Children’s Emergencies

INTRODUCTION

Important childhood emergencies include respiratory distress, poisoning, infections including severe gastroenteritis, seizures and SIDS/ALTS. Identification of the very sick infant is fundamental to emergency care.

A golden rule: Babies who are febrile, drowsy and pale are at very high risk and require hospital admission.

Strategic approach to evaluation

One general pattern for appraisal of the sick child is ABCDEFG:

• A—airway

• B—breathing

• C—circulation

• D—disability (neurological assessment)

• E—exposure

• F—fluids in and out

• G—glucose (not to be overlooked)

Another approach to risk and indicator of toxicity is ABCD:

• A—poor arousal, alertness and activity

• B—breathing difficulty

• C—poor circulation (persistent pallor, cold legs)

• D—decreased fluid intake and/or urine output

  • ‘fluids in’ = feeding < half normal in 24 hrs

  • ‘fluids out’ = <4 wet nappies in 24 hrs

Children with any of these signs must be seen early, investigated and treated as a priority.

MENINGITIS OR ENCEPHALITIS

See pages under central nervous system infections 89–93.

ACUTE EPIGLOTTITIS

Epiglottitis is characterised by the sudden onset of a toxic febrile illness, a soft voice, lack of a harsh cough, a preference to sit quietly (rather than lie down) and esp. by a soft stridor with a sonorous expiratory component. It is now uncommon where Haemophilus influenzae immunisation is routine but can be caused by Strep. pneumoniae.

Management

• Do not examine the throat in the office.

• Escort the child to hospital—almost all require nasotracheal intubation.

• Keep the child calm—allow mother to nurse child.

• If obstruction, gently bag and mask with 100% oxygen.

Method of emergency cricothyroidotomy (last resort)

• Lie the child across your knees with neck fully extended.

• Insert a number 14 needle or angiocath through the cricothyroid membrane.

Always try to intubate once before resorting to cricothyroidotomy.

Hospital treatment Intubation: in theatre suck away profuse secretions and perform nasotracheal intubation.

Antibiotics: cefotaxime 50 mg/kg IV (max. 2 g) 8 hrly or ceftriaxone 50 mg/kg to max. 2 g/d IV as single daily dose. Can add dexamethasone IV (single dose).

Note: Continue therapy for 5 days. Early transfer to oral therapy (e.g. amoxicillin/clavulanate) is desirable.

ACUTE HEART FAILURE

• Admit to hospital; treat complications

• Assess pulse oximetry, ECG, CXR, echocardiogram

• ACE inhibitors (consider digoxin)

• O₂ to maintain ...