Professional Documents
Culture Documents
Guidelines
2014-2015
Contents
Acute liver failure ................................................................................. 1
Anaphylaxis........................................................................................... 7
Arrhythmias ........................................................................................ 14
Asthma................................................................................................ 21
Bronchial foreign body aspiration ...................................................... 23
Croup .................................................................................................. 31
Dehydration ........................................................................................ 35
Diabetes mellitus, preoperative preparation in ................................. 43
Diabetic ketoacidosis .......................................................................... 53
Febrile seizures ................................................................................... 56
G6PD deficiency.................................................................................. 58
Heart failure........................................................................................ 59
Hypoglycemia ..................................................................................... 60
NG tube insertion ............................................................................... 61
Poisoning ............................................................................................ 63
Scorpion envenoming ......................................................................... 71
Sepsis .................................................................................................. 74
Status epilepticus ............................................................................... 78
Transfusion ......................................................................................... 80
a.
b.
c.
d.
e.
Uremic encephalopathy
Severe or persistent hyperkalemia > 7 meq/L
Severe metabolic acidosis
Fluid overload (pulmonary edema, severe hypertension)
Hyponatremia (120 meq/L or symptomatic) or
hypernatremia
Ascites
1. If patient has respiratory compromise due to tense ascites or
there is concern for peritonitis, perform therapeutic
paracentesis.
2. Infuse 25% albumin while doing paracentesis.
3. Provide < 3 mEq/kg of sodium daily to minimize water
retention and worsening the ascites.
4. Start lasix and aldactone at a ratio of 1:2.5 (maximum dose of
lasix 160 mg and aldactone 400 mg). Closely monitor fluid
status including renal function, I/O and weight.
5. Consider Diuril (2-8 mg/kg/day IV in 2 divided doses or 20-40
mg/kg/day PO in 2 divided doses) for persistent ascites
and/or edema.
6. Avoid overhydration.
Liver transplantation
This is the only definite treatment. King's College Hospital criteria
for liver transplantation in acute liver failure are:
A. Paracetamol (acetaminophen) overdose
1. pH < 7.3 (irrespective of encephalopathy)
or all of the following:
Anaphylaxis
Definition
Anaphylaxis is defined as a serious allergic reaction that is rapid
in onset and may cause death. Anaphylaxis in children,
particularly infants, is frequently underdiagnosed.
It occurs when there is a sudden release of potent biologically
active mediators from mast cells and basophils, leading to
cutaneous (urticaria, angioedema, flushing), respiratory
(bronchospasm, laryngeal edema), cardiovascular (hypotension,
dysrhythmias, myocardial ischemia), and gastrointestinal
(nausea, colicky abdominal pain, vomiting, diarrhea) symptoms.
Etiology
1. Food: peanuts, tree nuts (walnut, hazelnut, cashew, pistachio,
Brazil nut), milk, eggs, fish, shellfish (shrimp, crab, lobster,
clam, scallop, oyster), seeds (sesame, cottonseed, pine nuts,
psyllium), fruits (apples, banana, kiwi, peaches, oranges,
melon), grains (wheat)
2. Drugs: penicillins, cephalosporins, sulfonamides, nonsteroidal
anti-inflammatory agents, opiates, muscle relaxants,
vancomycin, dextran, thiamine, vitamin B12, insulin,
thiopental, local anesthetics
3. Hymenoptera venom: honeybee, yellow jacket, wasp, hornet,
fire ant
4. Latex
5. Allergen immunotherapy
6. Exercise: food-specific exercise, postprandial (nonfoodspecific) exercise
d. Persistent gastrointestinal
abdominal pain, vomiting)
symptoms
(e.g.,
crampy
Epinephrine
(1:1000) IM (1
mg/mL)
Each amp = 1 mL = 1
mg
H1 antagonists
Cetirizine PO (> 2
yr)
Frequency of
administration
Dosage
Immediately, then
every 515 min as
required
0.01 mg/kg up to
0.03 mg/kg
OR by age
> 6 yr: 150 mcg =
0.15 mL IM
6-12 yr: 300 mcg =
0.3 mL IM
12-18 yr: 500 mcg =
0.5 mL IM
Loratidine
Desloratidine
0.25 mg/kg up to 10
mg
2-5 yr: 5 mg
> 5 yr: 10 mg
6-12 mo: 1 mg
Chlorpheniramine
IM/IV
Every 46 hr as
required for
cutaneous
manifestations
Repeat up to 4
times/24 hr
1.25 mg/kg up to 50
mg
< 6 mo: 250 mcg/kg
(max. 2.5 mg)
6 mo-6 yr: 2.5 mg
6 yr-12 yr: 5 mg
12 yr-18 yr: 10 mg
H2 antagonists
Ranitidine PO/IV
Cimetidine
Every 8 hr as
required for
cutaneous
manifestations
Every 12 hr or as
required
1 mg/kg up to 50 mg
4 mg/kg up to 200
mg
Corticosteroids
Prednisone PO
Methylprednisolone
IV
Salbutamol
Nebulized
epinephrine
(1:1000)
10
Every 6 hr as
1 mg/kg up to 75 mg
required
Every 6 hr as
1-2 mg/kg up to 125
required
mg
Every 20 min or continuously for
respiratory symptoms (wheezing or
shortness of breath)
Every 20 min to 1 hr for symptoms of
upper airway obstruction (stridor)
Post-emergency management
Cetirizine
or
H1 antagonist
Lortin
Oral
Corticosteroid
prednisolone
Prevention
1. Patients experiencing anaphylactic reactions to foods must be
educated in allergen avoidance, including actively reading
food labels and acquiring knowledge of potential
contamination and high-risk situations, as well as in the early
recognition of anaphylactic symptoms (sensation of warmth
and facial pruritus) and ready administration of emergency
medications.
2. Patients with egg allergy should be tested before receiving the
influenza vaccine, which contain egg protein.
3. In cases of food-associated exercise-induced anaphylaxis,
children must not exercise within 2-3 hr of ingesting the
triggering food, stop exercising, and seek help immediately if
symptoms develop.
4. Reactions to medications can be reduced and minimized by
using oral medications in preference to injected forms.
5. Hypo-osmolar radiocontrast dyes can be used in patients in
whom previous reactions are suspected.
11
Patient education
1. Instruction on avoidance of causative agent
2. Information on recognizing early signs of anaphylaxis
3. Stress early treatment of allergic symptoms to avoid systemic
anaphylaxis
12
13
Arrhythmias
Tachyarrhythmias
Tachyarrhythmias are classified into:
1. Atrial tachycardia: AF, EAT, MAT
2. Conduction system tachycardia
tachycardia: AVRT, AVNRT, PJRT
3. Ventricular tachycardia: VT, VF
or
o
o
o
o
o
o
14
supraventricular
o
o
o
irregularly irregular
multiple different P wave morphologies,bizarre and chaotic
no two RR intervals the same
15
o
o
o
o
Bradyarrhythmias
Bradycardia
16
Heart blocks
QRS Width
Narrow QRS
Wide QRS
P/QRS ratio
P/QRS ratio
> 1:1
Regular ( Atrial
Flutter)
Variable (EAT)
Chaotic
(MAT/Fib)
1:1
< 1:1
QRS-P
interval
JET
VT (< 1:1)
VT(1:1)
SVT + BBB
Antifromic AVRT
Very long
(PJRT/EAT)
short follows QRSP wave
(orthodromic AVRT)
not visible (AVNRT)
17
Tachyarrhythmia
Narrow QRS
Wide QRS
Stable
Unstable
stable
Unstable
vagal
manoeuvers
adenosine
propranolol
amiodarone
synchronized
cardioversion
amiodarone
lignocaine in
ventricular
tachycardia
synchronized
cardioversion
or
defibrillation
Management
Hemodynamically stable
1. Vagal manoeuvers:
a. Icepack/iced water for infants; apply to face for a
maximum of 30 seconds.
b. Valsalva manoeuver if child is old enough (blow into a
pinched straw).
2. IV adenosine: 0.1 mg/kg (max. 6 mg) rapid push; increase by
0.1 mg/kg every 2 min until tachycardia terminates or up to a
maximum of 0.5 mg/kg (max. 18 mg).
3. IV propranolol 0.1 mg/kg over 5 min; can be repeated every 5
min for 3 times.
18
o
o
o
o
Abbrevations
AVNRT: atrioventricular nodal re-entry tachycardia; AVRT:
atrioventricular re-entry tachycardia; BBB: bundle branch block;
EAT: ectopic atrial tachycardia; Fib: fibrillation; JET: junctional
ectopic tachycardia; MAT: multifocal atrial tachycardia; PJRT:
19
permanent
junctional
reciprocating
tachycardia;
supraventricular tachycardia; VT: ventricular tachycardia
Pediatric advanced life support
20
SVT:
Asthma
Diagnosis
History: Does the patient have established disease or not?
Consider differential diagnoses if this is the first presentation.
Assess severeity:
1. Mild: SpO2 >95% on room air (treated as outpatient with
bronchodilator)
2. Moderate: SpO2 91%-95% on room air and PEF 50%
3. Severe: SpO2 <91% on room air and PEF <50%
Initial treatment for moderate and severe asthma
1. O2: to maintain SpO2 above 92%
2. Salbutamol nebulizer: 3 doses at 20-minute intervals
a. < 20 kg 0.5 mL + 3 mL NS
b. > 20 kg 1 mL + 3 mL NS
3. Ipratropium bromide nebulizer:
a. < 1 yr 0.5 mL
b. > 1 yr 1 mL
4. Steroid:
a. Methylprednisolone initial 2 mg/kg/dose IV, followed
by 1 mg/kg/dose IV 6-hourly
b. Hydrocortisone vial initial 10 mg/kg/dose IV, followed
by 1 mg/kg/dose 4 times daily
c. Prednisolone 1-2 mg/kg/day orally
21
Improvement
Salbutamol nebulizer
hourly for 2-4 hr
OR
Oral salbutamol +
short course steroid
Magnesium sulfate 30
mg/kg in 30 mL NS over
30 min; repeat after 6
hr.
Terbutaline
infusion
loading
dose
5-10
mcg/kg followed by
maintenance dose 2-10
mcg/kg/hour.
Aminophylline infusion
5 mg/kg in 30 mL NS
over 20 min; reduce
terbutaline by 50%.
22
Mechanical ventilator
Introduction
Foreign body aspiration is a common pediatric problem and a
leading cause of accidental death in children under 5 years of age.
Children between the ages 1-4
4 years explore their environment,
which often includes introducing objects into their mouths. It
23
follows that nearly all foreign body aspirations occur in this age
group.
The most commonly aspirated objects are food materials, such as
peanuts, seeds (sunflower and watermelon), nuts, and beans.
Some insert objects that are easily aspirated into the childs
airway include small toys, buttons, toy parts, lids or straight pins.
Diagnosis of bronchial foreign body aspiration is challenging in
children and delayed diagnoses occur for several reasons. The
aspiration event is often unwitnessed or denied by parents. Most
aspirated objects are radiolucent.
After the initial coughing paroxysm, there is usually a quiescent
(relatively asymptomatic) phase for about a week before
pneumonia or other complications occur. Factors that might cause
delays in diagnosis are:
o
o
o
o
o
Pathophysiology
The pathophysiology depends on the site of the impaction, age of
the child, and the nature of the foreign body. Near total
obstruction of the larynx or trachea can cause immediate
24
asphyxia and death, whether the object passes the carina or not, it
depends on the patients age and physical position at the time of
the aspiration.
Until the age of 15 years, foreign bodies are found on either side
with equal frequency, but once aspirated; objects may
subsequently change position or migrate distally.
The object itself might cause obstruction or induce inflammation,
edema, cellular infiltration, ulceration, and granulation tissue
formation, which may contribute to airway obstruction.
Distal to the obstruction, air trapping leading to local emphysema,
atelectasis, hypoxic vasoconstriction, post-obstructive pneumonia
and possible volume loss, necrotizing pneumonia or abscess,
suppurative pneumonia, or bronchiectasis may occur.
The likelihood of complications increases after 24-48 hrs, making
quick removal of the foreign body urgent.
Assessment and evaluation
Often, the child presents after a sudden episode of coughing or
choking while eating with subsequent wheezing, coughing, or
strider. However, in numerous cases, the choking episode is not
witnessed, and, in many cases, the choking episode is not recalled
at the time the history is taken.
The most tragic cases occur when acute aspiration causes total or
near-total occlusion of the airway, resulting in death or hypoxic
brain damage.
The more difficult cases are those in which aspiration is not
witnessed or is unrecognized and, therefore, is unsuspected.
25
Management
Prevention is the most important point in management:
1. No child less than 15 months old should be offered foods such
as popcorn, hard lollies, raw carrot or apples. Children under
the age of 4 years should not be offered peanuts.
2. Encourage the child to sit quietly while eating and offer food
one piece at a time.
26
3. Avoid toys with small parts for children under the age of 3
years.
Treatment includes:
1. Bronchodilators and corticosteroids should not be used to
remove the foreign body, and chest physical therapy with
postural drainage may dislodge the material to an area where
it may cause more harm, such as at the level of the vocal cord.
2. Place child upright in the position they feel most comfortable ,
Arrange for urgent removal of foreign body in the operating
theatre. Rigid bronchoscopy is almost always successful.
3. Medications are not necessary before removal, although the
endoscopist may observe enough focal swelling after the
material is removed to recommend a short course of systemic
corticosteroids.
4. Unless the airway secretions are infected with organisms
present, antibiotics are not necessary.
5. Treat complications.
Complications
1.
2.
3.
4.
5.
6.
7.
8.
9.
Atelectasis
Recurrent pneumonia
Penumonitis
Bronchial Granulomas.
Pneumomediastinum
Bronchiactasis
Obstructive emphysema
Lung abscess
Bronchocutanious or bronchovascular fistula if untreated.
27
Aim
Aim of this guideline is to decrease morbidity and mortality
associated with bronchial aspiration, and help more accurate
diagnosis and choice of medication, with avoidance of misuse or
overuse of medications and performing unnecessary invasive
procedures.
Inclusion criteria
1. Stable children suspected of unilateral foreign body aspiration
2. Foreign body aspiration confirmed by a witness in a stable
child with respiratory complain
Exclusion criteria
1. Forign body ingestion with no respiratory complian.
2. Upper airway aspiration including laryngeal or pharyngeal
(strider, cough, hoarseness, in ability to speak)
3. Bilateral bronchial aspiration
4. Clinically unstable child with respiratory failure and
decreased level of consciousness
Key points
1. History of chocking in a clinically stable child with mild or no
respiratory complain should elicit suspicion of bronchial
aspiration in a child 1-4 years of age.
2. Local wheeze or local diminished air entry should be looked
for, in examining a child with suspected bronchial aspiration.
28
29
30
Croup
Consider alternative
diagnoses:
1. Inhaled foreign body
2. Congenital anomalies
3. Epiglottitis/tracheitis
Diagnosis of croup
Is life-threatening airway
obstruction present?
1. Cyanosis
2. level of consciousness
Yes
1. 100% O2
2. Nebulized adrenaline
3. Intubation (by
experienced personnel)
4. Systemic corticosteroid
No
Mild croup
Barking cough
Nil or
intermittent
stridor
No cyanosis
1. Explanation to
parents
2. No specific
treatment
3. Discharge
Moderate croup
Persisting stridor
at rest
Some recession
May have
cyanosis
1.
Dexamethasone
0.6 mg/kg
2. Observe in > 4
hr
Severe croup
Persisting/soft
stridor at rest
Marked
recession
Apathetic or
restless, cyanosis
1. Do not agitate
the child
2. O2, nebulized
adrenaline
4. Steroid
5. Observe in > 4
hr
31
Improvement
Yes
Discharge when
there is no more
stridor.
Partial
1. Admit/observe
2. Repeat steroid
in 12 hr
3. Explanation to
parents
4. Written follow
up
No
1. Inform
consultant
2. Nebulized
adrenaline (same
as previous dose)
3. Steroid (same
as previous dose)
4. Consider
intubation
32
Croup grade
Dose
Systemic
corticostero
id*
Moderate or
severe
Dexamethasone
0.6 mg/kg, single
dose, IV/IM/PO
Moderate or
severe
Adrenaline
1:1000, 1 mg/1
mL, (0.5-1
mL/dose in 3 mL
of NS) nebulized
Nebulized
adrenaline
Notes
Acts within 1
hr
Repeat in 1224 hr
Acts within
minutes
May need
repeat doses
after 30 min if
no response
33
O2
34
Severe (SpO2
< 90%)
Very severe
with central
cyanosis
Mask with
minimum
amount of 6
L/min
Dehydration
Signs and symptoms of severe dehydration
Body weight loss
General appearance
Respiration*
Eyes
Tears
Anterior fontanelle
Mucous membranes
Capillary refill time*
Tissue turgor*
Radial pulse
Blood pressure
>10%
Drowsy, limp, cold, sweaty, cyanotic
extremities
Deep and rapid
Grossly sunken
Absent
Very sunken
Very dry
Prolonged (>3 seconds)
Retracts very slowly
Rapid, thready, may be impalpable
Low
Urine output
Marked oliguria
* These are the most reliable and helpful signs.
Management
Total IV fluid requirement in severe dehydration
Treat shock
Fluid deficit (mL)
= % of
dehydration x 10
x weight in kg
Maintenance
(see table
below)
Ongoing losses
Fever
Dehydration
Diarrhea & vomiting
Pooling of fluid in
the gut
Capillary leak
35
Body weight
Fluid
mL/kg/24
hr
Sodium
mmol/kg/24
hr
Potassium
mmol/kg/24
hr
1st 10kg
100 mL
2-4
1.5-2.5
2nd 10 kg
50
1-2
0.5-1.5
Subsequent kg
20
0.5-1
0.2-0.7
Phase 2:
Rehydration
repeat up to 3 times
Improvement*
No improvement*
no improvement after 2
hr and 3 boluses of NS
Phase 1: Treat
shock (0-30 min)
Na+
135 145
Na+
> 150
no improvement
after 45 min
36
in 1st 8 hr then in 16
hr.
in 1st 18 hr then in 30
hr
37
38
Treatment of
malnutrition
severe
dehydration
in
children
with
39
40
Yes
No
No
Is IV treatment
available nearby
(within 30 min)?
Yes
41
Yes
Yes
No
No
Refer URGENTLY to
hospital for IV
treatment.
Note:
If possible, observe the patient for at least the first 6 hours after
rehydration in order to make sure that the mother is able to keep
the child normally hydrated.
42
Type 1 DM or type 2 DM on
insulin
Major surgery
Minor surgery
43
44
45
46
47
Morning operations
Morning operations
Evening operations
(if unavoidable)
Evening operations
(if unavoidable)
48
49
50
51
52
Diabetic ketoacidosis
DKA diagnostic criteria
Blood sugar > 300 mg/dL
Acidosis (serum HCO3 < 15 mEq/dL)
Intravenous fluid
Total amount = (85 mL/kg + maintenance)/24 hr
of this is given within 12 hr bolus given in basic life
53
Unit/kg of insulin
> 600
0.1
300-600
0.05
Note: Mix 25 units of insulin with 250 mL N/S. In this way each
mL will contain 0.1 unit. Thus you can give 1 cc/kg/hr.
Potassium
Potassium should be added after the 1st hr of treatment by
giving 1 mEq/kg of potassium phosphate if available.
If this is not available then give KCl as follows (after checking
urine output):
Serum K+ 3.5-5 give 20 mmole/L.
Serum K+ < 3 give 40 mmole/L and do an ECG.
If the patient is hyperkalemic potassium should not be given
and they should be followed up.
Antibiotics
Give ceftriaxone or amoxiclave to cover underlying infections.
54
Improvement
(no emesis, improved consciousness, can take orally,
acidosis corrected)
< 100
100200
200300
300400
400500
> 500
0
0.1 u/kg
0.2 u/kg
0.3 u/kg
0.4 u/kg
0.5 u/kg
No improvement
Treat ICP:
1. Elevate head
1. Exclude hypoglycemia.
2. Are there signs of ICP
(e.g. apnea, bradycardia,
seizure,
papilledema,
deterioration, LOC)?
Consider cerebral edema
and send for a CT scan.
55
Febrile seizures
Febrile seizures are seizures that occur between the age of 6-60
mo with a temperature of 38 C or higher, that are not the result
of central nervous system infection or any metabolic imbalance,
and that occur in the absence of a history of prior afebrile
seizures.
A simple febrile seizure is a primary generalized, usually tonicclonic attack associated with fever, lasting for a maximum of 15
min, and not recurring within a 24-hr period.
A complex febrile seizure is >15 min, focal, and/or recurs within
24 hr.
Febrile status epilepticus is a febrile seizure lasting >30 min.
Risk factors for recurrence
Major
1. Age <1 yr
2. Duration of fever <24 hr
3. Fever 38-39 C
Minor
1.
2.
3.
4.
5.
6.
56
Management
1. Positioning: left lateral
2. Resuscitation
3. Stop seizure
1. History
2. Vital signs: HR, SpO2, RR, temperature, BP
3. Physical examination: consciousness, GCS, irritability,
bulging fontanelle, signs of meningeal irritation (neck
stiffness, Kernig sign, Brudzinski sign)
Investigations:
1. RBS, serum electrolytes (Na+, K+, Ca2+, Mg2+)
2. Lumbar puncture: indications are age < 1 yr
atypical febrile seizure not regaining
consciousness within 30 min post-ictal
drowsiness
3. Others: infection screen (blood culture, urine culture,
CXR), neuroimaging
57
G6PD deficiency
Diagnosis
History: presence of history of G6PD in the patient and/or in the
family; history of precipitating factors.
Physical examination: pallor and jaundice.
Investigations: PCV (hematocrit), reticulocyte count,
reticulocyte production index (RPI), Heinz bodies and fragmented
RBCs on blood film.
Management
<7g
Give blood
Hb > 7 g and
clinically stable
Hb < 7 g
>7g
Clinically stable
Clinically unstable
( PR, BP, LOC)
Give blood
58
SI: stroke index; CI: cardiac index; SVRI: systemic vascular resistance index; TFI: thoracic fluid index.
Heart failure
59
Hypoglycemia
Hypoglycemia
(RBS < 45 mg/dL)
Unconscious (drowsy)
1. Insert IV cannula
2. Place a urine bag to collect next
urine passed
3. Send blood for lab
measurement of glucose level for
confirmation
4. Give an IV bolus of 5-10 mL/kg
of 10% dextrose
5. Start a continuous IV infusion
of 10% dextrose/0.45% saline at
a rate of 2.5-5 mL/kg/hr (6
mg/kg/min glucose)
6. Recheck RBS at 5 min intervals
until RBS is stable > 54 mg/dL.
Conscious
< 1 yr milk feeding
> 1 yr quick-acting
carbohydrate such
as pure fruit juice
60
NG tube insertion
Indications
1. Feeding
2. Administering drugs
3. Aspiration of gastric secretions swallowed air in
gastrointestinal obstruction preparation before surgery
under GA gastric fluid for analysis
Contraindications
1.
2.
3.
4.
Complications
Minor
1. Nose bleeds
2. Sinusitis
3. Sore throat
Major
1.
2.
3.
4.
61
Placement
Before an NG tube is inserted the appropriate length must be
measured from the tip of the patient's nose backwards, looping
around their ear and then down to roughly 5 cm below the
xiphoid process.
The tube is then marked at this level to ensure that the tube will
be inserted far enough into the patient's stomach.
The end of a plastic tube is lubricated (local anesthetic, such as
2% xylocain gel, may be used).
To ensure proper placement air is injected into the tube while
holding a stethoscope on the epigastric area; if the air is heard in
the stomach with a stethoscope then the tube is in the correct
position.
62
Poisoning
Poisons can cause harm by a wide range of mechanisms and can
cause a wide range of symptoms including unconsciousness,
nausea, vomiting, burning pain in the mouth or throat, headache,
blurred vision, seizures, difficulty breathing, respiratory arrest,
and cardiac arrest.
Harmless substances
There is a list of substances that if ingested by the child cause no
harm and only re-assurance of the family is needed.
Topical
antibiotic
Contraceptives
pills
Topical
antifungal
Topical
corticosteroids
Bubble bath
soap
Crayons
Calamine
lotion
Candles
Chalk
Children's toy
cosmetics
Clay
Deodorants'
underarm
Soap of hand
and dish
Diaper rash
cream
Glues
Grease
Hand lotion
and cream
Mineral
oil
Play- Doh
Ink (non
Water
permemanent) color
Laxatives
Vaseline
Lipstick
Shampoo
Magazines
Shaving
creams
Makeup
Matches
Starch
Sunscreen
Zinc oxid
63
Management of poisoning
Decontamination
Resuscitation and
supportive care
Specific
management
64
65
Additional antidotes
Toxin or poison
Black widow spider
66
Antidotes
Latrodectus antivenin
Botulinum toxin
Botulin antitoxin
Dystonic reactions
Diphenhydramine and/or
benztropine
Calcium salts
Heparin
Protamine
Methotrexate, trimethoprim,
pyrimethamine
Folinic acid
Rattlesnake envenomation
Sodium bicarbonate
Recognizable syndromes
Poison syndrome
Signs: Vitals | Mental status | Pupils |
Skin | Bowel sounds | Other
Sympathomimetic
BP, HR, hyperthermia
Agitated, psychosis, delirium
Possible toxins
Amphetamines,
cocaine,
ecstasy,
pseudoephedrine,
caffeine,
theophylline
Dilated pupils
Diaphoretic
Normal to increased bowel sounds
67
Anticholinergic
BP, HR, hyperthermia
Agitation, delirium, mumbling speech
Dilated pupils
Antihistamines,
tricyclic
antidepressants,
atropine,
jimson
weed,
phenothiazines
Dry skin
Decreased bowel sounds
Cholinergic
HR (though may show HR), BP and
temperature typically normal
Organophosphates,
nerve
gases,
Alzheimer
medications
Methadone,
suboxone,
morphine,
oxycodone, heroin,
etc.
Pinpoint pupils
Normal skin
Normal to decreased bowel sounds
Sedative-Hypnotics
68
Barbiturates,
benzodiazepines,
ethanol
Somnolence, coma
Small pupils
Normal skin
Normal bowel sounds
Serotonin syndrome
Hyperthermia, HR, BP or BP
(autonomic instability)
SSRIs,
lithium,
MAOIs,
linezolid,
tramadol,
meperidine
Aspirin,
bismuth
subsalicylate
(Pepto-Bismol),
methyl salicylates
Normal pupils
Diaphoretic
Normal bowel sounds
Nausea, vomiting, tinnitus, ABG with
primary respiratory alkalosis and
primary metabolic acidosis
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Withdrawal
HR, RR, hyperthermia
Lethargy, confusion, delirium
Dilated pupils
Diaphoretic
Increased bowel sounds
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Withdrawal from
opioids, sedativehypnotics, ethanol
Scorpion envenoming
Grade 1
Diagnosis
Local pain, paresthesia, erythema, and blisters.
Management
Symptomatic treatment:
1.
2.
3.
4.
Grade 2
Diagnosis
These include symptoms of grade 1 in addition to:
1. Sympathetic overstimulation: tachycardia, peripheral
vasoconstriction (cool limbs), hypertention
2. Metabolic: hyperthermia, hyperglycemia, acidosis
3. Neuromuscular: confusion, dystonia, fasciculation, ptosis,
vision disorders, aberrant eye movements, mydriasis,
agitation, tremor
4. Cholinergic syndrome: hypersecretions like salivation,
sweating, vomiting, diarrhea, bronchial hypersecretion,
priapism
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Grade 3
Diagnosis
Life-threatening envenoming consisting of findings of grade 2 in
addition to multiorgan failure. Extra findings are:
1.
2.
3.
4.
5.
Decrease O2 saturation
Diaphoresis
Convulsions, paralysis
GCS < 6 (in absence of sedation)
Heart failure, cardiogenic shock, pulmonary edema
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Sepsis
Sepsis: is a systemic inflammatory response resulting from a
suspected or proven infection.
Severe sepsis: sepsis + organ dysfunction.
Septic shock: severe sepsis + hypoperfusion or hypotension for
more than one hour.
Risk groups for sepsis
1. Infants.
2. Malnourished children.
3. Immunosuppressive
drug
regimen,
e.g.
steroid,
chemotherapy.
4. Children with chronic use of antibiotics.
5. Hospital patient who has urinary catheter or endotracheal
tube.
Management
Diagnosis of sepsis
( HR, RR, BP, mental status changes)
Send for
investigations
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1.
2.
3.
4.
5.
Blood culture
Urine culture
CSF
CBC, ESR, CRP
Blood sugar
Improvement
No improvement
Continue O2
Maintenance
fluid
I.V
Change antibiotics
according to C/S
Transfer patient to
ICU with diagnosis
of severe sepsis or
septic shock.
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Response to fluids
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No response to fluids
(fluid-resistant)
Give dopamine
mcg/kg/min.
Response to dopamine
observe
Dopamine-resistant shock
10-20
Give
adrenaline
mcg/kg/min.
Response to adrenaline
observe
Adrenaline drip 1 mg +
100 mL N/S at 0.1
mL/kg/min).
Give hydrocortisone 50
mg/kg bolus, then 50
mg/kg/day.
Resuscitation goals
1. Normal mental status
2. Normal blood pressure
3. Normal heart rate with no difference
between central and peripheral pulses
4. Warm extremities
5. Urine output > 1 ml/kg/hr
6. Capillary refill < 2 seconds
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Status epilepticus
Status epilepticus is defined as a seizure that lasts for >30 min or
recurrent seizures without full recovery in between seizures for
>30 min.
Convulsion for more than 5 minutes should be treated as status
epilepticus.
Initial management
Manage ABCs
1. Stabilization of airway
2. Maintenance of adequate ventilation
3. Circulatory support
4. RBS: give dextrose if hypoglycemic
Yes
IV line establishment
1. RBS, CBC, serum electrolytes
(if abnormal treat accordingly)
2. IV diazepam 0.3 mg/kg over
2 min (max. 5 mg in infants and
10 mg in older chldren); can be
repeated every 5 min for a max.
of 3 times
No (after 3 attempts
or 30 seconds)
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No
IV/IO phenytoin 20
mg/kg in normal
saline over 20 min
(max. 100 mg) with
ECG monitoring.
No
1. Rapid sequence
intubation
2. I.V / I.O midazolam
0.1 mg/kg loading
dose (max. 8 mg) over
2-3 min.
Then start infusion of
120 g/kg/hr, and
increase by 120
g/kg/hr every 5 min
(max. 1.5mg/kg/hr).
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Transfusion
Indications for transfusion
Packed RBCs
Red blood cells (RBCs) are transfused to increase the oxygencarrying capacity of blood and, in turn, to maintain satisfactory
tissue oxygenation.
1. Premature infant
a.
b.
c.
d.
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B. Treatment
1. Patients with active bleeding and platelet count < 50,000/uL
2. Diffuse microvascular bleeding in association with
cardiopulmonary bypass or extracorporeal membrane
oxygenation (ECMO) with platelet count < 100,000/uL or
laboratory value not available
3. Bleeding in a patient with a qualitative platelet defect
regardless of platelet count
Granulocytes
1. Bacterial sepsis in an infant < 2 wk of age with neutrophil
count < 3 x 109/L
2. Bacterial sepsis or disseminated fungal infection that is
unresponsive to antibiotics in a patient > 2 wk of age with
neutrophil count < 0.5 x 109/L and whose neutrophil count is
expected to recover.
3. Infection that is unresponsive to antibiotics and the presence
of a qualitative neutrophil defect regardless of neutrophil
count.
Fresh frozen plasma
1. INR > 1.5-2 times the mean normal value in a nonbleeding
patient scheduled for surgery or invasive procedure
2. Diffuse microvascular bleeding in a patient with a PT or PTT >
1.5 times the mean normal value or values not yet available
3. Warfarin overdose with major bleeding or impending surgery
4. Patients with thrombotic thrombocytopenic purpura (TTP)
undergoing transfusion or plasma exchange
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Platelets
1. Bone marrow failure
Platelets < 10 x 109/L if no other risk factors for bleeding
Platelets < 20 x 109/L if risk factors present (fever, antibiotics,
haemostatic failure, risk of intracranial haemorrhage)
2. Surgery/invasive procedure
Platelets < 50 x 109/L (however, higher counts may be needed
in surgeries with high risk of bleeding, e.g. neurosurgery)
3. Platelet function defects
Transfuse if there is bleeding or high risk of bleeding,
regardless of actual platelet count
4. Bleeding/massive transfusion
Maintain platelets > 50 x 109/L if thrombocytopaenia is likely
contributing to bleeding
Maintain platelets > 100 x 109/L in the presence of diffuse
microvascular bleeding (DIC) or CNS trauma
Fresh frozen plasma
1. Warfarin effect, in the presence of life-threatening bleeding in
addition to the use of vitamin K and vitamin K dependent
clotting factor concentrates for bleeding with abnormal
coagulation
2. Liver disease, if bleeding with abnormal coagulation
3. Acute DIC when there is bleeding and abnormal coagulation
following massive transfusion or cardiac bypass for bleeding
in the presence of abnormal coagulation
Cryoprecipitate
Fibrinogen deficiency, in the setting of clinical bleeding, an
invasive procedure, trauma or DIC.
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Pre-transfusion assessment
1. Determine the indication for transfusion.
2. Collect pre-transfusion sample (except in infants on ASBT
protocol).
a. A sample for cross-matching must be collected in a 1.4 mL
red EDTA tube (NOT bullet tubes). Patients known to have
red cell antibodies or haemolytic anaemia will require a
larger sample.
b. Correctly identify the patient during the collection of the
pre-transfusion sample. Identification must include 3
unique identifiers (full name, DOB, and UR). This, together
with completing the bedside check prior to blood
administration are the most vital steps in preventing
serious transfusion errors.
3. Request the appropriate blood component and special
requirements:
a. Leukocyte depleted blood products should be given to:
o Immuno-compromised patients (oncology, transplant
recipients, ICU patients, and other congenital and acquired
immune deficiencies)
o Patients requiring chronic transfusions
o Infants under 12 mo
o Intrauterine or exchange transfusions
b. Irradiated blood products should be given to: all immunocompromised patients, including all oncology patients,
cardiac neonates and all patients in ICU, to prevent graftversus host disease.
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o
o
Cryoprecipitate
o
o
o
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Management of transfusion
The key steps include:
1. A formal checking process prior to commencement of
transfusion
2. The use of correct equipment (filters, pump, consideration of
blood warmer)
3. Correct transfusion documentation including patient
observations, start and finish times
Monitoring of the patient:
Observations should be undertaken for every unit transfused.
Minimum monitoring of the patient should include:
o
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reactions
to
Hepatitis C
1 in 1,149,000
Hepatitis B
West Nile Virus
1 in 282,000
Uncommon
50-85% of donors are carriers.
Leukocyte reduction is protective
1 in 2-3,000 (mostly platelets)
Cytomegalovirus
. Bacterial Infection
Parasitic Diseases
Babesiosis, Chagas, Malaria
Relatively uncommon
After transfusion
Document the effect of transfusion on the patient's condition
including Hb if repeated.
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