AKTH paediatric protocol. For educational

Brief summary

1. AMINU KANO TEACHING HOSPITAL, KANO
DEPARTMENT OF PAEDIATRICS
MANAGEMENT PROTOCOL FOR COMMON PAEDIATRIC EMERGENCIES
FIRST EDITION, 2018
List of Contributors:
1

2. Table of content
2

3. NEONATAL EMERGENCIES
1. Neonatal Seizures
Can be recognized as:
Subtle: Have ocular presentation e.g. sustained age eye opening, fixed gaze,
horizontal deviation, eye blinking, eye rolling, sucking movement and apnoea
3

4. Clonic:
Tonic:
Myochlonic
Common causes include:
Hypoglycaemia
Bilurubin Encephlolopathy
Low Ca
2+
, Mg
2+
, Na
+
, Pyridoxine
Infections
Birth trauma – Intraventricular haemorrhage, Subarachnoid haemorrhage,
Intracranial haemorrhage, Subgaleal haemorrhage
Inborn errors of metabolism – galactosaemia, Phenylketonuria
Developmental brain abnormalities
Investigations:
Check random blood sugar using glucometer or dextrostic
Serum Ca
2+
, Po
2-
4 Magnesium Na
2+
Sepsis screening
Lumbar puncture for CSF chemistry andMcs
Cranial USS, EEG, CT Scan or MRI
Pyridoxine levels
Check for inborn errors of metabolism e.Guthrie test.
Treatment:
Maintain airway breathing and circulation
secure venous access
Give 10% D/W 2-4ml/kg (200-400mg) if hypoglycean is present. Then maintain
on 0.06ml/kg/minute – 0.08ml/kg/minute
Check RBS after 30mins, then hourly x 3hrs.
If no hypoglyceamia, correct hypocalcaemia empirically with 2ml/kg of 10%
calcium gluconate in 1:1 dilution slowly i.v over 10-15 minute under cardiac
monitoring
4

5. if no response give 50% Mg SO4 0.25ml/kg im 12hourly x 3 doses
If no response to above give 0.05 – 0.1mg/kg/dose 6hrly of lorazapam slowly or
i.v diazepam.
If no response give phenorbabitone, loading dose of 20mg/kg slowly. If seizure
persist repeat a dose of 10mg/kg followed by maintenance at 5-7mg/kg/day in
2÷doses starting 12 hours after the loading dose.
If no response give phenytoin loading dose of 15mg/kg in normal saline at rate
not greater than 1mg/kg/minute over 30 minutes. Maintain on 4-8mg/kg/day in
2÷doses.
If no response give 1.v 50-100mg of pyridozime for pyridoxine dependent or
deficient seizures.
Treat the underlined cause of the seizures.
2. Neonatal Hypoglycaemia
Random blood sugar < 2.2mmol/l
Presentation: Non-specific and can be similar to other disorders in neonates.
Symptoms include:
Apnoea
Cyanotic spells
Convulsions
Irritability
Jitteriness
Lethargy
Tarchypnoea /Bradycardia
CAUSES:
Diminished production/stores e.g prematurty, IUGR
Increased utilization e.g stressfull condition such as asphyxia, sepsis, Congenital
heart disease
Infant of diabetic mothers, Beckwith Weidman Syndrome, After EBT
Inborn errors of metabolism, Congenital adrenal hyperplasia, Polycythemia
5

6. MANAGEMENT
Include: High index of suspicion in high risk babies.
 Do RBS If < 2.2mmol, Hypoglyceamia is present
 well infants at risk of hypoglycemia should be fed within 30mm – 1 hour of
delivery e.g 1DM and then 2 hrly.
Those who cannot tolerate orally and are give 200mg – 400mg (2-4ml/kg) of
10%DW bolus then maintain on 6-8mg/kg/ (0.06.0.08ml/kg/min of 10% D/W
 Recheck RBS after 30min and hourly until stable then taper off rate of infusion,
start maintenance fluids.
With stable glucose levels gradually wean off glucose infusion as oral feeds
inform of breast milk, EBM/BMS are increased.
If patient requires >12mg/kg/min to maintain normoglyceamia give i.v
hydrocortisone 10mg/kg in 2 divided doses
1.m glucogon 0.1mg/kg to mobilize glucose temporarily for 2-3 hours in
emergency until i.v glucose can be given.
Epinephrine, dianzoxide and growth hormone are used occasionally for persistent
hypoglycaceamia
Treatment of the underline cause of the hypoglycaceamoa
INVESTIGATION FOR PERSISTANT HYPOGLYCAEMIA INCLUDE:
Venous gas
Hormones: insulin, cortisol, growth hormone
Lactate pyruvate
Amino acids
Urine for reducing substances, organic amino acids
Kerones in blood and urine
BIRTH PERINATAL ASPHYXIA/PERINATAL ASPHYXIA
6

7. This is failure of a newborn baby to establish spontaneous respiration or circulation or both
associated with hypoxemia hypercapnoea and metabolic acidosis.
CRITERIA FOR DIAGNOSING BA/PA
1.Umbilical cord arterial blood or mixed acidaemia (PH<7.0)
2.Apgar score 0 - 3 for >5min
3.Clinical neurologic sequel in immediate neonatal period (Hypoxic Ischaemic
Encephalopathy)
4.Evidence of multiorgan dysfunction eg CNS, Renal, Digestive system.
MANAGEMENT
If an infant is born via meconium stained liquor and is non-vigorous (poor resp effort, HR
<100bpm decreased tone) he must be intubated and suctioned through direct laryngascopy using
meconium aspirator.
The above management is not required for a vigorous baby. Dry baby keep warm and give
mother to start breast feeding.
POST RESUSCITATIVE MANAGEMENT
Establish effective airway and ventilation
Establish circulatory support if needed.
Avoid over heating the baby
VENTILATION
Limit inspired O2 to keep SPO2 between 88 – 95% maintain PC02 between 40-55mmhg
7

8. PERFUSION
Limit fluid intake to 75-80% of maintenance for the first 48-72 hours or until renal
function recovers.
Usually correction of acidosis occurs spontaneously over a few hours after birth with
adequate resuscitation.
Hence non – K (continuing 10% D/W) with no alkaline is recommended.
If base deficit persist at >12mmol/l or standard bicarbonate <15mmol despite adequate
ventilation and perfusion, giving sodium bicarbonate can be considered.
The dose is 2 boluses of 8.4% NaHCO3 at 0.5-1ml/kg mixed with equal volume of sterile
water to be infused over 30 minutes.
 If acidosis persist add 8.4% NaHCO3 (4-8ml/100ml) to the dextrose solution being used.
This regimen can be stopped once the standard bicarbonate exceeds 18mmol/l.
Vasopressors such as dopamine are effective in normalizing blood pressure in
asphyxiated babies.
Start antibiotics if sepsis is suspected, avoid aminoglycosides in asphyxiated babies
because of toxicity.
Place baby on NPO for 24-48 hours.
Monitor and treat convulsion promptly, if convulsions develop use phenobarbitone,
phenytoin, depending in the response.
Maintenance phenorbabitone at 5-7mg/kg/day, continue phenobab for 7 days for the
confirmed sezuires.
Temparature fluctuation are noted and many be attributed to the effects of the insult on
the hypothalamus. Pyrexia requires stoppage of supplementary heating e.g. warm
incubator, and occasional use of antipyretic e.g pcm.
Asphyxia requires multidisciplinary approach, hence allied health workers such as
physiotherapist, neurologist, social workers must be involved.
ADMISSION TO ICU
8

9. All infants with asphyxia that require resp. support should be put on mech. Ventilation
for at least 24-48 hours and then reassesed.
However this is usually not feasible due to limited resources.
CRITERIA FOR NOT PUTTING BABY ON MV
Took >10 minutes to spontaneous resp. (must exclude effects of maternal anesthesia, or
pethidine use first) with a base deficit of >16mmol/L.
Developed convulsion requiring > 2 doses of anticonvulsants to control.
Comatose (HIE 3).
A decision not to ventilate an asphyxiated infant should be discussed with the consultant
on call.
NEONATAL SEPSIS
NNS is the systemic inflammatory response to infection in a neonate from 0-28 days of
life: Clasification
a)Early onset NNS- 0-72hours
b)Late onset NNS- 4-7days
c)Very late onset- 8-28days
Infants with NNS presents with non specific signs and symptoms such as
Apnoea
Feeding intolarence
Abdominal distension
Tarchypnoea/bradycardia
Lethargy, seizure
Temperature instability
Metabolic acidosis
Hypoglyceamia/Hyperglycaemia
9

10. DIC
Refusal to suck
irritability
Diarrhea/vomiting
Complete history and physical examination with clinical experience are the best guides.
CAUSATIVE ORGANISMS
a)Causative organisms of EONNS are maternal acquired. These include GBS, enteric
bacilli, Staph aureus, E coli.
b)Those that cause late onset NNS are usually hospital acquired and are predominantly
MRSA, Klebsiella, E coli Pseudomonas, Acinotobacter, Enterobacter etc.
RISK FACTORS FOR PERINATAL INFECTIONS.
Major Risk Factors
Rupture of membranes of 18-24 hours
Maternal lntrapartum fever > 38%
Chorioamnionitis
Sustained fetal Heart rate > 160pm
Minor Risk Factors
Rupture of membranes >12 hours
Maternal intrapartum fever 737.5c
0
Maternal wbc >15,000/ul
Low Apgar score<5 at 1 minute, <7 at 5 minute
Preterm labour
10

11. multiple gestatation
foul locia
Maternal GBS colonization.
Any infant with one major or two minor risk factors should have full sepsis screening.
Investigations:
Random blood sugar
FBC: Wbc< 5000 or > 20,000
absolute neutrophil count < 1750 or > 5400.
 Band neutrophil ration > 0.2
mini ESR> 15mml/L.
Thrombocytopenia.
Presence of 2 or more suggest infection.
Blood culture
Urine culture (SPA)
Surface swabs/gastric aspirate for Mcs
LP for CSF chemistry
U&E, Clotting profile
TREATMENT
Secure airways, give O2 if needed.
Secure i.v access if needed
Feeding/i.vf
restrict fluids to 65% maintenance if child has meningitis.
Give i.v Amoxillin 30mg/kg/day 2÷doses.
i.v Gentamycin 2.5mg/kg/dose 12hourly
If meningitis is suspected
11

12. Give i.v ceftazidime 100mg/kg/day in 2÷doses
Expose and tepid sponge febrile babies
Those in shock manage appropriately.
Confirmed sepsis is treated for 10-14 days.
Menigitis by Gram negative organism – treat for 21 days.
Monitor urine output SPo2, ABG, BP RBS,.
If FBC and culture are negative and infant is well antibiotics may be stopped after 48-72hours.
NEONATAL HYPOCALCEAMIA
Neonatal hypocalcaemia is referred as total serum Ca
2+
of <2mmol/L in term infant and <
1.75mmol/L in preterm infants and ionised Ca
2
of < 0.75mm/l.
Risk Factors
Premature babies
 Babies of mothers with Preeclampsia
Asphyxiated babies
Infant of diabetic mother
Alkali therapy
Maternal hypoparathyrodism
After EBT
Maternal intake of anticonvulsant (Phenytoin, Phanorbab).
Types
a)Early onset hypocalcaemia presents within 72 hours and requires treatment with Ca
2
for
at least 72 hours.
12

13. b)Late onset hypocalcaemia usually present after 7 days and requires long term therapy
with calcium.
Clinical Features
(CATS pneumonic)
C = Convulsions
A = Arrythmia
T = Tetany
S = Spasm and Stridor
Investigations
Do serum Ca
2
,PO4
2-
, Mg
2
Management of Early Neonatal Hypocalcaemia
Asymptomatic
80mg/kg/day for 48 hours
(8ml/kg/day of 10% calcium gluconate
13
Hypocalcaemia
Total serum Ca
2
<7mg/dl

14. Taper to 40mg/kg/day for one day then stop
Symptomatic
Bolus of 2ml/kg calcium gluconase 1:1 diluted with 5% dextrose water and administered over
10-15 minutes under cardiac monitoring.
Followed by 80mg/kg/day for 48 hours
(8ml/kg/day of 10% calcium gluconate)
Document normal calcium at 48 hours
Then taper to 40mg/kg/day for one day then stop.
Intravenous treatment is usually indicated in patients having seizure, those critically ill and those
planning to have surgery.
Oral calcium therapy is used in asymptomatic patient and as follow up to intravenous calcium
therapy.
NEONATAL TETANUS
Is an acute spastic paralytic illness caused by tetanus toxin, the neurotoxin liberated by
Clostridium tetani. It occurs.
In infant of unimmunized mothers.
Poor cord care.
Uvulectomy /scarification marks
14

15. Female genital mutilation
It presents within 3-12 days of birth (average 6 days)
Clinical presentation
Difficulty in opening the month.
Inability to suck
Stiffnesss/spasms
Opistothonus
Risus Sardonicus
Fever due to energy consumed by spastic muscles.
Autonomic symptoms such tachycardia, arrhythmias, labile hypertension, urinary
retention.
Tetanus is a vaccine preventable disease
Principle of Management
Control seizure/spasms using diazepam at 1mg/kg i.v
Then place on triple regiment of anticonvulsants: phenorbabitone 2mg/kg/dose, diazepam
1mg/kg/dose, chlorpromazine 2mg/kg/dose in staggered dosages.
Neuralization of the toxin using ATS at 5000iu to 10,000i.u stat.
Debride the wound and eradicate the clostridium tetani by giving i.v Crystalline
penicilline at 0.2mu/kg/day in 4 ÷ doses. Or i.v metronidazole at 7.5mg/kg/dose
Press NGT when patient is well sedated.
Provision of fluids and calories
Provision of meticulous supportive care
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16. Nursing in secluded room
Minimal handling but careful turning of patient to prevent bed sores.
Active immunization on discharge.
Management
Do rapid assessment of ABC
Give O2 when necessary at 1-2L/min
Control ongoing spasms with i.v diazepam at 1mg/kg start
Pass NGT
secure i.v line and take samples for FBC, E,U,CR after full sedation
Assess tetanus score and open seizure chart.
PROPOSED PROTOCOL FOR MANAGEMENT OF STATUS
EPILEPTICUS IN EPU, AKTH, KANO
DEFINITION OF STATUS EPILEPTICUS
It can simply be defined as seizure (clinical and/ or electroencephalographic) lasting more than 5
mins or recurrent seizures without recovery (regain of consciousness) between the seizures.
(ILAE 2017)
GOALS OF MANAGEMENT
1.)To ensure brain oxygenation and cardio-respiratory function
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17. 2.)To terminate clinical and electrical seizure activity as rapidly as possible
3.)To prevent seizure recurrence
4.)To identify precipitating factor(s): fever, hypo – Glu, Na
2+,
Ca
2+
, Mg
2+
, toxins/ drugs
5.)To prevent systemic complication
6.)To evaluate and treat the cause(s) of status epilepticus
STEPS OF MANAGEMENT
STEPTIME (min) ACTION MONITORING
1 0 - 5 Establish it is Status Epilepticus,
Call for help,
Positioning (left lateral) ± Oro-pharyngeal airway
Oxygen via face mask
IV line ± Normal saline
Oxygen saturation
Pulse rate, volume
Blood pressure
Glucose
Temperature
2 6 - 9 IV Diazepam 0.2 – 0.3mg/kg or Blood pressure
17

18. Intra-nasal Midazolam 0.2mg/kg or
IM paraldehyde 1ml/yr of life up to 5yrs
IV Glucose 4mls/kg bolus if required
U/E/Cr, Ca
2+
, Mg
2+
3 10 - 30 Repeat IV Diazepam 0.3mg/kg bolus
If no seizure control after 5min of 2
nd
Benzos
IV Phenobarb 15mg/kg bolus or
IV Phenytoin 15mg/kg in Normal saline infusion
Oxygen saturation
Pulse rate
Blood pressure
ECG
EEG
4 31 - 60Oral/ NGT Levetiracetam (Keppra) 20mg/kg or
IV Valproate (Epilim) 20 – 30mg/kg bolus
Neurology consults
Consult ICU
Ensure above
5 61 - 90IV Pentobarbital 5mg/kg
ET tube should be inserted
Mechanical ventilation
Continuous ECG,
EEG, vitals
DEHYDRATION
Dehydration is defined as a loss of total body water resulting in hypovoloemia.
 It leads to significant depletion of body water and to varying degrees to loss of
electrolytes. It is a symptom or sign of another disorder.
Do a primary assessment
18

19. Ensure Airway patency, patient is breathing and patient is not in shock(see
features of shock)
Take a history- trying to identify the cause.
Most common causes in children are
-Increased fluid output as in diarrhea and vomiting,
-decreased fluid intake during illness like malaria, pharyngitis, urinary tract
infection
-increased fluid loss as in fever, tachypnea,
-3
rd
space loss as in intestinal obstruction and
-other sources like diabetic keto acidosis
Drugs given
Patient’s background medical condition
Complications-urine output, convulsions, electrolyte derangements etc.
Do a detailed physical and systemic examination
-Vital signs
-Determine underlying cause
-Assess the severity by classifying the degree of dehydration
-These vary according to the degree of deficit.
SEVERITY Fluid deficit in ml/kg
( estimated weight loss)
Clinical signs
Mild 50 (5%) Dry mucous membranes
Moderate 75 (7.5%) Restless, irritable, sunken
eyes, sunken fontanel, drinks
eagerly, thirsty, skin
pinch/skin tugour goes back
slowly, tachycardia, quiet
tachypnea
Severe 100 (10%) Lethargic or unconscious, not
able to drink, skin pinch goes
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20. back very slowly, marked
tachycardia then hypotension,
increased respiratory rate,
capillary refill time greater
than 2 seconds
WHO recommends ORAL rehydration for MILD and MODERATE dehydration with low
osmolarity ORS (LO-ORS)
MILD DEHYDRATION -uses 4 rules for home treatment
Give extra fluid- approximately 50ml/kg of LO-ORS, if child is breastfeeding tell
mother to continue.
Teach mother to prepare ORS and how to give it. Quantify amount for her to give in
simple terms
Give Zinc- for full 10-14 days even if diarrhea stops
-up to 6 months=10mg daily for 10-14 days
-over 6 months=20mg daily for 10-14 days
Advise mother to continue feeding- to give 1 or 2 extra meal in addition to regular
feeds.
Tell mother when to return-
-when child is unable to drink or breast feed,
-becomes sicker, develops a fever,
-blood in stool if child has diarrhea.
MODERATE DEHYDRATION - Under observation in the hospital
Give ORS 75ml/kg over 4 hours (calculate how much child needs/hour)
Show the mother how to prepare and give the ORS using cup and spoon for less
than 2 years and if older how to give frequent sips from cup.
Observe her as she gives the first few sips.
20

21. Monitor frequently to reassess the child and whether ORS is tolerated or not and
also if the mother has problems or concerns with the ORS.
If not tolerating ORS, try giving through syringe without needle or use a naso-
gastric tube.
If still not tolerating ORS or the rate of vomiting/diarrhea cannot keep up with the
ORS administration, give intravenous fluid.
Ensure daily maintenance via oral route.
SEVERE DEHYDRATION-
Deficit (100ml/kg) plus daily maintenance plus ongoing fluid losses (10mls/kg).
Daily maintenance is based on the weight(Holliday-Segar Formula)
-First 10kg=100mls/kg/24 hours
-Second 10kg=50mls/kg/24 hours
-Next/subsequent 10kg=20mls/kg/24 hours
Give fluid resuscitation with boluses of isotonic fluid- 0.9% NORMAL SALINE
OR RINGER’S LACTATE 20Ml/kg intravenous over 20 to 30 minutes for > 1
year and over 1 hour for < 1 year.
Reassess the pulse rate and volume, capillary refill time, respiratory rate, urine
output.
If no improvement, 3 boluses of 20ml/Kg may be required.
The end point of the fluid resuscitation phase is reached when the capillary refill
time, blood pressure and heart rate have returned to normal.
Add the remaining 80mls/kg to the daily maintenance and give half of the total
calculated over first 8 hours.
Give the remaining calculated fluid (80mls/kg + daily maintenance) over the next
16 hours.
Do an urgent Random blood sugar and if <2.2mmol/L, correct. See
hypoglycaemia
Use glucose containing fluid at this stage.
Once urine flow/output is established/adequate=1ml/kg/hour, give potassium
containing fluid.
Monitor vital signs frequently and also reclassify the degree of dehydration.
21

22. Do a secondary Reassesment
Reasses the patient
-Check the vital signs
-Recheck/reclassify the degree of dehydration
Detailed history and examination.
Take/order appropriate investigations to identify the cause
-Stool M/C/S if diarrhea
-Malaria parasite
-Sepsis screen-Full blood count, blood culture,
-Urine M/C/S, urinalysis
-Random blood sugar
-Electrolytes and urea
Reassess and determine the type of dehydration
-Hyponatraemic dehydration- Serum sodium <130mmol/l
-Isonatraemic dehydration- fluid loss=Sodium loss. Most common type
-Hypernatraemic dehydration-serum sodium>
Assess for electrolyte derangements and correct appropriately-see electrolytes
derangement and correction.
Monitor patient frequently as clinical condition can change.
Do a tertiary assessment
Reassess hydration status
Invite /consult if specialist care required
-DKA
-Intestinal obstruction-paediatric surgeons
Shock in children
Shock is inadequate provision of oxygen and other essential metabolic substrates to vital
organs. It may occur with a normal, increased or decreased blood pressure.
 Hypotension is a late and poor prognostic sign of shock.
Resuscitation/primary assessment
A-maintain a patent airway
22

23. B-Support breathing-give high concentration of supplemental oxygen (4-
6L/min) to all children in shock regardless of oxygen saturation reading.
C- Secure vascular access, if IV difficult to establish x 3 attempts, secure
Intraosseus.
Fluid resuscitation
 Give 20mls/kg of 0.9% Normal saline or Ringers Lactate as rapidly as
possible (5-10 minutes), give it push. Do not hang up fluid and leave.
 Give 5-10mls/kg (over 10-20 minutes) for those with suspected or
known heart disease, myocardial dysfunction and in obstructive shock.
Those with severe anaemia in shock should have early blood
transfusion.
If bleeding, use blood for replacement as soon as it’s available.
If however, patient is still hypotensive despite 2-3 boluses of fluid and
blood is taking too long, consider type specific uncross matched blood
or as a last resort O negative for females or O positive or negative for
males.
Reassess if no improvement, repeat fluid bolus.
3 fluid boluses can be administered = 60mls/kg, while carefully
monitoring for pulmonary oedema or worsening tissue perfusion. If
such features occur, stop infusion, maintain oxygenation and
ventilation.
Do urgent random blood sugar, if < 2.2mmol/l, correct for
hypoglycaemia.
Reasses patient frequently- pulse rate, respiratory rate, blood pressure,
urine output, capillary refill time, mental status.
Secondary assessment
Reassess patient and check vital signs
Take a brief history- trying to identify the cause and type of shock
Types of shock and common aetiologies
Hypovoloemic
shock
Distributive shock Cardiogenic shockObstructive shock
Fluid and
electrolyte loss
-Diarrhea and
vomiting
-DKA
Septic shock
Anaphylaxis
Toxic
ingestions/poisoning
Spinal cord injuries
Myocardial
dysfunction from
-infectious
myocarditis(sepsis
etc)
Pleural collections
-pneumothaorax
Aortic stenosis
Coartation of aorta
Pulmonary
23

24. -polyuric states
Plasma and
protein loss
-burns
-bowel
obstruction
-peritonitis
Haemorrhage-
-trauma
-bleeding
disorders
-coagulopathy
-GIT bleeding
Spinal/epidural
anaesthesia
Drugs(antihypertensives,
barbiturates)
-cardiomyopathies
Congenital heart
lesions
Dysrhythmia
-bradycardia
-ventricular
tachycardia
-supraventricular
tachycardia
Acidosis
Hypoxic-
ischaemic events
embolism
Pericardial
tamponade
Do a general physical and systemic examination looking for the underlying cause.
Signs of shock- depends on the severity
-Increasing tachycardia
-Diminishing or absent peripheral pulses
-Weakening central pulses
-narrowing pulse pressure
-Cold distal extremities with prolonged capillary refill
-decreasing level of consciousness
-Hypotension(late sign)
Parameter Compensated shockDecompensated
shock
Irreversible shock
HR high High High/low
RR N High High/low
BP N Low Unrecordable
Urine output N Low Very low/
Pulse pressureN Low Anuric
Skin Cool Mottled Cold,cyanotic
Mental status Anxious Obtunded Coma
Monitoring/frequent reassessment-
condition of a child in shock is dynamic hence continuous and frequent monitoring are
essential
Heart rate, oxygen saturation, blood pressure, pulse pressure, urine output, respiratory
rate, mental status
Re-evaluate condition, determine response to therapy and plan next intervention.
24

25. Laboratory studies/ Identify aetiology –to help identify metabolic derangements,
identify /evaluate aetiology, evaluate organ dysfunction and to evaluate response to
therapy.
Blood glucose-all critically ill children should have an urgent
blood glucose test to rule out hypoglcaemia.
Full blood count
Electrolytes and urea-potassium, bicarbonate, sodium
Calcium
Lactate
Cultures if indicated
Medication therapy
Medication therapy is mainly used in shock in those that are fluid
refractory shock or for specific aetiology.
 Give vasoactive and ionotropic drugs when shock persists
despite adequate volume resuscitation ( 20-30mls/kg x 3 boluses)
to optimize preload.
Give Dopamine 5-10ug/kg/min as infusion in normal saline.
-It has dose related clinical effects.
-At low doses, it causes renal vasodilatation.
- At intermediate doses; it causes inotropy, chronotropy and
vasodilatation.
- Higher doses >10ug/kg/min increases systemic and pulmonary
vascular resistance.
Give Adrenaline 0.05-0.5ug/kg/min – in shock occurring after
cardiorespiratory arrest and in patients where dose of >15-20ug/kg/min of
dopamine is required to maintain blood pressure.
-At higher doses, it has vasoconstrictor effects.
-At lower doses it has primarily cardiac effects.
- It’s the drug of choice for cold septic shock, anaphylactic shock
and cardiogenic shock with hypotension.
 Give Drugs for specific aetiologies
-Antibiotics should be given within one hour of presentation in
sepsis.
-Glucose- if there is hypoglcaemia
-Correct electrolyte derangements.
Tertiary assessment
Monitor/reassess frequently
Ensure all investigation samples are taken.
Consult for specialist care- intensive care unit, surgeons.
25

26. Summary of management steps for shock
output
DYSELECTROLYTAEMIA
1.Hypernatremia (Na>145 mmol/L)
a.Gradual lowering of Na is required over 2-3 days, not more than 10-12 mmol/day
26
Improved
Evaluate for
aetiology and
associated
derangements
Monitor/frequent
Reassessment
No improvement= fluid refractory
shock
If sepsis suspected:
-give first dose antibiotics STAT
-Establish second vascular access for
vasoactive drugs
-Dopamine 5-10ug/kg/min infusion
-give hydrocortisone
--get blood for transfusion
Within the first hour of
admission
If no improvement
Repeat fluid bolus 20mls/kg of 0.9%
Normal Saline or Ringers Lactate
Reassess
3 fluid boluses can be repeated if no
improvement
0.9% Normal Saline or Ringers Lactate, 20mls/kg over 5-10 mins
5-10mls/kg if cardiogenic shock suspected or severe anaemia
Give blood if severe anaemia or bleeding
Monitor vitals/urine output/put catheter
Urgent RBS-give glucose if low
Reasses- HR, RR, BP, urine output, capillary refill, mental status
Assess airway
Administer Oxygen
Secure IV access
Shock
Tachycardia, hypotension, acidosis,
Oliguria, depressed mental status

27. b.Never give hypotonic fluids as bolus and avoid rapid correction as this may lead
to fatal brain oedema, herniation and then death
c.If shock present, give 20 mL/Kg of 0.9% saline also called normal saline (NS)
over 30 min and repeat if necessary
d.Fluid volume is calculated by considering maintenance, ongoing losses and free
water deficit
e.Free water deficit (FWD) can be calculated from
i.FWD (in litres) = 0.6 x body weight (Kg) x [(current Na/140) – 1]
f.Usually a fluid combination of the following is helpful in achieving daily target
i.25-30 mL NaHCO3 + 500 mLs 5%DW + K (maintenance) or
ii.450 mL of N/S + 900 mL 5%DW + K (maintenance)
g.Electrolytes 6 hourly is recommended to adjust therapy
h.If refractory hypernatremia or AKI present, consider dialysis
i.Please note that NS (0.9%) has no free water, ½ NS has 50% free water, 5%DW
has 100% free water

2.Hyponatremia (Na <135 mmol/L)
a.0.6 x body weight (Kg) x deficit
b.Severe/symptomatic e.g. seizures: Increase Na by 3 mmol/L in 1 hour or 5
mmol/L in 2 hours
i.0.6 x body weight (Kg) x 5mmol = 3mmol/Kg of Na in the first 2 hours
ii.This translates into 6 mL/Kg of hypertonic (3%) saline or 20 ml/Kg of
Normal (0.9%) saline over 2 hours
c.If dilutional e.g SIADH, restrict water intake to 60-70% maintenance
d.If dehydration involved, correct dehydration over ± 24 hours and repeat
electrolytes
e.Correction of Na should not exceed 10 mmol/day or 0.5 mmol/hour except where
symptomatic
27

28. 3.Hyperkalemia (K >5.5 mmol/L)
a.Eliminate all potassium intake
b.ECG changes
i.~6: peak T waves
ii.~7: increased PR interval
iii.~8: absent P wave with widening QRS complex
iv.Ventricular fibrillation
v.Asystole
c.Administer sodium bicarbonate to correct metabolic acidosis, 1-2 mmol/kg
d.Salbutamol nebulisation (2.5 – 5mg salbutamol) over 20 min, can be repeated
three times
Or, IV Salbutamol 4 mcg/kg in 5ml water given over 10-20min
e.IV 10% Calcium gluconate, 0.5-1.0ml/kg or 50-100mg/kg IV slowly
f.Give glucose with soluble insulin
i.10% DW 4ml/kg/h + 0.1u/kg/h
ii.Or glucose 0.5 g/kg over 1 hour with soluble insulin 0.1u/kg
g.Sodium polystyrene sulphonate: 1 g/kg orally or per rectum
h.Consider dialysis
4.Hypokalemia (K <3.5 mmol/L)
a.Symptomatic (paralysis including ileus, arrhythmia) requires emergency
management 0.2 mmol/kg/h with ECG monitoring
i.IV 0.2 mmol/L (5 mL/kg/h) of 40 mmol/L of KCL in 20 mL of 5%
glucose over 30 min with ECG monitoring, not exceeding 80 mmol/L
b.Asymptomatic usually improves with oral supplementation
i.Each slow K tablet contains 8mmol/L (600 mg) of potassium chloride
5.Hypercalcaemia (Corrected Ca>2.6 mmol/L or ionized Ca<1.3 mmol/L)
a.Severe if Corrected Ca>3.0 mmol/L or ionized Ca>1.5 mmol/L
b.Rule out secondary causes
28

29. c.Often asymptomatic, other findings include FTT, nephrocalcinosis/lithiasis,
polyuria, e.t.c
d.Treat underlying cause
e.Supportive
i.Hyperhydration with IVF normal saline
ii.Loop diuretics
iii.Bisphosphonate
iv.dialysis
6.Hypocalcaemia (Corrected Ca<2.1 mmol/L or ionized Ca<1.2 mmol/L)
a.Severe if Corrected Ca<1.75 mmol/L or ionized Ca<0.8 mmol/L
b.Acute symptomatic (tetany, paraesthesis, seizures, myopathy, psychosis,
dementia, laryngospasm, Chvostek sign, Trousseau sign, hypotension, ventricular
arrhythmia
i.0.3 ml/kg 10% Ca gluconate IV over 10-30 min with cardiac monitoring
for bradycardia; can repeat until normal
ii.Correct hypomagnesaemia if present
iii.Consider ongoing replacement therapy infusion 10% Ca gluconate (0.2-1
mmol/kg/day) or oral Ca supplement (50-75 mg/kg/day of elemental Ca in
four doses)
c.Chronic hypocalcaemia especially in CKD
i.1,25-dihydroxycholecalciferol (calcitriol) 15ng/kg (max of 1.5
microgram/day) in two divided dose
or
1-α- hydroxycholecalciferol (alfacalcidol) 10-25 ng/kg/daily (max 2
microgram/d)
7.Hypermagnesaemia (Mg>1.0 mmol/L)
a.Symptomatic if Mg>2.0 mmol/L – lethargy, drowsiness, nausea, loss of DTR,
ileus, ECG changes (prolonged PR and QT, widened QRS), coma, apnoea
b.Calcium gluconate infusion antagonises its toxic effect
29

30. c.IV furosemide may promotes its excretion
d.Use of glucose and insulin may shift magnesium into the cells
8.Hypomagnesaemia (Mg<0.7 mmol/L)
a.Usually asymptomatic
b.Symptomatic (Mg<0.5 mmol/L) – weakness, tremors, seizures, positives
Chvostek and Trousseau, ECG changes, ventricular arrhythmias
c.Treatment: 0.1-0.2 mmol/kg of 10% Mg sulphate (0.25-0.5 mL/kg) IV over 30
min; repeat as necessary
d.Chronic asymptomatic hypomagnesaemia: oral Mg 0.2 mmol/kg/day in three
divided dose.
9.Acidosis (Blood pH<7.35 or Serum HCO3<18-20 mmol/L)
a.The anion gap (AG) may differentiate metabolic acidosis due to loss of
bicarbonate (most common) or accumulation of acid
i.AG = [Na+] – {[Cl-] + [HCO3-]}
ii.Normal value is 8 – 12
iii.Normal AG acidosis indicates bicarbonate loss e.g in GIT (diarrhoea, GI
fistula, stoma) or Urine (renal tubular acidosis)
iv.Increased AG acidosis indicate excess accumulation of acid (MUDPILES-
metformin, metabolic disease; uraemia; DKA; paraldehyde, propylene
glycol, phenformin; isoniazid, iron; lactic acidosis; ethanol, ethylene
glycol; starvation, salicylates
b.Diagnose and treat underlying cause e.g. correct dehydration, give oxygen, treat
sepsis,
i.Avoid lactate containing replacement IVF
ii.Replace bicarbonate in chronic bicarbonate loss
iii.Severe intractable acidosis – dialysis or haemofiltration may be considered
c.Acute alkali replacement should be done with caution due to potential harmful
effects of volume overload, hypernatremia, hypercapnia, worsening intracellular
acidosis
30

31. 31

32. ACUTE KIDNEY INJURY
Sudden, potentially reversible inability of the kidney to maintain its normal physiological
function. Causes are pre-renal, renal and post-renal.
The modified pRIFLE criteria for AKI
pRIFLE
Serum Cr
increase
GFR decrease
by
Urine output
R
Risk of kidney
dysfunction
Cr x 1.5 25% < 0.5 ml/Kg/h x 6h
IInjury to the kidney Cr x 2 50%
< 0.5 ml/Kg/h x
12h
F
Failure of kidney
function
Cr x 3 75%
< 0.3 ml/Kg/h x
24h
or anuria x 12h
LLoss of kidney function – Persistent failure > 4 weeks
EEnd stage renal disease – Persistent failure > 3 months)
The GFR can be calculated from the modified Schwartz formulae
eGFR = 36.5 x height (cm) /serum Cr (µmol/l)
OR
0.41 x height (cm) /serum Cr (mg/dL)
1.Investigate and treat underlying cause
a.Investigation: E/U/Cr, FBC (± blood film), urine dipstick, urine mcs, abdo USS,
serum Ca & P, other supportive as indicated e.g. ESR, LFT, ASOT, anti-DNAse
B, C3/C4, Blood culture, urine electrolytes, CXR, serum Mg, alphos, PTH, etc
b.Treat underlying cause: e.g. treat shock and dehydration, sepsis, etc
2.Treat fluid overload and hypertension
a.Input-output recording
32

33. b.Daily weighing
c.Once hydration is adequate, IV furosemide may be of benefit (max 12mg/Kg/24h)
d.Give insensible loss as 400 mL/m2/day or 30 ml/kg/day plus urine output and
other ongoing losses (give 100% of U/O if euvolaemic and 50-75% if overloaded)
e.Consider calcium channel blockers (amlodipine 2.5-5 mg/kg/day) or beta-
blockers (metoprolol 1-2 mg/kg/day) in addition to diuretics, avoid ACE
inhibitors and ARBs
f.Treat severe hypertension with sublingual nifedipine or IV labetalol
3.Correct anaemia if present
4.Correct hyperkalaemia and acidosis
5.Ensure adequate nutrition
6.Dialysis
a.Indications for dialysis
i.Hyperkalaemia >6.5 mmol/L
ii.Sever fluid overload with pulmonary edema
iii.Urea > 40 mmol/L (>30 mmol/L in a neonate)
iv.Severe hypo- or hypernatraemia or acidosis
v.Multi-system failure
vi.Anticipation of prolonged oliguria e.g. HUS
33

34. SEVERE ACUTE MALNUTRITION
Severe acute malnutrition is defined in children 6-59 months as severe wasting (a mid-upper arm
circumference <115 mm or a weight-for-height/length <–3 Z-scores of the WHO growth
standards), or by the presence of bilateral (nutritional) oedema. 
Oedema can be categorized as:
Mild (+): oedema in both feet/ankles
Moderate (++): oedema in both feet plus lower legs, hands or lower arms
Severe (+++): generalized oedema including both feet, legs, hands, arms and face
Children with SAM who have medical complications (hypoglycaemia, hypothermia, fever >
39°C, pneumonia, extensive skin lesions, infection, severe dehydration/shock, severe
anaemia, jaundice, bleeding tendencies, etc) severe oedema, or poor appetite or present with
one or more IMCI danger signs such as unable to drink or breastfeed; vomits everything; has
had convulsions (more than one or prolonged >15 min); lethargic or unconscious; convulsing
now should be treated as inpatients.
Children who have appetite and are clinically well and alert should be treated as outpatients.
Common medical complications associated with SAM
1.Hypoglycemia
a.All children with SAM are at risk of hypoglycaemia and should be assumed to
have hypoglycaemia and treated accordingly and commence feeding immediately
b.Diagnosis is RBS of <3 mmol/L (< 54 mg/dl)
c.Treatment:
i.Give 50 ml of 10% DW or sucrose solution orally (one rounded teaspoon
of sugar in 3 tablespoons of water) orally or via NGT, followed by the first
feed (F75 milk) and continue 2-3 hourly.
ii.If unconscious, treat with IV 10% DW 5ml/kg and continue with NGT
feeds to prevent relapse. You can also give via NGT if unable to secure IV
34

35. access or give one teaspoon of sugar moistened with one or two drops of
water sublingually, and repeat every 20 min to prevent relapse
d.Monitoring:
i.Repeat RBS after 30 min
ii.If RBS < 3 mmol/L, repeat 10% DW or sucrose solution
iii.If the rectal temperature falls to < 35.5 °C, or if the level of consciousness
deteriorates, repeat RBS measurement and treat accordingly.
35

36. 2.Dehydration
a.D not give IV fluids except in shock
b.Children with signs of shock or severe dehydration who cannot be rehydrated
orally or by nasogastric tube should be treated with IVF at 15 ml/kg
i.Half-strength Darrow’s solution with 5% dextrose or
ii.Ringer’s lactate solution with 5% dextrose.
iii.If neither is available, 0.45% saline + 5% dextrose should be used
c.Children with some dehydration or severe dehydration but who are not shocked
should be rehydrated slowly, either orally or by nasogastric tube, using oral
rehydration solution for malnourished children-
i.ReSoMal (5–10 mL/kg/h up to a maximum of 12 h)
d.Do not use full-strength, standard WHO low-osmolarity ORS (75 mmol/L of
sodium), give either ReSoMal or half-strength standard WHO low-osmolarity
ORS with added potassium and glucose, unless the child has cholera or profuse
watery diarrhoea
i.Dissolve one sachet of standard WHO low-osmolarity oral rehydration
solution in 2 L water (instead of 1 L).
ii.Add 1 level scoop of commercially available combined minerals and
vitamins (CMV) mix1 or 40 ml of mineral mix solution (5)
iii.Then add and dissolve 50 g of sugar.
iv.For sachets are designed to make 500 mL of standard WHO low-
osmolarity oral rehydration solution, dilution can be revised to add 1 L
v.Do not give ReSoMal if children are suspected of having cholera or have
profuse diarrhoea, give standard WHO low osmolarity ORS that is
normally made
e.Treat septic shock with whole blood 10ml/kg over 3 hours in addition to
antibiotics
3.Hypothermia
a.Very common and may indicate hypoglycaemia or presence of serious infection
36

37. b.Diagnosis:  
i.Axillary temperature is < 35 °C (< 95°F) or does not register on a normal
thermometer
ii.Or when a low-reading thermometer is available, rectal temperature < 35.5
°C (< 95.9 °F) confirms hypothermia.
c.Treatment:
i.All children with hypothermia should be treated routinely for
hypoglycaemia and infection
ii.Re-warm the child (active re-warming):
Make sure the child is clothed (especially the head)
Cover with a warmed blanket and place a heater (not pointing
directly at the child) or lamp nearby
Or put the child on the mother’s bare chest or abdomen (skin-to-
skin) and cover them with a warmed blanket and/or warm clothing.
iii.Keep child away from cool air
d.Monitoring:
i.Check rectal temperature every 2 h until it rises to > 36.5 °C. Take it every
30 min if a heater is being used because may become overheated.
ii.Ensure that the child is covered always, especially at night.
iii.Keep the head covered, preferably with a warm cap/hat, to reduce heat
loss.
iv.Check for hypoglycaemia whenever hypothermia is found.
4.Infection
a.Give antibiotics to all children with SAM starting from the first day
b.Parenteral antibiotic for in-patients to treat possible sepsis or other medical
conditions
i.If the child is severely ill (apathetic, lethargic) or has complications
(hypoglycaemia, hypothermia, raw skin/fissures, meningitis, respiratory
tract or urinary tract infection) give IV/IM Ceftriaxone 100mg/kg/day
37

38. ii.If the child has medical complications but not seriously ill, give IV/IM
Ampicillin: 50mg/kg IM/IV 6-hourly for 7 days AND Gentamicin:
7.5mg/kg IM/IV once daily for 7 days.
c.Oral antibiotic is recommended for children not requiring admission or children
with no medical complications
i.Give oral Amoxicillin15mg/kg 8-hourly for 5 days
ii.If a child fails to improve after 48 hours, search for new infection, then
change to Ceftriaxone 100mg/kg daily IM/IV for 5-7 days (or guided by
local microbiological flora). NOTE:
d.Treat fungal infection
i.oral thrush with nystatin drops
ii.give fluconazole for systemic candidiasis
e.Avoid steroids as these depress immune function.
f.Give measles vaccine if due.
g.Continue use of cotrimoxazole to prevent PCP pneumonia if indicated.
h.Treat for intestinal infestation (parasitic worms) once stable:
i.1-2 yrs old or < 10kg, Mebendazole 100mg po bd for 3 days
ii.> 2 yrs and > 10kg, Mebendazole 500mg po single dose
i.Investigate for TB. Do Tuberculin Skin Test and read it within 48 hours. Record
the findings.
j.Counsel and Test for HIV.
38

39. 5.Anaemia
a.Indication for transfusion
i.Hb ≤ 4 g/dl
ii.Hb < 6 g/dl with respiratory distress
iii.Septic shock
b.Give 10 ml/kg of packed cells or whole blood slowly >3h
c.Transfuse in aliquots is preferable to prevent circulatory overload and
exacerbation of heart failure
d.Blood transfusion should be given within the first day of admission
6.Electrolyte imbalance
a.Do not treat oedema with diuretics and, do not add salt to food and give extra
potassium and magnesium as added mineral and vitamins in feeds or as
supplements
b.Children is on stabilizing feed with added minerals and vitamins (CMV) will
receive the necessary Potassium, Magnesium, Copper and Zinc within their feeds
daily
c.Or give daily:
i.Potassium (4mmol/kg/day body weight) as Oral Mist Pot Chlor (MPC)
solution: MPC 1ml/kg 8 hourly (1ml=1mmol K+)
ii.Magnesium (0.4-0.6mmol/kg/day) individually as single IM injection of
50% magnesium sulphate (0.3ml/kg body weight) to a maximum of 2ml or
1ml of 2% MgS04 daily mixed with food.
iii.Trace element mix (contains MgSO4 280mg/ml, ZnSO4 36mg/ml, CuSO4
0.1mg/ml,) daily orally.
7.Micronutrient deficiencies
a.Vitamin A
i.Give high dose Vitamin A orally on day 1.
If < 6 months give 50,000 units
39

40. if 6-11 months give 100,000 units
and if 12-59 months give 200,000 units.
ii.If the child has any signs of vitamin A deficiency (eye changes:
xeropthalmia/drying of the eye), repeat this dose on day 2 and day 14.
iii.Children with severe measles should receive vitamin A on days 1,2 and 14
iv.Or provide about 5000 IU vitamin A as daily recommended intake
throughout treatment, either as an integral part of therapeutic foods or as
part of a multi-micronutrient formulation
v.Do not give high dose of vitamin A as a supplement if they are receiving
F-75, F-100 or ready-to-use therapeutic food that complies with WHO
specifications (and therefore already contains sufficient vitamin A), or
vitamin A is part of other daily supplements
b.Folic acid
i.Give Folic acid 5 mg on day 1 and then 2.5mg daily orally
ii.Folic acid is in CMV, if CMV is used in feeds then give only the 5mg
dose of day 1
c.Zinc
i.If CMV or TEM not available then give Zinc 2mg/kg/day
d.Copper
i.If CMV or TEM not available then give copper sulphate solution 0.3mg
Cu/kg/day.
e.Iron
i.Start iron 3mg/kg/day when you change to the F100 catch-up formula.
ii.DO NOT GIVE IRON IN THE INITIAL & STABILISATION PHASE
EVEN IF ANAEMIC
NB: Children on Stabilizing feed with CMV will receive the necessary Potassium,
Magnesium, Copper and Zinc within their feeds, or
f.If CMV is not used give daily orally trace element mix (TEM) (ZnSO4 36mg/ml,
CuSO4 0.1mg/ml, MgSO4 280mg/ml):
40

41. i.2.5ml if weight up to 10kg
ii.5ml if weight ≥ 10kg
8.Feeding
a.Initial or Stabilization phase: F75
i.Give stabilizing feed (F75- feeding chart for volumes).
ii.Provides energy: 100kcal/kg/day and Protein: 0.9g /kg/day.
iii.The fluid requirement is 130ml/kg/day.
iv.Give 8-12 feeds over 24 hours.
v.Monitor intake and output (vomiting, diarrhoea, urine output) in Feed
Chart/Fluid Balance Charts. Keep a 24-hour intake chart.
vi.Measure feeds carefully. Record leftovers.
vii.If the child has gross oedema (oedema 3+), reduce the volume to 100
ml/kg/day (see F75 feed chart for gross oedema for volumes)
viii.If the child has poor appetite, encourage the child to finish the feed.
 If not finished, keep the leftovers and re-offer later.
If less than 80% of the amount offered is not taken, insert a
nasogastric tube to feed the child.
If in doubt, check feeding chart for intakes
ix.If the child is breastfed, encourage continued breastfeeding.
x.Weigh daily and plot weight daily
b.Rehabilitation phase:
i.Children have been stabilized, have appetite and reduced oedema,
transition over 2-3 days as tolerated to F100 at 100-135 kcal/kg/day
ii.Transition to catch-up feed (F100) as soon as appetite has returned
(usually within one week) and/or oedema is lost or is reduced.
iii.F100 provides energy: 150-220Kcal/kg/day and Protein: 4-6 g/kg/day.
iv.Transition Phase:
For 2 days, replace F75 with the same amount of F100.
41

42. On day 3, increase each feed by 10ml until some feed remains.
v.Give 8 feeds over 24 hours.
vi.As the child is eager to eat, progress to 5 feeds of F100 and 3 specially
modified family meals, high in energy and protein.
vii.Ready-to-Use Therapeutic Food (RUTF) may be introduced and given at
discharge for catch-up growth.
viii.Encourage the child to eat as much as possible, so that the child can gain
weight rapidly. If the child has finished everything, offer more and
increase subsequent feeds. Make sure that the child is actively fed.
ix.Involve the mother/caregiver in the feeding all the time.
x.Weigh daily and plot weight daily. Use daily weight chart for recording
and monitoring weight changes.
NB: F75 contains 75 kcal or 315 kJ/100 ml and F100 contains 100kcal or 420 kJ/100ml of feeds
9.Discharge and follow-up:
a.Discharge from treatment: when there are signs of improvement: good
appetite, infection resolved, oedema resolved AND consecutive weight gain
for 5 days
i.weight-for-height/length is ≥–2 Z-score and they have had no oedema
for at least 2 weeks, or
ii.mid-upper-arm circumference is ≥125 mm and they have had no
oedema for at least 2 weeks.
iii.The anthropometric indicator that is used to confirm severe acute
malnutrition should also be used to assess whether a child has reached
nutritional.
iv.Percentage weight gain should not be used as a discharge criterion.
b.Infants < 6 months of age and have been admitted to inpatient care can be
transferred to outpatient care when:
i.all clinical conditions or medical complications, including oedema, are
resolved, and
42

43. ii.the infant has good appetite, is clinically well and alert, and
iii.weight gain on either exclusive breastfeeding or replacement feeding is
satisfactory, e.g. above the median of the WHO growth velocity
standards or more than 5 g/kg/day for at least 3 successive days
iv.the infant has been checked for immunizations and other routine
interventions, and
c.Give health and nutritional education.
i.Issue mother/caregiver with the Family Booklet for Child Health.
ii.Share educational messages about the child and self or example,
Family Practices booklet containing information on when to return
urgently to Clinic, hygiene, infant feeding and complementary feeding
advice, stimulation, family planning, HIV, immunization, role of male
partner.
iii. Work with Dietician to counsel mothers/caregivers on how to modify
family foods, how often to feed and how much to give.
d.Follow-up
i.Ensure child is enrolled on nutrition programme at local clinic or child
returns to hospital outpatient in one week.
ii.Child should be reviewed periodically for signs of improvement
VASOOCCLUSIVE PAIN MANAGEMENT PROTOCOL IN CHILDREN WITH
SICKLE CELL DISEASE
43

44. Acute Pain Management
• Rapid assessment of pain intensity

0 1 2 3 4 5 6 7 8 9 10

No Pain Mild Pain Moderate Pain Severe Pain
Mild Pain
• Paracetamol 10-20mg/kg/dose 6 to 8hly with/without Ibuprofen 5-10mg/kg /dose 8hrly
• Dihydrocodiene 1mg/kg 8hrly
• Encourage adequate oral fluid intake
• If no acute complication, discharge home on oral analgesics.
Moderate to Severe pain
• Morphine 0.1 mg/kg IV x1 (max 10 mg)
 If no pain relief then give 0.025 – 0.05 mg/kg IV every 30mins up to 2 subsequent doses
If Morphine is not available give
Pentazocine 0.5mg/kg/dose 6 to 8 hourly:
 Children 5-8 years 15mg/ dose 6 to 8 hourly dose
44

45.  8-14 years 30mg/dose every 6-8 hours
• If adequate pain relief achieved by ≤2 doses of parenteral morphine, prescribe oral
morphine 0.2-0.5 mg/kg PO q4-6h prn; Start: 0.3 mg/kg PO q3-4h prn
• IM Diclofenac 1mg/kg after opoids
• IV Tramadol 1 mg/kg/dose 1-2 hrs after NSAIDs
• IV Fluid 5% D/W or 4.3% dextrose in 0.18 % saline
• Reassess pain relief and sedation every 15-30-60 minutes of each analgesic
administration.
• Monitor vital signs: Respiratory rate and oxygen saturation: every hour30 min until pain
is controlled and patient is stable; then every 2 hours.
• Incentive spirometer (or encourage patient to blow balloon): 10 inspirations q2hrs
• If patient has nausea/vomiting, administer Ondansetron 0.15 mg/kg stat. Repeated doses
may be given as necessary.
• Identify and treat the precipitating cause of the pain crisis
Basic Laboratory investigations
□ Malaria Parasites
□ FCBC
□ Reticulocyte count
□ Urinalysis
45

46. □ Transfuse If hemoglobin <6g/dl or ≥ 2g below baseline
Discharge Criteria & Instructions
□ Adequate pain relief on oral analgesics
□ Afebrile
□ Resolution of any pulmonary symptoms
□ Documentation of no supplemental O2 need.
□ Stable/baseline hemoglobin and reticulocyte levels
□ No evidence of enlarging spleen.
□ Encourage patients to go back to school the day after being off of all morphine.
□ Arrange for out-patients follow up clinic visit within 7-14 days of discharge.
□ Prescribe laxatives (e.g. Lactulose 1ml/kg/dose PO BD) for prevention of opioid-induced
constipation
References
1. Okpala I. The management of crisis in sickle cell disease. Eur J Haematol.1998;60(1):1-6
2. Federal Ministry of Health, National Guideline for the control and management of sickle
cell disorder 2013, available @ www.health.gov.doc.SCDGuideline.com. Accessed November
7th, 2015.
46

47. 3. Michael R DeBaun, MD, MPH, Elliott P Vichinsky, MD. Acute pain management in
adults with sickle cell disease. Uptodate. February 2013
4. Platt OS, Thorington BD, Brambilla DJ, et al. Pain in sickle cell disease. Rates and risk
factors. N Engl J Med 1991; 325:11.
5. Okpala I, Tawil A. Management of pain in sickle-cell disease. J R Soc Med 2002;
95:456.
6. Meiring M (2009). Guidelines for managing pain in children. Adcock Ingram, South
Africa.
ACUTE CHEST SYNDROME (ACS)
I. DEFINITION
Acute chest syndrome (ACS) - presence of new infiltrates on chest radiograph with one or more
of the following clinical signs:
 Fever >38.50C
 Chest pain,
 Respiratory symptoms like cough, dyspnoea or
 Lung abnormalities on auscultation (reduce breath sounds, crepitation, bronchial
breathing).
 Decrease in oxygen saturation < 95% or > 4% baseline or Increase in oxygen requirement
II.RISK FACTORS
 Hb SS or Sβo
47

48.  Young age
 History of ACS or Asthma
 High steady state Hb and/or WBC count
 Low fetal haemoglobin (HbF) level
III.INITIAL ASSESSMENT/ WORK UP
 Chest radiograph
 FBC, reticulocyte count
 E&U Cr.
 Blood culture
 Urine MCS
 LFTs
 GXM 25ml/kg AA genotype blood
IV.MANAGEMENT
Admit all cases of suspected ACS
Consider simple transfusion if:
 Hb < 76g/dl or >2g/dl decrease from baseline (steady state)
Consider Exchange Blood Transfusion (EBT) if:
 Worsening of respiratory symptoms
48

49.  Lack of clinical improvement with simple transfusions
 Hemoglobin at baseline > 7gm/dl
Subsequent management
1. Monitoring:
 4 hourly vital signs including SaO2
 Maintain oxygen saturation > 92%
 Ten Incentive spirometry attempts ALTERNATIVELY encourage patients to blow
balloon every 2 hours
 Commence empiric antibiotics (Cephalosporin + Macrolide)
(1) Ceftriaxone 50-100mg/kg/day
(2) Azithromycine 10mg/kg/day X 5days OR Erythromycine 40-50mg/kg/day, orally,
divided every 6 hours for 7 days
IVF 5% Dextrose with 0.45% saline + oral intake should be kept at approximately 1.5 –
2L/M2 /day
Pain management preferably with Morphine (As per pain management protocol)
Encourage ambulation/activity daily
- SalbutamolAlbuterol nebulizer therapy and steroids should be given to patients with prior
history of asthma.
Transfer to ICU/ PICU if:
49

50.  Decreasing level of consciousness.
 Decreasing oxygen saturations (measured by pulse oximetry) on air.
 Increasing oxygen requirements to maintain 100% oxygen saturations, or failure of
oxygen to correct saturations.
 Increasing tachypnoea.
 Increasing pain.
 Increasing shadowing on chest x-ray.
 Falling haemoglobin, increasing white cell count.
Discharge criteria
 Resolution of respiratory distress
 Resolution of fever and chest pain for at least 12 hours
 Decrease oxygen requirement
REFERENCES:
1. Vichinsky E, Gladwin MT. Pulmonary complications of sickle cell disease. NEJM 2008;
359 (21): 2254-2265.
2. Melton CS, Haynes J. Sickle acute lung injury: Role of prevention and early aggressive
intervention strategies on outcome. Clin Chest Med 2006; 27: 487-502.
3. Johnson, CS. The acute chest syndrome. Hematol Oncol Clin N Am 2005; 19: 857-879.
50

51. 4. Bernard AW, Zahida Yasin Z, Venkat A. Acute Chest Syndrome of Sickle Cell Disease.
Hospital Physician January 2007;44:15-23
5. Platt OS. The acute chest syndrome of sickle cell disease [published erratum appears in N
Engl J Med 2000; 343:591] [editorial]. N Engl J Med 2000; 342:1904–7.
6. Charache S, Scott JC, Charache P. “Acute chest syndrome” in adults with sickle cell
anemia. Microbiology, treatment, and prevention. Arch Intern Med 1979; 139:67–9.
7. Hassell KL, Deutsch JC, Kolhouse JF, et al. Elevated serum levels of free fatty acid in
sickle cell patients with acute chest syndrome and multiorgan failure syndrome. Blood 1994;
84:1633.
8. Castro O, Brambilla DJ, Thorington B, et al. The acute chest syndrome in sickle cell
disease: incidence and risk factors. The Cooperative Study of Sickle Cell Disease. Blood 1994;
84:643–9.
STROKE MANAGEMENT IN CHILDREN WITH SCD
Definitions
51

52.  Stroke - focal neurologic symptoms or signs lasting > 24 hours.
Evaluation of the stroke patient
At presentation with acute stroke
• History suggests focal neurological deficit
• Inform haematology/ oncology unit
Differential diagnosis of acute stroke
• Acute Arterial Stroke (Ischemic Infarct)
• Hemorrhagic Stroke
• Seizure disorder
• Hemiplegic Migraine
• Posterior Reversible Encephalopathy Syndrome
• Cerebral Sinus Venous Thrombosis
Initial evaluation of the stroke patient
• FBC w/differential
• Reticulocyte count
• PT, PTTK
• Grouping and cross-matching of blood for transfusion (HbAA).
• EU&Cr
• HPLC
• Serum Calcium
52

53. • Malaria parasite: Thick and Thin blood films/ Rapid diagnostic test
• Lumbar puncture if meningitis suspected clinically
• Computed tomography (CT) scan of brain (If affordable)
Initial management of the acute stroke patient
• Oxygen administration to keep 02 sat > 95%.
• If febrile, blood culture, antipyretics, and antibiotics
• Monitor and maintain normal BP
Blood transfusion therapy: Simple or Exchange
• An exchange transfusion is preferred; however, an initial simple transfusion is
appropriate when evaluating the status of the patient, followed shortly thereafter by an exchange
transfusion.
• Refer to Exchange Transfusion Guide when indicated
• Surgical consultation in cases of Hemorrhagic Stroke
PROTOCOL ON EXCHANGE BLOOD TRANSFUSION
Indication for EBT in Children with SCD
1. Stroke
2. Severe Acute chest syndrome
3. Multi-organ failure including systemic fat embolism
4. Prevention of recurrent stroke
5. Prior to surgery requiring general anaesthesia.
53

54. Relative indications are
1. Intractable or very frequent severe crises
2. Major priapism unresponsive to other therapy.
PREPARATION FOR EBT
1. Discuss objective with patient/parents.
2. Obtain informed consent and body weight
3. Coagulation screening to detect any bleeding tendency
4. Blood chemistry including calcium level and FBC
5. Group and cross-match
MATERIALS NEEDED
1. Six (6) wide bore cannulae
2. 1-2 units of paediatric saline
3. Blood and infusion giving sets (2 each)
4. 5 pieces of 20ml needle and syringes
5. 5 ampoules of sterile water for flushing
6. 4 pairs of sterile gloves
7. Container for blood collection and disposal
8. Screen
9. Machintosh
MANUAL EBT
45ml/kg of compatible AA genotype packed RBC is required for the procedure.
54

55. PROCEDURE
1. Document vital signs prior to commencement.
2. Secure at least two peripheral lines with wide-bore cannula depending on the age of the
child
3. If PCV is less than 21% (Hb 7g/dl) give additive transfusion 10 – 15mls/kg of packed red
cells before the EBT.
4. Give 15ml/kg of Paediatric saline over 30min
5. Drain 15ml/kg of venous blood over 30 min
6. Give another 15ml/kg of paediatric saline over 30 min
7. Drain another 15ml/kg of patients’ blood over 30 min
8. Transfuse with 10ml/kg of packed RBCs over 1 hour
9. Drain the third 15ml/kg of venous blood over 30min
10.Finally, transfuse 35ml/kg of packed cells over 8-12 hours
For those with PCV<15% additive transfusion aiming at 30% will achieve the same result as
EBT.
If there is evidence of fluid overload after the procedure, give 2mg/kg of frusemide.
POST EBT: monitor vital signs two hourly for 6 hours.
 Temperature
 Pulse rate
 Respiratory rate
 Blood pressure
 Oxygen saturation
55

56. References:
1. VERLHAC S, BERNAUDIN F, TORTRAT D, BRUGIERES P, MAGE K, GASTON
A, REINERT P Detection of cerebrovascular disease in patients with SCD using transcranial
doppler sonography : correlation with MRI, MRA, and conventional angiography. Pediatr
Radiol., 1995,25, S14-S19.
2. BERNAUDIN F, VERLHAC S, FREARD F, et al. Multicenter prospective study of
children with sickle cell disease : radiopsychometric correlation . J Child Neurol. 2000 May ;
15(5) :333-43
3. Dowling MM, Quinn CT, Rogers ZR, Buchanan GR. Acute Silent Cerebral Infarction in
Children with Sickle Cell Anemia. Pediatr Blood Cancer 2010;54:461–464
4. Mussalam KM, Khoury RA, Abboud MR. Cerebral infarction in children with sickle cell
disease: a concise overview. Hemoglobin. 2011;35:618-24.
5. Federal Ministry of Health, National Guideline for the control and management of sickle
cell disorder, 2013
Risk factors for acute priapism in SCD
• Stuttering episodes (<4 hours)
56

57. • Low hemoglobin F levels and high platelet count
• Fever and/or dehydration
Initial evaluation for acute priapism
• Obtain adequate history of priapism
• Determine if acute and/or stuttering episodes
• Baseline FBC, UE,Cr , HPLC if is avoidable
**Do not delay emergency treatment while awaiting test results
Treatment of ischemic priapism
• Duration ><2 hours: patient to
• start oral hydration and
• aAnalgesics (refer to pain management protocol),
• uEncourage patient to Urinate.
• Duration >2 hours:
• Admit
• IV Fluid 5% D/W or 4.3% dextrose in 0.18 % saline 120mls – 150mls/kg/day
• Analgesics,hospitalize commence intravenous fluid and analgesics, use guidelines in
management of VOC.
• Duration > 4 hours:
• call Urology consult for intracavernosal aspiration or shunt placement
- Exchange transfusion, can be considered, but limited evidence of efficacy and caution,
Transfusion if hemoglobin is less than 10g/dL but not to exceed 10g/dl
57

58. Management of recurrent priapism
• Modify risk factors when applicable
• Hydroxyurea- suggested starting dose of 210 mg/kg per day, titrating up to 30 mg/kg as
tolerated.
• Chronic blood transfusion — monthly, chronic blood transfusions to decrease percent Hb
S (40-50%). Not feasible in our setting if feasible
• Parents’ and patient’s counseling
• Erectile dysfunction: referral to Urology for consultation
References:
1. Joshua J Field, MD, Vijaya M Vemulakonda, MD, JD, Michael R DeBaun, MD, MPH.
Diagnosis and management of priapism in sickle cell disease. Uptodate: Apr 10, 2013.
2. Aboseif SR, Lue TF. Hemodynamics of penile erection. UrolClin North Am 1988; 15:1.
3. American Urological Association website: www.auanet.org/content/guidelines-and-
quality-care/clinical-guidelines.cfm?sub=priapism (Accessed on August 05, 2009).
4. Montague DK, Jarow J, Broderick GA, et al. American Urological Association guideline
on the management of priapism. J Urol 2003; 170:1318.
5. Champion HC, Bivalacqua TJ, Takimoto E, et al. Phosphodiesterase-5A dysregulation in
penile erectile tissue is a mechanism of priapism. ProcNatlAcadSci U S A 2005; 102:1661.
6. Adeyoju AB, Olujohungbe AB, Morris J, et al. Priapism in sickle-cell disease; incidence,
risk factors and complications - an international multicentre study. BJU Int 2002; 90:898.
GUIDELINES FOR MANAGEMENT OF ACUTE SPLENIC SEQUESTRATION IN
CHILDREN WITH SICKLE CELL DISEASE.
58

59. Splenic Sequestration is defined as sudden enlargement of the spleen and reduction in Hb
concentration by at least 2g/dL below the baseline value. Occurs primarily in infants and can
occur as early as 5 weeks of age.
Aetiology:
Unknown
Clinical / Laboratory Features:
Splenomegaly/ abdominal Pain ( left upper quadrant)
Increased reticulocytes count, plus or minus thrombocytopenia ( < 50,000/mm3 )
Tests :
FBC and differentials
Reticulocyte count
GxM blood type
O2 Saturation
Treatment :
Conduct a history and physical exam with emphasis on signs and symptoms of
Cardiovascular collapse (shock), anaemia, and hypovolemia.
Reset I V-line
Maintain hemodynamic stability using isotonic fluid.
If blood is required, typically 5mL/ kg of packed red blood cells(RBCs) is given.
When there is evidence of rising Hb and diminishing spleen size, the patient can be
discharged.
Follow up appointment with sickle cell team should occur within two weeks of
discharged.
Teach the parents and primary caregivers how to palpate to the spleen to determine if it is
enlarging.
References:
1.Nelson Textbook of Paediatrics 20
th
Edition Page 2338
59

60. 2.Management of Acute Complications of Sickle Cell Disease Timothy McCavit,
MD, MSCS University of Texas Southwestern Medical Center. Payal Desai, MD The
Ohio State University, the James Cancer Center
3.Edmond AM, Collis F, Darvill D, et al. Acute splenic sequestration in homozygous
sickle cell disease: natural history and management. J Pediatr. 1985;107(2):201-06
4. National Heart, Lung, and Blood Institute. Evidence-based management of sickle cell
disease: Expert panel report, 2014
5. Powell RW, Levine GL, Yang YM, et al. Acute splenic sequestration crisis in sickle
cell disease: early detection and treatment. J Pediatr Surg. 1992;27(2):215-19.

BLOOD AND BLOOD PRODUCTS TRANSFUSION GUIDELINES
60

61. SEVERE ANAEMIA
Is defined as Haematocrit of ≤ 15% or Haemoglobin of ≤ 5G/dl
Give blood transfusion as soon as possible to:
Children with a haematocrit of ≤15% or Hb of ≤ 5G/dl
Less severely anaemic children (haematocrit 15–18%; Hb 5–6 g/dl) with any of the following
clinical features:
1) Clinically detectable dehydration
2) Shock
3) Impaired consciousness
4) Heart failure
5) Deep and laboured breathing
6) Very high malaria parasitaemia (>10% of red cells with parasites).
Note please: For children with haematocrit of 15-18% with dehydration, the PCV should be
repeated after correction of dehydration.
COMMON CAUSES OF SEVERE ANAEMIA IN THE ENVIROMENT
1) Severe malaria
2) Haemoglobinopathies
3) Malnutrition
4) Gastrointestinal bleeding
5) Infections (Acute and Chronic)
6) Chronic kidney disease
7) Malignancies
61

62. INDICATIONS FOR BLOOD TRNSFUSION
There are five general indications for blood transfusion:
1) Acute blood loss, when 20–30% of the total blood volume has been lost and bleeding is
continuing
2) Severe anaemia
3) Severe sepsis
4) Septic shock (if IV fluids are insufficient to maintain adequate circulation
and in addition to antibiotic therapy)
5) To provide plasma and platelets for clotting factors, if specific blood components are
not available
6) Exchange transfusion in neonates with severe jaundice or children with sickle cell
anaemia associated with certain forms of crises
INDICATIONS FOR WHOLE BLOOD TRANSFUSION
1) Red cell replacement in acute blood loss with hypovolaemia
2) Exchange blood transfusion
3) Patients needing red cell transfusions where red cell concentrates or suspensions are not
available
Whole blood transfusion is rarely required what is recommended is to give the component that is
lacking e.g. packed cells.
In severely malnourished children, fluid overload is a common and serious complication. Give
packed cells where available or whole blood, 10 ml/kg body weight (rather than 20 ml/kg), once
only and do not repeat the transfusion
62

63. PROCEDURE/ STEPS OF BLOOD TRANSFUSION
Calculate the required volume of packed cells or whole blood to be transfused.
Formular for packed cells transfusion -:
Desired Hb (g/dl) – Actual Hb (g/dl) x Weight (kg) x 3
Formular for whole blood transfusion-:
Desired Hb (g/dl) – Actual Hb (g/dl) x Weight (kg) x 6
Transfuse packed cells or whole blood over 3-4 hours
Storage of blood
1) Use blood that has been screened and found negative for transfusion transmissible infections.
Do not use blood that has passed its expiry date or has been out of the refrigerator for more than
2 hours. Large volume rapid transfusion at a rate >15 ml/kg/hour of blood stored at 4 °C may
cause hypothermia, especially in small babies.
Problems with blood transfusion
Blood can be the vehicle for transmitting infections (e.g. Malaria, Syphilis, Hepatitis B and C,
HIV). Therefore, screen donors for as many of these infections as possible. To minimize the risk,
only give blood transfusions when essential.
Before transfusion, check the following:
1) The blood is the correct group and the patient’s name and number are on both the label and
the form (in an emergency, reduce the risk of incompatibility or transfusion reactions by cross-
matching group-specific blood or giving O-negative blood if available). If possible cross check
with another nurse or doctor in the ward.
2) The blood transfusion bag has no leaks
3) The blood pack has not been out of the refrigerator for more than 2 hours, the plasma is not
pink or has large clots, and the red cells do not look purple or black
63

64. 5) Obtain pre-transfusion vital signs (temperature, respiratory rate and pulse rate).
6) Give 1mg/kg of furosemide IV at the start of the transfusion in children whose circulating
blood volume is normal.
5) Record the time the transfusion was started, ended and the volume of blood transfused.
During transfusion:
1) If available, use an infusion device to control the rate of the transfusion
2) Check that the blood is flowing at the correct speed
3) Look for signs of a transfusion reaction (see below), particularly carefully in the first 15
minutes of the transfusion
4) Record the child’s general appearance, temperature, pulse and respiratory rate every
30 minutes
5) Monitor during transfusion for signs of
• Cardiac failure
• Fever
• Respiratory distress
• Tachypnea
• Hypotension
• Acute transfusion reaction
• Shock
• Haemolysis (jaundice, hepatosplenomegaly)
• Bleeding due to DIC
After transfusion:
64

65. Reassess the child. Do a post transfusion PCV. If more blood is needed, a similar quantity
should be transfused and the dose of furosemide repeated.
Transfusion reactions
If a transfusion reaction occurs, first check the blood pack labels and patient’s identity. If there is
any discrepancy, stop the transfusion immediately and notify the blood bank.
Mild reactions (due to mild hypersensitivity)
Signs and symptoms:
Itchy rash
Management:
1) Slow the transfusion
2) Give chlorphenamine 0.1 mg/kg IM, if available or give IV promethazine
0.5mg /kg and IV Hydrocortisone 5mg/kg
3) Continue the transfusion at the normal rate if there is no progression of symptoms after
30 minutes
4) If symptoms persist, treat as moderate reaction (see below).
Moderately severe reactions (due to moderate hypersensitivity, non-haemolytic reactions,
pyrogens or bacterial contamination)
Signs and symptoms:
1) Severe itchy rash (urticaria)
2) Flushing
3) Fever >38 °C or >100.4 °F (Note: fever may have been present before the transfusion)
4) Rigors
65

66. 5) Restlessness
6) Tachycardia
Management:
1) Stop the transfusion, but keep the IV line open with normal saline
2) Give IV 200 mg hydrocortisone and IV Phenergan 25mg, or Chlorphenamine 0.1 mg/kg IM,
if available
3) Give a bronchodilator, if wheezing
4) Send the following to the Blood Bank: the blood-giving set that was used, blood sample from
another site, and urine samples collected over 24 hours.
5) If there is improvement, restart the transfusion slowly with new blood and observe carefully
6) If no improvement in 15 minutes, treat as life-threatening reaction (see below).
Life-threatening reactions (due to haemolysis, bacterial contamination and septic shock, fluid
overload or anaphylaxis)
Signs and symptoms:
1) Fever >38 °C or >100.4 °F (note: fever may have been present before the transfusion)
2) Rigors
3) Restlessness
4) Tachycardia
5) Tachypnea
6) Black or dark red urine (haemoglobinuria)
7) Unexplained bleeding
8) Confusion
66

67. 9) Collapse.
Note that in an unconscious child, uncontrolled bleeding or shock may be the only signs of a life-
threatening reaction.
Management:
1) Stop the transfusion, but keep the IV line open with normal saline
2) Maintain airway and give oxygen
3) Give epinephrine (adrenaline) 0.01 mg/kg body weight (equal to 0.1 ml of
1 in 10 000 solution
4) Treat shock
5) Give IV 200 mg hydrocortisone and IV Phenergan 25mg or Chlorpheniramine 0.1 mg/kg IM,
if available
6) Give a bronchodilator, if wheezing
7) Maintain renal blood flow with IV furosemide 1 mg/kg
9) Give antibiotic as for septicaemia
PLATELET CONCENTRATE
1. Treatment of bleeding due to
• Thrombocytopenia
• Platelet function defect
2. Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure
DOSAGE- 1 Unit raises the platelet concentrate by 20-40 x 109/L
FRESH FROZEN PLASMA
INDICATIONS FOR FFP
67

68. 1. Replacement of multiple coagulation factor deficiency
• Liver disease
• Warfarin anticoagulant overdose
• Depletion of coagulation factors in patients receiving large volume transfusions
2. Disseminated intravascular coagulation (DIC)
3. Thrombotic thrombocytopenic purpura (TTP)
DOSAGE- 15mls/kg
CRYOPRECIPITATE
INDICATIONS FOR CRYOPRECIPITATE
1. As an alternative to factor VIII concentrate in treatment of inherited deficiencies of
• Von Willebrand disease
• Factor VIII
• Factor IX
2. As a source fibrinogen in acquired coagulopathies e.g DIC
FACTOR VIII CONCENTRATE
INDICATIONS FOR FACTOR VIII CONCENTRATE
1. Treatment of haemophilia A
2. Treatment of von Willebrand disease
Dosage:-
Hemarthrosis/ muscle or significant subcutaneous hematoma/ Epistaxis – 20 units/kg if
haemorrhage is severe repeat dose the following day and consider additional treatment every
other day until the joint normalises/ bleeding resolves.
68

69. Major surgery, life threatening haemorrhage- 50 units/kg, then 25 units/kg every 12hr until
asymptomatic, then 20unit/kg every other day until bleeding resolves
Alternatives to factor VIII concentrate – Cryoprecipitate, fresh frozen plasma
PROTHROMBIN FACTOR CONCENTRATE AND FACTOR IX CONCENTRATE
INDICATIONS
1. Treatment of haemophilia B
2. Immediate correction of very prolonged Prothrombin time
Dosage:-
Hemarthrosis – 30units/kg
Major surgery, life threatening haemorrhage - 80 units/kg then 20-40 units/kg every 12-24hrs
until bleeding resolves.
Alternative to factor IX concentrate - Plasma
Note:
 With recombinant products, a dose of one unit/kg should increase the Factor VIII level by
1.5 to 2.0% and Factor IX level by 1.0%.
 The half-lives for the first doses of Factors VIII and IX are 6 – 8 hours and 4 – 6 hours
respectively. Of 18 – 24 hours.
 With subsequent doses, Factor VIII has a half-life of 8 – 12 hours, while Factor IX has a
half-life of 18 – 24 hours.
 Thus, for serious bleeding, the second dose of Factor VIII should be given 6 – 8 hours
after the first while for Factor IX, 4 – 6 hours after the first.
 Subsequent doses are usually given every 12 hours for Factor VIII and every 24 hours for
Factor IX.
69

70. ADMINISTRATION
1. Whole blood and Red blood cells
• Must be ABO and Rh compatible
• Complete transfusion within 4 hours of commencement
• Never add medications to a unit of blood
2. Platelet concentrate
• After pooling platelet concentrates should be infused as soon as possible generally within
4 hours because of the risk of bacterial proliferation
• Must not be refrigerated before infusion as this reduces platelet function
• Should be infused through a fresh standard blood administration set
3. Fresh frozen plasma
• Must be ABO- compatible
• No cross matching needed
• Before use must be thawed in water which is between 30°C and 37°C. Higher
temperatures will destroy clotting factors and proteins
• Once thawed should be stored in a refrigerator at 2° - 6°C
• Infuse using a standard blood infusion set as soon as possible after thawing
• Labile coagulation factors rapidly degrade, use within 6 hours of thawing
4. Cryoprecipitate
• If possible use ABO- compatible products
• No compatibility testing is needed
• After thawing infuse as soon as possible through a standard blood administration
70

71. • Must be infused within 6 hours
Factor VIII and IX concentrates
• Reconstitute according to manufacturer’s instructions
• Once the powder is dissolved the solution should be drawn up using a filter paper needle
and infused through a standard infusion set within 2 hours
References
1. The clinical use of blood in medicine, obstetrics, paediatrics, surgery and anaesthesia,
trauma and burns. World Health organization blood transfusion safety Geneva.
2. The anaemias Ifeoma Emordi In: Azubuike JC and Nkanginieme KEO editors.
Paediatrics and child health in a tropical region. 2nd ed. Owerri, Nigeria: African Educational
services; 2007.p.355-363.
3. Practical Pediatric hematology 2nd Edition Anupam Sachdeva
4. Severe anaemia in Zambian children with Plasmodium falciparum malaria. Trop Med Int
Health. 2000 Jan;5(1):9-16.
ESSENTIAL/ BASELINE INVESTIGATIONS FOR CHILDREN WITH SUSPECTED
MALIGNANCY
1. Tissue Biopsy/ Fine needle Aspiration Cytology
2. Bone marrow Aspiration Cytology
3. Complete Blood Counts*
71

72. 4. Blood Film*
5. Erythrocytes Sedimentation Rate (ESR)*
6. Haemoglobin Electrophoresis*
7. Electrolytes, Urea and Creatinine (EUCr)*
8. Liver Function Tests (LFTs)*
9. Serum Calcium and Phosphate*
10.Cerebrospinal Fluid Analyses (Tumour cells, protein, sugar)
11.Retroviral Screening*
12.Hepatitis serology
13.Chest Radiograph*
14.Abdominal Ultrasonography
* Indicated for all patients with suspected malignancy
Others as appropriate depending on the nature of presentation
PRACTICAL NOTES
1. Chemotherapy should be administered on weekdays, when trained staff is on duty to
reduce the risk for errors.
2. Chemotherapy must not be given unless the total white cell count is ≥ 1.0 × 109/L.
3. Chemotherapy must be delayed if the patient has fever.
72

73. 4. Chemotherapy drugs must be mixed in a quiet, separate room with a hood above the
mixing surface, and the mixer should wear protective clothing.
5. A clinical photograph provides a record and assists in follow-up.
6. Chemotherapy is also commenced in critically ill patients.
7. Good control of drug stocks prevents shortages and waste.
8. Vincristine sulfate causes irreversible fatal encephalopathy if injected intrathecally
inadvertently.
9. The IT MTX and IT HC should not be administered at the same time as the IV vincristine
to avoid this.
10.The cost of treatment should be guaranteed when treatment starts.
NB. For the management of various types of malignancy, please refer to the unit protocol for
childhood cancers.
POISONING
KEROSENE POISONING
Main danger is aspiration pneumonia and all its complications- collapse, pneumothorax
and pleural effusion.
 Fatal dose of 30ml-fatality occurs within 24 hours depend on amount ingested.
Resuscitate patient
 A= Ensure airway is patent, clear secretions,
Use guedel airway if tongue is obstructing airway.
73

74. B= Ensure patient is breathing-if not, give rescue breaths by bag and
mask.
If oxygen saturation is <92% give oxygen.
 If breathing but not adequate initiate CPAP,
 if not responding intubate and needs respiratory support,
contact ICU.
C=Ensure adequate circulation- Obtain venous access using a wide
bore cannula,
if in shock, give normal saline 20mls/kg, reassess
check random blood sugar, if 2.2mmol and below, give 10%
dextrose water 2-4mls/kg,
 If convulsing, abort with intravenous diazepam 0.1-0.3mg/kg
or rectal diazepam 0.5mg/kg.
Take blood samples for full blood count, electrolytes, chest x-ray
which may be normal especially in the early stages.
Check vital signs- PR, RR, temperature, oxygen saturation, blood
pressure and conscious level.
Observe all patients with kerosene ingestion for any sign of kerosene
toxicity, for at least 6 hours.
Take a detailed history
Amount ingested
Time ingested and duration from ingestion to presentation in hospital
First aid given before presentation
Any previous episodes in patient or siblings.
Background medical condition.
Do a detailed physical and systemic examination, looking for clinical
features
Local-Irritation of the oral mucosa, nausea, vomiting, abdominal discomfort
Choking
Respiratory distress- can progress to respiratory failure
Pyrexia- common, may persist 7-10 days. Symptoms can worsen over next 24
hours.
Headache
Euphoria
Lethargy/drowsiness
Restlessness
Muscle twitching
Seizures
Coma
Crepitations with rhonchi on chest examination
74

75. Cardiac arrhythmias
Haemolytic anaemia
Acute kidney injury
Hepatotoxicity
Bone marrow suppression.
Gastric lavage is contraindicated except for large volume ingestions >1ml/kg,
if the kerosene is mixed with pesticide, heavy metal and other toxic
substance.
Monitor vital signs closely
Antibiotics
Prophylactic antibiotics are not recommended
Indications include-proven/highly suspected bacterial pneumonia,
superimposed/pre-existing infection, severely malnourished child,
immunocompromised, child with restricted respiratory reserve.
Steroids-may enhance risk of superadded infection, hence not
recommended
Bronchodilators- if there are features of bronchospasm. Use nebulised
salbutamol.
Ensure daily fluid maintenance is achieved either orally or parenterally.
Ensure adequate feeding orally or via nasogastric tube
Counsel parents/ caregiver about prevention strategies to prevent re-
occurrence
ORGANOPHOSPHATE POISONING
Organophosphates and carbamates are used extensively in agriculture. They are sometimes
mixed with kerosene to kill insects and house hold rats. They are available as liquids, dusts and
granules and can be absorbed by transdermal, transconjuctival, inhalational and through direct
ingestion.
Symptoms and signs
1.Muscarinic/parasympathetic manifestations
75

76. SLUDGE- Salivation, Lacrimation, Urination, Diarrhea,
Gastrointestinal distress, Emesis.
DUMBELS- Diaphoresis, Diarrhea, Urination, Miosis,
Bradycardia, Bronchospasm, Bronchorrhea, Emesis,
Lacrimation, Salivation.
2.Nicotinic/ autonomic ganglionic effects
Muscle fasciculation, cramping, weakness, twitching, diaphragmatic failure,
hypertension, tachycardia, mydriasis, pallor.
3.Central nervous system effects
Restlessness, headache, drowsiness, convulsions, ataxia, slurred speech,
chyne-stokes respiration, delirium, coma, absent reflexes, psychosis and
death.
Treatment
A-ensure airway is patent
B-ensure patient is breathing adequately
C-ensure circulation is adequate. Secure intravenous access. Look and
treat for hypoglyacemia. Assess and treat for shock. Take samples for
urgent investigation- electrolytes and urea, full blood count, Random
blood sugar, Pack cell volume, calculate anion gap, blood levels for
suspected poison (contact the laboratory).
Take a detailed history-type of compound(ask for container if
available), amount ingested, first aid given, general health of the
patient, duration between ingestion and arrival at hospital etc.
Do a thorough general and systemic examination
REMEMBER ORGANOPHOSPHATE POISONING CAN MIMIC
OTHER DISEASES,SO CONSIDER DIFFERENTIALS
DIAGNOSIS AS WELL
If in doubt of ingestion, do P-nitro phenol test
Treatment depends on severity of exposure
All suspected organophosphate poisoning should be admitted
Do a gastric lavage, remember to protect the airway.
Use activated charcoal-1g/kg
Give atropine –to block muscarinic receptors
0.05-0.2mg/kg intravenous every 5-15 minutes until signs of
atropinization occur (drying up of secretions).
Then adjust dose to 0.02-0.05mg/kg and maintain for at least
24 hours.
Note mydriasis is an early response to atropine and not an end
point of atropinization.
76

77. Use with caution in Down syndrome, those with brain damage,
cardiac arrythmias, hypertension, peritonitis, hepatic diseases,
hiatal hernia, reflex oesophagitis.
Glycopyrrolate –to be substituted-can be used in Down
syndrome, hiatal hernia and hyperthyroidism.
4-10mg/kg intravenous repeated after 3-4 hours, not to exceed
0.2mg/dose and 0.8mg in 24 hours.
Caution as it may produce intra-ocular tension, blurred vision,
cyclopegia, urinary retention.
Pralidoxime (2-PAM)
20-40 mg/kg intravenous dissolved in 0.9% normal saline
solution and infused slowly over 15-30 minutes.
Repeat at 1-2 hours if muscle weakness is not relieved and again
after 8-10 hours.
I.M/SC can be used if I.V is not feasible.
Caution-avoid rapid IV bolus
Pralidoxime for carbamate poisoning use is controversial.
Atropine and 2-PAM can be given together as they are synergistic
against symptoms and signs of cholinesterase inhibition.
Diazepam- for seizures and neuropathy
Supportive care
Sunction PRN
For bronchospasm-give atropine not bronchodilators
Opoids can worsen CNS manifestations
Monitor vital signs closely
Monitor and treat hypoglycaemia.
Give antibiotics to prevent pulmonary infection.
Intubate and ventilate early.
All patients must be followed up and neurologic sequalae should be
looked for.
Counsel parents/caregivers on prevention strategies
Management of Dog bite in children
Dog bite that is provoked rather than unprovoked should not be considered a guarantee
that the dog is not rabid.
A history of rabies vaccination in the dog is not always a guarantee that the biting animal
is not rabid.
Resuscitation/Initial evaluation
A-ensure adequate airway
77

78. B-ensure patient is breathing adequately.
C-assess circulation. Secure vascular assess. Assess and treat shock, assess and
treat hypoglycaemia especially for crush injuries.
Irrigate/ wash wound under running water or using copious amount of tap water or
Normal Saline and soap. Remove any foreign body like teeth. Consider wound
debridement if necessary.
Do a pain assessment and alleviate pain. Use Paracetamol 10mls/kg
Raise/immobilse limb if associated with swelling.
Take a detailed history
Circumstances leading to bite, provoked vs unprovoked
Location of the bite
Vaccination status of the dog
Patient underlying medical condition
Do a thorough physical examination
General appearance
Vital signs
Systemic signs- fever, chills, nausea/vomiting, weakness, pain,
erythema, exudates, oedema.
Associated damage-tendon, nerve, bones, joint.
Inspect wound
Draw/take picture of wound
Length/depth of wound
Classify wound-abrasion, puncture, laceration, avulsion or crush wound.
If infected wound take pus/swab for m/c/s, Pasteurella Multicida is the most
common organism and most virulent organism responsible for infected dog-bite.
If fracture suspected take x-ray of affected site after stabilization
Do not suture wound ,delay closure as much as possible
Give prophylactic/therapeutic antimicrobial agents especially for high risk
wounds
Deep puncture wounds
Wound > 6 hours
Moderate to severe wounds with associated crush injury
Wounds in areas of underlying venous and/or lymphatic compromise
Wounds in the hands, genitalia, face and/or in close proximity to a bone
or joint
Wounds requiring closure
Bite wounds in immunocompromised, absent spleen or splenic
dysfunction and diabetes mellitus
Previously sutured wound
Devitalized tissue
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79. High risk patient- children especially infants/neonates, asplenia,
prolonged steroid therapy, diabetes mellitus.
Use amoxicillin-clavulanic acid /kg, for penicillin sensitive use clindamycin
with Trimothoprin-Sulfamethoxazole or Doxycycline if older than 8 years.
Give antibiotics for 5-7 days if for prophylaxis, and 10-14 days if for
therapeutic use.
Give tetanus toxoid= 0.5ml intra muscular, if wound is infected/ high risk
wound, give anti tetanus serum (ATS)=
Assess for Rabies Risk using WHO guide as below
Category Description Type of
exposure
Action
CAT 1 Licking, touching on
intact skin
None None
CAT 2 Saliva on
scratches
Abrasions on
the skin
without
bleeding
Nibbling of
uncovered skin
Minor Clean wound
Immediate
Rabies
vaccination
Stop vaccine if
animal remains
healthy through
an observation
period of 10
days.
CAT 3 Bites or
scatches that
penetrate the
skin
Exposure of
the eye or
mouth to
saliva from
lick
Exposure to
bats
Severe Clean wound
Immediate
rabies
vaccination
Stop
vaccination if
animal remains
healthy through
an observation
period of 10
days
Immediate
rabies
immunoglobuli
n if available.

4 doses of rabies vaccine, intramuscular on day 0,3 , 7 and 14
79

80. For immunocompromised patients, give on day 0,3,7,14 and 28.
Management of Snake bite in Children
Common snakes in Nigeria are:
carpet viper (Echis carinatus)- poison is usually haemorrhagic haematoxic. Commonest
in west Africa and Nigeria.
Black necked spitting Cobra ( Naja Nigricollis)-bite usually produces local tissue reaction
and bleeding from site of bite. Poison is neurotoxic.
-Puff Adder ( Bitis arientans)- Poison is cytotoxic and causes cardiotoxicity and renal
failure.
Venomous snakes have fangs and usually leave fang marks.
Non-venomous snakes do not have fangs. They instead have small teeth and leave bite
marks similar to that of small rodents.
Also it should be noted that no anti-venom can include the venom of all toxic snakes.
First Aid treatment: use mnemonic Do it R.I.G.H.T.
R-Reassure the patient as sometimes the bite is from a non-venomous snake.
I-Immobilize the limb as for a fractured limb using cloth or bandage to hold the
splints. A small child should be carried. Applying tourniquet is discouraged
instead the limb should be immobilized. The victim should not walk as walking
more than 10 minutes enhances venom circulation.
G.H. - Get to Hospital immediately. Traditional medications have not been shown
to be beneficial
T- Tell the doctor about any systemic symptoms like bleeding, ptosis etc.
Resuscitation/supportive measures
A- Ensure Airway is adequate
B-ensure the patient is breathing.
Circulation- secure vascular access. If hypotensive/shock, give 0.9% Normal
Saline 20mls/kg. If fluid refractory shock, give dopamine infusion. Monitor
mental status, Heart rate, blood pressure, respiratory rate, oxygen saturation
and urine output.
All snake bite victims should be admitted at least for 24 hours unless it’s very
clear that the snake is non-venomous.
Analgesia- to relieve pain. Use Paracetamol 10mg/Kg intravenous. Avoid
NSAIDS as it causes bleeding. Also avoid morphine because of respiratory
depression especially for neurotoxic venoms. Analgesic should be a regular
dosage not on PRN basis.
Avoid Intra muscular injections as it can make the victim susceptible to
haematoma formation.
Give broad spectrum antibiotics especially against anaerobes.
80

81. Ensure prophylaxis against tetanus for all victims of snake bite.
Diagnosis
Take brief history- time of bite, site of bite, circumstances leading to
bite, type of snake (if killed).
 Do Physical and systemic examination- HR, RR, Mental status, BP,
urine output=1ml/kg/hour.
 Check for Systemic signs- bleeding /coagulopathy, neurological signs
like ptosis, convulsions, vomiting, respiratory difficulty
 Check the site of bite- Inspect for local painful swelling, necrosis,
bite/fang marks, bruising.
 Do the 20 minutes whole blood clotting time- It is the standard test for
coagulopathy. Few mls of fresh venous blood is put in a test
tube/sample bottle and left undisturbed for 20 minutes and then gently
tilted, if blood is still liquid, it demonstrates evidence of coagulopathy
and indicates the snake is a viper.
Anti snake venom (ASV)
Indications for use include
Systemic manifestations Local reactions
Spontaneous bleeding Necrosis at bite site-Bitis arietans
Signs of coagulopathy from 20 mins
whole blood clotting test
Rapid progressive swelling around
joint
Hypotension/shock Rapid progressive swelling
involving ½ of the bitten limb
Signs of cardiotoxicity Bites on digits
Rhabdomyolysis
Impaired counsciousness
Neurologic signs like
ptosis,convulsions
Signs of acute kidney injury
Main ASV approved in Nigeria and available in this hospital(check A/E
pharmacy)
Echitab- monovalent anti venom viperine venom 10-20 mls slow IV
injection or as an infusion over 1 hour.
Echitab plus- polyvalent Fab Afrique. Give 40 mls also over 1 hour.
Patients should be closely monitored as anaphylactoid reactions can
occur.
Check for Signs of anaphylactoid reactions
-urticaria -abdominal cramps
81

82. -itching - tachycardia
-fever - hypotension
-shaking/chills - bronchospasms
-nausea - angio-oedema
-vomitting
-diarrhea
If signs occur, discontinue ASV
Give adrenaline 1:1000, 0.01mg/kg
Give hydrocortisone 2mg/kg
Antihistamine 0.2mg/kg
Monitor and Reasses the patient frequently as clinical condition is dynamic and
can change.
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