Emergency Management
<![if !supportLists]>· <![endif]>Stephanie Chin-Sang MD
Harriet Lane Handbook, The, Chapter 1, 3-18
Open reading mode
When approaching a patient in cardiopulmonary arrest, one must first and foremost focus on the A, B, C, D, and Es. The history, physical exam, and laboratory studies should closely follow a rapid primary assessment. NOTE: The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care updates the 2005 guidelines by recommending that immediate chest compressions should be the first step in reviving victims of sudden cardiac arrest, so the new acronym C-A-B has come into use and is presented in this section. The original A-B-C pathway remains the accepted method for rapid assessment and management of any critically ill patient. 1
See the 2010 AHA CPR guidelines .
I
Initial Assessment: C-A-B
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Assess pulse: If infant/child is unresponsive and not breathing (gasps do not count as breathing), health care providers may take up to 10 seconds to feel for pulse (brachial in infant, carotid/femoral in child). 2
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If pulseless, immediately begin chest compressions (see Circulation, B.1 ).
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If pulse, begin A-B-C pathway of evaluation.
II
Airway 3456
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Assessment
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Assess airway patency; think about obstruction: Head tilt/chin lift (or jaw thrust if injury suspected) to open airway.
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Assess for spontaneous respiration: If no spontaneous respirations, begin ventilating via rescue breaths, bag-mask, or endotracheal tube.
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Assess adequacy of respirations:
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Look for chest rise.
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Recognize signs of distress (stridor, tachypnea, flaring, retractions, accessory muscle use, wheezes).
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Management 3456789101112
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Equipment
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Bag-mask ventilation with cricoid pressure may be used indefinitely if ventilating effectively (look at chest rise).
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Use oral or nasopharyngeal airway in patients with obstruction:
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Oral: Unconscious patients—measure from corner of mouth to mandibular angle.
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Nasal: Conscious patients—measure tip of nose to tragus of ear.
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Laryngeal mask airway (LMA): Simple way to secure an airway (no laryngoscopy needed), especially in difficult airways; does not prevent aspiration.
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Intubation: Indicated for (impending) respiratory failure, obstruction, airway protection, pharmacotherapy, or need for likely prolonged support
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Equipment (see page i): SOAP ( S uction, O xygen, A irway Supplies, P harmacology)
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Laryngoscope blade:
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Miller (straight blade):
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#00-1 for premature to 2 months
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#1 for 3 months to 3 years
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#2 for > 3 years
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Macintosh (curved blade):
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#2 for > 2 years
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#3 for > 8 years
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Endotracheal tube (ETT):
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Size determination: Internal diameter of ETT (mm) = (Age/4) + 4, or use length-based resuscitation tape to estimate.
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Approximate depth of insertion in cm = ETT size × 3.
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Uncuffed ETT for patients <8 years of age (note: cuffed tube can be used in children <8 y/o—see AHA guidelines for sizing recommendations).
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Stylet should not extend beyond the distal end of the ETT.
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Attach end-tidal CO 2 monitor as confirmation of placement and effectiveness of chest compressions if applicable.
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Nasogastric tube (NGT): To decompress the stomach; measure from nose to angle of jaw to xiphoid for depth of insertion.
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Rapid sequence intubation (RSI) recommended for aspiration risk:
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Preoxygenate with non-rebreather at 100% O 2 for minimum of 3 minutes:
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Do not use positive-pressure ventilation (PPV) unless patient effort is inadequate.
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Children have less oxygen/respiratory reserve than adults, owing to higher oxygen consumption and lower functional residual capacity.
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See Fig. 1-1 and Table 1-1 for drugs used for RSI (adjunct, sedative, paralytic). Important considerations in choosing appropriate agents include clinical scenario, allergies, presence of neuromuscular disease, anatomic abnormalities, or hemodynamic status.
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FIGURE 1-1
A, Treatment algorithm for intubation. B, Sedation options.
(Modified from Nichols DG, Yaster M, Lappe DG, et al [eds]. Golden Hour: The Handbook of Advanced Pediatric Life Support. St Louis: Mosby; 1996:29.)
TABLE 1-1
RAPID-SEQUENCE INTUBATION MEDICATIONS
Drug
|
Dose
|
Comments
|
ADJUNCTS (FIRST)
| ||
Atropine (vagolytic)
|
0.01–0.02 mg/kg IV/IO
Adult dose: 0.5-1.0 mg; max: 3 mg |
+ Vagolytic; prevents bradycardia, especially with succinylcholine, and reduces oral secretions
− Tachycardia, pupil dilation eliminates ability to examine pupillary reflexes Less than 0.1 mg may case paradoxical bradycardia Indication: Can be used as premedication in all circumstances |
Lidocaine (optional anesthetic)
|
1 mg/kg IV/IO; max 100 mg/dose
|
+ Blunts ICP spike, decreased gag/cough; controls ventricular arrhythmias
Indication: Good premedication for shock, arrhythmia, elevated ICP, and status asthmaticus |
SEDATIVE-HYPNOTIC (SECOND)
| ||
Thiopental (barbiturate)
|
3–5 mg/kg IV/IO if normotensive
1–2 mg/kg IV/IO if hypotensive |
+ Decreases O 2 consumption and cerebral blood flow
− Vasodilation and myocardial depression; may increase oral secretions, cause bronchospasm/laryngospasm (not to be used in asthma) Indication: Drug of choice for increased ICP |
Ketamine (NMDA receptor antagonist)
|
1–2 mg/kg IV/IO or
4–10 mg/kg IM |
+ Bronchodilation; catecholamine release may benefit hemodynamically unstable patients
− May increase BP, HR, and oral secretions; may cause laryngospasm; contraindicated in eye injuries; likely insignificant rise in ICP Indication: Drug of choice for asthma |
Midazolam (benzodiazepine)
|
0.05–0.1 mg/kg IV/IO
Max total dose of 10 mg |
+ Amnestic and anticonvulsant properties
− Respiratory depression/apnea, hypotension, and myocardial depression Indication: Mild shock |
Fentanyl / Duragesic (opiate)
|
1–5 mcg/kg IV/IO
NOTE:Fentanyl is dosed in mcg/kg, not mg/kg. |
+ Fewest hemodynamic effects of all opiates
− Chest wall rigidity with high dose or rapid administration; cannot use with MAOIs Indication: Shock |
Etomidate /Amidate (imidazole/hypnotic)
|
0.3 mg/kg IV/IO
|
+ Cardiovascular neutral; decreases ICP
− Exacerbates adrenal insufficiency (inhibits 11-beta hydroxylase) Indication: Patients with severe shock, especially cardiac patients |
Propofol / Diprivan (sedative-hypnotic)
|
2 mg/kg IV/IO
|
+ Extremely quick onset and short duration; blood pressure lowering; good antiemetic
− Hypotension and profound myocardial depression; contraindicated in patients with egg allergy Indication: Induction agent for general anesthesia |
PARALYTICS (NEUROMUSCULAR BLOCKERS) (THIRD)
| ||
Succinylcholine / Anectine (depolarizing)
|
1–2 mg/kg IV/IO
2–4 mg/kg IM |
+ Quick onset (30–60 sec), short duration (3–6 min) make it an ideal paralytic
− Irreversible; bradycardia in <5 years old or with rapid doses; increased risk of malignant hyperthermia; contraindicated in burns, massive trauma/muscle injury, neuromuscular disease, myopathies, eye injuries, renal insufficiency |
Vecuronium/vecuron (non-depolarizing)
|
0.1 mg/kg IV/IO
|
+ Onset 70–120 sec; cardiovascular neutral
− Duration 30–90 min; must wait 30–45 min to reverse with glycopyrrolate and neostigmine Indication: When succinylcholine contraindicated or when longer-term paralysis desired |
Rocuronium/Zemuron (non-depolarizing)
|
0.6–1.2 mg/kg IV/IO
1.8 mg/kg IM |
+ Quicker onset (30–60 sec), shorter acting than vecuronium; cardiovascular neutral
− Duration 30–60 min; may reverse in 30 min with gylcopyrrolate and neostigmine |
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+, Potential advantages; −, potential disadvantages or cautions; BP, blood pressure; HR, heart rate; ICP, intracranial pressure; MAOI, monoamine oxidase inhibitor.
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For patients who are difficult to mask ventilate or have difficult airways, may consider sedation without paralysis and the assistance of subspecialists (anesthesiology and otolaryngology).
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Procedure (attempts should not exceed 30 seconds):
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Preoxygenate with 100% O 2 .
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Apply cricoid pressure to prevent aspiration (Sellick maneuver) during bag-valve-mask ventilation and intubation. (Note: Use of cricoid pressure is optional; no benefit has been demonstrated.)
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Use scissoring technique to open mouth.
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Hold laryngoscope blade in left hand. Insert blade into right side of mouth, sweeping tongue to the left out of line of vision.
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Advance blade to epiglottis. With straight blade, lift up, directly lifting the epiglottis to view cords. With curved blade, place tip in vallecula, elevate the epiglottis to visualize the vocal cords.
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If possible, have another person hand over the tube, maintaining direct visualization, and pass through cords until black marker reaches the level of the cords.
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Hold endotracheal tube firmly against the lip until tube is securely taped.
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Verify ETT placement: observe chest wall movement, auscultation in both axillae and epigastrium, end-tidal CO 2 detection (there will be a false-negative response if there is no effective pulmonary circulation), improvement in oxygen saturation, chest radiograph, and repeat direct laryngoscopy to visualize ETT.
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If available, in-line continuous CO 2 detection should be used.
III
Breathing 341314
<![if !supportLists]>· <![endif]>A.
Assessment
Once airway is secured, continually reevaluate ETT positioning (listen for breath sounds). Acute respiratory failure may signify D is placement of the ETT, Obstruction, Pneumothorax, or Equipment failure (DOPE).
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Management
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Mouth-to-mouth or mouth-to-nose breathing: provide two slow breaths (1 sec/breath) initially. For newborns, apply one breath for every three chest compressions. In infants and children, apply two breaths after 30 compressions (one rescuer) or two breaths after 15 compressions (two rescuers). Breaths should have adequate volume to cause chest rise.
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Bag-mask ventilation is used at a rate of 20 breaths/min (30 breaths/min in infants) using the E-C technique:
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Use non-dominant hand to create a C with thumb and index finger over top of mask. Ensure a good seal, but do not push down on mask. Hook remaining fingers around the mandible ( notthe soft tissues of the neck!), with the fifth finger on the angle creating an E, and lift the mandible up toward the mask.
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Assess chest expansion and breath sounds.
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Decompress stomach with or gastric or nasogastric tube with prolonged bag-mask ventilation.
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Endotracheal intubation: See prior section.
IV
Circulation 34513
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Assessment
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Rate/rhythm: Assess for bradycardia, tachycardia, abnormal rhythm, or asystole. Generally, bradycardia requiring chest compressions is <60 beats/min; tachycardia of >220 beats/min suggests tachyarrhythmia rather than sinus tachycardia.
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Perfusion:
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Assess pulses, capillary refill (<2 sec = normal, 2 to 5 sec = delayed, >5 sec suggests shock), mentation, and urine output (if Foley in place).
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If one cannot identify a pulse within 10 seconds, initiate cardiopulmonary resuscitation (CPR).
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Blood pressure (BP): Hypotension is a late manifestation of circulatory compromise. Can be calculated in children >1 year with
formula: Hypotension=Systolic BP<[70+(2×Age in years)]formula: Hypotension=Systolic BP<[70+(2×Age in years)]
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Chest compressions
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Press hard (⅓ to ½ anteroposterior [AP] diameter of chest) and fast (100-120 per minute) on backboard base with full recoil and minimal interruption.
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Use end-tidal CO 2 to estimate effectiveness (<20 mmHg indicates inadequate compressions).
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Use two-finger technique for infant if single rescuer available; otherwise, two thumbs with hands encircling chest is preferable.
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Use of automated external defibrillator (AED): To determine whether rhythm is shockable, use an AED/defibrillator.
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Resuscitation with poor perfusion and shock:
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Optimize oxygen delivery with supplemental O 2 .
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Support respirations to reduce work of patient.
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Place intraosseous (IO) access immediately if in arrest and/or if intravenous (IV) access not obtained within 90 seconds.
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Resuscitation fluids are lactated Ringer's or normal saline.
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Give up to three 20-mL/kg boluses each within 5 minutes for a total of 60 mL/kg in the first 15 minutes after presentation, checking for hepatomegaly after each bolus.
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5- to 10-mL/kg bolus in patient with cardiac insufficiency.
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Consider colloid such as albumin, plasma, packed red blood cells (PRBCs) if poor response to crystalloids.
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Identify type of shock: Hypovolemia, cardiogenic (congenital heart disease, myocarditis, cardiomyopathy, arrhythmia), distributive (sepsis, anaphylaxis, neurogenic), obstructive (pulmonary embolus [PE], cardiac tamponade, tension pneumothorax).
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Pharmacotherapy (See inside front cover and consider stress-dose corticosteroids and/or antibiotics if applicable.)
TABLE 1-2
MANAGEMENT OF CIRCULATION
Location ∗
|
Rate (per min)
|
Compressions: Ventilation
| |
Infants
|
1 fingerbreadth below intermammary line
|
>100
|
15:2 (2 rescuers)
30:2 (1 rescuer) |
Pre-pubertal children
|
2 fingerbreadths below intermammary line
|
≥100
|
15:2 (2 rescuers)
30:2 (1 rescuer) |
Adolescents/adults
|
Lower half of sternum
|
100
|
30:2 (1 or 2 rescuers)
|
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∗ Depth of compressions should be one third to one half anteroposterior diameter of the chest.
V
Allergic emergencies (anaphylaxis) 1617
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Definition
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A rapid-onset immunoglobulin (Ig) E–mediated systemic allergic reaction involving multiple organ systems, including two or more of the following:
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Cutaneous/mucosal (flushing, urticaria, pruritus, angioedema); seen in 90%
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Respiratory (laryngeal edema, bronchospasm, dyspnea, wheezing, stridor, hypoxemia); seen in ≈70%
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Gastrointestinal (GI) (vomiting, diarrhea, nausea, crampy abdominal pain); seen in ≈ -40% to 50%
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Circulatory (tachycardia, hypotension, syncope); seen in ≈ -30% to 40%
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Initial reaction may be delayed for several hours AND symptoms may recur up to 72 hours after initial recovery. Patients should therefore be observed for a minimum of 6 to 24 hours for late-phase symptoms.
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Initial Management
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Remove/stop exposure to precipitating antigen.
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Epinephrine = mainstay of therapy. While performing ABCs, immediately give intramuscular (IM) epinephrine, 0.01 mg/kg (0.01 mL/kg) of 1:1000 subcutaneously (SQ) or IM (maximum dose 0.5 mg). Repeat every 5 minutes as needed. Site of choice is lateral aspect of the thigh, owing to its vascularity.
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Establish airway and give O 2 and PPV as needed.
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Obtain IV access, Trendelenburg position with head 30 degrees below feet, administer fluid boluses followed by pressors as needed.
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Histamine-1 receptor antagonist such as diphenhydramine, 1 to 2 mg/kg via IM, IV, or oral (PO) route (maximum dose, 50 mg). Also consider a histamine-2 receptor antagonist (e.g., ranitidine).
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Corticosteroids help prevent the late phase of the allergic response. Administer methylprednisolone in a 2-mg/kg IV bolus, followed by 2 mg/kg/day IV or IM, divided every 6 hours, or prednisone, 2 mg/kg PO once daily.
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Albuterol 2.5 mg for <30 kg, 5 mg for >30 kg, for bronchospasm or wheezing. Repeat every 15 minutes as needed.
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Racemic epinephrine 0.5 mL of 2.25% solution inhaled for signs of upper airway obstruction
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Patient should be discharged with an Epi-Pen (>30 kg), Epi-Pen Junior (<30 kg), or comparable injectable epinephrine product with specific instructions on appropriate use, as well as an anaphylaxis action plan.
VI
Respiratory emergencies 18
The hallmark of upper airway obstruction is stridor, whereas lower airway obstruction is characterized by cough, wheeze, and a prolonged expiratory phase.
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Asthma 1920
Lower airway obstruction resulting from triad of inflammation, bronchospasm, and increased secretions:
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Assessment: Respiratory rate (RR), work of breathing, O 2 saturation, heart rate (HR), peak expiratory flow, alertness, color
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Initial management:
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Give O 2 to keep saturation >95%.
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Administer inhaled β-agonists: Nebulized albuterol as often as needed.
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Ipratropium bromide
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Steroids: Methylprednisolone, 2 mg/kg IV/IM bolus, then 2 mg/kg/day divided every 6 hours; or prednisone/prednisolone, 2 mg/kg PO every 24 hours; requires minimum of 3 to 4 hours to take effect.
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If air movement is still poor despite maximizing above therapy:
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Epinephrine: 0.01 mg/kg (0.01 mL/kg) of 1:1000 subcutaneously (SQ) or IM (maximum dose 0.5 mg)
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Bronchodilator, vasopressor, and inotropic effects
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Short-acting (~15 min) and should be used as temporizing rather than definitive therapy
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Magnesium sulfate: 25 to 75 mg/kg/dose IV or IM (maximum 2 g) infused over 20 minutes.
<![if !supportLists]>§ <![endif]>(a)
Smooth muscle relaxant; relieves bronchospasm.
<![if !supportLists]>§ <![endif]>(b)
Many clinicians advise giving a saline bolus prior to administration, because hypotension may result.
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Contraindicated if patient already has significant hypotension or renal insufficiency.
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Terbutaline: 0.01 mg/kg SQ (maximum dose 0.4 mg) every 15 minutes up to three doses.
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Systemic β 2 -agonist limited by cardiac intolerance.
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Monitor continuous 12-lead electrocardiogram (ECG), cardiac enzymes, urinalysis (UA), and electrolytes.
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Further management: If incomplete or poor response, consider obtaining an arterial blood gas value.
NOTE: A normalizing P co 2 is often a sign of impending respiratory failure.
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Maximize and continue initial treatments.
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Terbutaline 2 to 10 mcg/kg IV load, followed by continuous infusion of 0.1 to 4 mcg/kg/min titrated to effect in increments of 0.1 to 0.2 mcg/kg/min every 30 minutes depending on clinical response. Infusion should be started with lowest possible dose; doses as high as 10 mcg/kg/min have been used. Use appropriate cardiac monitoring in intensive care unit (ICU), as above.
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A helium (≥70%) and oxygen mixture may be of some benefit in the critically ill patient but is more useful in upper airway edema. Avoid use in the hypoxic patient.
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Methylxanthines (e.g., aminophylline) may be considered in the ICU setting but have significant side effects and have not been shown to affect intubation rates or length of hospital stay.
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Noninvasive positive-pressure ventilation (e.g., BiPAP) may be used in patients with impending respiratory failure, both as a temporizing measure and to avoid intubation, but requires a cooperative patient with spontaneous respirations.
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Intubation of those with acute asthma is dangerous and should be reserved for impending respiratory arrest.
<![if !supportLists]>§ <![endif]>a.
Indications for endotracheal intubation include deteriorating mental status, severe hypoxemia, and respiratory or cardiac arrest.
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Consider using an inhaled anesthetic such as isoflurane.
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Hypotension: Result of air trapping, hyperinflation, and therefore decreased pulmonary venous return. See Section [CR] for management. Definitive treatment is reducing lower airway obstruction.
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Upper Airway Obstruction 21222324
Upper airway obstruction is most commonly caused by foreign-body aspiration or infection.
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Epiglottitis: Most often affects children between 2 and 7 years, but may occur at any age. This is a true emergency involving cellulitis and edema of the epiglottis, aryepiglottic folds, and hypopharynx.
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Patient is usually febrile, anxious, and toxic appearing, with sore throat, drooling, respiratory distress, stridor, tachypnea, and tripod positioning (sitting forward supported by both arms, with neck extended and chin thrust out). Any agitation of the child may cause complete obstruction, so avoid invasive procedures/evaluation until airway is secured.
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Unobtrusively give O 2 (blow-by). Nothing by mouth, monitor with pulse oximetry, allow parent to hold patient.
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Summon epiglottitis team (most senior pediatrician, anesthesiologist, intensive care physician, and otolaryngologist in hospital).
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Management options:
<![if !supportLists]>§ <![endif]>(1)
If unstable (unresponsive, cyanotic, bradycardic) → emergently intubate.
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If stable with high suspicion → take patient to operating room for laryngoscopy and intubation under general anesthesia.
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If stable with moderate or low suspicion → obtain lateral neck radiographs to confirm.
<![if !supportLists]>§ <![endif]>e.
After airway is secure, obtain cultures of blood and epiglottic surface. Begin antibiotics to cover Haemophilus influenzae type B, Streptococcus pneumoniae, group A streptococci, Staphylococcus aureus .
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Epiglottitis may also be caused by thermal injury, caustic ingestion, or foreign body.
<![if !supportLists]>o <![endif]>2.
Croup (laryngotracheobronchitis): Most common in infants 6 to 36 months. Croup is a common syndrome involving inflammation of the subglottic area; presents with fever, barking cough, and stridor. Patients rarely appear toxic, as in epiglottitis.
<![if !supportLists]>§ <![endif]>a.
Mild (no stridor at rest): Treat with minimal disturbance, cool mist, hydration, antipyretics, and consider steroids.
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Moderate to severe:
<![if !supportLists]>§ <![endif]>(1)
The efficacy of mist therapy is not established.
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Racemic epinephrine. After administering, observe for a minimum of 2 to 4 hours, owing to potential for rebound obstruction. Hospitalize if more than one nebulization required.
<![if !supportLists]>§ <![endif]>(3)
Dexamethasone, 0.3 to 0.6 mg/kg IV, IM, or PO once. Effect lasts 2 to 3 days. Alternatively, nebulized budesonide (2 mg) may be used, though little data exist to support its use, and some studies find it inferior to dexamethasone.
<![if !supportLists]>§ <![endif]>(4)
A helium-oxygen mixture may decrease resistance to turbulent gas flow through a narrowed airway.
<![if !supportLists]>§ <![endif]>c.
If a child fails to respond as expected to therapy, consider other etiologies (e.g., retropharyngeal abscess, bacterial tracheitis, subglottic stenosis, epiglottitis, foreign body). Obtain airway radiography, computed tomography (CT), and evaluation by otolaryngology or anesthesiology.
<![if !supportLists]>o <![endif]>3.
Foreign-body aspiration: Occurs most often in children 6 months to 3 years old. It frequently involves hot dogs, candy, peanuts, grapes, or balloons. Most events unwitnessed, so suspect this in children with sudden-onset choking, stridor, or wheezing.
<![if !supportLists]>§ <![endif]>a.
If the patient is stable (i.e., forcefully coughing, well oxygenated), removal of the foreign body by bronchoscopy or laryngoscopy should be attempted in a controlled environment.
<![if !supportLists]>§ <![endif]>b.
If the patient is unable to speak, moves air poorly, or is cyanotic:
<![if !supportLists]>§ <![endif]>(1)
Infant: Place infant over arm or rest on lap. Give five back blows between the scapulae. If unsuccessful, turn infant over and give five chest thrusts ( not abdominal thrusts).
<![if !supportLists]>§ <![endif]>(2)
Child: Perform five abdominal thrusts (Heimlich maneuver) from behind a sitting or standing child.
<![if !supportLists]>§ <![endif]>(3)
After back, chest, and/or abdominal thrusts, open mouth using tongue-jaw lift and remove foreign body if visualized. Do not attempt blind finger sweeps. Magill forceps may be used to retrieve objects in the posterior pharynx. Ventilate if unconscious, and repeat sequence as needed.
<![if !supportLists]>§ <![endif]>(4)
If there is complete airway obstruction and the patient cannot be ventilated by bag-valve mask or ETT, consider percutaneous (needle) cricothyrotomy ( Fig. 1-2 ). 4
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FIGURE 1-2
Percutaneous (needle) cricothyrotomy. Extend neck, attach a 3-mL syringe to a 14- to 18-gauge intravenous catheter, and introduce catheter through cricothyroid membrane (inferior to thyroid cartilage, superior to cricoid cartilage). Aspirate air to confirm position. Remove syringe and needle, attach catheter to an adaptor from a 3.0-mm endotracheal tube, which can then be used for positive-pressure oxygenation.
(Modified from Dieckmann RA, Fiser DH, Selbst SM. Illustrated Textbook of Pediatric Emergency and Critical Care Procedures. St Louis: Mosby, 1997:118. )
VII
Neurologic emergencies
<![if !supportLists]>· <![endif]>A.
Altered States of Consciousness 25
<![if !supportLists]>o <![endif]>1.
Assessment: Range of mental status includes alert, confused, disoriented, delirious, lethargic, stuporous, and comatose.
<![if !supportLists]>§ <![endif]>a.
History: Consider structural versus medical causes ( Box 1-1 ). Obtain history of trauma, ingestion, infection, fasting, drug use, diabetes, seizure, or other neurologic disorder.
BOX 1-1
I
Structural Causes
<![if !supportLists]>§ <![endif]>Vascular—e.g., cerebrovascular accident, cerebral vein thrombosis
<![if !supportLists]>§ <![endif]>Increased intracranial pressure—e.g., hydrocephalus, tumor, abscess, cyst, subdural empyema, pseudotumor cerebri
<![if !supportLists]>§ <![endif]>Trauma (intracranial hemorrhage, diffuse cerebral swelling, shaken baby syndrome)
II
Medical Causes
<![if !supportLists]>§ <![endif]>Anoxia
<![if !supportLists]>§ <![endif]>Hypothermia/hyperthermia
<![if !supportLists]>§ <![endif]>Metabolic—e.g., inborn errors of metabolism, diabetic ketoacidosis, hyperammonemia, uremia, hypoglycemia, electrolyte abnormality
<![if !supportLists]>§ <![endif]>Infection—e.g., sepsis, meningitis, encephalitis, subdural empyema
<![if !supportLists]>§ <![endif]>Seizure/postictal state
<![if !supportLists]>§ <![endif]>Toxins/ingestions
<![if !supportLists]>§ <![endif]>Psychiatric/psychogenic
DIFFERENTIAL DIAGNOSIS OF ALTERED LEVEL OF CONSCIOUSNESS
Modified from Avner J. Altered states of consciousness. Pediatr Rev . 2006;27:331-337.
<![if !supportLists]>§ <![endif]>b.
Examination: Assess HR, BP, respiratory pattern, Glasgow Coma Scale ( Table 1-3 ), temperature, pupillary response, funduscopy (a late finding, absence of papilledema does not rule out increased intracranial pressure [ICP]), rash, abnormal posturing, and focal neurologic signs.
TABLE 1-3
COMA SCALES
Glasgow Coma Scale
|
Modified Coma Scale for Infants
| ||
Activity
|
Best Response
|
Activity
|
Best Response
|
EYE OPENING
| |||
Spontaneous
|
4
|
Spontaneous
|
4
|
To speech
|
3
|
To speech
|
3
|
To pain
|
2
|
To pain
|
2
|
None
|
1
|
None
|
1
|
VERBAL
| |||
Oriented
|
5
|
Coo/babbles
|
5
|
Confused
|
4
|
Irritable
|
4
|
Inappropriate words
|
3
|
Cries to pain
|
3
|
Nonspecific sounds
|
2
|
Moans to pain
|
2
|
None
|
1
|
None
|
1
|
MOTOR
| |||
Follows commands
|
6
|
Normal spontaneous movements
|
6
|
Localizes pain
|
5
|
Withdraws to touch
|
5
|
Withdraws to pain
|
4
|
Withdraws to pain
|
4
|
Abnormal flexion
|
3
|
Abnormal flexion
|
3
|
Abnormal extension
|
2
|
Abnormal extension
|
2
|
None
|
1
|
None
|
1
|
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Data from Jennet B, Teasdale G. Aspects of coma after severe head injury. Lancet . 1977;1:878; and James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann . 1986;15:16.
<![if !supportLists]>o <![endif]>2.
Acute traumatic head injury: 26
<![if !supportLists]>§ <![endif]>a.
Assess pupillary response:
<![if !supportLists]>§ <![endif]>(1)
Blown pupil: Elevate head of bed, hyperventilate, maintain blood pressure, administer hypertonic saline and/or mannitol.
<![if !supportLists]>o <![endif]>3.
Management of coma:
<![if !supportLists]>§ <![endif]>a.
A irway (with cervical spine immobilization), B reathing, C irculation, D -stick, O xygen, Naloxone, T hiamine (ABC DON'T)
<![if !supportLists]>§ <![endif]>(1)
Naloxone, 0.1 mg/kg IV, IM, SQ, or ETT (maximum dose, 2 mg). Repeat as necessary, given short half-life (in case of opiate intoxication).
<![if !supportLists]>§ <![endif]>(2)
Thiamine, 100 mg IV (before starting glucose in adolescents, in case of alcoholism or eating disorder).
<![if !supportLists]>§ <![endif]>(3)
D 25 W, 2 to 4 mL/kg IV bolus if hypoglycemia is present.
<![if !supportLists]>§ <![endif]>b.
Laboratory tests: Consider complete blood cell count (CBC), electrolytes, liver function tests, NH 3 , lactate, toxicology screen (serum and urine; always include salicylate and acetaminophen levels), blood gas, serum osmolality, prothrombin time (PT)/partial thromboplastin time (PTT), and blood/urine culture. If patient is an infant or toddler, consider assessment of plasma amino acids, urine organic acids, and other appropriate metabolic workup.
<![if !supportLists]>§ <![endif]>c.
If meningitis or encephalitis is suspected, consider lumbar puncture (LP) and start antibiotics and acyclovir.
<![if !supportLists]>§ <![endif]>d.
Request emergency head CT after ABCs are stabilized; consider neurosurgical consultation and electroencephalogram (EEG) if indicated.
<![if !supportLists]>§ <![endif]>e.
If ingestion is suspected, airway must be protected before GI decontamination (see Chapter 2 ).
<![if !supportLists]>§ <![endif]>f.
Monitor Glasgow Coma Scale and reassess frequently (see Table 1-3 ).
<![if !supportLists]>· <![endif]>B.
Status Epilepticus 2728
See Chapter 20 for non-acute evaluation and management of seizures.
<![if !supportLists]>o <![endif]>1.
Assessment: Common causes of childhood seizures include electrolyte abnormalities, hypoglycemia, fever, subtherapeutic anticonvulsant levels, central nervous system (CNS) infections, trauma, toxic ingestion, and metabolic abnormalities. Consider specific patient history, such as shunt malfunction in patient with ventriculoperitoneal shunt. Less common causes include vascular, neoplastic, and endocrine diseases.
<![if !supportLists]>o <![endif]>2.
Acute management of seizures ( Table 1-4 ): If CNS infection is suspected, give antibiotics and/or acyclovir early.
TABLE 1-4
ACUTE MANAGEMENT OF SEIZURES
Time (min)
|
Intervention
|
0–5
|
Stabilize patient.
Assess airway, breathing, circulation, and vital signs. Administer oxygen. Obtain IV or IO access. Consider hypoglycemia, thiamine deficiency, intoxication (dextrose, thiamine, naloxone may be given immediately if suspected). Obtain laboratory studies: consider glucose, electrolytes, calcium, magnesium, blood gas, CBC, BUN, creatinine, LFTs, toxicology screen, anticonvulsant levels, blood culture (if infection is suspected). Initial screening history and physical examination |
5–15
|
Begin pharmacotherapy:
Lorazepam (Ativan), 0.05–0.1 mg/kg IV/IM, max dose 2 mg Or Diazepam (Valium), 0.2–0.5 mg/kg IV (0.5 mg/kg rectally); max dose <5 y/o: 5 mg, >5 y/o: 10 mg May repeat lorazepam or diazepam 5–10 min after initial dose |
15–25
|
If seizure persists, load with one of the following:
<![if !supportLists]>§ <![endif]>1.
Fosphenytoin ∗ 15–20 mg PE/kg IV/IM at 3 mg PE/kg/min via peripheral IV line (maximum 150 mg PE/min). If given IM, may require mulitple dosing sites.
<![if !supportLists]>§ <![endif]>2.
Phenytoin † 15–20 mg/kg IV at rate not to exceed 1 mg/kg/min via central line
<![if !supportLists]>§ <![endif]>3.
Phenobarbital 15–20 mg/kg IV at rate not to exceed 1 mg/kg/min
|
25–40
|
If seizure persists:
Levetiracetam 20–30 mg/kg IV at 5 mg/kg/min; or valproate 20 mg/kg IV at 5 mg/kg/min May give phenobarbital at this time if still seizing at 5 minutes and (fos) phenytoin previously used Additional phenytoin or fosphenytoin 5 mg/kg over 12 hr for goal serum level of 10 mg/L Additional phenobarbital 5 mg/kg/dose every 15–30 min (maximum total dose of 30 mg/kg; be prepared to support respirations) |
40–60
|
If seizure persists, ‡ consider pentobarbital, midazolam, or general anesthesia in intensive care unit. Avoid paralytics.
|
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BUN, Blood urea nitrogen; CBC, complete blood cell count; CT, computed tomography; EEG, electroencephalogram; LFTs, liver function tests; IM, intramuscular; IO, intraosseus; IV, intravenous.
Modified from Abend, NS, Dlugos, DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol . 2008;38:377.
∗ Fosphenytoin dosed as phenytoin equivalent (PE).
† Phenytoin may be contraindicated for seizures secondary to alcohol withdrawal or most ingestions (see Chapter 2 ).
‡ Pyridoxine 100 mg IV in infant with persistent initial seizure.
<![if !supportLists]>o <![endif]>3.
Diagnostic workup: When stable, workup may include CT or magnetic resonance imaging, EEG, and LP
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