Emergency Treatment in Pediatric: November 2015

Coma in Pediatric Emergency

Coma is a symptom, not a diagnosis. The aim of management is to minimise any ongoing neurological damage. History, examination, investigation and treatment will be simultaneous.

Immediate resuscitation and management

The primary assessment should be as for any seriously ill child. A structured approach to the primary survey is particularly important; if a problem is found during the initial ABCDE assessment, then immediate treatment and resuscitation should start, remembering to treat the treatable as you progress through the primary survey.

Supporting an inadequate airway, ineffective breathing or compromised circulation should reduce the likelihood that the reduced conscious level is secondary to hypoxia and fluid loss and of any further deterioration of conscious level due to these two mechanisms. Thus, you must clear and protect the airway and assist the breathing as necessary. If a traumatic cause for the symptoms is likely, immobilise the cervical spine and arrange urgent neurosurgery-involvement.

Check the pulse and insert an intravenous line and perform a blood sugar test; if blood glucose is less than 2.5 mmol 1 −1 in a person who is not diabetic, send specific blood tests and administer 10% dextrose i.v., 5 ml/kg weight bolus. Consider naloxone, 0.1 mg/kg weight (max 2mg) if pupils are small. Assess and monitor pulse, respiratory rate, BP, temperature, oximetry and conscious state. Consider signs of raised intracranial pressure and look for subtle signs of continuing convulsions.

History and examination

Consider the onset and duration of symptoms. Is there a past history? Relevant conditions include seizures, diabetes, adrenal insufficiency, infection and cardiac problems. Other signs and symptoms may suggest the cause of the coma (Figure 1).

Figure 1: Cause of Coma in Pediatric

Investigations and further management

Consider these investigations in the light of the possible diagnoses, if not already done:

• full blood examination

• urea and electrolytes

• glucose

• liver function

• arterial blood gas

• urine drug ± metabolic screen

• urine antigens

• blood and urine culture

• ammonia

• cortisol

• coagulation screen

• ECG

Investigation and management of coma

Figure 2 shows the investigation and management of coma. It is important that raised intracranial pressure is always excluded before lumbar puncture in all cases.

Figure 2: investigation and management of coma

Figure 2 Lumbar puncture, imaging and antibiotics in coma. Abbreviations:CT, computed tomography; EEG electroencephalogram; ICP, intracranial pressure; LP, lumbar puncture; MRI, magnetic resonance imaging.

Ongoing care

Continue to assess and support the airway, breathing and circulation. Care will depend on the diagnosis, level of consciousness and degree of ventilatory and circulatory support required. Consider an early transfer to a pediatric intensive care unit.

Definition

A pneumothorax is defined as the presence of air in the intrapleural space. Spontaneous pneumothorax is unusual. It is often associated with trauma but can be spontaneous, particularly if a person has a marfanoid habitus. It can occur secondary to a bullous or a cyst. Children with cystic fibrosis are more at risk of developing pneumothoraces. Consider pneumothorax in a child presenting with pleuritic chest pain or shortness of breath. There may be a previous history of pneumothorax. On examination, there may be reduced air entry and a deviated trachea (away from the collection) and hyper-resonance, but no added breath sounds.

Management

In small pneumothoraces, a conservative approach is appropriate. Where there is less than 30% reduction of total lung capacity (TLC), initial high flow oxygen will help absorb the intrapleural air and in most cases the pneumothorax will resolve over a 1–2 week time scale. Where there is between 30–50% reduction in TLC there are three steps depending on response:

• Oxygen therapy in cases where there are no major symptoms and observation and repeat X-ray over 12 hours.

• Oxygen therapy and a needle thoracocentesis using a small catheter attached to a 3-way tap. This is inserted in the second intercostal space above the rib and in the midclavicular line. Air is aspirated, the tap is closed off and chest X-ray repeated over the following 6 hours. If the air has not reaccumulated, the catheter can be removed and the patient reviewed 24 hours later with repeat X-ray.

• Insertion of an intercostal drain with a valve or underwater seal. This should be placed in the anterior axillary line in the fourth intercostal space.

Pneaumonia in Pediatric Emergency Thorax Xray

Pneumonia is common, but the cause may vary with age. The commonest bacterial causes are:

• Staphylococcus aureus in children <1 year

• Streptococcus pneumoniae in children <4 years

• Hemophilus influenzae in children <10 years

• Group A streptococcus in children >10 years

Viral infection with RSV (respiratory syncytial virus) and parainfluenza occurs in children, especially in those under 2 years of age, and with influenza virus in older children. Mycoplasma infection is more common in older children. In a previously well child older than 1 month, consider pneumonia in infants and children with the following signs and symptoms.

Chest X-ray (AP) should be performed to confirm or exclude pneumonia. Patients with wheeze and air trapping most commonly have bronchiolitis or asthma. Neonates who are unwell, or have a temperature over 38°C, should have a chest X-ray as part of a septic work-up, especially if the respiratory rate is elevated or there are other signs of respiratory embarrassment.

Management of pneumonia

Pneumonia can be managed with inpatient or outpatient care depending on the severity of the condition.

Croup or Barky Cough (Laryngotracheobronchitis)

This tends to occur in a previously well child aged 3 months to 6 years but can occur in older children. The term croup refers to a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice. It results from viral infection, most often with parainfluenza virus with inflammation of the upper airway, including larynx, trachea and bronchi; hence the term laryngotracheobronchitis.

The symptoms are typically worse at night and peak on about the second or third night. Differentiating spasmodic croup from viral croup is diffi-cult and often not useful.Consider other causes of acute stridor, such as epiglottitis (much rarer since Hib vaccine), bacterial tracheitis (rare), or laryngeal foreign body (very rare). Refer to upper airways obstruction section.

History

The loudness of the stridor is not a good guide to the severity of obstruction. Children with pre-existing narrowing of the upper airways (e.g. subglottic stenosis, congenital or secondary to prolonged neonatal ventilation) or children with Down syndrome are prone to more severe croup and admission should be considered even with mild symptoms.

General Management

Avoid distressing procedures, e.g. examining throat, because anxiety exacerbates croup. Nurse the child on the parent’s lap. Blood tests, pulse oxymetry, or O2 mask are rarely indicated. A routine nasopharyngeal aspirate (NPA) is not required for children with a ypical clinical picture of croup.

Primary assessment and initial management of croup

1. Mild

Signs: No stridor at rest, Not distressed, No sternal retraction, No signs of hypoxia.

Managements: Can be managed at home. No specific treatment is usually required, although steroids can be considered if the patient is seen early in the course of the illness. Explanation to parent needed

2. Moderate

Signs: Stridor at rest, Distressed, Sternal retraction at rest, Normal breath sounds, No signs of hypoxia

Managements: Administer steroids, Observe and settle child with minimal interventions, Consider use of nebulized epinephrine (adrenaline) (1% eye drop solution 0.05 mg/kg weight or 1:1000 preparation 0.5 ml/kg weight (max 2ml), If settles well after prednisolone consider discharge (see notes on discharge)

3. Severe

Signs: Marked stridor at rest or may be soft, Very distressed, Marked increase work of breathing, Reduced breath sounds, Evidence of hypoxia (restless, lethargy, pallor, cyanosis)

Managements: Continually assess the child and response to therapy, Involve senior staff early on Administer nebulized epinephrine, Administer steroids, Rarely will require intubation, Admission to PICU

Steroids

There is little evidence supporting the use of steroids in mild croup, although the current studies are underpowered. However there is good evidence for the efficacy of corticosteroids for the treatment of moderate to severe croup. There are a number of ways of administering the steroids: use nebulized budesonide, oral prednisolone or dexamethasone or i.m. dexamethasone. Varying doses have been suggested in the literature and all are effective in the treatment of the acute symptoms. Cost and availability may influence the treatment choice. Suggested doses are prednisolone (1 mg/kg weight), nebulized budesonide 2 mg, dexamethasone (0.15 mg/Kg weight).

Epinephrine (adrenaline)

There has been a change in the use of nebulized epinephrine (adrenaline) in the last few years and nebulized epinephrine (adrenaline) no longer needs to be reserved only for children with severe croup. Current evidence would support the use of nebulized epinephrine (adrenaline) in children with moderate and severe croup. In a number of selected children following observation in the Emergency Department for 3 hours after the administering of nebulized epinephrine (adrenaline) and the start of steroid treatment,it may be safe to discharge the child home. Nebulized epinephrine (adrenaline) may cause circumoral pallor.

Admission or discharge

The decision to admit a child is made after initial treatment and observation. As is usual with other children, the time of the day, parent’s anxiety and access to transport, and ability of early review should be taken into account if admission or discharge is being considered. Some centres will suggest that if the child still has stridor at rest after treatment, he or she should be admitted. It has been suggested that if there is no sign of increased work of breathing and no sternal recession but minimal stridor at rest, then they could be discharged with adequate explanation and follow up.

Examination and assessment

A harsh barking cough with stridor in a child with minimally raised temperature suggests croup (see below). Cough with low pitched expiratory stridor and drooling suggests epiglottitis. Sudden onset of coughing, choking, drooling and aphonia suggests a laryngeal foreign body (this is extremely rare). Swelling of the face and tongue with wheeze and urticarial rash suggests anaphylaxis. The differential diagnosis is seen in

Examination

The mouth and throat should not be examined if signs of partial upper airway obstruction are present, as complete obstruction can ensue during the examination. Partial acute upper airways obstruction is characterised by stridor and increased work of breathing. Signs of deterioration are those of hypoxia (worried, restless), fatigue, decreased conscious state, and increased and then decreased work of breathing. Heart rate may be rapid or indeed slow. A child’s general appearance is more useful.

Treatment

Allow the child to settle quietly on the parent’s lap and observe closely with minimal interference. Treat specific cause (see croup/anaphylaxis guidelines). Call the Pediatric Intensive Care Unit (ICU) if the child’s condition is worsening or there is severe obstruction, or call for senior doctors (ENT/anesthetics) if an ICU is not available in your hospital

Oxygen may be given while you are awaiting transfer transport. It can be falsely reassuring because a child with quite severe obstruction may look pink with oxygen.

Note that:

• Intravenous access should be deferred—upset can cause increasing obstruction.

• Lateral X-rays do not assist in management. In severe airways obstruction, X-rays cause undue delay in definitive treatment and may be dangerous (positioning may precipitate respiratory arrest).

• Do not examine the throat with a tongue depressor.

• If intubation is considered necessary, this should be done by the most experienced medical personnel present, using a smaller than normal endotracheal tube

This should ideally be done in the operating room with tracheostomy equipment and a surgeon in attendance.

• Once the airway is protected, then full blood count (FBC)/blood cultures, i.v. cannulation and antibiotics can be started.

Emergency Treatment in Pediatric