Initial assessment(ABC s)

Tissue perfusion and oxygenation

Oxygen delivery depends on CO and Hbgconcentration , Hbg oxygen concentration.

Onset of symptoms , details of events , brief identification of underlying medical problem

ABC sA:air way and neurologically injured child Protection of the cervical spineB:breathing (pulse oximeter)C:circulatory(palpitation for distal and central

pulsesBounding pulses and wide pulse pressure

are sign of vasodilatory phase of shock.D:neurologic systemE:exposure

1-respiratory failure

2-shock

Pulse oximetry and bed side measurement of glucose level

CXR : in Child with respiratory distress is important.

Culture ….when sepsis is suspected.

Electrolyte….Inadequate intravascular volume

Oxygen supplementation

Isotonic crystalloids

Packed red blood cell….If hemorrhage is highly suspected

Vasoactive substances …When respiratory and fluid are insufficient

Outcome is poor

Survival is about 6% for out of hospital arrest and 27%in hospital arrest.

Goal is optimize CO and tissue oxygen delivery , which accomplished by artificial

ventilation and chest compression.

Pediatric advanced life support and CPR:

Start chest compression immediately rather than beginning with airway and breathing.

Table 38-2 Warning Signs and Symptoms Suggestingthe Need for Resuscitation*SYSTEM SIGNS AND SYMPTOMSCentral nervoussystemLethargy, agitation, delirium, obtundation,confusionRespiratory Apnea, grunting, nasal flaring, dyspnea,retracting, tachypnea, poor air movement,stridor, wheezingCardiovascular Arrhythmia, bradycardia, tachycardia, weakpulses, poor capillary refill, hypotensionSkin and mucousmembranesMottling, pallor, cyanosis, diaphoresis, poormembrane turgor, dry mucous membranes*Action would seldom be taken if only one or two of these signs and symptomswere present, but the occurrence of several in concert foreshadows graveconsequences

Chest compression : effective CPR requires compression depth of one third to one half

of the ANT-POST diameter of chest with complete chest recoil.

Chest compression Rate 100\min and breaths 8-10 times per min

Head tilt –chin lift maneuver

Jaw thrust

Cricoid pressure

Induction medication

Correct size for tube:mid-fifth phalanx

4+(age\4)

DOPE : in deteriorates patient

Displacement

or Obstruction

Pneumothorax

Equipment failure

Table 38-3 Target Organs for Hypoxic-IschemicDamageORGAN EFFECTBrain Seizures, cerebral edema, infarction,herniation, anoxic damage, SIADH, diabetesinsipidusCardiovascular Heart failure, myocardial infarctLung and pulmonaryvasculatureAcute respiratory distress syndrome,pulmonary hypertensionLiver Infarction, necrosis, cholestasisKidney Acute tubular necrosis, acute corticalnecrosisGastrointestinaltractGastric ulceration, mucosal damageHematologic Disseminated intravascular coagulationSIADH

Interosseous is recommended when iv access is not present.

Some drugs are effectively through endotrachealtube.

Epinephrine

Sodium bicarbonate is not recommended.

side effects are:

hyper Na,

hyper osmolality

Hyper K

Metabolic alkalosis

Table 38-5 Recommendations for Defibrillation

and Cardioversion in Children

DEFIBRILLATION

Place self-adhesive defibrillation pads or paddles with electrode

gel at the apex of the heart and the upper right side of the chest

• Use infant paddles or self-adhesive pads for children <10 kg;

adult size for children >10 kg

Notify all participating personnel before discharging paddles so

that no one is in contact with patient or bed

Begin with 2 J/kg; resume chest compressions immediately

If unsuccessful, increase to 4 J/kg and repeat

Higher energy levels may be considered, not to exceed 10 J/kg or

the adult maximum dose

CARDIOVERSION

Consider sedation if possible

For symptomatic supraventricular tachycardia* or ventricular

tachycardia with a pulse, synchronize signal with ECG

Choose paddles, position pads, and notify personnel as above

Begin with 0.5–1 J/kg

If unsuccessful, use 2 J/kg

ECG, Electrocardiogram.

Classified by:

Hypercarbic (pa co2 greater than 50 mmhg)

Hypoxemic(pao2 less than 60 mmhg) it cause by V\Q mismatch.

Acute Respiratory failure may occure with (ALI) or (ARDS)

Early sign of hypoxic respiratory failure:

Tachypnea and tachycardia

Late signs of inadequate oxygen delivery include cyanosis and altered mental status.

CXR

In pt with stridor or upper airway obstraction

LAT NECK or CT

Flexible bronchoscopy shows abnormalities of anatomic airway.

Bag mask ventilation is for pt with apnea.

Oxygen therapy….appropriate method

Intubation..based on pco2 alone

Noninvasive ventilation

Mechanical ventilation

Multi organ dysfunction 2 or more of following: respiratory failure - cardiac failure

Renal insufficiency or failure – GE or hepatic insufficiency – intra vascular coagulation and

hypoxic –ischemic brain injury.

Shock is inability to provide sufficient perfusion of oxygenated blood and substrate

to tissue to meet metabolic demands .

Oxygen delivery is directly related to the arterial o2 content and CO

diabetes mellitusBurnsAdrenogenital syndromeCapillary leakDistributive Vasodilation →venous pooling →decreased preloadSepsisMaldistribution ofregional blood flowAnaphylaxisCNS/spinal injuryDrug intoxicationCardiogenic DecreasedmyocardialcontractilityCongenital heart diseaseArrhythmiaHypoxic/ischemic injuriesCardiomyopathyMetabolic derangementsMyocarditisDrug intoxicationKawasaki diseaseObstructive Mechanicalobstruction toventricular filling or

Most common cause:

Vomiting

Diarrhea

Blood loss

Capillary leak syndrome

Pathologic renal fluid losses

Septic shock is the most common type of distributive shock in children.

It present with systemic inflamatory response syndrom(SIRS):

T greater than 38 or less than 36HR}90 min or more than 2 standard deviation above

normal for ageTachypneaWBC]12000 cell\mm3 or less than 4000 cell\mm3 or

greater than 10% immature forms

Other cause of shock are anaphylaxis , neurologic injury, drug related cause

It occur in:

Congenital heart disease

In healthy children secondary to:

viral myocarditis ,

dysrhythmias

toxic metabolic

after hypoxic –ischemic injury

Causes by:

CO_ AO

Interrupted AO arch

Sever AO valvular stenosis

Acquired disease (hypertrophic cardiomyopathy)

Increase HR

Abnormal BP

Altrations of peripheral pulses

Absence of sign of heart failure or sepsis

Tachycardia

Vasoconstriction

Clinical manifestation are :

Sign of dehydration such as:

Dry mucous membrane

Decrease urine out-put

pallor

Tachycardia

Alteration of peripheral perfusion

Because of :

Heart failure progressing to death may be rapid.

Tachycardia

Tachypnea

Enlarge liver

Gallop

Distension of jugular vein

Oliguria

Peripheral edema

Narrow pulse pressure

Capillary refill is delayed

Enlarged liver

Distention of jugular vein

Tachycardia

Tachypnea

Altration of mental status

Cardiovascular collaps

In all pt with shock check:Blood glucose

ABGblood lactate level

CBCElectrolyte(Na,K,Ca,P,Mg)

BUNdistributive shock require bacterial and viral

cultureCardiogenic or obstructive need ECHO

ABC resuscitation

Intubation ,combined with mechanichalventilation

Blood pressure support

Monitoring require maintaining access to the arterial and central venous circulation

Fluid resuscitation Crystalloid volume expanded are recommended20 cc\kg bolus of isotonic crystalloid over 5-15 min.Cardiovascular support:Dopamin at 3 to 15 mcg\kg\minEpinephrin or NE prefer in patient withv decompensated shockRenal salvagePrerenal azotemia is associated with :Serume BUN to Cr ratio greater than 10:1 andUrine Na level less than 20mEq\LATN:BUN\Cr 10:1 or less and urine Na level between 40-60

mEq\L

Some form of septic shock prevented by immunization(HI ; influ type b;

meningococcal, pneumococcal vaccine)

Decrease the risk of sepsis by:

Hand washing

Isolated practices

Minimizing the duration of catheters

52%of death caused by Motor car crashes Drowning 15%Poisoning 9%Burns 5%Suffocation 4%Injury occurs through interaction of the Host

and agentThe age of the child may determine the

exposure to various agent and enviroments.

Assessment and resuscitation

Pre hospital trauma care are :

Immobilization ; trasportation

Primary survey ; resuscitation ; secondary survey ; post resuscitation monitoring and

definitive care

Primary survey include…..ABCDE

Airway and breathing and cervical spine

Full stomach (risk of aspiration pneumonia)

Circulation(HR;skin collor;mental status)and control of bleeding

Disability(neurological status include pupilsize and reactivity

mental status(AVPU_Glasgow coma scale)

Secondary survey :head to toe examination

Tertiary survey include repeat primary and secondary survey along laboratory tests and

radiologic studies

Table 42-2 Initial Laboratory Evaluation of the MajorTrauma PatientHEMATOLOGYComplete blood countPlatelet countType and cross-matchURINALYSISGrossMicroscopicCLINICAL CHEMISTRYAmylaseAST/ALTRADIOLOGYCervical spine filmsAnteroposterior chest radiographRadiographs of all apparent fracturesComputed tomography scans where indicated for head, chest,and abdominal traumaAST/ALT, Aspartateaminotransferase/alanineaminotransferase.

Radiologic studies are determined by the pattern of injury.

CT : in patient with head trauma or history of LOC

FAST

DPL

Enhanced CT in Ao injury

Spinal cord injury:

Cervical spine radiographs

SCIWORA:spinal cord injury without radiologic abnormality

Thoracic trauma:

Lung contusion

PNX

Rib fracture

Abdominal trauma:occure 8% of pediatric traumaAbdominal CT and serial PH\EXPresence of peritoneal irritation or abdominal wall

discoloration ; together with signs of intravascular volume loss ;indicates laparotomy

Spleen injury is most common (kehr sign)Liver trauma is a seriouse cause of morbidityRenal injury : IN YOUNG CHILDREN KIDNEY IS

VULNERABLE IN TRAUMAPANCREATIC INJURY : LESS COMMONELEVATION OF AMYLASE AND LIPASE SEVERAL DAYS

AFTER INJURYINTESTINALINJURY: DEODENAL HEMATOMA

RF secondary to myoglobinuria

ETIOLOGYSubmersion or immersion results in

aspiration of small amounts of fluid into the larynx ;triggering breath holding or laryngo

spasm

EPIDEMIOLOGY

Cause of injury death for 1-4 years of age and the second leading cause of injury death

for 1-18 years of age

Hypoxemia

Secondary to pulmonary endothelial injury ; increased capillary permeability ; destruction

of surfactant

The hypoxic ischemic injury lead to depressed myocardial function resulting in

tachycardia impaired perfusion and cardiovascular collapse.

Laboratory and imaging studies

ABG

Elevated liver Enz

Electrolytes

ABC s

Victim of unwitnessed drowning required:

Stabilized cervical spine

Optimizing oxygenation

Patient with evidence lung injury ;cardiovascular compromise should be

monitored in ICU.

Prophylactic AB not beneficial.

Unfavorable prognostic markers include:

the need for CPR for more than 25 min ,

continued CPR at the hospital ;

glosgow coma scale of 5 or less

fixed and dilated pupils seizure and coma for more than 72 H

ETIOLOGYPathophysiology of burn injury is caused by

disruption of the 3 key function of the skin:Regulation of heat lossPreservation of body fluidBarrier to infection BURN CLASSIFIED: on the basis of 4 criteria:Depth of injuryPercent of body surface area involvedLocation of the burnAssossiation with other injury

SUPERFICIAL(first degree):Red;painful;drySeen with sun exposureHeal in 2-5 days without scarring and not included in

burn surface area calculations.SECOND degree: entire epidermis and superficial

dermis….deep partial thickness is also second degreeThird and four degree:full thickness

Inhalation injuries

Estimate :

Each upper extremity 9%

Each lower extremity 18%

Ant trunk 18%

Post trunk 18%

Head 9%

Perineum 1%

CBC

Type and crossmatch

Coagulation studies

ABG

CXR

Cyanid level(smoke inhalation and loc)

American burn association criteria :

Partial and full thickness burns greater than 10%total body surface area(TBSA)

in patient less than 10 years old

Or

more than 50 years old

or

greater than 20% TBSA in other age groups

p artial and full thickness burns involving the face; hand; feet; genitalia ; perineum

or

major joints ;

electerical burns

chemichal burns

inhalation injury

in patient with preexisting medical condition that could complevated management prolong recovery ; increase mortality ; any burn with concomitant trauma in

wich the burn inury poses the greatest risk.

Significant burn :

Rapid bolus 20 cc\kg of lactate ringer solution

Total fluids are 2-4 cc\kg\percent burn\24 h

Half in 8 hours

Colloid therapy in extensive burns

Hypermetabolic response:require nutritional support

Factors that may modify the hypermetabolic state such as beta blocker ;androgenic steroids,and

other are being investigated

Wound care :Cleaning and debridingSilver sulfadiazineIf the burn is shallow; poly myxin

B\bacitracin\neomycinSulfamylon has the benefit of penetrating

eschar;but it is pailfull and can cause methabolic acidosis

Silver cause electrolyte abnormality

Table 44-1 Complications of Burns

PROBLEM TREATMENT

Sepsis Monitor for infection, avoid

prophylactic antibiotics

Hypovolemia Fluid replacement

Hypothermia Adjust ambient temperature: dry

blankets in field

Laryngeal edema Endotracheal intubation, tracheostomy

Carbon monoxide

poisoning

100% oxygen, hyperbaric oxygen

Cyanide poisoning 100% O2 plus amyl nitrate, sodium

nitrate, and sodium thiosulfate

Cardiac dysfunction Inotropic agents, diuretics

Gastric ulcers H2-receptor antagonist, antacids

Compartment syndrome Escharotomy incision

Contractures Physical therapy

Hypermetabolic state Enteral and parenteral nutritional

support

Renal failure Supportive care, dialysis

Transient antidiuresis Expectant management

Anemia Transfusions as indicated

Psychological trauma Psychological rehabilitation

Pulmonary infiltrates PEEP, ventilation, oxygen

Pulmonary edema Avoid overhydration, give diuretics

Pneumonia Antibiotics

Bronchospasm β-Agonist aerosols

PEEP, Positive

Etiology and epidemiology in children include cosmetics

person care product

analgesics

cleaning solution

Fetal childhood poisoning are commonly caused by:

analgesics

anti histamin

sedative hypnotics ;fumes ; gases;vapors

Any child who presents with unexplained symptoms include altered mental

status;seizure;cardiovascular compromise or metabolic abnormality should be considered

A poisoned child can exhibit any one of six basic clinical patterns:

Coma;toxicity;metabolic acidosis;heartrhythm abberantion ;gasterointestinal

symptms;seizure

Emesis or lavage should not be initated in a child who has ingested volatile hydrocarbons.

Caustic ingestion may cause dysphasia ;epigastric pain ; oral mocusal burns and

low grade fever

Bateries: remain in the esophagus and cause esophageal burns and erosion and should

remove with endoscope.

Acid agents can injured the lungs

Metabolic acidosis

Metabolic acidosis with high AG(mnemonic MODPILES)

Dysrhythmias:

Prolonged QT (phenothiazine-anti histamin)

QRS widening(TCA-quinidine)

Brady cardia suggest:

digoxin;cyanid;cholinergic agent or BB ingestion.

ABG

Electrolyte

Osmolel

Glucose

AG and Osmolar gap

ECG

Urine screen

Four foci of treatment are :Supportive careDecontaminationEnhanced eliminationSpecific antidotesIf the level of consciousness is depressed and a

toxic substance is suspected Glucose 1gr\kg 100% o2naloxone

IPECAC should not be administered Gastric lavage not be used

Single dose activated charcoal within 1 hour of ingestion.

Charcoal is ineffective against…….. Caustic

corrosive agentshydrocarbons

;heavy metals(arsenic,lead;iron;Li;glycols and water insoluble compounds)

A cathartic (sorbitol or Mg citrate)alone has no role in the management of the poisoned patient.

Whole bowel irrigation using PEG effective for toxic ingestion or sustained –release or enteric –coated drugs.

Multi dose activected charcoal should be considered only if patient has ingested a

life-threatening amount of carbamazepin;dapson;phenobarbital;quinine;

theophylline.

Alkalinization of urine :salicylate or MTX ingestion

Dialysis : methanol ; ethylen glycol;salicylate ; theophylline ; bromide; li

Table 45-5 Drugs Amenable to Therapeutic

Monitoring for Drug Toxicity

ANTIBIOTICS

Aminoglycosides—gentamicin, tobramycin, and amikacin

Chloramphenicol

Vancomycin

IMMUNOSUPPRESSION

Methotrexate

Cyclosporine

ANTIPYRETICS

Acetaminophen

Salicylate

OTHER

Digoxin

Lithium

Theophylline

Anticonvulsant drugs

Serotonin uptake inhibitor agent

Nonprocedural sedation:

Many ventilated pediatric pt require sedation and some analgesia while intubated.

Most common choice is a combination of a longer acting BNZ and an opioid.

Local anesthetics such as lidocaine use for minor procedures.

Use of EMLA a cream containing lidocaine and prilocaine is less effective than interadermal

lidocaine .

Table 46-1 Agents that Produce SedationSEDATIVES EFFECT CONCERNSMidazolam Anxiolysis, sedation, muscle relaxation, amnesia Tolerance is

possible; apnea, hypotension, depressed myocardialfunction; short actionLorazepam Anxiolysis, sedation, muscle relaxation, amnesia Same as

midazolam; long actionDexmedetomidine Sedation without respiratory depression May cause

bradycardiaKetamine Anesthesia, analgesia, amnesia Dissociative reactions,

tachycardia, hypertension, increasedbronchial secretions, emergent delirium, hallucinations; increasesintracranial pressureChloral hydrate Sedative Emesis, hypotension, arrhythmias, hepatic

dysfunctionPropofol Rapid-onset sedative for induction andmaintenance of anesthesiaMetabolic acidosis in children; may depress cardiac function

Table 46-2 Agents that Produce AnalgesiaANALGESIC EFFECT COMPLICATIONSAcetaminophen andNSAIDsModerate analgesia, antipyresis Ceiling effect, requires PO administrationNSAIDs—gastrointestinal bleed, ulcerationOpioids No ceiling effect; respiratory depression, sedation, pruritus,

nausea/vomiting,decreased gastric motility, urinary retention, tolerance with abuse potentialMorphine Analgesia May cause myocardial depressionCodeine Analgesia Nausea/vomitingFentanyl, alfentanil,sufentanilAnalgesia, sedation No adverse effects on cardiovascular system; stiff chest

syndromeMethadone AnalgesiaNSAIDs, Nonsteroidal anti-inflammatory drugs; PO, oral