PEDIATRIC EMERGENCIES

pediatric emergencies: dehydration, trauma, poisoning, foreign bodies and imperf-orate anus

1. PRESENTATION ON PEDIATRIC EMERGENCIES Dehydration Trauma Poisoning Foreign Bodies Imperfofate Anus Presented by: Baby Haokip 2 nd Year MSc (N)

2. children presenting with the following signs should be treated as emergencies: • obstructed or absent breathing, • severe respiratory distress, • central cyanosis, • signs of shock • coma • seizures or, • in a child with diarrhea, any two signs of severe dehydration signs

3. DEFINITION: Critical illness: any severe problem with the airway, breathing or circulation, or acute deterioration of conscious state; includes apnoea , upper airway obstruction, hypoxaemia , central cyanosis, severe respiratory distress, total inability to feed, shock, severe dehydration, active bleeding requiring transfusion, unconsciousness or seizures (W.H.0)

4. EMERGENCY TRIAGE Triage is the process of rapidly screening sick children soon after their arrival in hospital in order to identify: • Those with emergency signs, who require immediate emergency treatment • Those with priority signs, who should be given priority while waiting in the queue so that they can be assessed and treated without delay • Non-urgent cases, who have neither emergency nor priority signs

5. EMERGENCY SIGNS:

6. PRIORITY SIGN:

7. DEHYDRATION: the condition that results from excessive loss of body water. In severe acute malnutrition, dehydration is caused by untreated diarrhoeal disease which leads to the loss of water and electrolytes

8. TYPES OF DEHYDRATION:

9. CAUSES OF DEHYDRATION: Increased sweating from a very hot environment Excessive urination -diabetes insipidus cystic fibrosis or celiac disease -do not allow food to be absorbed and can cause dehydration Burns - blood vessels can become damaged, causing fluid to leak into the surrounding tissues fever, diarrhea, vomiting, and a decreased ability to drink or eat associated with Viral, Bacterial and Parasitic infection

10. CLINICAL MANIFESTATION

11. MANAGEMENT: 1. ASSESSMENT:

12. TREATMENT PLAN A: WITHOUT PHYSICAL SIGNS OF DEHYDRATION. Age Amount of ORS or other culturally appropriate ORT fluids to give after each loose stool Amount of ORS to provided at home Less than 24 months 50-100ml 500 ml/day 2 to 10 years 100-200 ml 1000 ml/day 10 years or more As much as they want 2000 ml/day Mother should be ask to take the child to health worker if the child does not get better in 3 days or develops any of the following dangers sign: Many watery stool Repeated vomiting Marked thirst Eating or drinking poorly Fever, blood and stool

13. PLAN B:WITH PHYSICAL SIGNS OF DEHYDRATION Age Less than 4 months 4-11 months 12-23 months 2-3 years 5-14 years 15 yrs above Wt in Kg Less than 5kgs 5-8 kgs 8-11 kgs 11-16 kgs 16-20 kgs >30 kgs ORS in ml 200-400 400-600 600-800 800-1200 1200-2200 >2200 Local measures (glass) 1-2 2-3 3-4 4-6 6-11 12-20

14. Maintenance fluid therapy? Begins when dehydration disappear usually within 4 hours ORS should be administered in volume equal to diarrhea losses, 10-20ml/kg body weight for each liquid stool Administered until diarrhea stop Offer plain water in between When is oral rehydration therapy ineffective? High stool purge, more than 5ml/kg body weight per hour Persistent vomiting <3 vomiting per hour Incorrect preparation of ORS- highly concentrated Abdominal distension Glucose malabsorption.

15. TREATMENT PLAN C: CHILDREN WITH SEVERE DEHYDRATION: Start Iv fluids immediately. RL with 5% Dextrose, if not available Ns 0.9% Give 100ml/kg All children should be given ORS 5ml/kg/ hr when they can drink without difficulty while getting IV fluids. If IV fluids unable to give, start ORS using Naso -gastric tube 20ml/kg/ hr Reassess the child every 1-2 hours If there is no vomiting or abdominal distension, give slowly. INTRAVENOUS FLUID THERAPY IN SEVERE DEHYDRATION: Age First give Then give <12 months 30ml/kg in 1 hour 70ml/kg in 5 hours 12 months to 5 years 30ml/kg in 30 minutes 70ml/kg in 2.5 hours

16. Monitoring: Reassess every 15 minutes until strong radial pulse. If hydration not improved, give more rapidly If signs of severe dehydration persist, repeat IV fluid infusion. If child improving and shows some sign of dehydration, discontinue IV fluid and start ORS for 4hrs (Plan B) If child is normally breastfeed, encourage mother to continue. Observe the child for 6 hours before discharge.

17. TRAUMA Leading cause of death in children between the age of 1 – 19 years For each death, there are 32 hospitalization 954 ED visits 1866 visits to Doctors office (CDC 2000) Trauma is an injury or damage to a biological organism caused by physical harm from an external source. Trauma is an emotional response to terrible event like an accident, rape or natural disaster. Immediately after the event shock and denial are typical. Long term reactions includes unpredictable emotions, flashback, strained relationships and even physical symptoms like headache or nausea (APA)

18. TYPES OF INJURIES: 1-5 years: Child abuse, poisoning, burns, foreign body, aspiration and falls 6-12 years: accident injuries, non-vehicle bicycle accident 13-19 years: motor vehicle accident, homicide, suicide, drowing

19. CLASSIFICATION OF TRAUMA: A number of pediatric trauma classification systems are used to predict morbidity, mortality and resource utilization. Classification based upon three categories: body region (local or multiple) mechanism (blunt or penetrating) severity (mild, moderate or severe) Other classifications are based upon; physiology anatomy or combination of both physiology and anatomy.

20. MECHANISM OF TRAUMA:

21. TRAUMA SCORE/SEVERITY OF INJURY: PHYSIOLOGIC SYSTEM:

22. Anatomic system:

23. MANAGEMENT: PRIMARY ASSESSMENT: Assess level of consciousness, use AVPU method Open airway, use appropriate method In child with head, trunk or multi system trauma, modified jaw-thrust is preferred Activate EMS if the child is 8 years or older, less than 8 yrs perform 2 minutes CPR, then activate EMS. Assess for breathing, begin rescue breathing Assess for circulation, begin chest compression Palpate carotid artery in children 1 year or older Palpate brachial artery in infants younger than 1 year Observe for hemorrhage, control bleeding

24. Systemic head to toe assessment: Neck and cervical spine-palpate for point tenderness, observe for distended neck vein, tracheal shift-immobilize neck with cervical collar Scalp and skull: palpate for indentation, deformity, observed CSF in ears, battle sign face: observe for deformity, CSF in nose. Eyes: observe for pupillary response, equality. Mouth: observed for possible obstruction, breathe odour , loose teeth. Chest and ribs-palpate for possible fractures, deformity, observe and feel equal expansion asymmetry. Abdomen: auscultate, palpate all quadrants Lumbar spine: palpate for deformity, tenderness Pelvis and hip: three way compression test

25. Groin: observed for bleeding, priapism Extremities: deformity, crepitus, bleeding, sensory, motor and circulatory function. Re-assess airway patency, breathing, circular, LOC, bleeding control and vital sign.

26. Management: Apply pressure direct to wound site. Elevate wound site Assess for further injury don’t remove objects protruding from childs body Check for evidence of decreased motor and sensory function Elevated pain: attempt to alleviate with non pharmacologic Assess pulse in extremity distal to injury Manage injuries appropriately (splinting) Maintained body heat Obtain information regarding injury from witness.

27. POISONING: Poisoning in children in developing is usually caused by ingestion of pesticides and plants while pharmaceuticals and chemicals form the major cause of poisoning A poison is any substance that is harmful to the body. It might be swallowed, inhaled, injected or absorbed through the skin. Poisoning can be acute or chronic

28. CORROSIVE POISONING: (Strong acids or alkali): toilet cleaners, dishwasher detergent, batteries, bleach. Severe burning paining pain in mouth throat and stomach White, swollen mucous membrane; edema of lips, tongue and pharynx, oral ulceration Hemoptysis Drooling and inability to clear secretion Signs of shock Anxiety and agitation Inducing emesis is contra-indicated ( vomiting redamages the musoca ) Dilute corrosive with water or milk Do not neutralize. Maintain patent airway Administer analgesics Do not allow oral intake

29. HYDROCARBONS Gagging, chocking and coughing Nausea Vomiting Altered sensorium . Weakness Respiratory or pulmonary involvement: tachycardia, cyanosis, retraction and grunting Immediate danger is aspiration, even small amount can cause bronchitis and pneumonia. Gasoline, kerosene, lamp oil, lighter fluids, turpentine, paint thinner and removal Inducing emesis is contraindicated Gastric decontamination and lavage are not advisable Most common treatment includes: high humidity, oxygen, hydration and Antibiotics for secondary infection.

30. ACITAMINOPHEN: most common drug poisoning in children it occurs primarily from acute ingestion. Toxic dose is 150mg/kg or greater four stages: Initial period: 2-4 hours after ingestion; nausea, vomiting, sweating and pallor Latent period: 24-36 hours; patient improves Hepatic involvement may last upto 7 days and be permanent: pain in right upper quadrant, jaundice, confusion, stupor and coagulation abnormalities. Gradual recovery for patient who do not die during hepatic stage. Antidote N-acetyl cysteine ( mucomyst ) :orally first diluted in fruit juice or Soda because of the offensive odour Might be given intravenously.

31. ASPIRIN (ASA): Acute ingestion: severe toxicity occurs with 300 to 500 mg/kg Chronic ingestion: more than 100 mg/kg/day for 2 or more days Acute poisoning: Nausea , Disorientation , Vomiting , Dehydration , Diaphoresis , Hyperapnea , Hyperthermia , Oliguria , Tinnitus , Coma , Convulsion. Chronic poisoning: Same as acute poisoning, Dehydration Coma and seizures often more severe Bleeding tendencies Hospitalization for severe toxicity emesis, lavage , activated charcoal and or cathartic if life threatening. Sodium bicarbonate transfusion to correct metabolic acidosis. External cooling: hyperthermia Administer anticonvulsant. Use oxygen and ventilator for respiratory depression. Administer vitamin K for bleeding In severe cases haemodialysis

32. IRON: Mineral supplement or vitamin containing iron. Toxic dose is based on the amount of elemental iron in various salts (sulphate gluconate , fumarate ) which ranges from 20% to 33%; ingestion of 6o mg/kg are considered dangerous. Occur in five stages: Initial; half to 6 hours ingestion : if child does not developed GI symptoms in 6 hours, toxicity is unlikely, vomiting, hematemesis, diarrhoea, hematochezia gastric pain. Latency: 2 to 12 hours patient improves. Systemic toxicity: 4 to 24 hours : metabolic acidosis, fever, hyperglycemia , bleeding, shock and death may occur Hepatic injury 48 to 96 hours: seizures, coma Rarely, pyloric stenosis develops at 2 to 5 weeks Lavage: for all chewable tablets or liquids if spontaneous vomiting has not occurred. Chealation therapy with deferoxamine is used in severe intoxication (may turn urine a red to orange colour) If intravenous deferoxamine is given too rapidly, hypotension, facial flushing, rash, urticaria , tachycardia and shock may occur, stop the infusion, maintain the intravenous line with normal saline.

33. PLANTS: plants are some of the most commonly ingested substance. They rarely cause serious problems although some plants ingestion can be fatal. They can also cause chocking and allergic reaction. Depends on the type of plants ingested May cause local irritation of oropharynx and entire gastrointestinal tract May cause respiratory, renal and central venous system symptoms Topical contact may cause dermatitis Gastric lavage with activated charcoal until patient improves Wash from skin or eyes Supportive care as needed.

34. DIAGNOSIS OF POISONING: Urine test: Urine should be examine for abnormal colour. Phenol poisoning: smoky dark green colour Ethylene glycol: Oxalate crystal Change of colour to red: Salicylates poisoning Purple green: phenothiazine Violet: Phenol Ketones: suggest exposure to acetone, salicylates and isopropyl alcohol. Blood test: Blood test turns Chocolatre colour: Methe-moglobinemia Pink: potassium cyanide Gastric aspirate: Addition of two drops of 30% hydrogen peroxide and deferoxamine (0.5ml 125mg/ml) to 1 ml of gastric fluid leads to colour change in iron poisoning

35. MANAGEMENT: Airway maintenance, Breathing, Circulation Supportive therapy: maintenance of homeostasis and prevention and treatment of complications. Indications for intensive care include a). Evidence of severe poisoning, coma, respiratory depression, hypotension, cardiac conduction abnormalities, arrhythmias, hypothermia or hyperthermia. b). Need for antidote or enhanced elimination therapy c). Progressive clinical deterioration. Prevention of further absorption of poison: these measures target preventing absorption of the toxin and depend upon the site and route of poisoning and patients age and general condition a). Dilution: this involve the application of water in an effort to reduce the duration of exposure to the toxin.

36. b). Gastro-intestinal decontamination : prevention of continued absorption of poison from the gut into the bloodstream in asymptomatic children. The procedure of choice for decontamination : is activated charcoal with whole bowel irrigation. Size of tube is selected according to age ( neonates 28F older children 36F). Lavage should be done with 15ml/kg of normal saline until clear fluid is drained. Activated charcoal should be instilled after lavage is completed. c). Binding agents: activated charcoal, clay and cholestyramine may be helpful in reducing absorption of ingested toxins. It acts by binding and elimination of toxin. It is used at the dose of 1-2 g/kg. d) Whole bowel irrigation: with polyethylene glycol has been used in patients with poisoning and drug over-dosage. It is the only procedure, which decontaminates beyond the pylorus without inducing emesis or causing fluid overload or dyselectrolytemia .

37. e). Administration of antidote : antidote counteracts the effects of poison by neutralizing them or or by antagonizing their effects. Antidotes significantly reduce the morbidity and mortality f). Enhancing elimination( Dialysis) : it is indicated in patients with significant delay following poisoning or when methods for prevention of absorption are ineffective or not applicable.

38. FOREIGN BODIES: Foreign bodies refer to any object that is placed in the ear, nose, or mouth that is not meant to be there and could cause harm without immediate medical attention

39. FOREIGN BODIES IN THE AIRWAY: Seeds Toy parts Grapes Pebbles Nuts Buttons Coins Carrots Batteries Choking or gagging when the object is first inhaled Coughing at first Wheezing S ymptoms may indicate that the foreign body is still causing an airway obstruction: Stridor Cough that gets worse Child is unable to speak Pain in the throat area or chest Hoarse voice Blueness around the lips Not breathing The child may become unconscious Prolonged impaction may lead to pneumonitis and bronchiectesis . Complications of long standing foreign bodies in the respiratory tract may present with repeated pneumonia, lung abscess atelectesis and emphysema .

40. DIAGNOSIS: clinical features. Plain chest X-ray including neck and diaphragm usually helps to locate the foreign bodies, mainly the radio-opaque materials. diagnosis cum therapeutic bronchoscopy . EMERGENCY: at home hanging the child upside down. Thumping over the back Groping with fingers in the pharynx Backblows Chest thrusts Heimlich maneuver . In hospital, once the diagnosis is confirmed, the child should be given Oxygen therapy Parenteral steroids. Antibiotics Chest physiotherapy. Tracheostomy may be needed when large vegetables foreign body swells up and in case of laryngeal obstruction. Thoracotomy and Bronchotomy may be required in case of long standing foreign bodies in the bronchus.

41. FOREIGN BODIES IN THE EAR: Food Insects Toys Buttons Pieces of crayon Small batteries Some objects placed in the ear may not cause symptoms, while other objects, such as food and insects, may cause pain in the ear, redness, or drainage. Hearing may be affected if the object is blocking the ear canal.

42. MANAGEMENT: The treatment for foreign bodies in the ear is prompt removal of the object. Instruments may be inserted in the ear to remove the foreign bodies. Magnets are sometimes used if the object is metal Cleaning the ear canal with water A machine with suction to help pull the object out After removal of the object, re-examine should be done to determine if there has been any injury to the ear canal. Antibiotic drops for the ear may be prescribed to treat any possible infections.

43. FOREIGN BODIES IN THE NOSE usually soft things such as tissue , clay, and pieces of toys, or erasers. Sometimes, a foreign body may enter the nose while the child is trying to smell the object . Unilateral discharge: Mucopurulent or bloody Nasal obstruction Sneezing Mucosal swelling and irritation. Pain Nasal Bleeding. Treatment involves prompt removal of the object. Sedating the child is necessary Suction machines with tubes attached Instruments may be inserted in the nose After removal nasal drops or antibiotic ointments to treat any possible infections .

44. FOREIGN BODIES IN THE EYES : Foreign bodies in the eyes is also common incident found in the children. Dust sand, wood, glass particles metal splinters etc. may get enlodged into the eye, making injury to the cornea, conjunctiva, sclera and even the eyeball. The child may present with Severe pain Lacrimation Foreign body sensation Photophobia Redness Itching Swelling Severe infection may occur within hours in wood and plant foreign body Instruct to avoid rubbing If the foreign body is not embedded, it can be removed by corner of clean cloth or by blinking eyelids under water. The embedded foreign body should be removed through irrigation or cotton tip applicator or magnet. Surgical removal may be needed in case of intra-ocular foreign body. Antibiotic therapy should be given to prevent infection Aseptic eye care and follow up are essential.

45. IMPERFORATE ANUS : incidence of approximately 1 in 4000 to 5000 birth ( levitt and pena , 2005 ). An imperforate anus or anorectal malformations (ARMs) are birth defects in which the rectum is malformed. ARMs are a spectrum of different congenital anomalies in males and females that varies from fairly minor lesions to complex anomalies

46. FEATURES OF ANORECTAL MALFORMATION

47. Imperforate anus is associated with an increased incidence of some other specific anomalies as well, together being called the VACTERL association: V – Vertebral anomalies A – Anal atresia C – Cardiovascular anomalies T – Tracheoesophageal fistula E – Esophageal atresia R – Renal (kidney) and/or radial anomalies L – Limb defects ASSOCIATED ANOMALIES

48. CLASSIFICATION OF ANORECTAL MALFORMATIONS:

49. PATHOPHYSIOLOGY: During embryonic development that cloaca becomes the common channel for developing urinary, genital, and rectal system. The cloaca is divided at the sixth week of gestation into an anterior urogenital sinus and a posterior intestinal channel by the urorectal septum. After the lateral folds join the urorectal septum , separation of the urinary and rectal segments takes place . Further differentiation results in the anterior GU system and the posterior anorectal channel. An interruption of this development leads to incomplete migration of the rectum to its normal perineal position.

50. CLINICAL MANIFESTATION: The clinical manifestation of imperforated anus are no anal opening anal opening in the wrong place, such as too close to the vagina no stool in the first 24 to 48 hours of life stool passing through the wrong place, such as the urethra, vagina, scrotum, or the base of their penis a swollen abdomen An abnormal connection, or fistula, between baby’s rectum and their reproductive system or urinary tract.

51. DIAGNOSIS: Physical examination USG helps to locate the rectal pouch. X-ray with inverted infant (upside down position), i,e invertogram or wangensteen -Rice X Ray is usefull to locate rectal pouch which can be performed only after the infant is 24hrs of age. Urinary fistula can be diagnosed by urine examination for presence of meconium and epithelial debris. Micturating cystourethrogram (MCU) can be done to detect urinary abnormalities.

52. MANAGEMENT The reconstructive surgery : repair the congenital malformations. depends upon the type of anomalies and sex of the infant. In case of low ARMs: rectal cutback anoplasty or Y-V plasty : for male infants and dilatation of fistula with perineal anoplasty : for female infants. In case of high ARMs : initial colostomy is done in the neonatal period followed by definitive reconstructive surgery as posterior sagittal ano-rectoplasty (PSARP) at the age of 10 to 12 months or when the infants is having 7 to 9kg body weight. Colostomy closure is done after 10 to 12 weeks of successful definitive surgery.

53. NURSING MANAGEMENT: Special interventions in pre-operative period should be include maintenance of warmth, fluid and electrolyte balance and general stability of the infants. Measurement of abdominal girth is most important before surgery. Special care to be provided for colostomy. In post-operative period, prevention of infections around colostomy wound are important measures. Maintenance of fluid and electrolyte balance Emotional support for family coping and demonstration of colostomy care are essential aspects of nursing management. Health education to be given about continuation of care at home, diet modification, prevention of fecal impaction, bowel habit training and need for medical help

54. SUMMARY

55. Thank you