Childhood emergencies

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Chapter 33 Childhood emergencies

Gary Browne, Bruce Fasher

The child in the emergency department presents a challenge to the busy emergency physician, particularly in a setting where both adults and children are being treated and the general culture is not a paediatric one. Children are different in that they are dependent, developing and growing rapidly (see Table 33.1). They also differ in their spectrum of disease and response to illness.

Table 33.1 Normal respiratory rate and cardiovascular values

Age	Normal respiratory values (breaths/min)^∗	Normal cardiovascular values (beats/min)^∗∗
Infants	40	160
Preschool	30	140
School age	20	120

∗ Endotracheal tube size = (age in years ÷ 4) + 4

∗∗ Blood volume = 80 mL/kg; systolic blood pressure = 80 mmHg + (age in years x 2)

Keep in mind that you are managing both the child and the family. Parents may often perceive their children to be sicker than staff assess them to be. In many instances they may prove to be right! It is crucial for a successful consultation to listen to the parents and get a clear understanding of their concerns. At the same time, do not be dismissive of the child; involve him/her in your history taking as a prelude to examination. Parental anxiety and coping skills also need to be assessed and any social disadvantage noted.

In all childhood emergencies, take a careful history and examine the whole child. A child can deteriorate rapidly. This must be anticipated. If there is any doubt about a child’s condition, a paediatrician should be involved and transfer to a paediatric hospital considered.

PAEDIATRIC PARAMETERS

In dealing with a sick child it is important to recognise how physiological parameters change with age and the impact that this may have on the interpretation of observations and management.

Respiratory and cardiovascular

Weight

In ideal circumstances, a child should be weighed and the weight, height and head circumference plotted on appropriate growth charts. In emergencies, weight can be estimated using the simple formula:

IMMUNISATION IN CHILDHOOD

The emergency department offers an excellent chance to give catch-up immunisations. The recommended schedule changes frequently and is listed in the current Australian Immunisation Handbook (readily available from the Commonwealth Department of Health and Aged Care, tel. 1800 671 811, or from the website, see ‘Recommended reading’). There are few contraindications.

RESUSCITATION

In the emergency situation, a child’s condition can deteriorate very rapidly. This is due to:

• the dynamic and unpredictable responses a child can have to stress

• physiological limitations, e.g. hypoglycaemia

• anatomical differences, e.g. small airways and fatiguable respiratory muscles

• developmental differences, e.g. immune system

• ability or inability to communicate

• less characteristic illness responses, e.g. meningitis/neck stiffness.

There may also be a greater risk of acute deterioration in the following cases:

• neonates and small infants

• children with congenital or genetic disorders

• children with chronic disease

• immunodeficiency or child undergoing chemotherapy.

The key to success in managing seriously ill children is early recognition. The outcome from paediatric cardiac arrest is extremely poor, as most children who arrest do so from progressive unrecognised hypoxia or through inadequate or inappropriate resuscitation.

When assessing children, attention should focus on the three major systems—respiratory, cardiovascular and central nervous system (CNS)—to identify the very sick child early.

Respiratory

Increased breathing effort is a sign of increasing respiratory insufficiency and is characterised by: tachypnoea, use of accessory muscles, expiratory grunting, stridor, wheezing, nasal flare, dyspnoea and cyanosis. Other important but often forgotten signs of impending respiratory embarrassment in children are exhaustion and apnoea.

Table 33.2 NSW Immunisation schedule from 1 July 2007

Monitor closely:

• respiratory rate

• effort of breathing

• oxygen saturation using pulse oximeter.

Cardiovascular

A child’s haemodynamic status is assessed by examining pulses, capillary refill, blood pressure, mental status and urine output. It must be remembered that in children the ability to compensate through vasoconstriction is strong, hence blood pressure is always one of the last indicators of a decompensated haemodynamic state.

The signs of shock are:

• tachycardia/bradycardia

• decreased pulse volume

• poor peripheral perfusion

• abnormal mental status

• hypotension.

CNS

The level of consciousness in children may be impaired for many reasons. However, invariably in the seriously ill child it is due to hypoxia. Mental state change is one of the most consistent features of shock and generally occurs when cerebral perfusion is being compromised. Neurological assessment therefore involves:

1. Level of consciousness.

V—responds only to vocal stimuli

P—responds only to painful stimuli

U—unresponsive

Children who are unresponsive to painful stimuli are very likely to have difficulty with their airway and ventilation.

2. Pupils. Pupillary size, reaction to light, and inequality need to be assessed. Fixed dilated pupils are a sign of severe cerebral injury.

3. Posture. Tone and posture need to be assessed. Decorticate (flexed arms, extended legs) or decerebrate (extended arms, extended legs) posture indicates severe cerebral injury.

The principles of resuscitation

These are similar in children and adults.

A—airway

In children the goals are to recognise and relieve obstruction, to prevent aspiration and to allow adequate oxygenation.

B—breathing

If breathing is laboured or poor in children, it should be supported with either a bag-valve-mask device or through intubation with mechanical ventilation.

C—circulation

The rate-limiting step in many resuscitative efforts in children is achieving IV access. If unsuccessful after an initial attempt, an intraosseous line should be promptly attempted. An initial fluid bolus to resuscitate a shocked child is 20 mL/kg of normal saline or Hartmann’s solution. A colloid such as 5% albumin can also be used.

D—drugs

When using drugs in resuscitation in children, it is important to be aware that their effect depends on:

• appropriate dosage on a weight-determined basis

• how they are delivered, e.g. diluted or undiluted

• the route of administration, e.g. IV, endotracheal, rectal

• how they are absorbed and metabolised, e.g. endotracheal adrenaline

• if there are any unwanted effects in children, e.g. verapamil/asystole.

E—environment

In children it is important to consider hypothermia, hypoglycaemia and other reversible causes early in the process of resuscitation.

When CPR is performed in children, how it is performed is determined by the child’s size and age (see Chapter 1, ‘Cardiopulmonary resuscitation’).

IDENTIFYING THE SICK CHILD

Identifying the sick child can be difficult even for experienced staff. The younger the child, the more difficult it can be, particularly when trying to exclude focal bacterial infection. The following simple guidelines will help screen out those children with a greater likelihood of serious illness. The following guidelines provide a useful approach to detecting serious illness in the child under 36 months of age. Combinations of symptoms are even more concerning. No child should be sent home from the emergency department without having had a thorough assessment, appropriate investigations and preferably a period of observation.

Other features of concern include fever, apnoea, convulsions, a petechial rash, cyanosis and the rapid onset of symptoms. Antibiotic use, prolonged symptoms and chronic illness are important features to note. Do not ignore the signs of bile-stained vomiting or blood in the stools alone or in the presence of abdominal pain.

AIRWAY EMERGENCIES

Croup

Croup is viral laryngotracheobronchitis characterised by a barking cough. Often several days of upper respiratory tract symptoms precede the cough. The associated respiratory distress is worse at night and with anxiety in child or parent. Spasmodic croup occurs without accompanying infective symptoms and is often recurrent. Stridor at rest is an indication of severity, while cyanosis is a pre-arrest state. Lateral airways X-rays are not needed and are dangerous as the child is unstable.

A calming environment with the child on the mother’s lap is therapeutic.

If there is moderate or severe airway obstruction, nebulised adrenaline (0.5 mL/kg of 1:1000, maximum 5 mL) can be used as a temporising measure, but rebound after 20 minutes has been well described. Oral dexamethasone (0.15 mg/kg) or prednisolone (1 mg/kg) reduce the risk of intubation and in moderate cases may allow the child to be discharged with review arranged. If this is not tolerated, IV dexamethasone or nebulised budesonide 2 mg can be given. Attention to hydration of the child is important. Humidified air has not been shown to help, and numerous burns occur from steam at home.

Epiglottitis

Epiglottitis is a severe bacterial infection of the epiglottis less commonly seen since Haemophilus influenzae immunisation. The disease is usually rapidly progressive over hours and the child drools, is unable to phonate, does not cough and assumes the ‘sniffing the air’ position to maximise the airway calibre. Cyanosis is a late, pre-arrest state. Interventions should be avoided unless the child is pre-arrest. The initial treatment is rapid transfer to the operating suite for administration of an inhalational anaesthetic and intubation. If there is doubt about the diagnosis, this can be diagnostic. If a respiratory arrest occurs before an inhalational anaesthetic is available, bag-and-mask ventilation, intubation with sedation only or needle cricothyroidotomy is needed. Muscle relaxants must not be used with the anaesthetic as the airway will be lost. Once the airway is controlled, take a swab and commence IV third-generation cephalosporins.

Bacterial tracheitis

This is a rare infection presenting similarly, with acute upper airway compromise. Usually the child appears toxic.

Foreign body inhalation

This causes an acute onset of respiratory distress, often in a child between 6 months and 2 years. If the object is in the upper airway, complete or partial obstruction may be present. If the child is moving air or coughing, removal under inhalational anaesthetic by skilled personnel is advisable. If the airway is completely obstructed, rapid back blows in an infant or the Heimlich manoeuvre in an older child should be performed. Direct visualisation and removal of the object with Magill’s forceps may be possible. If this is not successful, a needle cricothyroidotomy should be performed. Cricothyroidotomy using a scalpel is not recommended for children under 5 years.

What else could it be?

Peritonsillar or retropharyngeal abscess or anaphylaxis.

RESPIRATORY EMERGENCIES

Asthma

Asthma in childhood is a common condition. Signs of respiratory distress indicating severity include tachypnoea, intercostal recession, use of accessory muscles, prolonged expiration, cyanosis and altered level of consciousness. Exacerbations are treated with salbutamol, initially with spacers or nebulised if moderately severe bronchospasm prevents adequate inspiration. In severe cases, IV salbutamol initially as a bolus, or an infusion if improvement is not maintained, speeds recovery. Except in mild cases nebulised ipratropium bromide is also given. A short course of steroids (prednisolone 1 mg/kg) for 3–5 days is given, by the IV route in severely ill patients. Ventilatory support with either continuous positive airway pressure (CPAP) or intubation, often with assistance with expiration, is needed with apnoea or altered level of consciousness. There is a high attendant risk of barotrauma. Inhalational anaesthetics can also be used as bronchodilators. Long-term preventative therapy aims to reduce the incidence and severity of exacerbations: inhaled sodium cromoglycate and, if needed, inhaled steroids.

Pneumonia

This also presents with respiratory distress. Auscultatory signs may be subtle, especially in the younger child, and X-ray is needed to confirm the diagnosis. Treatment is with antibiotics, either oral or IV.

Organisms causing pneumonia include:

• common bacterial agents—Streptococcus pneumoniae, Staphylococcus aureus (< 5 years), Mycoplasma pneumonia (> 3 years)

• common viral agents—parainfluenza, influenza, respiratory syncytial virus (RSV), Epstein-Barr virus (EBV).

Bronchiolitis

Bronchiolitis occurs particularly in 2–6-month-olds, and is caused by RSV in 75% of cases. After two days of coryza, increasing respiratory distress with tachypnoea, nasal flaring, wheezing and fever is seen and lasts several days. There may be apnoea or difficulty feeding, requiring IV hydration. Chest X-ray is normal or shows hyperinflated lungs with peribronchial cuffing in approximately 50% of cases. Treatment involves oxygen, if required, via nasal prongs, headbox or intubation and attention to hydration. Bronchodilators and steroids are of no proven benefit but a trial of brochodilators may be warranted in the older infant. Patients who are discharged need early review by their local doctor.

Cystic fibrosis patients commonly present with respiratory decompensation related to infection. They have a chronic cough and purulent sputum, and benefit from chest physiotherapy and IV antibiotics.

Chronic lung disease occurs in premature infants and some develop respiratory failure with subsequent upper respiratory tract infection.

Pertussis is associated with spasms of coughing, an inspiratory whoop in older children and then frequently a vomit. Apnoea may be the only symptom in the infant less than 3 months old. Between coughing paroxysms the child is often asymptomatic. There is a leucocytosis of 20,000–50,000 with a predominance of lymphocytes. X-rays are usually normal. Treat with oxygen during spasms, IV rehydration if necessary, and erythromycin if the patient is in the early phase or for prophylaxis of contacts.

THE UNCONSCIOUS CHILD

Remember that the brain is more commonly the target of insult than the primary cause. Always consider and treat those conditions that are correctable, such as hypoglycaemia and hypoxia.

Always examine the whole child in the light of a thorough history.

Ask about

• Events prior to the child’s presentation

• Past medical history

• Medication the child may be taking or may have been exposed to

• Specifically, accidental ingestion, diabetes, whether there has been a convulsion

Management

1. After initial stabilisation, consider the need for mechanical ventilation.

2. Check a dextrose stick and if low administer 5 mL/kg 10% dextrose solution.

3. Consider poisoning and antidotes, e.g. naloxone, flumazenil.

4. Consider sepsis and administer antibiotics if necessary.

5. Consider dexamethasone 0.6 mg/kg before antibiotics if meningitis is likely.

Investigations to be considered

• Full blood count

• Blood culture

• Formal blood glucose

• Electrolytes and urea

• Urine for glucose, ketones and drug assay

• Lumbar puncture if meningitis is considered and no evidence of raised intracranial pressure exists and patient is not obtunded

Monitor closely

• Level of consciousness, perfusion, respiratory rate, blood pressure, heart rate, urine output, temperature—clinically.

• Re-evaluate and reassess regularly.

THE FEBRILE CHILD

If the cause is still not evident consider intussusception (may have a ‘cerebral’ presentation). Fever is one of the most common causes of presentation to an emergency department. Most fevers are due to viral infections, but care must be taken to exclude a bacterial infection. Diagnosis can often be difficult, particularly in the younger child where caution is advised. The child without a clear focus presents a real challenge, with pneumococcal and meningococcal infections being the most common infective condition encountered. Various approaches are advised in the literature, ranging from cautious assessment and observation through to aggressive management (see Figure 33.1).

Figure 33.1 Flowchart for an infant with fever

NSW Health, Acute management of infants with fever. Assessment and management: flowchart for child < 3 years old with fever (> 38°C) axillary, p 4

Factors to consider when assessing a febrile child:

• child’s age

• height of temperature

• severity of illness

• presence of a focus of infection

• white cell count.

A thorough clinical assessment is recommended. Appropriate investigations include a full blood count, blood culture, chest X-ray, urine microscopy and culture, and lumbar puncture in the younger child, where there are associated convulsions, meningism or where the child is on antibiotics. Ensure appropriate observation, review and, if in doubt, seek further consultation. The dilemma of when and where to treat and which antibiotic to use depends upon the individual and the local environment. It is better to err on the side of overinvestigating and treating.

In the acute situation the age of the child, the highest recorded temperature (>39.5°C) and an elevated white cell count with a shift to the left are the most useful guides to underlying serious bacterial infection, in combination with the severity of illness.

Is the child toxic?

Toxicity is determined by the ABCD method. Use this simple system to work out how sick a child appears to be:

A is for arousal, alertness and activity.

B is for breathing difficulties.

C is for poor colour (pale) and poor circulation (cold peripheries).

D is for decreased fluid intake (less than half normal) and decreased urine output (fewer than four wet nappies a day).

Abnormality of any of these signs places the child at high risk of serious illness. The presence of more than one sign increases the risk.

Although temperatures in febrile children fluctuate and may be modified by antipyretics and the technique of measurement, children with high temperatures are more likely to have a serious focus. The risk of acute occult pneumococcal bacteraemia increases from 1.2% for children with temperatures of 39.0–39.4°C to 2.5% for temperatures of 39.5–39.9°C, to 3.2% for temperatures of 40.0–40.4°C and 4.4% for temperatures over 40.5°C. A threshold of 39°C is a reasonable balance between sensitivity and specificity.

The higher the white cell count, the greater the risk of bacteraemia, ranging from 6% for counts greater than 10,000 to 30% and higher for counts above 20,000. Do not be lulled into a false sense of security by a temperature that responds to temperature control measures, or by a normal white cell count. Your initial assessment should set the pace for further assessment. Staging a septic work-up is only likely to delay care.

Children with a definite focus of infection should have specific investigations of that focus unless they are very young or toxic. Very young and toxic children require empiric antibiotics and a full septic work-up in that order. Remember, in some conditions such as meningococcaemia, delay in the administration of antibiotics may result in a poor clinical outcome. A full septic work-up consists of blood count, blood cultures, chest X-ray, urine culture and lumbar puncture. Antibiotic choice depends upon your patient population and local resistance rates. The antibiotics listed in Table 33.3 are suggested only as a starting point; we strongly recommend you discuss this with your infectious disease consultant.

Table 33.3 Initial choice of antibiotics in the child with fever

Condition	Age	Antibiotic
Fever with no focus	0–3 months4 months–4 years > 4 years

Ampicillin and gentamicin

Benzylpenicillin

Benzylpenicillin and flucloxacillin

Meningitis

Ampicillin and cefotaxime

If pneumococcus consider cefotaxime and vancomycin

Pneumonia

Benzylpenicillin

Benzylpenicillin and roxithromycin

In severe cases consider cefotaxime

Urinary tract infection All ages Ampicillin and gentamicin

What else could it be?

Always think of underlying metabolic, cardiac and endocrine problems. The fever may be the simple harbinger of acute deterioration in these patients. One possible approach to management of the febrile child is given in Figure 33.1.

Prolonged fever of unknown origin

Most children in whom fever has been prolonged for 7 days or more will be found to have infectious diseases. The most common infection to consider is Epstein–Barr virus infection; however other viruses may be found as the cause for fever. Autoimmune disorders, Kawasaki disease and malignancy should be considered. In these cases early consultation and hospital admission should be considered.

Follow-up

All children who are discharged home from the emergency department with fever should be followed up the next day, either in the emergency department or by the family doctor. This is to detect progression of infection, response to treatment and results of investigations.

Parents should be encouraged to look for signs of toxicity every 4 to 6 hours, and to seek clinical review if the child becomes toxic or unwell. Clear communication from a doctor with empathy for the parents may enhance safety and improve the functioning of stressed families.

COMMON INFECTIONS

• Preschool children normally experience 6–8 upper respiratory tract infections (URTIs) per annum.

• Antibiotics neither cure the URTI nor prevent complications.

• Exclude common and dangerous causes:

• otitis media

• tonsillitis

• bronchiolitis

• urinary tract infection.

• Decongestants and antihistamines are of dubious value.

• Take an immunisation history.

• Paediatric symptoms are often non-specific—fever, diarrhoea, off feeds etc.

The common exanthemata are not always easy to diagnose, and have significant morbidity and mortality. You should be familiar with the classic presentations. If in doubt, consult.

The use of paracetamol in febrile illnesses is conjectural (fever has an active role in the anti-infection cascade). Vigorous control of fever should be restricted to the child with a known propensity to febrile convulsions, or in whom the fever exceeds 38.5°C and who is in obvious discomfort. Be cautious in your prescribing. Occasionally you may use doses of up to 15 mg/kg, but mostly 10 mg/kg 6-hourly is adequate. Remember there is a real risk of hepatotoxicity.

Tepid sponging may make the child more comfortable as an adjunctive treatment, but it is not essential.

Aspirin for the management of fever is contraindicated in childhood.

CONVULSIONS

Is the seizure a simple uncomplicated febrile convulsion? Is there a treatable cause?

Management principles

Consider treatable causes—urgent

• Hypoglycaemia

• Herpes simplex encephalitis (focal seizure, cold sores)

• Electrolyte disturbance (especially sodium—persistent vomiting and diarrhoea)

GASTROENTERITIS

Gastroenteritis is a common childhood complaint, the commonest complication of which is dehydration.

Organisms to consider include:

• viruses—rotavirus, enteroviruses, enteric adenovirus, Norwalk

• bacteria—Salmonella, Shigella, Campylobacter, Yersinia, E. coli

• protozoa—Giardia, amoebae.

Most cases will be viral. Bloody diarrhoea often suggests a bacterial cause.

Signs include vomiting, diarrhoea, fever and abdominal pain. The diarrhoea with rotavirus and adenoviruses often lasts for 5–12 days, and that of bacterial diarrhoea (especially Campylobacter) is often bloodstained. Giardia infection commonly causes an epidemic and is complicated by asymptomatic carriers. Beware of attributing vomiting without diarrhoea to gastroenteritis.

Assessment

Assessment includes the degree of dehydration. Evidence of sepsis is important, especially in the young infant. Of children under 3 months of age with Salmonella, 5–10% are bacteraemic. Salmonella can also cause focal infections in children with sickle cell anaemia. Abdominal X-ray commonly shows multiple fluid levels representing ileus: it is rarely helpful unless obstruction is suspected. Stool culture is advisable when bacterial or parasitic infections are suspected.

Treatment

Try oral rehydration solution in small frequent sips at a rate of 1 mL/kg every 10 minutes. If this fails, commence nasogastric tube rehydration with an oral rehydration solution. If this is not tolerated, commence IV rehydration remembering to check the sodium level. Volumes to replace the fluid deficit and volumes for maintenance requirements should be calculated separately, added together then divided by 24 to get the hourly rate. Frequent reassessment to monitor progress is important. Antibiotics (third-generation cephalosporins) are recommended for Salmonella in the young septic infant, or one with a prolonged severe course of illness. Otherwise they do not convey any benefit as they do not shorten the course or reduce the infectivity of the patient with SalmonellaCampylobacter infection should be treated with erythromycin only if the symptoms are prolonged. Giardia infection causing symptoms should be treated with metronidazole.

Think again if

• Vomiting bile or blood

• Severe abdominal pain

• Toxic, high fever

• Abdominal signs: distension; tenderness, guarding; mass, visceromegaly

• Failure to thrive

What else could it be?

• Intussusception

• Appendicitis

• Urinary tract infection

• Sepsis, otitis media

See also ‘Fluid therapy’, ‘Surgical abdominal emergencies’ below.

FLUID THERAPY

Children can rapidly become dehydrated because of their small size and large, insensible fluid loss (they have a high surface area to volume ratio). The aim of fluid therapy is to continue maintenance fluid intake and replace fluid in the dehydrated child. Common causes of fluid loss are gastroenteritis, fever, blood loss and poor oral intake in respiratory distress.

Maintenance fluids

• Maintenance fluids can be estimated using:

• 100 mL/kg for the first 10 kg

• 50 mL/kg for the next 10 kg

• 20 mL/kg for every subsequent kg.

• Maintenance fluids should be one-quarter normal saline + 3.75% dextrose.

• Potassium requirements of 2–3 mmol/kg/day should also be met.

Signs of dehydration

Signs of dehydration can become more evident with the extent of fluid imbalance, but are altered in hypernatraemia. Percentages of fluid loss give a guide to the rate at which fluids need to be given, but frequent reassessment of the child’s fluid state is vital:

• 3% dehydration manifests with reduced urine output and thirst but no clinical signs.

• 5% presents with sunken eyes, dry mucous membranes and reduced skin turgor.

• 7% manifests with a more severe presentation of the above signs and irritability, lethargy and tachycardia.

• 10% presents with marked lethargy, irritability and even coma, plus cardiovascular compromise with tachycardia, hypotension, coldness and sweating.

REHYDRATION

Acute resuscitation of the child with cardiovascular compromise should include a bolus of fluid 20 mL/kg of crystalloid such as normal saline or Hartmann’s solution or 5% normal serum albumin (NSA) colloid. Half normal (N/2) and quarter normal (N/4) saline should not be used for resuscitation.

Volume required to replace the fluid deficit can be estimated using:

More sodium is needed in this replacement fluid so half normal saline + 2.5% dextrose is used. This should be administered over 24 hours and regularly reviewed to allow for further losses to be replaced. In the case of hypernatraemia, slower rehydration over 48–72 hours is required.

Remember

• Decreased oral intake or vomiting may rapidly lead to dehydration in a child.

• Serum electrolytes, urea, creatinine should be checked if rehydrating intravenously.

• Rehydrate slowly in hypernatraemia.

• Reassess the child clinically and monitor the urine output to see if the fluid therapy is appropriate.

• If no improvement, consider repeating electrolytes and an alternative diagnosis.

DIABETIC KETOACIDOSIS AND HYPOGLYCAEMIA

These are not uncommon problems, but are best managed in a children’s centre experienced in such specialised care, hence early referral is recommended.

Children with diabetic ketoacidosis at diagnosis of their diabetes have often been unwell for 4–6 weeks with progressive weight loss, dehydration and altered mental state. Because of this, mistakes in diagnosis can be made early in the acute phase.

Management

1. If shocked, ensure adequate airway and ventilation while administering high-flow oxygen via a face mask. Administer 20 mL/kg fluid (saline or normal serum albumin) rapidly and then reassess the child’s haemodynamic status. Remember, children are at risk of cerebral oedema if fluid resuscitation is too aggressive.

2. Assess the degree of dehydration.

3. Commence replacing sodium with 0.9% saline and aim to correct over 48 hours. Be careful not to give too much fluid too soon, as children are prone to develop cerebral oedema.

4. Add potassium to fluids 5 mmol/kg/day once urine has passed.

5. Strict fluid balance is essential.

6. After rehydration has commenced, commence insulin infusion at a rate of 0.05 units/kg/h, aiming to lower blood glucose 4–5 mmol/L/h. A larger drop in the first hour is acceptable as fluid alone would lower the blood glucose to some extent.

7. When the blood glucose falls below 12 mmol/L, change IV fluid to 0.45% saline and 5% dextrose. Maintain the blood glucose level between 5 and 10 mmol/L. If glucose falls below 5 mmol/L, do not decrease the insulin infusion but rather increase the amount of glucose in the infusion.

Cerebral oedema/brainstem herniation

Brainstem herniation is a sudden and unpredictable complication of therapy for diabetic ketoacidosis; it occurs during the first 24 hours of treatment.

Monitor all patients for evidence of raised intracranial pressure with particular attention to those most at risk:

• severe dehydration

• severe acidosis with low potassium

• hypernatraemia

• deteriorating conscious state

• severe hyperosmolality on presentation (> 320 mosm/L).

The onset of headache should be taken seriously.

Transfer to an ICU and arrange neurological assessment and CT head scan. Management should be aimed at aggressively controlling any elevation in intracranial pressure.

Hypoglycaemia

Blood glucose levels < 2.5 mmol/L. In diabetic children hypoglycaemic symptoms often occur at blood glucose levels under 3 mmol/L. Prolonged hypoglycaemia can cause irreversible brain damage.

In children substrate deficiency is the most common cause, either as a result of prolonged fasting or due to specific conditions such as ketotic hypoglycaemia. Other important causes include hepatic disorders, metabolic disorders and, rarely, insulin excess (Beckwith syndrome, nesidioblastosis).

Presentation

• Anxiety, flushing

• Nausea/vomiting

• Trembling, weakness

• Tachycardia

• Confusion, drowsiness or coma

Investigations

• Blood glucose

• Sodium, potassium, urea, creatinine

After consultation, further special tests may be necessary: alanine, cortisol, growth hormone, amino acids, free fatty acids, ammonia etc.

Management

1. Resuscitate as necessary.

2. Check blood glucose, draw blood for investigations.

3. Administer a glucose bolus 0.5 g/kg as 5 mL/kg 10% glucose or 2 mL/kg 25% glucose IV if symptomatic and the blood glucose is < 2.5mmol/L. After recovery if necessary continue a 10% glucose infusion at maintenance rate. If unable to secure IV access, glucagon 0.03 mg/kg IM may be used to a maximum of 1 mg (ineffective in hepatic disease). In some cases where a child is awake and cooperative, oral glucose drinks may be satisfactory.

4. Early referral to a specialist children’s centre is recommended in difficult or refractory cases.

5. Monitor closely.

DEVELOPMENT

Assessing normal development is a skill acquired only from constant practice and observation. Always consider seriously parents’ concerns of loss of recently acquired skills or slow development of others. If you are not confident of your own skills in assessing development do not dismiss parents’ concerns but rather refer appropriately. See Table 33.4 for the normal development milestones.

Table 33.4 Normal developmental milestones

FEEDING

Feeding problems are rarely emergencies. The notable exception is the parental offering that the child is ‘going off his feeds’. This can be the result of any illness from a cold to congestive cardiac failure.

History and examination are paramount: 1) to elucidate a cause (infection, surgical condition, etc) or 2) to assess effect (weight loss, dehydration etc).

It is important to be familiar with basic feeding practices and to be able to support a breastfeeding mother through a crisis when her child is unwell. Milk allergies and intolerances are not common. Resist changing milk formulas for the lack of better inspiration. Rather than give inappropriate advice, refer the infant and mother to their local doctor, paediatrician, community health centre or, in some instances, an appropriate mothercraft centre.

THE INCONSOLABLE INFANT

The inconsolable infant will test the patience of all attendants. The condition is always worse in the quiet of night. Listen to the parents. Don’t be dismissive—they are at the end of their tether.

Consider physical causes of pain and discomfort, especially treatable conditions such as:

• intussusception/malrotation volvulus

• otitis media

• dental problems (rarely ‘teething’)

• peptic ulceration (oesophagitis secondary to clinical reflux)

• missed fractures (intentional or accidental)

• stones—renal/gall bladder

• infection (paradoxically, sepsis often leads to quietening)

• ischaemic heart disease (anomalous coronary arteries—rare).

There is a group of children (infants) for whom no physical cause can be elucidated. Their parents require immense support.

Consider admission if:

• There is a physical condition to treat.

• Children are at risk from tired, frustrated carers.

Always acknowledge carers’ concerns and frustrations. This often resolves 50% of problems. Plug them into ‘the system’ (for ongoing support) if you intend sending the child home.

JAUNDICE

Neonatal jaundice is a concern in emergency departments with the advent of early discharge obstetric programs.

Kernicterus (significant brain damage due to jaundice) can occur with high levels of unconjugated (indirect) bilirubin.

Be concerned by

• Jaundice in the first 24 hours of life

• Bilirubin greater than 240 μmol/L

• Conjugated bilirubin greater than 30 μmol/L

• Jaundice present after day 10 of life

• Jaundice in an unwell infant

Investigations

• Bilirubin, total and direct

• Haemoglobin, film, haematocrit, blood cultures, group, Coombs’ test, reticulocytes

• Torch titres

• Urine microscopy, culture and sensitivity, reducing substances

• Thyroid function (check neonatal screen)

• Galactosaemia screen

Physiological jaundice and ‘breast milk’ jaundice

Physiological jaundice (slow maturation of glucuronyl transferase) and ‘breast milk’ jaundice (competitive use of glucuronyl transferase) are not diagnoses of convenience. Continue to monitor the child until either a cause is found or the jaundice disappears.

CHILD ABUSE

This is a common problem. It should be in the differential diagnosis of all injuries, burns, poisonings and genital injuries in both sexes.

Suspect child abuse if

• The physical findings are inconsistent with the explanation given for the injury.

• There is delay in seeking medical attention.

• The explanation for the injury varies.

• There are multiple injuries at different stages of healing.

• There is a spiral fracture (an unusual fracture in childhood suggesting a twisting, shearing force) or metaphyseal chip fractures.

• There are two black eyes and/or haematomas on the ears.

• Retinal haemorrhages are present.

• There is fingerprint bruising (e.g. on upper arms, cheeks or trunk) caused by violent gripping.

• Bruising in soft tissue areas not normally injured in play.

• Burns on the buttocks and perineum (from dunking in boiling water) or discrete burns in other areas consistent with cigarette burns.

• There is vaginal or anal bleeding or injury in the absence of an adequate explanation.

Management

1. Admit the child to hospital for protection and treatment.

2. Treat the injuries.

3. Do skeletal survey and radionuclide scan in children under 2 years, looking for old fractures at different stages of healing.

4. Consider CT for subdural haematoma.

5. Obtain clinical photographs.

6. Take appropriate forensic specimens for semen and check for sexually transmitted diseases (use sexual assault kit).

7. Assess child’s development and behaviour.

8. Take a full social history.

9. Avoid having the child interviewed on multiple occasions. Questions must not be suggestive or leading.

10. Consult a paediatrician and social worker experienced in this area.

11. Record all findings and conversations accurately in the hospital record (they and you may be required in court later).

12. Notify the statutory authority in those places that have mandatory notification laws.

SUDDEN INFANT DEATH SYNDROME (SIDS)

By definition there is no evident cause of death. The diagnosis thus cannot be confirmed until after the autopsy. These facts dictate management.

Resuscitation attempts are dictated by the clinical situation. Be alert for a treatable condition.

Parents and family, including siblings, should not be excluded from the resuscitation despite the uneasiness this may cause staff.

Family counselling should involve the most experienced staff available. Note the necessity of police interviews because of the coroner’s involvement.

The family should be able to stay with the deceased infant as long as they wish, preferably in a quiet room and supported by staff.

Photographs and hand and foot prints are often appreciated at a later date.

Follow-up for the parents is important. This may need to be organised later.

It is often useful to involve your local SIDS association.

Prevention

• Position infants on their backs.

• Do not overheat.

• Provide loose fitting clothes.

• Provide a smoke-free environment.

SURGICAL ABDOMINAL EMERGENCIES

Abdominal pain may be difficult to assess in a young child. Examination requires warm hands and a gentle approach to gain the child’s trust. The examination will be limited once pain has been elicited. Consider analgesia to aid examination.

Intussusception

Intussusception classically presents between 3 months and 5 years. It frequently follows a minor viral illness, and involves intussusception of a lymphoid follicle through the bowel, causing intermittent screaming with pallor and vomiting, usually without diarrhoea. Increasing lethargy develops between exacerbations of pain. The abdomen is usually tender and a sausage-shaped mass is often palpable in the right upper quadrant. Blood in the stools and shock are late presentations. X-ray may reveal an area of paucity of gas or obstruction; however, 30% have normal X-rays. Abdominal ultrasound can be diagnostic.

Treatment involves reduction under surgical supervision, preferably in a paediatric facility, by air enema under radiological visualisation. Cases that present late or may have perforation require reduction (and repair) in theatre. Be aware that intussusception may present masquerading as a cerebrally depressed child such that investigations pursue this avenue (CT head, cerebrospinal fluid, drug screen) until all return normal.

Inguinal hernias

Inguinal hernias are common in the first year of life and need early correction as they are liable to become incarcerated. Gentle reduction is often possible in the emergency department. If they become irreducible, IV fluid therapy and urgent surgery are required.

Henoch-Schönlein purpura

This is a vasculitis which commonly occurs in the bowel causing intermittent abdominal pain in children 3–5 years. It is also associated with a purpuric rash developing on the buttocks, and arthropathy and haematuria signify renal involvement. Management is usually conservative.

Hirschsprung’s disease

Hirschsprung’s disease is absence of intramural ganglion cells, usually in the rectosigmoid region. It is four times more common in males. It presents early in life with increasing constipation and abdominal distension from the newborn period to early childhood. Rectal examination often reveals explosive release of stool under pressure. Abdominal X-ray shows faecal loading. The complications are enterocolitis and perforation. The treatment is surgical.

Appendicitis

Appendicitis can occur at any age. Under 2 years the appendix is an intra-abdominal organ. Appendicitis is difficult to diagnose and the appendix is often perforated at the time of surgery. The child has abdominal tenderness and sometimes fever, vomiting and diarrhoea.

Pyloric stenosis

Pyloric stenosis occurs from 1 week to 3 months of age with males four times more commonly affected than females. They present with increasing vomiting, dehydration and hypokalaemia, with a hypochloraemic metabolic alkalosis. A pyloric mass can often be felt, particularly at the end of a test feed; ultrasound or barium meal can confirm this. The child needs IV fluids and operative treatment.

What else could it be?

Urinary tract infection, mesenteric adenitis, gastroenteritis, child abuse, constipation, diabetic ketoacidosis

ORTHOPAEDIC PROBLEMS

Septic arthritis

Septic arthritis can occur in any joint and is characterised by pain, restricted joint movement and sometimes fever, raised white cell count and erythrocyte sedimentation rate (ESR). Suspicion requires confirmation and treatment by surgical drainage in theatre, culture of the fluid, irrigation and intravenous antibiotics.

Irritable hip

An irritable hip commonly occurs in children and is often (but not always) associated with a viral illness. The important differential to consider is septic arthritis. Serial examination often reveals limitation of internal rotation of the hip but preservation of some hip movement, absence of constitutional symptoms and normal blood pathology.

Limp

The child with a limp needs careful assessment to establish where the problem lies. Trauma, irritable hip, Perthes’ disease, slipped capital femoral epiphyses, septic arthritis or effusion in any of the joints of the limb, tumours, leukaemia, spinal problems, soft tissue injuries and foreign bodies in the sole of the foot must all be considered. Spinal discitis may be suggested by the child refusing to walk or sit.

Pulled elbow

A pulled elbow occurs when the radial head is pulled out of the annular ligament sling with traction on the arm. It sometimes occurs recurrently in children between 1 and 4 years. Check that the story is consistent with this diagnosis, and exclude bony injury with X-ray. To relocate the annular ligament, feel over the radial head, and firmly supinate and extend the arm. Often a click is felt and the child begins using the arm within 10 minutes. If this does not occur, check that nothing has been missed and arrange review the following day. The natural history is for these to spontaneously relocate over a few days.

What else could it be?

• Child abuse, bony tumour

PAIN MANAGEMENT

Pain control during procedures and with painful conditions greatly reduces the anxiety experienced by children and parents.

Anxiety reduction minimises the pain felt and should be used with all frightening or painful procedures. A confident, caring approach to the family and enlisting the parents’ support for the child is vital. Clear, non-threatening and age-appropriate explanation to the child just prior to and during the procedure reduces the fear of the unknown.

Analgesics

Paracetamol preparations in a dose of 15 mg/kg are very effective in children.

Narcotics IV (in frequent small doses), IM or orally (morphine 0.1 mg/kg, pethidine 1 mg/kg, codeine 1 mg/kg).

Sedatives

Nitrous oxide/oxygen mixture is used with great success in experienced hands. It reduces anxiety, especially when combined with verbal relaxation methods and topical cream if necessary, but consciousness is maintained. A maximum of 70% N₂O can be used. The main side effect is vomiting. This can be minimised by having the child fasted for at least 2 hours before proceeding.

Midazolam can be given orally (in juice or frozen in ice-blocks to disguise the taste) or nasally at a dose of 0.5mg/kg or IV at 0.1–0.2mg/kg. It is effective in about 70% of children. The main side effect is respiratory depression, especially after the noxious stimulus is withdrawn. Recovery with careful observation and oximetry for 2 hours after the procedure is important.

Ketamine, a dissociative anaesthetic given IV or IM, is very effective. Paediatric airway expertise should be present as should venous access. The airway is maintained but there is an increase in salivation. Its side effects include occasional prolonged vomiting and hallucinations. This agent is not commonly used in paediatrics but may be useful in the adolescent.

Anaesthetics

General anaesthetics should be available, especially for procedures involving intricate work and cooperation of a small child.

Topical prilocaine creams reduce the pain felt during procedures involving needles (IV cannulas, blood taking, lumbar punctures). They are safe, but should not be used under 6 months of age because of toxicity and methaemoglobinaemia. The area should be completely occluded with a dressing once the cream is applied and left for 45 minutes to ensure maximal efficacy. The cream cannot be applied to mucosal areas or areas of broken skin. Topical mixtures such as TAC (tetracaine, adrenaline and cocaine in a gel preparation) are very effective for lacerations. Toxicity from cocaine is minimised if it is not used on mucosal surfaces, where absorption is rapid.

PRESCRIBING FOR THE PAEDIATRIC PATIENT

When prescribing for the paediatric patient, oral therapy is preferred where possible. If parenteral antibiotics need to be given, avoid IM injections. Plan ahead by leaving a cannula in situ when taking blood. Dosages should be based on weight and the manufacturers’ instructions carefully adhered to. There are many useful pocket guides available. Special care should be taken with newborns. Maximum doses should be calculated based on a patient’s weight not exceeding 50 kg.

Parents should be given clear written instructions on dosage and guidance on administration. Children mostly do not enjoy taking medications and will not always cooperate. When a child refuses to take medication, gentle restraint, recruiting another adult to assist or using a syringe (without needle) to instil the medication into the buccal cleft may all help.

PROCEDURES

What size tube?

Most items of equipment vary depending upon the age, weight and size of the patient. Table 33.5 provides only a guide to the size of commonly used items of equipment for use in emergency circumstances. In certain circumstances it may be necessary to modify the tube size (e.g. a child with croup may need a smaller tube).

Table 33.5 Equipment sizes for children

Obtaining blood

It is always possible to get sufficient blood from paediatric patients for all tests—it is a matter of patience, having the right equipment and technique. Depending on the laboratory, you may be able to use smaller samples. A superficial peripheral vein is the preferred location. If inserting an IV line, plan your investigations so that you can take blood for investigations at the same time to avoid unnecessarily hurting the child. Use topical EMLA if time allows.

Urine sampling

To adequately diagnose a urinary tract infection, a sterile sample must be collected. Midstream urines are only of value in the older child. Bag urines are inadequate. Younger children require either a suprapubic aspirate or catheterisation. Over 1 year catheterisation is preferred.

Suprapubic aspiration

1. Ensure that the bladder is full by percussion and that the child has not passed urine for 60 minutes.

2. Use EMLA cream in anticipation.

3. Be prepared with appropriate equipment and assistant.

4. Gently restrain the child supine with legs held at the knees.

5. Prepare the site. Cleansing may lead to urination—be prepared to catch a midstream sample.

6. Insert a 23 gauge 32 mm needle on a 5-mL syringe 1 cm above the symphysis in the midline. Direct the needle caudally at a 20° angle to the vertical. Gently aspirate while advancing.

7. Repeat the procedure once only if unsuccessful, by withdrawing the needle just below the skin and advancing it with a slightly greater degree of angulation caudally.

Urinary catheterisation

Urinary catheterisation is an acceptable alternative to suprapubic aspiration. The procedure is essentially no different to that in adults. Use aseptic techniques, have an assistant, be prepared and most importantly be gentle. In young females be familiar with the anatomical landmarks. If you are unable to identify the urethra, do not proceed.

Urinary tract infection (UTI)

Criteria for the diagnosis of a UTI:

• > 10⁵ organisms (pure growth of a single organism).

• > 100 white cells/high power field.

• positive leucocytes and nitrites on dipstix (should not be relied upon as a screening test).

• negative microscopy does not exclude UTI.

• up to 20% of children with UTIs have negative dipstick analysis.

Lumbar puncture

1. No child will cooperate willingly with a lumbar puncture. Use EMLA cream in anticipation but local infiltration is still preferable. Ensure adequate restraint with proper positioning.

2. Consider nitrous oxide.

3. Position the patient in the lateral decubitus position, making sure the patient is well flexed and the back is vertical to the bed.

4. Prepare the skin and drape the site.

5. Identify the L3/4 interspace (at the level of the superior edge of the iliac crest).

6. Insert spinal needle (with stylet) in interspinous space, directed slightly cephalad towards the umbilicus.

7. Advance the needle slowly. A ‘give’ may be felt as the dura is penetrated.

8. Remove stylet and, if no fluid is obtained, rotate the needle 90° so that the bevel is pointing in a cephalad direction.

9. If CSF does not flow freely, replace the stylet and advance the needle until fluid is obtained.

10. Pressures should be measured using a manometer.

11. Collect adequate samples for testing. If blood-stained fluid is obtained, use the last tube for microscopy.

Contraindications

• Obtunded patient

• Raised intracranial pressure

• Infection at the site

• Bleeding diathesis including thrombocytopenia

EDITOR’S COMMENT

In dealing with children there is a combination of clinical science, listening to parents, soft clues and suspicions (‘rule out’) which always totally justifies a conservative and cautious approach.

RECOMMENDED READING

Baren J., Rothrock S., Brennan J., et al. Pediatric emergency medicine. Philadelphia: Elsevier Saunders; 2008.

Browne G., Choong R.K.C., Gaudry P.L., Wilkins B.H. Principles and practice of children’s emergency care. Sydney: Maclennan and Petty; 1997.

Cameron P., Jelinek G., Everitt I., et al. Textbook of paediatric emergency medicine. Edinburgh: Churchill Livingstone Elsevier; 2006.

Crain E., Gershel J. Clinical manual of emergency pediatrics, 4th edn. New York: McGraw-Hill; 2003.

Hewson P., Oberklaid F. Recognition of serious illness in infants. Modern Medicine of Australia. 1994;37(7):89-96.

Kilham H., Isaacs D., editors. The Children’s Hospital at Westmead handbook: clinical practice guidelines for paediatrics. Sydney: McGraw-Hill, 2003.

National Health and Medical Research Council. The Australian immunisation handbook. 8th edn. NHMRC; 2003. Online. Available: http://immunise.health.gov.au/handbook.htm.

Strange G., et al. Pediatric emergency medicine, 2nd edn. New York: McGraw-Hill; 2002.

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