COMMON CHILDHOOD EMERGENCY

Moderators; DR. Courage/Dr Akinade

GROUP MEMBERS

• JOSEPH EUNICE. BHU/17/01/01/0193
• JOSEPH JOY OJIMA-OJO. BHU/17/01/01/0053
• KUM NANJI. BHU/17/01/01/0057
• KURIYA MARTHA. BHU/17/01/01/0088
• LAT RINRET. BHU/17/01/01/0051
• MAIDAWA BAMAS. BHU/17/01/01/0156
• MANGVEEP SEKYEN BHU/17/01/01/0031
• MAOR SAATER GABRIEL. BHU/17/01/01/0171
• MAYAKI JOY. BHU/17/01/01/0166

INTRODUCTION

• Emergency refers to life threatening medical conditions that require immediate intervention.
• Children present with a wide range of such conditions. However, some present more commonly, as emergencies, than others. E.g, dehydration, convulsions, severe anaemia, childhood poisoning, bites and stings, Allergic disorders in children e.t.c.
• We would look briefly into each one listed above.

Dehydration

• Many diseases lead to water inbalance in children and depending on the relative effects of intake and loss, either dehydration or overhydration may result.
• Children, especially infants are more prone to dehydration than adults due to their relatively high water turn over and body surface area relative to weight.
• Major causes of dehydration in children include:
• Acute Gastroenteritis
• Diabetes mellitus/ diabetes insipidus
• Reduced water intake e.g. bowel obstruction.

Dehydration Cont.

• Classification of level of dehydration:
• Mild dehydration – refers to less than 5% loss of body weight.
• Moderate dehydration – 5-10% loss of body weight.
• Severe dehydration – 10-15% loss of body weight.
• In management,
• Mild dehydration – oral rehydration therapy e.g. ORS, SSS
• Moderate dehydration – oral if patient tolerates or parenteral of patient not tolerating oral fluids.
• Severe dehydration – parenteral fluid replacement.

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PREVENTION OF DEHYDRATION

• Advise unrestricted oral fluids
• Continue breast feeding
• In high risk cases-advice unrestricted normal drinks and 10ml/kg of ORS after each watery stool passed
• Teach mother how to prepare SSS at home

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CORRECTION OF DEHYDRATION

Note:

Rehydration can be achieved either by oral or intravenous route

• Oral rehydration therapy (ORT) is used for most cases
• Rehydration (correction of deficit) is achieved in 4 hours.

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FLUID AND AMOUNT REQUIRED

Some Dehydration

• 75ml/kg of ORS over 4 hrs
• *Re-assess after 4 hrs, if dehydration persists, Repeat above

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ORT is inappropriate for

• Initial treatment of severe dehydration with signs of shock
• Patients with paralytic ileus or marked abdominal distention
• Patients unable to drink (However ORS solution can be given to such patients through N/G tube if IV is not possible).

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ORT is unsuccessful in

• Patients with very rapid stool loss (>15ml/kg/hr)
• Patients with severe, repeated vomiting
• Patients with glucose malabsorption (rare)

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Intravenous Therapy (IVT)

• Mainly used for initial treatment of severe (life threatening) dehydration, to rapidly restore blood volume and correct shock.
• In severe dehydration with shock

* Give 20-30ml/kg IV boluses of Ringer’s lactate or normal saline until organ perfusion is restored. Then continue rehydration with ORT

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Intravenous Therapy (IVT)

In case child is not able to drink, continue rehydration with IVT using 0.45% saline in 5% dextrose (or 0.18% saline in 4.3% dextrose based on serum sodium values).

• Calculate deficit and maintenance
• Give ½ deficit and 1/3 maintenance in 7hrs and the remaining deficit and maintenance in 16 hrs
• Add KCL (10-20mmol/500ml bag) soon as urine is passed.

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Intravenous Therapy (IVT)

• Isonatraemic Dehyration

- treat as per standard protocol

• Hyponatraemic Dehydration

- relatively greater loss of Na than water. Tends to be more common in malnourished children.

* Treat if serum Na <120mq/L. Calculate deficit thus (135-serum Na) x 0.6 x wt in kg.

* Correct deficit over 24 to 48 hours.

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Convulsions in the Emergency Paediatric Unit

• Seizure is a clinical condition in which there is a sudden disturbance of neurological function caused by an abnormal or excessive neuronal discharge which manifests as motor, sensory, psychic or autonomic.
• Convulsion refers to the motor component of seizure and represents the most conspicuous thus its frequent use interchangeably.
• Classified into:
• Febrile and afebrile convulsions
• Febrile futher into simple febrile and complex febrile convulsions
• Recurrent afebrile convulsions is known as epilepsy.

Convulsions in the Emergency Paediatric Unit Cont.

• Causes:
• Febrile convulsions
• Conditions that cause brain inflammation e.g. meningitis, encephalitis, head injury, stroke, brain tumour.
• Metabolic conditions e.g. hypoglycaemia, hyperglycaemia, uraemia, hypocalcaemia, hypomagnesemia, hyponatraemia, hypernatraemia.
• Seizure disorder.
• Poisoning e.g lead, alcohol overdose/withdrawal.
• Others – breath holding in infants, pertussis, severe anaemia, cerebral hypoxia.

Convulsions in the Emergency Paediatric Unit Cont.

• NB: the commonest cause is febrile convulsions which is defined as: a seizure accompanied by fever( temp.>38*C) without any central nervous system pathology, occurring in infants and children 6 months to 5 years of age.
• Principles of Treatment:
• ABC’s of Resuscitation
• Abort seizure
• Iv diazepam 0.2-0.5mg/kg(0.3mg/kg) to a max. of 10mg every 5 mins for about 3 doses. Could be rectal at 0.5mg/kg to a max of 20mg if iv access not readily available.
• Temperature control- expose patient, tepid sponge, use antipyretics
• Finding the cause and treating it.

Severe Anaemia

• Severe anaemia is defined as reduction of the red blood cell volume or heamoglobin concentration below 5g/dl or 15%PCV.
• Causes (age related):
• Newborn to 3months:
• Haemolysis
• Blood loss from obstetric complications
• Reduced RBC production.
• Older Children:
• Severe falciparum malaria and infection
• Genetic disorders e.g. haemoglobinopathies, haemophilia, enzymopathies
• Severe Protein Energy Malnutrition, gastrointestinal blood loss, malignancies.

Severe Anaemia Cont.

• Emergency Management of Severe Anaemia:
• Urgent PCV
• Blood Transfusions
• Find cause and treat(nutritional supplementation, etc.)

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Childhood Poisoning

• Very common phenomenon.
• Children are curious and explore their world with all their senses including taste. Hence can be easily exposed to poisoning substances in the environment which they may inadvertently ingest.
• 1.) Alcohol Poisoning in Children:
• sources:
• Mothers give to cause sleep and calmness
• Trado-cultural where some children are allowed to take alcohol during festivities.
• Accidental ingestion of antiseptics, window cleaners, sanitizers, mouth washes which all have varying degrees of alcohol content.
• From the breastmilk of alcoholic mother
• Ingestion of antifreeze.

Childhood Poisoning Cont.

• Clinical Features:
• Stupor and confusion
• Vomiting
• Tachycardia with a bounding pulse
• Hypothermia
• Depressed respiration leading to apnoea
• Convulsions and coma
• Life threatening Complications:
• Hypoglycaemia
• Respiratory depression

Childhood Poisoning Cont.

• Treatment:
• Mainstay of treatment is conservative and supportive and includes:
• Nursing patient in the left lateral decubitus position to prevent choking and vomiting
• Deliver oxygen via AMBU bag, nasal prongs or endotracheal intubation
• Treat hypoglycaemia (4ml/kg of 10% dextrose then maintain on 10% dextrose drip)
• Gastric lavage

Childhood Poisoning Cont.

• 2.) Kerosene Poisoning
• Common in children <5years especially in developing and underdeveloped countries.
• Has poor GI absorption but has rapid absorption after inhalation or aspiration.
• Vomiting plays a role in pneumonitis
• Clinical Features:
• Cough, tachypnoea, retraction, grunting, wheezing, cyanosis and fever
• Abdominal pain, nausea, vomiting, diarrhea

Childhood Poisoning Cont.

• Management:
• If symptoms do not appear within 6 hrs of ingestion, the patient will be normal. Many patients remain well and need no treatment.
• Symptomatic patient need chest radiograph.
• Stabilising airway and administration of oxygen.
• Avoid induction of vomiting and gastric lavage.
• General preventive measures.
• Other examples of childhood poisoning:
• Acetaminophen Poisoning
• Lead Poisoning
• Iron Poisoning
• Caustic Soda Poisoning

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Bites and Stings

• Scorpion Sting:
• Common in our environment.
• Children present with more severe and protracted symptoms than adults: in most cases, the scorpion sting immediately produces intense local signs like acute pain which can last from about 5mins to an hour and inflammation followed by general manifestation like a tendency to faint, excessive salivation, sneezing, lacrimation and diarrhea. Death is usually due to respiratory failure due to anaphylaxis, bronchoconstriction,pharyngeal secretions and diaphragmatic paralysis. Also, venom-induced multisystemic failure plays a vital role.

Bites and Stings Cont.

• Treatment:
• Ensure no further stings and reassure victim who may be in intense pain, terrified and hysteric.
• Do tamper with wound site(no massaging)
• Give pain reliever- cold pack, analgesics
• Supportive treatment such as adequate ventilation and correction of hypotension, atropine to block induced bradycardia and bronchorrhoea.
• Abort any seizures

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Bites and Stings Cont.

• Antivenin is the definitive treatment after stabilizing and supportive care. It significantly decreases the level of circulating unbound venom within a few hours.
• Bee and Wasp Stings:
• They can cause significant reactions ranging from localized pain and swelling to serious and even potentially fatal conditions. Most deaths occur as a result of serious anaphylactic sting reactions.

Bites and Stings Cont.

• Treatment of Bee and Wasp Stings:
• Depends on the severity. Problems requiring medical attention are from allergic reaction to the sting. Early care involves:
• Removal of stingers
• Applying ice pack to site to relieve pain
• Local cleaning of wound and application of antibiotic ointment.
• When signs and symptoms of allergy are apparent, the patient will benefit from the use of antihistamines and NSAID’s. in anaphylactic shock, iv infusion, adrenaline injection and iv hydrocortisone are mandatory.

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Bites and Stings Cont.

• Snake Bites:
• There are about 3,000 species of snakes worldwide but only 15% of these snakes is considered dangerous to humans. Snakes bites are common.
• The composition and effects of a venom can be broadly divided into categories which include:
• Cytotoxins which cause local swelling and tissue damage
• Haemorrhagins which disturb the integrity of blood vessels
• Neurotoxins which cause neurotoxicity
• Myotoxins which cause muscle breakdown
• Compounds which cause consumption coagulopathy

Bites and Stings Cont.

• Treatment:
• Supportive as required
• Mainstay of treatment is intravenous injection of an appropriate antivenin. Its purpose is to bind the toxins in the venom and prevent both local and systemic effects. Should be administered within 4-6hrs of a bite to achieve maximum efficacy.
• Monovalent immunoglobulin fragment
• Polyvalent immunoglobulin fragment

Bites and Stings Cont.

• Dog Bite:
• Dogs are the reservoir of rabies infection especially in most developing countries where unattended dog population constitutes a public health hazard.
• Human rabies is endemic in Nigeria largely affecting the group 5-14years. Dog bites and attacks are common as dogs are used as domestic pets, for security, and for consumption.
• Rabies is caused by the virus specie in the genus Lyssavirus of the Rhabdoviridae family.

Bites and Stings Cont.

• Clinical Features:
• The initial symptoms are fever, pain or an unusual or unexplained tingling, pricking or burning sensation at the wound site. As the virus spreads through the CNS, progressive fatal inflammation of the brain and spinal cord ensues causing episodic delirium, psychosis, restlessness, thrashing, muscular fasciculations, seizures, and aphasia. Hydrophobia and aerophobia occur in 50% of patients.
• Post-exposure prophylaxis:
• Washing and wound debridement, antibiotic prophylaxis, rabies immunoglobulin(HRIG-20IU/kg at wound site and as deep IM. Also given at the deltoid at 1ml on day 0, 3, 7, 14 and 28)

Bites and Stings Cont.

• Factors suggesting risk of rabies are:
• The biting dog is known as a rabies carrier
• Dog looks sick or has abnormal behavior
• The wound or mucous membrane was contaminated by the dog’s saliva
• The bite was unprovoked
• The dog has not been vaccinated or immunization status not known.
• NB:
• Regardless of treatment, symptomatic rabies is almost invariably fatal.
• Pre-exposure immunization is recommended for veterinarians, adults and their families who are involved in dog trade.

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Allergic Disorders in Children

• Allergy is the study of human hypersensitivity reaction producing a pathologic response to non-self molecules termed allergens.
• Hereditic predisposition to produce IgE antibodies against common environmental allergens and have clinical manifestation of one or more of the disease.
• Two major types:
• IgE-dependent mechanisms(Atopic allergic conditions) e.g. allergic rhinitis, asthma, atopic eczema, e.t.c.
• IgE-independent mechanisms(non-atopic allergic conditions) e.g. contact dermatitis, hypersensitivity pneumonitis.

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Allergic Disorders Cont.

• Pathophysiology:
• The underlying theme in allergic disorders is an abnormal and often exaggerated response to foreign objects.
• This response consists of a complex interplay between cellular and humoral immunity.
• Largely IgE-mediated.

Allergic Disorders Cont.

• Aetiology:
• Exact cause of allergic disorders is unknown.
• Major roles are played by both genetic and environmental factors.
• About two-thirds of patients with atopic dermatitis have a family or personal history of asthma or allergic rhinitis.
• Individuals with two atopic parents are at greater risk of developing an allergic disease than those with only one atopic parent.

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Allergic Disorders Cont.

• There are a wide variety of allergens that can be categorized into 5 major classes:
• Aeroallergens. E.g. pollens
• Food allergens. E.g. milk, egg, peanuts and wheat.
• Drug allergens. E.g. penicillins, sulpha drugs,
• Latex allergens. A reaction to proteins found in natural latex rubber
• Others e.g. venom allergens

Allergic Disorders Cont.

• Major examples of allergic diseases include – asthma, allergic rhinitis, atopic dermatitis, anaphylaxis, urticaria, angioedema, food hypersensitivity, allergic conjunctivitis.
• Principles of Diagnosis:
• Suggested by occurrence of typical symptoms and signs of an allergic syndrome which are often recurrent and situationally supported by a family history.
• FBC and Differentials – eosinophilia
• Elevated IgE
• Positive skin test.

Allergic Disorders Cont.

• Priciples of Treatment:
• It is to be noted that treatment is multidisplinary.
• ABC’s of resuscitation.
• Suppression of allergic response. E.g. use of corticosteroids, antihistamines, sympathomimetics, antipyretics.
• Environmental manipulation/modification to reduce contact between patient and allergen.
• Patient education.

Conclusion

• Childhood emergencies are potentially fatal conditions. Prompt recognition followed by adequate appropriate measures yields better outcomes and prognosis.
• THANK YOU