Revised March 2011 Triage Definition 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. In our department this is done in A&E by the triage nurse at the desk in front of room 1. The health passport is stamped E (emergency) P (priority) or Q (queue). Emergency signs include: obstructed breathing severe respiratory distress central cyanosis signs of shock (cold hands plus capillary refill longer than 3 seconds plus weak, fast pulse) coma convulsions signs of severe dehydration in a child with diarrhoea (lethargy, sunken eyes, very slow return after pinching the skin—any two of these). Children with emergency signs require immediate treatment to avert death – see the diagram on the following page. In A&E they should go immediately to the resuscitation room. Priority signs include (abbreviated to 3TPR MOB): Tiny baby: any sick child aged under 2 months Temperature: child is very hot Trauma or other urgent surgical condition Pallor (severe) Poisoning Pain (severe) Respiratory distress Restless, continuously irritable, or lethargic Referral (urgent) Malnutrition: visible severe wasting Oedema of both feet Burns (major) The priority signs identify children who are at higher risk of dying. These children should be assessed without unnecessary delay and wait on the priority bench immediately outside room 1. 13 Revised March 2011 Reference: WHO Pocket book of Hospital Care for Children 14 Revised March 2011 Airway Obstruction Causes (common causes in bold) Airway swelling Infective Viral croup (laryngotracheobronchitis) Bacterial tracheitis Retropharyngeal abscess Epiglottitis Diphtheria URTI in an infant Severe tonsillitis Non infective Recurrent croup Anaphylaxis Adenoidal hypertrophy Laryngeal burns e.g. due to hot gases in fire Airway obstruction Congenital Laryngomalacia Choanal atresia Subglottic stenosis Laryngeal web Acquired Foreign body Tumour e.g. vocal cord papillomas, mediastinal tumour Extrinsic haematoma causing airway compression e.g. post thyroidectomy Airway collapse Depressed conscious level Drug intoxication Opiates Benzodiazepines Chlorpromazine Organophosphate poisoning Bulbar palsy Myopathy Important points in history Length of history of stridor (Stridor since birth suggests a congenital anomaly) Is it present all the time or only when upset / feeding / lying down? Coryzal symptoms , fever Barking cough, hoarse voice (suggests croup) Rapid deterioration or sudden onset when playing (suggests foreign body) History of choking episode (suggests foreign body inhalation) Recurring episodes (? recurrent croup or papillomas) Pain on swallowing (? Retropharyngeal abscess) Ingestion of drug or food possibly allergy Immunization history (? Haemophilis influenza B in epiglottitis) HIV status (Kaposi‘s sarcoma or laryngeal papillomas) Important points in examination Toxic (? Epiglottitis), shock, temperature Hoarse voice, barking cough (Croup) Severity of respiratory distress / central cyanosis Agitation / drowsiness Respiratory rate / heart rate Drooling (? Epiglottitis, retropharyngeal abscess) Posture - e.g. sitting up, leaning forward. Unilateral hyperexpansion or wheeze (? Foreign body) Bull neck appearance, blood stained nasal discharge, grey pharyngeal membrane (suggest diphtheria) Associated urticaria or lip swelling (? Anaphylaxis) 15 Revised March 2011 Croup v Epiglottitis Feature Onset Preceding coryza Cough Able to drink Drooling saliva Appearance Fever Stridor Voice muffled Need for intubation Croup Over days Yes Severe, barking Yes No Unwell <38.5 C Harsh, rasping Hoarse 1% Epiglottitis Over hours No Absent or slight No Yes Toxic, very ill >38.5 C Soft Reluctant to speak 80% Severity of upper airway obstruction Remember! The loudness of the stridor does not reflect the severity of the airway obstruction! Upper airway noise Work of breathing Mild Hoarse voice Barking cough Mild or loud stridor Mild intercostal recession and tracheal tug Efficacy of breathing Alert Not distressed Cardiovascular effects Mild increase in heart rate Moderate More severe stridor Severe Stridor may reduce as exhaustion occurs. Moderate increase in effort: Nasal flare Tracheal tug Accessory muscles Alert Distressed ↓O2 sats Huge increase in work of breathing: Severe distress Exhaustion Respiratory arrest Moderate rise in heart rate Reduced conscious level Cyanosis Severe tachycardia Bradycardia if exhausted Investigations If ?croup/epiglottitis- O2 saturations if able, nil else If ?foreign body / tumour / retropharyngeal abscess – CXR, lat neck X-ray If ?toxic - blood culture ONLY once airway stable. Avoid painful or frightening procedures (including PCV and MPS) until you are sure the airway is stable or secure 16 Revised March 2011 X-rays: CXR – May see foreign body if radio-opaque Unilateral hyper-expansion suggests FB in main bronchus with air-trapping If a coin seen above the carina: Seen as a circle – likely in the oesophagus Seen as a straight line – likely between the vocal chords Lateral neck – Retropharyngeal abscess – distance between the anterior vertebral body wall and the air column in the pharynx is increased. (At C3 this distance should be no more than ½ of the vertebral body diameter) Indications for admission All but the mildest case of croup will need to be admitted. If severe upper airway obstruction d/w senior/ anaesthetist re admitting to ICU. Treatment TRY AND KEEP CHILD CALM - let child sit on parent‘s knee If severe obstruction give nebulised adrenaline 1-2ml of 1 in 1000 in 2mls of saline/water while calling for senior help and anaesthetist. Repeat 2 hourly as necessary Severe airway obstruction: call ENT (Dr W Mulwafa) and anaesthetist on call Croup stay calm, O2, prednisolone 1mg/kg. Bacterial infection (tracheitis, retropharyngeal abscess): ceftriaxone Foreign body: if acutely compromised try backslaps etc, call for help- anaesthetist and senior colleagues and surgeon. If not acutely ill, organise bronchoscopy (ENT, surgeons) Epiglottitis stay calm, O2, call for help as above. DO NOT EXAMINE THROAT, OR PUT IN AN IV, OR DO ANY BLOOD TESTS.Transfer to ICU for intubation. Anaphylaxis: see anaphylaxis protocol Laryngomalacia usually resolves as child gets older Supportive care Ensure adequate analgesia, fluid and nutritional intake. Monitoring Keep patient in high dependency area of Special Care If transferred from ICU monitor closely for deterioration. When to discharge When child fully recovered and no longer has respiratory distress. 17 Revised March 2011 Oxygen Therapy in Children Oxygen therapy should be guided as far as possible by pulse oximetry. Oxygen should be given to children with SaO2 <90%, and oxygen increased to achieve a SaO2 >90%. If pulse oximeters are not available or not working it may be necessary for Oxygen therapy to be guided by clinical signs – however these are less reliable. Where the oxygen supply is limited and need for oxygen concentrators is greater than the number available it may be necessary to prioritise certain children. DO check to see whether there are any concentrators available in any other wards first. Priority should be given to children with very severe pneumonia, bronchiolitis, asthma and congestive cardiac failure who: have central cyanosis, or are unable to drink (where this is due to respiratory distress). When oxygen concentrators are available, oxygen should be given to children with any of the following severe lower chest wall indrawing respiratory rate of 70/min or above grunting with every breath (in young infants) head nodding Oxygen delivery Three methods are recommended for the delivery of oxygen: nasal prongs, nasal catheter and nasopharyngeal catheter. Nasal prongs or a nasal catheter are preferred in most circumstances. Nasal prongs are the best method for delivering oxygen to young infants and children with severe croup or pertussis. Use of a nasopharyngeal catheter calls for close monitoring and prompt action, in case the catheter enters the oesophagus or other serious complications develop. Face masks can be considered to supplement Oxygen delivery if enough concentrators are available – this will provide an additional 2-5 litres. Nasal prongs. These are short tubes inserted into the nostrils. Place them just inside the nostrils and secure with a piece of tape on the cheeks near the nose. Care should be taken to keep the nostrils clear of mucus, which could block the flow of oxygen. Set a flow rate of 1–2 litres/min (0.5 litre/min in young infants) to deliver an inspired oxygen concentration of 30–35%. Humidification is not required with nasal prongs. Nasal catheter. This is a 6 or 8FG catheter which is passed to the back of the nasal cavity. Place the catheter at a distance from the side of the nostril to the inner margin of the eyebrow. Set a flow rate of 1–2 litres/min. Humidification is not required with a nasal catheter. 18 Revised March 2011 Nasopharyngeal catheter. This is a 6 or 8FG catheter which is passed to the pharynx just below the level of the uvula. Place the catheter at a distance equal to that from the side of the nostril to the front of the ear. If it is placed too far down, gagging and vomiting and, rarely, gastric distension can occur. Set a flow rate of 1–2 litres/min, which delivers an inspired oxygen concentration of 45–60%. It is important that this flow rate is not exceeded because of the risk of gastric distension. Humidification is required. Monitoring Nursing and medical staff should know how to place and secure the nasal prongs or catheter correctly. Equipment should be checked regularly to ensure it is working properly. The prongs or catheter should be removed and cleaned at least twice a day. All children receiving Oxygen therapy need regular observations. They should preferably be monitored at least every 3 hours to identify and correct any problems, including: • SaO2 by pulse oximeter • nasal catheter or prongs out of position • leaks in the oxygen delivery system • oxygen flow rate not correct • airway obstructed by mucus (clear the nose with a moist wick or by gentle suction) • gastric distension (check the catheter‘s position and correct it, if necessary). Duration of oxygen therapy Continue giving oxygen continuously until the child is able to maintain a SaO2 >90% in room air. When the child is stable and improving, take the child off oxygen for a few minutes. If the SaO2 remains above 90%, discontinue oxygen, but check again 1/2 hour later, and 3 hourly thereafter on the first day off oxygen to ensure the child is stable. Where pulse oximetry is not available, the duration of oxygen therapy is guided by clinical signs (see above), which are less reliable. Care of Oxygen concentrators Oxygen concentrators need looking after if they are to continue to work for a long time. There are a few simple things that will help: If a concentrator is not being used for a patient turn it off Try to minimize moving concentrators Don‘t push the back of concentrators against a wall – this will damage the flex Get someone to show you how to clean the filter – this should be done regularly 19 Revised March 2011 Anaphylaxis Anaphylaxis is potentially life threatening and can present with or progress to: Shock with acute vasodilatation and capillary leak Upper and lower airway obstruction Anaphylaxis is immunologically mediated. Most common causes are reactions to: Allergy to Penicillin and other beta-lactam antibiotics Certain foods: eg Nuts Radiographic contrast media etc Prodromal symptoms: Flushing, itching, facial swelling, urticaria Abdominal pain, diarrhea Wheeze/ stridor might precede shock Patients might NOT have had a previous reaction to the same allergen Severity: Mild allergic reaction Itching, nausea, abdominal pain Urticarial rash, angio-oedema, conjunctivitis Moderate reaction Cough, wheeze, tachycardia, sweating, loose stools Severe reaction Severe bronchospasm or upper airway obstruction Shock Management: IF POSSIBLE REMOVE ALLERGEN Call for HELP!!! Airway Assess and manage airway O2 via face mask, max. flow available 10 micrograms/kg of Adrenaline IM – do NOT give IV adrenaline in anaphylaxis Nebulised Adrenaline Consider intubation (experienced paediatrician or anaesthesist) o A surgical airway might be needed in some situations Breathing In case of insufficient respiratory effort – start bag mask ventilation + consider intubation Wheeze/bronchospasm o Adrenaline IM o Nebulised Salbutamol o Hydrocortisone IV o Consider Aminophylline infusion 20 Revised March 2011 Circulation If no pulse – CPR Shock o IM Adrenaline o IV/IO access – 20ml/kg Normal Saline/Ringer Lactate – bolus o Re-assess Consider further IM Adrenaline + fluid bolus Consider Adrenaline infusion o IV Hydrocortisone Further Management Monitor on HDU Chlorpheniramine TDS for 48 hours Check blood sugar, MPS, PCV Drug doses in Anaphylaxis Adrenaline IM (NOT IV!) o 0.01ml/kg of 1:1000 Adrenaline (1mg/ml) o Or 0.1ml/kg of 1:10.000 Adrenaline (1mg diluted in 10ml Normal Saline) Doses of Adrenaline might have to be repeated o Adrenaline infusion in life-threatening shock, when IM Adrenaline is insufficient: 0.3mg/kg in 50ml Saline or Dextrose 5% 1ml/hr = 0.1 microgr/kg/min Dose = 0.05 – 2 microgr/kg/min Use syringe driver Ideally via central line, temporary via peripheral line – then use quarter strength Adrenaline Nebulised o 500 micrograms/kg Adrenaline (0.5ml of 1:1000) - max. 5mg Hydrocortisone IV o 4mg/kg, then 2-4mg/kg 6 hourly Salbutamol nebuliser o < 5years: 2.5mg dilute in 2-3 ml Normal saline o > 5years: 5mg Chlorpheniramine o > 12 years: 10-20mg o 6- 12 years: 5-10mg o 1-5 years: 2.5 – 5mg o 1 month- 1 year: 250 microgr/kg Aminophylline o 25 mg/kg in 500ml of Normal Saline (or 5mg/kg in 100ml via paediatric burette) o 10ml/hour = 0.5mg/kg/hour o Dose range: 0,3- 1mg/kg/hour use (use lower dose - 0.5mg/kg/hour in older children > 12 years) o Consider loading dose of 5mg/kg over 20 -30 min o Or 25mg/kg in 50ml N-Saline via syringe driver: 1ml/hour = 0.5mg/kg/hour Always re-check drug doses! Source: APLS Manual 4th edition PICU Standard Infusion Guidelines- Birmingham Children Hospital, UK 21 Revised March 2011 Shock Shock is an emergency. There are many potential causes (see below), with some being more common than others. The key to managing shock is: Prompt recognition Prompt initiation of emergency treatment Prompt management of the underlying cause Recognition of shock All children seen in hospital should be screened for the presence of shock: 1)When first presenting to hospital as part of Triage 2)Each time they are reviewed by medical or nursing staff A child is in shock if s/he has all three of: Cold Hands Capillary Refill time >3seconds Fast weak pulse Emergency Treatment of Shock When a child is found to be shocked do the following: Manage shock in Resus room or HDU First ensure adequate Airway and Breathing Give Oxygen If the child has any bleeding apply pressure to stop the bleeding Make sure the child is warm Select an appropriate site for administration of fluids Establish IV or intraosseous access Before giving IV fluids check for severe malnutrition (visible severe wasting or oedema of both feet) Begin giving fluids for shock (as below) Whilst giving IV fluids consider the cause (see below) If the child has NO severe malnutrition proceed as follows Insert an intravenous line (check blood glucose). Attach Ringer‘s lactate or normal saline - make sure the infusion is running well. Infuse 20 ml/kg as rapidly as possible (consider using 20ml or 50ml syringes). The circulation should be reassessed as described before. Improvement: warmer hands, pulse slows and capillary refill faster. 22 Revised March 2011 If there is NO improvement: Give another 20 ml/kg of Ringer‘s lactate or normal saline as quickly as possible. Reassess the circulation again If there is still NO improvement. Give another 20 ml/kg of Ringer‘s lactate or normal saline, as quickly as possible. The circulation should be assessed again. If there is still NO improvement – Call for senior help Give 20 ml/kg of blood over 30 minutes unless there is profuse watery diarrhoea. In this case, repeat Ringer's lactate. The circulation should be assessed again. If the child HAS severe malnutrition AND can tolerate oral/NG fluids Avoid IV if possible, find out if the child can drink or use a nasogastric tube (NGT). Weigh the child. Insert an intravenous line (check blood glucose) Give ReSoMal rehydration fluid orally or by NGT: o 5 ml/kg every 30 min for 2 hours, then o 5-10 ml/kg/hour for 4-10 hours If the child HAS severe malnutrition but CANNOT tolerate oral/NG fluids If the child is lethargic or unconscious or unable to tolerate oral/NG fluids give 15ml/kg half strength Darrows with 5% glucose (or R/L with added glucose) give over 1 hour Observe the child and check the pulse and breathing rate every 5-10 minutes. Discontinue the intravenous infusion if either of these increase (pulse by 15, respiratory rate by 5/min). Reassess the circulation again, and If there IS improvement: (pulse and breathing rate fall) If there is NO improvement: Call senior help. Repeat 15ml/kg over 1 hour. Give maintenance IV fluid 4ml/kg/hour while waiting for blood. Switch to oral or NGT rehydration with ReSoMal 10ml/kg/hour. Transfuse whole blood at 10ml/kg/hour slowly over 3 hours (use packed cells if in cardiac failure). 23 Revised March 2011 Further Treatment of the underlying cause of shock Gastroenteritis Intussusception, volvulus, peritonitis Burns Septicaemia Anaphylaxis Pressure to site of bleeding Involve surgeons early Urgent X-match Once shock treated manage as per acute gastroenteritis protocol Contact Surgeons If shock within few hours of burn consider other cause for shock Give fluids according to extent of burn IV antibiotics IM Adrenaline See Anaphylaxis protocol Contact orthopaedic surgeons Give resuscitation fluid cautiously Discuss with senior Tension pneumothorax Haemothorax Flail chest Cardiac Tamponade Needle thoracocentesis then chest drain Chest drain Consider advanced ventilatory support Emergency needle pericardiocentesis Profound Anaemia Urgent blood transfusion Cardiogenic Heart Failure Cardiomyopathy Valvular disease Duct-dependent congenital Heart disease Obstructive Spinal Cord Injury Specific management in addition management described above. Dissociative Distributive Hypovolaemic Causes of Shock T y Haemorrhage Unlikely to survive in this setting All children in shock or treated for shock should be initially admitted to an HDU. 24 Revised March 2011 Convulsions (epilepsy) Management of Status Epilepticus ABCD- Airway: airway adjuncts/ recovery position Breathing: support if necessary with oxygen, bag and mask Circulation: check adequacy, treat if required Don‘t Ever Forget Glucose! (correct hypoglycaeia with 1ml/ kg 50% dextrose i.v.) If the fit(s) has been going on more than 5 minutes: Paraldehyde 0.2ml/kg i.m. or 0.4ml/kg p.r Fit still ongoing after 10 minutes or has recurred: Paraldehyde 0.2ml/kg i.m. or 0.4ml/kg p.r Fit still ongoing after 10 minutes or has recurred: Diazepam 0.5mg/kg p.r. or 0.25mg/ kg i.v./ i.o. (not i.m.) or Paraldehyde 0.2ml/kg i.m. or 0.4ml/kg p.r Fit still ongoing after further 10 minutes or has recurred: Phenobarbitone 15mg/kg im/ slow iv STAT If fit still ongoing after another 10 minutes: Inform seniors +/- anaesthetist D/W research ward or ICU regarding admission for administration of phenytoin infusion or other therapies ****Once seizure has stopped, investigate and treat underlying cause**** 25 Revised March 2011 Causes of seizures Febrile convulsion with intercurrent illness e.g. malaria, viral or bacterial infection (febrile convulsions only occur in children 6 months – 6 years) Cerebral malaria Intracranial infections: Meningitis, Cerebral Abscess, Encephalitis Hypoxia of any cause Hypoglycaemia of any cause Other electrolyte or metabolic disturbances Cerebrovascular accidents Head Injury Seizure disorder (Epilepsy) Hypertensive encephalopathy Poisoning e.g. alcohol, tricyclic antidepressants, OPP poisoning Differential diagnosis of seizure-like episodes Reflex-Anoxic seizure / Breath-holding attack leading to seizure ‗Pseudo-seizures‘ Rigors Tetanus (muscle spasms) Rabies (agitation and spasms) Important points in the history Preceding symptoms of illness, fever. Recent new neurological deficit or history of headaches Preceding significant head injury Ingestion of any medication; drug history; compliance with anticonvulsants PMH: seizures/ neurological illness/ disability/ developmental delay / immunosuppression/ TB Family history of seizures Contact with source of infection e.g. meningitis case, herpes simplex Get an exact description of the seizure and document it Full description of ‗fit‘ by an eyewitness, especially: o What was child doing immediately before the fit? o Did child detect a prodrome to fit? (remember it ‗coming on‘) o Nature of seizure- what was seen and sequence, movements of which limbs, mouth, face etc. o WAS IT FOCAL OR GENERALISED? (may be important if epilepsy) o Colour of the child o Was the child responsive during the episode? o Duration o Incontinence/ tongue biting/ injuries sustained o Recovery period - ?post ictal Has full recovery been made? Ongoing symptoms e.g. Fever, headache, neck stiffness, rash, altered behaviour 26 Revised March 2011 Important points in examination Adequacy of: Airway, Breathing, Circulation Blantyre Coma Score/ AVPU and behaviour (irritable, lethargic, confused?) Evidence of ongoing seizure activity? Temperature Neck stiffness, Kernig‘s sign, rash, Fontanelle Blood pressure Abnormal neurology e.g. focal signs, papilloedema, asymmetrical pupils Evidence of head injury Any child with reduced conscious level or focal neurology following a seizure should be re-examined after an interval (e.g. 1 hour) to ascertain which (if any) features are „post-ictal‟, and to check for signs of deterioration. Relevant Investigations Blood sugar (BM stix)- ALWAYS if actively fitting/ reduced consciousness/ abnormal behaviour Blood film for malaria parasites Lumbar puncture- if meningitis cannot be confidently excluded, and no contraindications exist Blood culture if toxic-looking child or febrile infant U&E‘s if appropriate (e.g. seizures in dehydrated child) Indications for admission Most children should be admitted when there is a history of a convulsion. Consider short-stay ward and same-day discharge for children who are known to have febrile convulsions WITH a clear focus such as URTI or uncomplicated malaria AND who are well when seen in admissions Known epileptics may be discharged to the care of a competent guardian if child has recovered and no concerns about ongoing management. Ensure follow-up date given in general or neurology clinic NB The Convulsing Neonate (< 2 months old) Treat ABC, check glucose etc Give phenobarbitone 15mg/kg (Better than paraldehyde and diazepam in this age group). If the baby is still fitting after 20 minutes the dose can be repeated. Adjunctive treatments Fever: exposure, tepid sponging, paracetamol Diagnosis or suspicion of cerebral malaria, meningitis, encephalitis, hypertensive encephalopathy- see relevant protocol Head Injury: urgent neurosurgical opinion and consider neuroimaging Supportive Care Consider research ward if BCS < 3 Prevent recurrent hypoglycaemia if at risk (eg. unable to take adequate feeds). Consider iv fluids with added dextrose, or NGT feeding if airway is safe. Consider maintenance dose of phenobarbitone 5mg/kg/day if further seizures occur or if a high risk of further seizures is thought to exist. 27 Revised March 2011 Monitoring Nurses to be specifically informed of patients causing concern If reduced conscious level or at risk of deterioration- regular review Guardians to be asked to alert nurses or medical staff if further fits occur Guardian Advice Guardians are likely to be frightened, and need appropriate reassurance and education about the cause of the fits risk of recurrence and any measures they can take to prevent further seizures (eg. avoiding prolonged fasting periods) actions to take in the event of a further fit (protection from injury etc) Advise NOT to insert anything into mouth of convulsing child Is it epilepsy? Recurrent seizures without fever suggests epilepsy as a cause If a seizure disorder is suspected and frequency of fits is interfering with quality of life, the child may need to take a regular anticonvulsant- refer to a senior for decision Sodium valproate and carbamazepine (when available) are better first line choice drugs than phenobarbitone When to discharge Depends largely on cause of fit, and completion of cause-specific treatments (for example, infection adequately treated) Child must be clinically stable, fully conscious, behaving normally (unless a chronic neurological disability remains), and not at high immediate risk of further fits as far as can be predicted. Follow up If epilepsy, give date for general clinic (1.30 pm Wednesday) Consider neurology clinic if ‗complicated‘ epilepsy – discuss with Dr Mallewa If ongoing disability, consider what supports might be available to the child and family e.g. Chesire Homes or SOS Machinjiri for physiotherapy, mobility aids Guardians should be adequately informed about risk of further fits and what to do if they occur 28 Revised March 2011 Coma Common Causes Hypoxia / shock Infections Any cause Malaria, Meningitis, Encephalitis, Cerebral abscess Overt / subclinical seizures, post ictal Head Injury, Non-accidental injury (shaken baby) Hypoglycaemia, Hyperglycaemia, electrolyte imbalance, Renal failure, liver failure Opiates, salicylates, organophosphates, benzodiazepines, alcohol Seizures Trauma Metabolic Poisoning Tumours Vascular Haemorrhage, Thrombosis, Hypertension, Vasculitis Important Points in History Timing of onset of coma Symptoms of deterioration or recovery Infants – hx of poor or reduced feeding History of convulsions, either recently or in the past History of trauma, which may or may not be significant History or possibility of dog bite Availability of medications at home, belonging to the child, or another family member. Possibility of local mankhwala. Availability of potential poisons, e.g. organophosphates due to rat infestation Past Medical History, e.g. diabetes, including drug history Relevant family history, e.g. diabetes, bleeding diatheses Associated symptom Cough, vomiting, fever, rash Dog bite, unusual behaviour, fluctuating coma Profuse D+V Cough, dyspnoea Poor feeding, malaria (especially infant) Polyuria, polydypsia, vomiting Oliguria, haematuria, oedema Jaundice, bleeding, fever, vomiting 29 May indicate diagnosis of… Encephalitis,meningitis Rabies Dehydration, electrolyte imbalance Hypoxia Hypoglycemia Hyperglycemia Renal failure Liver failure Revised March 2011 Important Points Initial Examination AB Respiratory Pattern may be irregular due to brainstem lesion or raised intracranial pressure. May be rapid due to acidosis or drug ingestion C Pulse Bradycardia suggests raised intracranial pressure, or OPP poisoning Blood Pressure hypertension suggests raised ICP D Coma Score (Blantyre, AVPU) Pupil size and reactivity may reveal signs of drug ingestion (see poisoning protocol). May be unequal/unreactive due to raised intracranial pressure Posture – floppy, extensor posturing, decorticate, decerebrate Coma Scores – AVPU, Blantyre A V P U Alert responds to voice responds to pain unresponsive BCS Motor: BCS Verbal: BCS Eye: localises (2) withdraws (1) None (0) Appropriate cry (2) Inappropriate (1) None (0) Follows (1) Does not follow (0) Secondary examination Fundi may show papilloedema, retinal haemorrhages Examine for signs of dehydration or malnutrition Skin rashes may indicate infections e.g. meningococcal disease Breath Odour may indicate diabetic ketoacidosis, alcohol ingestion, inborn errors of metabolism Full Neurological examination to establish a baseline, identify focal deficits (space occupying lesions), lateralising signs (hemiplegia), neck stiffness (meningitis) Respiratory examination paying careful attention to breathing pattern (as above) and signs of respiratory disease Gastrointestinal examination particularly splenomegaly (malaria) and hepatomegaly (metabolic disorders) Relevant Investigations Blood glucose in all patients MPS and PCV Lumbar Puncture if MPS negative o or MPS positive but clinical picture does not fit with malaria o and child well enough to tolerate the flexed position o and cardiovascularly stable, with no signs of bleeding o and no features of raised intracranial pressure ALWAYS FOLLOW UP CSF RESULTS. DO NOT ASSUME IT IS OK BECAUSE IT IS ‗CLEAR‘ Blood culture if pyrexial Serum electrolytes Neuroimaging as dictated by individual cases and availability EEG d/w senior if unsure 30 Revised March 2011 Indications for Admission All comatose children should be admitted If the child has proven meningitis OR has a BCS of 2 or less from any cause, admit to the research ward Otherwise admit to PSCW/PN Treatment Call for help whenever uncertain. The earlier the better. A Position the airway (using head tilt, jaw thrust, chin lift) Consider use of Guedel airway B Apply oxygen C Support circulation in order to maintain normal cerebral perfusion pressure. Treat shock Don‟t ever forget glucose o If hypoglycaemic, give the child 1ml/kg of 50% dextrose, and follow up with regular feeds, or an infusion containing dextrose (see below) o If no blood sugar test available, assume hypoglycaemia, give 1ml/kg of 50% dextrose Seizures Treat if present (see seizures protocol). Fluids Maintain appropriate fluid balance. Consider giving 2/3 of the normal total maintenance requirements (to reduce cerebral oedema), providing no circulatory compromise. See fluid protocol. In order of preference use: o Half strength darrows with 5% dextrose o Normal Saline with added 50% dextrose to make 10% solution Antimalarials Unless there is an obvious cause for the coma (e.g. cloudy CSF indicating meningitis) all comatose children should be given quinine Antibiotics If proven meningitis (cloudy CSF or elevated white cell count on CSF microscopy), give 100mg/kg Ceftriaxone IV/IM daily, and refer to the research ward. When meningitis is strongly suspected clinically, but either the child is too sick for an LP, or the cell count is not available (e.g. at night), commence Ceftriaxone at above dose, or Chloramphenicol 25mg/kg tds IV/IM and Benzylenicillin 100,000U/kg qds IV/IM If doubt remains about the diagnosis (e.g. MPS and CSF negative), ensure a blood culture has been taken and start Chloramphenicol 25mg/kg tds IV/IM and Gentamicin 6mg/kg OD IV/IM. Other definitive management Other treatment will be guided by the history and clinical findings, e.g. o Aciclovir if suspicion of encephalitis o Hydralazine if hypertensive encephalopathy o Atropine if OP Poisoning (refer to poisoning protocol) o Surgical review if trauma suspected (refer to trauma protocol) 31 Revised March 2011 Supportive Care Nutritional Support The child should be encouraged to feed where this is possible. However it must be stressed to mothers that unconscious children are often not able to feed, and under NO CIRCUMSTANCES should they be forced If the child is not able to eat for more than 2 days, an NGT should be inserted. Give F100 from Moyo Other Supportive Care Regulate temperature Prevent bedsores by turning the patient. Use the recovery position where possible Maintain oral hygiene with mouth washes Encourage physiotherapy of chest to avoid hypostatic pneumonia, and of limbs to prevent joint contractions Monitoring A Comatose child should be monitored at least 4 hourly by a nurse and twice a day by a doctor. o Pulse o Respiratory rate o Temperature o Blantyre Coma Score Blood pressure should be checked if it were previously abnormal or the child has deteriorated Complications Acute Complications Aspiration Pneumonia Electrolyte imbalance Seizures Hypostatic pneumonia Joint contractures Secondary septicaemia Chronic complications Cerebral Palsy Deafness / Visual problems Behavioural and learning difficulties When to Discharge When the child has made a full recovery OR the child remains static, and after discussion with seniors it is thought unlikely that the child will benefit from any additional inpatient care, and is unlikely to recover further. Arrange support from Cheshire homes/ physiotherapy/ hospital clinics/ palliative care 32 Revised March 2011 Trauma Resuscitation - ABCDE - Call for HELP! Airway & Cervical Spine Protection Breathing: O2 and support of ventilation Circulation: correction of shock and haemorrhage control Disability Exposure Secondary survey Stabilisation - Monitor & Reassess Involve A&E, Paediatric, Surgical & / or Anaesthetic Consultants EARLY!!! Triage and emergency management Treat children with severe trauma immediately in the resuscitation room In a conscious child, a reassuring and kind manner will reduce stress As far as possible keep the child covered and warm Airway management & Cervical Spine Protection Check if the airway is patent In case of a compromised airway: o Jaw thrust – avoid ―head tilt‖ in case of cervical spine injuries o Suction/Removal of foreign body under direct vision (eg loose teeth) o Oxygen via face mask – maximum flow available o Consider oro-pharyngeal airways (Guedel airway) o If indicated: intubation & ventilation (see below) Cervical spine protection o Assume a spinal injury in any significant trauma (RTA, fall etc.) o Cervical spine protection is required until it can be ―cleared –see below‖ o In an uncooperative/combative child too rigid C-spine protection might not be beneficial. o o o o Place the child on a spinal board or a trolley with a firm surface. Immobilisation initially by ―in-line immobilisation‖ then: hard collar (if available), blocks (or Fluid bags) and straps Any case of position change: ―log-roll‖ the child keeping the spine ―in-line‖ Intubation with a hard collar can be difficult – in this case the collar might be taken off. Manual ―in-line immobilisation‖ is maintained. 33 Revised March 2011 Breathing O2 mask at highest flow rate available. Monitor O2 saturation if possible If respiratory effort is inadequate – start Bag Mask Ventilation This child might need intubation + ventilation – Call for HELP!!! Check trachea position Check chest expansion and check for signs of thoracic injuries o Pneumothorax/ haematothorax o Rib fractures/‖flail chest‖ o Open thoracic injury (eg ―sucking chest wound‖) In case of suspected pneumothorax o Needle thoracocentesis: 2nd intercostal space, mid-clavicular line, above the rib o Chest drain insertion will be needed subsequently. Call for HELP!!! While this is being arranged continue with ABC assessment + management In case of haematothorax or haemo-pneumothorax o Fluid resuscitation/transfusion o Chest drain Consider the possibility of cardiac tamponade o Urgent Echo o Pericardiocentesis if indicated Consider other mediastinal injuries, disruption of great vessels, diaphragmatic rupture etc. In case of stab or shot gun wounds – small entry lesions can be associated with significant ―internal trauma‖. Indication for intubation and ventilation: Persistent airway obstruction Predicted airway obstruction (eg inhalational burn, severe facial trauma) Loss or airway reflexes/loss of consciousness Inadequate respiratory effort or increasing fatigue Disrupted ventilator mechanism eg flail chest Persistent hypoxia despite O2 administration Severe traumatic brain injury Resources for mechanical ventilation are limited! A pragmatic approach to intubation + ventilation is needed! Call for HELP!!! – Experienced paediatrician and/or anaesthesist!!! Note on the usage of drugs: In our scenario we use ketamine as an induction agent. In traumatic brain injury (TBI) the theoretical risk of increasing intra- cranial pressure is outweighed by the relative haemodynamic stability compared with the use of other induction agents. 34 Revised March 2011 Circulation: Management of shock and control of haemorrhage Establish vascular access o Two ―large‖ peripheral IV cannulas o In the event of failure – consider rapidly other options – Call for HELP Intra-osseous cannulation of tibia – avoid injured limb (eg femur fracture etc.) External jugular vein, central line (femoral vein etc.) Cut down – cephalic vein (elbow) or long saphenous vein (ankle) o Sample for Cross-match, blood sugar, MPS & PCV Assses: HR, central/peripheral pulses, CRT, temperature gradient +/- pallor, BP- hypotension is a very late sign of severe shock Direct pressure to any obvious visible external site of bleeding In case of signs of shock/impaired perfusion o 10ml/kg Ringer Lacate or Normal Saline - bolus o Reassess and repeat fluid boluses o If 40ml/kg crystalloids have been administered – use blood transfusion if further fluid boluses are needed. o Consider type specific or O-negative blood in extreme emergencies o Contact surgical team early – especially if 20ml/kg do not stabilise the CVS Consider thoracic (pneumothorax/haematothorax), abdominal or pelvic trauma Consider bed-side ultrasound scan – FAST scan In case of stab wounds or shot gun wounds – a relatively small entry wound can be associated with significant internal injuries Blood loss in case of femur fractures can be massive – alignment and traction needed Disability Assess level of consciousness o AVPU-scale: Alert, responds to Voice, Pain or Unresponsive or use BCS/GCS Record pupil size and reactivity to light Urgently contact senior surgeon in case of suspected intracranial haemorrhage (eg extradural haematoma) o Discuss if MRI/CT should be done before potential intervention Basic management of traumatic brain injury (TBI) in order to prevent secondary brain injury: o Adequate oxygenation o Control of CO2 tension – (Intubation& ventilation might be needed) o Maintenance of adequate cerebral perfusion pressure (CPP): URGENT correction of shock –inotropes might be needed (currently only possible on ICU) CPP= Mean arterial pressure (MAP)- Central venous pressure (CVP) – intracranial pressure (ICP) o Control of potentially raised ICP Consider Mannitol: 250mg to 500mg/kg (1.25 -2,5ml of 20% Mannitol) IV –over approx. 30mi Or 2-3 ml/kg of 3% NaCL as a short infusion o Control of hypoglycaemia, convulsions o Head –up position - around 30 degrees o Avoid aspiration - insert OGT , aspirate and keep on free drainage o Avoid electrolyte imbalance (especially hyponatremia) Isotonic fluids or blood for fluid resuscitation Use Ringer Lactate or Normal Saline + added Glucose as maintenance fluids 35 Revised March 2011 Exposure Examine all parts of the body Straighten fractured limbs +/- traction in case of a fractured femur Provisional dressings of wounds/lacerations Other procedures + imaging Emergency imaging if indicated: o Bed-side ultrasound – FAST scan o XR‘s: Skull, C-spine (all 7 cervical vertebrae should be visible on XR‘s), Thorax, pelvis, limbs In our setting no portable XR is available The patient needs to be stabilised before being transferred to the radiology department o MRI scan brain +/- spine – discuss with consultant. Analgesia, keep the child warm Avoid opiates in the non-intubated head injured patient. Consider femoral nerve block in femur fractures (only by trained colleague)! In case of open wounds/open fractures: Tetanus toxoid and antibiotics Secondary survey after management of ABCDE If ABCDE was stabilised during primary survey , perform secondary survey Careful and quick ―head to toe examination‖ Take a more detailed HISTORY: Age, name Time, date, location, mechanism of injury Condition after accident – pre-hospital care Last meal PMH, SH, FH Allergies, immunisations, regular medication Is there any suspicion of non accidental injury -NAI? Secondary survey - some specific points: Reassess ABC + re-examine: thorax, abdomen, pelvis Quick neurological exam: o Level of consciousness, pupils, movements, tone, reflexes o Fundoscopy if possible o Assess spine: In case of suspected acute spinal cord injury – high dose Steroids should be started within 8 hours of the injury If a MRI/CT scan head is requested in case of TBI –ask radiologist to scan the Cspine as well!!! Check for injuries o Face & skull - including maxillar/mandibular, dental injuries, check ears, nose, mastoid Examine the back of the child. In case of potential spinal injury – the child needs to be “log-rolled” o Check for injuries/wounds: skull, neck, thorax, lumbar area, pelvis o Check spine Examination of limbs - Signs of fractures? o In case of severely angulated fractures - alignment and splinting +/- traction o Any signs of open fractures? 36 Revised March 2011 In this case TT and IV antibiotics needed Any deep wound within vicinity of a fracture could communicate with fracture Any signs of compartment syndrome? - Monitor perfusion and pulses Any signs of vascular injury? Guidelines for clearing a cervical spine Remember- despite normal XR‘s the child can have a spinal cord injury without radiological abnormalities (eg haematomas, ligament injuries) - SCIWORA The child should be cooperative and alert: No midline cervical tenderness on direct palpation No focal neurological deficit No painful distracting injuries Transfer & further management Reassess ABCDE regularly Children with significant trauma need to be observed on ICU or PSCW/HDU Transfer to PSCW, theatre, ICU, radiology department o Critically ill children need to be accompanied by nurse +/- doctor o Take resuscitation equipment/box + with you o Use O2 cylinder for transfer of sick children o Hand-over to receiving team Regular monitoring on HDU, including ―neuro-obs‖ in severely injured child Signs of raised ICP due to cerebral oedema or intracranial haematomas (eg extradural) can present even hours after initial presentation Encourage parents to alert nurses or medical team in case of any concern Reference: APLS manual 4th edition 37 Revised March 2011 Poisoning (including snake bite) Causes Organophosphates (carbamate) Local medicines Other causes Petroleum compounds: paraffin Carbon monoxide Plants (‗magic mushrooms‘) Bleach Snake bite Important points in history *Remember there may not be a clear history! Sudden unexplained illness in previously healthy child Unusual behaviour Try to establish the potential poison that the patient may have had exposure to Enquire about quantity exposed to / taken Earliest possible exposure time Ask if container or sample of poison available Other children involved? If so, what symptoms do they have? Ask about access to ―poisons‖ Important points in examination Drowsiness / coma/ BCS Convulsions (OPP) Shock Diarrhoea (OPP) {if a child is dehydrated but salivating ++ consider OPP confirm with pin point pupils} Hypersecretions (noisy wet breathing) (OPP) Pupillary abnormalities - (pin-point: - consider OPP, sometimes mushooms : dilated pupils consider barbiturates Ataxia Tachypnoea / tachycardia or flushing / bradycardia (in OPP) Wheezing (paraffin inhalation) Cardiac arrhythmia or hypotension Presence of burns within the mouth ( consider bleach or acid with oesophageal injury) Stridor (suggests laryngeal damage) Abdominal distension (local medicine intoxication) Acidotic? Investigations Mainly depend on the presentation and specific poison exposure 38 Revised March 2011 Indications for admission Exposure to potentially fatal poison Ill / haemodynamically unstable patient Deliberate poisoning Consider observation in Short Stay if well otherwise Management Primary assessment (A B C D) to recognize life-threatening emergencies Resuscitate / stabilize the patient if necessary Assess potential lethality of the overdose Definitive management of specific condition once stabilized Reassess ABCD at frequent intervals to assess progress / detect deterioration Test for hypoglycaemia, if present treat with 1ml/kg 50% glucose IV or PO Treat convulsions (see p25) Give maintenance IV fluids Use antidote for specific poison if available (see below) Use activated charcoal (1g/kg), except for heavy metals, if available Gastric lavage (used occasionally for ferrous sulphate poisoning) only if: o a potentially fatal dose has been taken o the airway is protected o Avoid if reduced level of consciousness, and in hydrocarbons or corrosives DO NOT Induce vomiting When to Discharge When the patient is stable Needs to be followed up with psychiatric assessment if deliberate Treatment of specific poisons A: Organophosphate compounds Get rid of poison o Eyes (irrigation) o Skin (remove clothing) and bathe Specific Rx o Atropine 20ug/kg IV or IM every 15 min until secretions have stopped the chest is dry Monitor regularly (respiratory rate, coma score, heart rate, secretions) e.g. every 15 minutes initially then every 30 minutes Assisted ventilation if necessary B: Local medicines Usually taken for diarrhoea and vomiting May lead to acidosis, respiratory distress, paralytic ileus Rehydration i.e. give IV fluids and glucose Pass an NGT and leave on free drainage 39 Revised March 2011 C: Petroleum compounds (Paraffin) May cause pneumonitis CXR if symptomatic Do not induce vomiting Give oxygen if necessary Antibiotic therapy may be needed for secondary chest infections D: Carbon monoxide poisoning Toxic effects are due to hypoxia Carboxyhaemoglobin estimation is useful (sometimes available in ICU). Oxygen saturations can be misleading. Give 100% oxygen E: Poisonous plants Usually only small quantities are ingested Treatment mainly supportive + activate charcoal if available F: Bleach Treatment: liberal fluids and milk Do not induce vomiting G:Snake bite Check for fang marks, note if scarifications present or not. Look for evidence of use of a tourniquet Ask about time of bite Check bitten limb for swelling, pulses, colour and viability Check for systemic evidence of envenoming – fever, altered coma score, shock, anaemia. Mark with a pen, the level of swelling on a limb so that further swelling can be assessed. Management ABC Do FBC and diff, blood culture and blood clotting time (see how long it takes for blood to clot in a plain tube) Group and cross match and hold blood unless anaemic. Place an IV infusion of normal saline Check that Tetanus toxid immnisation is up to date; if not give it If local swelling is marked or there is evidence of systemic envenoming: Inform senior. Anti snake venom will be required Give 40mls in 200mls of normal saline IV over 1hr but have adenaline standing by: anaphylactic reactions are not uncommon. If circulation is threatened inform the surgical team on call as compartment syndrome may need fasciotomy. Treat pain appropriately – morphine may be needed 40
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