cathartics

- Forced diuresis for excretion of waste


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Corrosive substances- NOT to remove by lavage / emesis

- Neutralization is not advised- Provide patent airway- Analgesics

Hydrocarbon- induce vomiting- assess vitals- symptomatic management

- observation

- emotional support- counselling


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EndocrineDisorders

-DKA

-Hypoglycemia

-Hyperglycemia


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Hypoglycemia

Causes : (in older children)

Poisonings/drugs

Liver diseaseAmino acid & organic acid disorders

Systemic disease


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Hypoglycemia

CNS and cardiopulmonary

disturbances.

Hypotonia

Lethargy, apathy

Poor feedingJitteriness,seizures

Congestive heart failure

Cyanosis

ApneaHypothermia


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Hypoglycemi

Clinical manifestations associatedwith activation of theautonomic

nervous system

Anxiety,tremulousness

DiaphoresisTachycardia

Pallor

Hunger, nausea, and vomiting

n ca man es a ons o ypog ycorr ac a or


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n ca man es a ons o ypog ycorr ac a or

neuroglycopenia

Headache

Mental confusion, staring, behavioralchanges, difficulty concentrating

Visual disturbances (eg, decreased

acuity, diplopia)

DysarthriaSeizures

Ataxia, somnolence, coma

Stroke (hemiplegia, aphasia),

paresthesias, dizziness, amnesia,decerebrate or decorticate posturing


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Treatment of hypoglycemia

Anti hypoglycemic agent:

Dextrose

DiazoxideOctreotide

Glucagon


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Signs and symptoms DKA

Abdominal Pain

Nausea/vomitingDehydration

LOC


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DKA Treatment

Fluids

InsulinElectrolyteimbalances


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Septic Shock

Peripheral hypoperfusion dueto

septicemia (blood infection)

Mostcommon in younginfants,

debilitated children


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PATHOPHYSIOLOGY

Severe peripheral vasodilation

Fluid loss fromvesselstointerstitial

space


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Signs/Symptoms

Warm shock

Tachycardia, full pulses

Slow capillary refill

Fever

Flushed skin


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Signs/Symptoms

Cold shock

Tachycardia, weak pulses

Slow capillary refill

Cool, pale,mottled skin


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Management

100%oxygen

RLin 20cc/kgboluses

Fill dilated vascularspace

Preventonsetof cold shock


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Respiratory failure

Clinical manifestations

Cardinal signs:

Restlessness

TachypneaTachycardia

Flaring nares

Chest wall retractions

Expiratory gruntWheezingor prolonged expiration


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Clinical manifestations

More SeverHypoxiaHypotension or hypertension

Dimnessofvision

StuporComa

Dyspnea

Depressed respirations

Bradycardia

Cyanosis (peripheral orcentral)

Principles of management:


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Principles of management:

Maintain ventilation and maximize

oxygen delivery

Correct hypoxia and hypercapnea

Treat the underlying cause

Minimize extrapulmonary organ

failure


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Jay Ped. Emergencies

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