47 -_ Pediatric _ emergency .pptx

Pediatric emergency

1. Pediatric emergencies

2. 1-status epilepiticus 2-status asthmaticus 3-shock child 4-hypoglycemia 5-DKA

3. Case no1 3 years old boy known case of epilepsy presented to the ER with 1 day history of fever and repeated convulsions 3 times since the morning , while they presenting him he was still convulsing for the last 30 minutes. 1-What is your immediate action? 2-What is the definition of status epilepticus? 3- what are the possible causes of his convulsions? 4- what investigations will you request? 5-what are complication of status epilepticus ?

4. Answers 1 1- start with ABC: Airway ( left lateral position) breathing (assess and give oxygen) circulation ( secure two iv line) DEFG ( don’t ever forget glucose) 2- CALL your senior

5. Answer 2 Seizures that persist without interruption for more than 5 minutes Two or more sequential seizures without full recovery of consciousness between seizures

6. Answer 3 febrile illness precipitate fits Missed dose of anti epileptic drug Watch TV or video games for long times Sleep deprivation Flashing lights Hypoglycemia Hypocalcemia , hypomagnesemia,hypo or hypernatrmia Meningitis, encephalitis, cerebral malaria

7. Answer 4 Fall septic screen: CBC, CRP, UG, blood culture,urine culture, depend on history Serum Electrolytes level antiepileptic drug level

8. Answer 5 Brain anoxia, haemorrhage Cerebral palsy Hyperthermia Acidosis Hypotension Respiratory failure Rhabdomyolsis Aspiration Death

9. Case 2 A mother brought her 9 months old baby to you with history of diarrhea for 3 days. 1-What questions will you ask the mother ?

10. the diarrhea was watery, yellowish, with mucus but no blood, occurs 5 times a day in large amount. There is no vomiting but there is low grade fever 2 times aday relived by paracetamol

11. 2-How would you examine the baby?

12. look for signs of dehydration: He is irritable, eager to drink , has sunken eyes and dry mucus membranes ( no tears) Skin pinch goes back slowely His weight was 10 kg Vitals : RR: 30/min PR: 130 bpm good volume temp: 38 3- how would you classify his dehydration and how would you manage him?

13. He has moderate dehydration Give him ORS 75ml/kg over 4 hrs by NG tube If has vomiting or not tolerated iv ringer lactate or normal saline 75 ml/kg And ORS 10ml/kg after each stools

14. 4-what investigations will you request?

15. CBC RFT + electrolytes RBS Stool general 5-When you come to assess the baby after 30 min you find him drowsy, refuse feeding , his skin pinch goes back very slowly his RR: 50/min, PR: 140 bpm and weak CRT: 5 sec what is his dehydration classification now and how would you manage him?

16. Sever dehydration should call the senior Give the patient iv ringer lactate or normal saline 100ml/kg according to his age : 1/3 over 1 hr and 2/3 over 5 hrs 6- while you are preparing his plan the nurse rush to you that the patient is gasping and not responding. What will you do?

17. The patient is having hypovolemic shock manage with ABC: Assess his pulse and breathing may need CPR Give him iv bolus fluid 20 ml / kg rapidly and can be repeated up to 3 times Measure his blood pressure Give him inotrops ( dopamine , dobutamine , adrenaline, noradrenaline) consider other causes of shock if not responding If septic shock benefit from hydrocortisone and early antibiotics Consider picu

18. Hypoglycemia

19. Hypoglycemia Definition: Plasma glucose below 2.6 mmol/l For practical purposes blood glucose below 3 mmol/l or 50 mg/dl For diabetics blood glucose 80mg /dl in infants and below 70 mg /dl in older children

20. Hypoglycemia: Symptoms: Shaking Fast Heartbeat Sweating Anxiety Dizziness Hunger Impaired Vision Weakness Fatigue Headache Irritability

21. Autonomic symptoms Tremors Pallor Sweating Tachycardia Weakness Anxiety Irritability Hunger Abdominal pain Hypoglycemia unawareness syndrome Neuroglycopenic Confusion Irritability Visual disturbance Headache Apnea in newborn Convulsion Nightmares Coma

22. Assessment : History Previously known illness Onset and progress Food intake /fasting Drugs and poisons Infections Associated symptoms Family history Neonatal development

23. examination smell hydration nutritional status skin hyperpigmentation liver size genitalia

24. Investigations: suspect and treat based on capillary or venous sample by meter draw samples for confirmation and find aetiology. Treat without waiting for lab result Don ’ t miss the opportunity of obtaining the samples during hypoglycemic attack

25. Treatment of unconscious or seizing patient : Newborn : 2-3 ml/kg of 10% dextrose bolus followed by 3-5ml/kg/hr (5-8mg/kg/minute) Children: 2-3ml/kg of 10% dextrose or 1 ml/kg of 25% dextrose followed by 2-3 ml/kg/hr of 10% dextrose 3-5mg /kg/minute . Check RBG after 30 minute till normal then 1-2 hourly till patient become stable

26. Treatment of conscious child : Oral 3 teaspoonful of sugar in water or a sugary drink ,honey or jam then feed thereafter. Other methods Unconscious hypoglycemic at home : Apply honey or jam mouth ,mucous membranes Don ’ t give drink Or IM glucagon(if available )0.5 -1 mg Then give a feed once conscious

27. DKA:Diabetic Ketoacidosis

28. 29 DKA Pathophysiology Lipid metabolism: increase lipolysis Increased concentration of total lipids, cholesterone, TG, free FA Free FA shunted into ketone body formation; rate of production>peripheral utilization & renal excretion  ketoacids Ketoacidosis  -hydroxybutyrate & acetoacetate  metabolic acidosis Acetone (not contribute to the acidosis)

29. 30 Electrolytes loss Potassium: 3-5 mEq/kg Phosphate: 0.5-1.5 mmol/kg Sodium: 5-10 mEq/kg

30. DKA: Presenting Features Polyuria Polydipsia Polyphagia Nocturia Enuresis Abdominal pain Vomiting Profound weight loss Altered mental status weakness 31

31. 32 DKA: Physical Exam Tachycardia Dry mucous membrane Delayed capillary refill Poor skin turgor Hypotension Kussmaul breathing

32. 33 DKA: Physical Exam Sever dehydration Hypotension Acidotic breathing Alter level of counciousness

33. 34 DKA: Laboratory Blood glucose Urinary/plasma ketones Serum electrolytes BUN/Cr Osmolarity CBC, blood cx (if infection is suspected) Blood gas

34. 35 DKA: Laboratory Findings Elevated blood glucose above 300mg /dl Aceton in urine Low bicarbonate level Anion gap metabolic acidosis

35. 36 DKA: Management Goals: correction of Dehydration Acidosis Electrolytes deficits Hyperglycemia

36. 37 DKA: Management Fluids: Avoid impending shock Treat as case of sever dehydration 100ml /kg plus the maintenance. Deficit should be corrected over 48 hours . Rehydration fluids should contain at least 115-135 mEq/L of NaCl Start with NS and switch to ½ NS .

37. 38 DKA: Management Postassium: Total body depletion will become more prominent with correction of acidosis. Continuous monitoring is standard of care.

38. 39 DKA: Management Insulin should be initiated after 1 hour of hydration. Insulin drips 0.1 U/kg/hr (NO BOLUS) Gradual correction reducing serum glucose by 50-100 mg/dL/hr Serum glucose often falls after fluid bolus: increase in glomerular filtration with increased renal perfusion.

39. 40 DKA: Management Dextrose should be added to IVF when serum glucose <300 Blood glucose levels often correct prior to ketoacidosis Should not lower insulin infusion unless: rapid correction of serum glucose or profound hypoglycemia

40. 41 DKA: Complication, Cerebral Edema Theories of cerebral edema Rapid decline in serum osmolality This leads to the recommendation of limiting the rate of fluid administration Edema due to cerebral hypoperfusion or hypoxia Direct effects of ketoacidosis and/or cytokines on endothelial function

41. 42 DKA: Complication, Cerebral Edema Cerebral edema: 0.5-1% of pediatric DKA Mortality rate of 20% Responsible for 50-60% of diabetes deaths in children Permanent neurologic disability rate of 25% Typically develops within the first 24 hrs of treatment Etiology is still unclear

42. Signs & symptoms: Headache Confusion Slurred speech Bradycardia Hypertension

43. DKA: Complications Thrombosis Cardiac arrhythmias Pulmonary edema Renal failure Infection Aspiration pneumonia Sepsis 44

44. Thanx