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Emergency Management 1. ETAT (Emergency Triage Assessment and Treatment) Sources: WHO, Pocket book of hospital care for children, 2013; American Heart Association, BLS for healthcare providers, 2015; WHO, Updates on paediatric emergency triage, assessment and treatment, 2016. • Discuss importance of triaging patientsºº If identify any emergency or priority signs → call for extra help and more senior providers Anatomy Differences for Children vs Adults • Infant tongue is larger in proportion to oropharynx → tongue lies more superiorly and therefore can cause airway obstruction more easily. • Infant/child subglottic airway is smaller and more compliant → more easily obstructed.ºº Trachea and larynx are funnel-­ shaped in children and cylindrical in adults.ºº Narrowest part in airway of a child is at the cricoid cartilage; in adults, at the glottic opening. • Ribs and sternum function to maintain lung volume in adults, but in infants these are more compliant/flexible → fail easier 6 Emergency Management to maintain lung volume. Infants are more dependent on diaphragm movement for lung expansion. • Infants/children have limited oxygen reserve. • Cardiac output in children primarily depends on maintaining an adequate heart rate; ie, bradycardia → rapid fall of cardiac output and is one of most common rhythms observed prior to child’s death. Emergency Signs These require immediate attention/intervention, starting with ABCs—Airway, Breathing, Circulation: • Airwayºº Obstructed or absent breathing • Breathingºº Severe respiratory distressºº Central cyanosis • Circulation * Signs of shock (cold extremities, capillary refill >3 seconds, weak pulse) • Convulsions • Coma (or seriously reduced level of consciousness) • Signs of severe dehydration in a child with diarrhea (lethargy, sunken eyes, very slow return of skin pinch) Priority Signs: 3TPR MOB Children with any of these signs should be assessed without undue delay: • Tiny infant (any sick child 3 sec, weak pulse), otherwise give over 30–60 minutes • Basic life support: If no pulse, provide compressions: 30 compressions , 2 breaths; if 2 rescuers, 15:2. Compressions should be about 1/3 of AP (anterior-­ posterior) diameter. If 8 y.o., 2-­ handed compressions as in adults. Convulsions • Diazepam, rectal or IV (see chapter 3) • Assess for hypoglycemia (see chapters 3 and 16) Coma • Position to protect airway • Assess for hypoglycemia (see chapters 3 and 16) Dehydration • See chapter 18. 2. Shock 9 2. Shock Sources: WHO, Pocket book of hospital care for children, 2013; The Harriet Lane handbook, 19th ed., 2012; Bugando Medical Centre, Paediatrics management guidelines, 2011; WHO, Updates on paediatric emergency triage, assessment and treatment, 2016; Maitland et al, “Mortality after fluid bolus in African children with severe infection,” NEJM 2011. Physiology Preload = amount of muscle stretch before contraction; ~end-­diastolic volume Afterload = impedance to ejection from ventricle; as this increases , the heart has to expend more energy to eject volume and ejects a greater volume (ie, increases end-­ systolic volume). Stroke Volume (SV) = end-­ diastolic volume minus end-­ systolic volume = volume of blood pumped out of ventricle with each beat; depends on heart size, preload, contractility, afterloadºº Increases with increases in preload (by Frank-­ Starling curve relationship) or contractilityºº Decreases with increases in afterload Cardiac Output (CO) = SV times Pulse Rate (PR) = volume of blood pumped from the heart every minute 10 Emergency Management Oxygen delivery = CO times oxygen content Oxygen content = Hb (g/dL) × 1.34 (ml O2 /g Hb) × SpO2 (oxygen saturation) + 0.0032 × PaO2 (partial pressure of oxygen in torr) Shock: Inadequate delivery of oxygen and nutrients to tissues for metabolic demands Compensated shock: Body able to maintain perfusion to vital organs → tachycardia Decompensated shock: Body unable to maintain perfusion → tachycardia, hypotension Causes Causes of shock depend on type: • Hypovolemic: Diarrhea, vomiting, hemorrhage, burns, inadequate fluid intake, DKA, third-­ space losses (ascites, pleural effusion ), trauma • Distributive: Septic (bacteremia, meningitis, PNA, osteomyelitis, UTI, etc), anaphylactic, neurogenic (head injury, spinal injury) • Cardiogenic: Congenital heart disease, myocarditis, cardiomyopathy , arrhythmias, poisoning, drug toxicity, myocardial injury (trauma) • Obstructive: Cardiac tamponade, tension pneumothorax, massive pulmonary edema, ductal-­ dependent congenital heart lesion WHO Shock Definition All 3 criteria are met: • Increased capillary refill > 3 seconds • Cold extremities • Weak pulse If does not meet all 3, then patient has impaired circulation but not shock per WHO. • Child also may have tachycardia +/-­hypotension. Summary of Shock Types, Signs, and Treatment Shock Type Pulse Rate Preload Contractility Systemic Vascular Resistance Treatment Hypovolemic Increased Decreased +/-­ Increased - High-­flow oxygen - Fluids (after 60ml/kg → pressors) Distributive Septic Increased Decreased Decreased Initially decreased, then increased - High-­flow oxygen - Fluids - Antibiotics Anaphylactic Increased Decreased Decreased Decreased - High-­flow oxygen - Epinephrine (adrenaline) - Fluids Neurogenic Increased Decreased +/-­ Decreased - Fluids - Pressors (norepinephrine) Cardiogenic Increased Increased Decreased...

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