Medical emergencies in pediatrics DEPARTMENT OF PEDIATRICS 3

Medical emergencies in pediatrics DEPARTMENT OF PEDIATRICS 3 WITH POSTGRADUATE EDUCATION ONMEDU

Anatomical and functional features of the child's body • Children lose their temperature gradient very quickly. • Small mouth, relatively large tongue and tonsils contribute to airway obstruction • Children are more inclined to aspirate stomach contents into the airways during vomiting and regurgitation • Children are prone to injury of the cervical spine; • The child`s skeleton is highly elastic and prone to curvature • Muscle tissue in children develops irregularly; • Heart rate in children is on average 80 -90 beats per minute. Arrhythmias are widespread; • Low blood pressure (80 -90 mm Hg); • The upper respiratory tract is narrower, the nasal cavity is small and undeveloped; • Breathing rate in newborns is 40 -60, at 2 -3 years old - 25 -30 per minute.

The most common diseases in children for which emergency care may be required § Hyperthermic syndrome §Convulsive syndrome §Terminal states §Foreign bodies (respiratory tract, nose, ears) §Child injury

The febrile child Most febrile children have a brief, selflimiting viral infection. Mild localized infections, e. g. otitis media or tonsillitis, may be diagnosed clinically. The clinical problem lies in identifying the relatively few children with a serious infection which needs prompt treatment.

How is fever identified in children? Rectal temperature remains the most widely used measure in infants under 3 months of age. Tympanic thermometers provide the most accurate assessment of core temperature, but the probe may be too large for an infant’s auditory canal. Measuring oral temperature requires patient cooperation and is generally unsuitable for children under the age of 5 years. Axillary temperature measurement is inaccurate and insensitive. The definition of fever is: § 38°C (rectal or tympanic) § 37. 5°C (oral) § 37. 2°C (axilla)

Are there risk factors for infection? § Illness of other family members § If a specific illness is prevalent in the community § Unimmunised § Recent travel abroad, e. g. malaria, typhoid § Contact with animals, e. g. brucellosis. § Increased susceptibility from immunodeficiency. This is usually secondary, e. g. postautosplenectomy in sickle cell disease or splenectomy or nephrotic syndrome, resulting in increased susceptibility to encapsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae and salmonella), or rarely, primary immune deficiency

How ill is the child? §Fever >38°C if 39°C if 3– 6 months §Colour – pale, mottled, blue §Level of consciousness is reduced, neck stiffness, bulging fontanelle, status epilepticus, focal neurological signs or seizures §Significant respiratory distress §Bile-stained vomiting §Severe dehydration or shock.

Fever in children may be classified into three groups: • Fever with localizing signs • Fever without focus • Pyrexia of unknown origin (PUO).

Fever with localizing signs Upper respiratory tract infection Very common, may be coincidental with another more serious illness Otitis media Always examine tympanic membranes in febrile children Tonsillitis Erythema or exudate on the tonsils? Stridor Epiglottitis? Viral croup? Bacterial tracheitis? Pneumonia Fever, cough, raised respiratory rate, chest recession, abnormal auscultation. In infants, auscultation may be normal – diagnosis may require chest X-ray Seizure Febrile convulsion? Meningitis? Encephalitis? Periorbital cellulitis Redness and swelling of the eyelids. May spread to orbit of the eye Rash Viral exanthema? Purpura from meningococcal infection Urinary tract infection Urine sample needed for any seriously ill young child or any febrile illness that does Abdominal pain Appendicitis? Pyelonephritis? Hepatitis? Diarrhea Gastroenteritis? Fever with blood and mucus in the stool: Shigella, Salmonella or Campylobacter Osteomyelitis or septic arthritis Suspect if painful bone or joint or reluctance to move limb Prolonged fever Bacterial infection, e. g. UTI, bacterial endocarditis. Other Meningitis/encephalitis Lethargy, loss of interest in surroundings, drowsiness or coma, infections – viral, fungal, seizures. Older children - headache, photophobia, neck stiffness, positive Kernig sign (pain protozoal. Kawasaki on leg straightening). Younger children and infants - non-specific symptoms and signs. disease. Drug reaction. Raised intracranial pressure - reduced concious level, abnormal pupillary responses, Malignant disease. abnormal posturing, Cushing triad (bradycardia, hypertension, abnormal pattern of Connective tissue breathing). Late signs – papilloedema disorder Septicemia Can be difficult to recognize in absence of rash before shock develops. Early signs are tachycardia, tachypnea and poor perfusion. Need to start antibiotics on clinical suspicion without waiting for culture results

Patients with unexplained fever with a higher likelihood for serious infection include the following patient groups or conditions: • Neonates (<1 month of age) • Incompletely immunized children • Immunocompromised (e. g. congenital immunodeficiency, human immunodeficiency virus (HIV), neutropenic and other oncology patients, cytotoxic drugs and steroids) • Asplenic children (congenital, post splenectomy or functional, e. g. sickle cell disease) • Patients who have received prior oral antibiotics; many of these patients have a viral infection, but meningitis or other serious bacterial infection (SBI) must be considered • Children with fever and prolonged convulsion • Children with underlying medical conditions (e. g. cystic fibrosis, structural cardiac defects, etc. ) • Children with central venous devices, shunts or other foreign material.

Management § Children who are not seriously ill can be managed at home with regular review by the parents, as long as they are given clear instructions (e. g. what clinical features should prompt reassessment by a doctor). § Children who are significantly unwell, particularly if there is no focus of infection, will require investigations and observation or treatment in a paediatric assessment unit or A&E department or children’s ward. A septic screen will be required. § Parenteral antibiotics are given immediately to seriously unwell children, e. g. a third -generation cephalosporin such as cefotaxime or ceftriaxone if >3 months old. § Aciclovir is given if herpes simplex encephalitis is suspected. Supportive care is given as indicated. The child should not be underdressed. § The use of antipyretic agents should be considered in children with fever who appear distressed or unwell. They should not be given if the child is otherwise well. Either paracetamol or ibuprofen can be used. They can be given alternatively if unresponsive to a single agent. § Evidence that antipyretics prevent febrile seizures is lacking.

Paracetamol §Paracetamol may be given orally, rectally or intravenously at a dose of 10– 15 mg kg – 1 4– 6 hourly. §In an unsupervised, community setting, the total daily dose should be limited to 60 mg kg – 1 , although up to 90 mg kg – 1 per 24 hours can be used under medical supervision. §Single doses of 30 mg kg – 1 may be used for night-time dosing. §Serious toxicity has been reported in children with chronic daily overdosage, mostly occurring in children who have a febrile illness and associated anorexia, vomiting and/or dehydration. § A child should be reviewed after 48 hours if regular paracetamol has been ‘required’ for this period.

Ibuprofen § Ibuprofen can be used as an alternative to paracetamol at a dose of 5– 10 mg kg – 1 (maximum of 400 mg per dose), given 6– 8 hourly (maximum daily dose of 30 mg kg – 1 or 2 g). § It is recommended that it be used alone and not in combination with paracetamol, as this practice may lead to an increase in adverse effects, including gastrointestinal bleeding, renal dysfunction and anaphylaxis.

Seizures A seizure is a clinical event in which there is a sudden disturbance of neurological function caused by an abnormal or excessive neuronal discharge. Seizures may be epileptic or non-epileptic.

Causes of seizures (non-epileptic) § Febrile seizures § Metabolic üHypoglycaemia üHypocalcaemia/hypomagnesaemia üHypo/hypernatraemia § Head trauma § Meningitis/encephalitis § Poisons/toxins.

Causes of seizures (epileptic) § Idiopathic (70– 80%) – cause unknown but presumed genetic § Secondary üCerebral dysgenesis/malformation ü Cerebral vascular occlusion üCerebral damage, e. g. congenital infection, hypoxicischaemic encephalopathy, intraventricular § Cerebral tumour § Neurodegenerative disorders § Neurocutaneous syndromes

Febrile seizures A febrile seizure is a seizure accompanied by a fever >38°C in the absence of central nervous system (CNS) infection in children aged 6 to 60 months.

Febrile seizures §Affect 3% of children; have a genetic predisposition §Occur between 6 months and 6 years of age §Are usually brief, generalised tonic-clonic seizures occurring with a rapid rise in fever § If a bacterial infection, especially meningitis, is present, it needs to be identified and treated §Advise family about management of seizures, consider rescue therapy § If simple – does not affect intellectual performance or risk of developing epilepsy §If complex, 4– 12% risk of subsequent epilepsy

Examanition §For the vast majority of children, the etiology appears to be viral or no identifiable cause. §Reactions to immunizations are not uncommon with DPT vaccine-related seizures generally occurs within 24 hours and MMR reactions 7 to 10 days postimmunization. §The indications for lumbar puncture have been modified and should be done if a CNS infection is suspected, and is an option in children 6 to 12 months of age who are deficient in their immunizations or have been pretreated with antibiotics as this may mask signs and symptoms of meningitis. §In contrast to afebrile seizures, an EEG is not recommended. § Although focal seizures are indications for neuroimaging in an unprovoked seizure, complex febrile seizures with focality do not appear to have a significant risk of intracranial pathology. Therefore, neuroimaging should not be obtained routinely for either simple or complex febrile seizures.

The treatment of febrile seizures § The treatment of febrile seizures is generally supportive. § If the patient`s seizure duration persists beyond 5 minutes treatment with benzodiazipines should be initiated. § Otherwise, antipyretics and comfort measures should be administrated if not already initiated. § If a bacterial source is identified, appropriate antibiotic therapy should be initiated. § Unfortunately, antipyretic agents do not appear to reliably prevent recurrences of febrile seizures.

GENRAL PRINCIPLES OF MANAGEMENT OF THE PATIENT WITН AN ACUTE SEIZURE Most patients who present for evaluation of an acute seizure are no longer seizing on arrival in the emergency department. Initial evaluation consists of §a brief and directed history and physical examination. § a determination as to whether the patient has had a seizure is made. §if the seizure is ongoing, our primary objectives are supporting airway, breathing, circulation (ABCs), and cessation of any seizure activity.

The seriously ill child The rapid clinical assessment of the seriously ill child will identify if there is potential respiratory, circulatory or neurological failure. This should take less than 1 minute. Regarding the seriously ill child • Prevention of cardiopulmonary arrest is by early recognition and treatment of respiratory distress, respiratory or circulatory failure.

Assessment of the seriously ill child The rapid clinical assessment: ABCDE Should take < 1 min Airway and Breathing Look, listen and feel for: Airway obstruction or respiratory distress Work of breathing (respiratory effort) Respiratory rate Stridor, wheeze Auscultation for air entry Cyanosis Circulation Feel and assess: Heart rate Pulse volume Capillary refill time Blood pressure Disability Observe and note: Level of consciousness Posture – hypotonia, decorticate, decerebrate Pupil size and reactivity Exposure Resuscitation (if necessary) Includes Basic/Advanced life support Consider: Jaw and neck positioning Oxygen Suction and foreign body removal Supporting breathing Chest compression Monitoring pulse oximetry and heart rate Secondary assessment History from: • parents • witnesses • general practitioner • paramedical staff • police Examination including: • evidence of trauma • rash, e. g. meningococcal • smell, e. g. ketones, alcohol • scars, e. g. underlying congenital heart disease • Medic. Alert bracelet Investigations • blood glucose Other emergency interventions

Presentation and causes of serious illness in children Presentation Shock Respiratory distress Cause Hypovolaemia Maldistribution of fluid Cardiogenic Upper airway obstruction (stridor) Lower airway disorders Examples Dehydration – gastroenteritis; Diabetic ketoacidosis ; Blood loss – trauma Septicaemia ; Anaphylaxis Arrhythmias ; Heart failure Croup/epiglottitis; Foreign body Congenital malformations; Trauma Asthma; Bronchiolitis; Pneumonia; Pneumothorax;

The drowsy or unconscious or seizing child Post-ictal Status epilepticus Infection Metabolic Head injury Drug/poison ingestion Intracranial haemorrhage Meningitis/encephalitis Diabetic ketoacidosis, hypoglycaemia, electrolyte disturbances (calcium, magnesium, sodium), inborn error of metabolism Trauma/non-accidental injury Appendicitis Peritonitis Surgical emergencies Acute abdomen Intestinal obstruction Intussusception Malrotation Bowel atresia/stenosis

Basic life support Check responsiveness: Ask 'Are you all right? ' Stimulate gently Do not shake infants or suspected cervical spine injury No response Open airway: • Head tilt, chin lift • Jaw thrust (if unsuccessful) No breathing Check breathing for max 10 s: • Look – for chest movement • Listen – for breath sounds • Feel – for air movement Breathe Remove any obvious obstruction Give 5 initial rescue breaths Assess ‘signs of life’ - movements, coughing, normal breathing Check pulse for max 10 s: >1 year old – carotid, femoral No ‘signs of life’ (unless definite pulse >60/min) Compress chest 15 chest compressions: 2 breaths Rate 100– 120 compressions/min Compression: ventilation ratio for all children: two rescuers (or lone trained resuscitator) – 15: 2 lone rescuer (not trained) – 30: 2