Standard
Treatment
Guidelines
Edition 2
June, 2010
Standard Treatment
Guidelines
Table of Contents
1. Resuscitation guidelines... 1
2. Emergencies... 12
1. Acute upper airway obstruction... 12
2. Anaphylaxis... 13 3. Hereditary angiodema ... 14 4. Near drowning... 16 5. Fluid management... 18 6. Endocrine Emergencies... 21 3. Poisoning guidelines... 40 1. Poisoning Management ... 40 4. Gastrointestinal diseases... 43 1. Acute vomiting ... 43 2. Diarrhoea... 43 3. Cholera... 47 4. Dysentery... 47 5. Typhoid fever... 48
6. Management at point of discharge for all diarrhoea... 49
7. Acute abdominal pain... 51
8. Constipation... 52
9. Oral candidiasis... 53
10. Stomatitis... 55
11. Peptic ulcer disease... 56
12. Hepatitis a infection... 57
5. Ear Nose Throat... 59
1. Tonsillo-Pharyngitis... 59 2. Otitis media... 60 3. Allergic rhinitis... 63 4. Sinusitis... 64 5. Epistaxis... 66 6. Ludwig's angina... 68 7. Menierre's Disease... 69
6. Respiratory tract conditions... 70
1. Pneumonia... 70 2. Asthma... 72 3. PCP... 79 4. Tuberclosis... 80 5. Viral croup... 83 6. Viral pneumonia/bronchiolitis... 84 7. Genitourinary disorders... 85
1. Urinary tract infection... 85
2. Minor penile inflammation... 86
3. Balanitis... 86
4. Acute urine retention... 87
5. Zipper injury ... 87
6. Phimosis... 89
7. Paraphimosis... 89
8. Acute scrotal pain... 90
8. CNS ... 92 1. Status epilepticus... 92 2. Febrile convulsions... 93 3. Bacterial meningitis... 94 4. Coma... 95 5. Cerebral palsy... 96 Standard Treatment Guidelines Booklet
Designed and printed for Gertrude's Children's Hospital
By
Lila Creative Design Agency Printed in Nairobi, Kenya
First Edition Copyright © 2009 Second Edition Copyright © 2010 Gertrude's Children's Hospital, Muthaiga All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, electrostatic, magnetic tape, mechanical, photocopying, recording or otherwise, without permission in writing from the Gertrude’s Children’s Hospital.
Disclaimer
Whereas all care has been taken in the compilation on this document, it is advised that any user of this book must exercise their clinical judgment in the management of each patient. Gertrude’s Children’s Hospital will not take any responsibility for the use of information that is herein contained.
Review
In case you would like to propose amendments to this protocol please send your request to:
The Secretary
Drugs and Therapeutics Committee Gertrude's Children's Hospital P.O. Box 42325, 00100, Nairobi E-mail: [email protected]
Compiled by
Dr. Rashmi Kumar, Paediatrician, Gertrude’s Children’s Hospital
Dr. Edwine Barasa, Drug Information Pharmacist, Gertrude’s Children’s Hospital Dr. David Kiptum, Paediatrician, Gertrude’s Children’s Hospital
Dr. Paul Laigong, Paediatrician, Gertrude’s Children’s Hospital Dr. Robert Nyarango, Chief Pharmacist, Gertrude’s Children’s Hospital
Reviewed by
Dr. Adil Waris, Consultant Paediatric Pulmonologist Dr. Admani Bashir, Consultant Paediatric Nephrologist
Dr. Berlinda Nganga, Pharmacist, Gertrude’s Children’s Hospital Dr. Bernadette Kimotho, Medical Officer, Gertrude’s Children’s Hospital Dr. Collins Jaguga, Pharmacist, Gertrude’s Children’s Hospital Dr. Dan Alaro, Medical Officer, Gertrude’s Children’s Hospital Dr. Doreen Karimi, Medical Officer, Gertrude’s Children’s Hospital Dr. Evans Amukoye, Consultant Paediatric Pulmonologist Dr. Hanna Wanyika, Consultant Dermatologist
Dr. Humar Darr, Medical Officer, Gertrude’s Children’s Hospital Dr. Joel Lesan, Consultant Paediatric Surgeon
Dr. Jonathan Mwambire, Medical Officer, Gertrude’s Children’s Hospital Dr. Margaret Njuguna, Consultant Ophthalmologist
Dr. Melanie Miyanji, Consultant Dermatologist
Dr. Michelle Ogola, Medical Officer, Gertrude’s Children’s Hospital Dr. Mureithi Muchiri, Consultant ENT Surgeon
Dr. Noel Orata, Medical Officer, Gertrude’s Children’s Hospital Dr. Osman Miyanji, Consultant Paediatric Neurologist
Dr. Pauline Samia, Paediatrician, Gertrude’s Children’s Hospital Dr. Peter Ngwatu, Consultant Paediatric Gastroenterologist Dr. Renson Mukhwana, Paediatrician, Gertrude’s Children’s Hospital
Dr. Thomas Ngwiri, Paediatrician & Head Clinical Services, Gertrude’s Children’s Hospital
Dr. Timothy Panga, Pharmacist, Gertrude’s Children’s Hospital Dr. Moraa Bisase, Medical Officer, Gertrude’s Children’s Hospital
Mr. Protus Letoya, Pharmaceutical Technologist, Gertrude’s Children’s Hospital
Edited by
Dr. David Kiptum, Paediatrician, Gertrude’s Children’s Hospital Dr. Paul Laigong, Paediatrician, Gertrude’s Children’s Hospital Dr.Robert Nyarango, Chief Pharmacist, Gertrude’s Children’s Hospital
A publication of The Drugs and Therapeutics Committee, Gertrude’s Children’s Hospital
9. CVS... 100
1. Rheumatic fever... 100
2. Infective endocarditis... 102
3. Congestive heart failure... 103
4. Hypertension... 105 10. Burns... 107 11. Infectious diseases... 113 1. Viral infections... 113 2. Fungal infections... 115 3. Parasitic infections... 117 12. Neonatology... 130 1. Neonatal sepsis... 130 2. Ophthalmia neonatorum... 130 3. Neonatal jaundice... 131 4. Crying baby... 132 5. Neonatal feeding... 133 13. Eye disorders... 135
1. Acute eye injuries in children... 135
2. Ocular burns – thermal, chemical... 136
3. The acute red eye... 137
14. Haematology... 141
1. Anaemia... 141
2. Iron deficiency anaemia... 142
3. Haemophilia... 143
4. Sickle cell disease... 148
5. Blood product transfusion... 155
15. Dermatology... 161
1. Bacterial skin infections (pyoderma)... 161
2. Nappy rash... 163
3. Atopic eczema... 164
4. Scabies... 165
5. Fungal skin infections... 165
6. Viral infections... 166
16. Bone and connective tissue disorders... 168
17. Endocrine disordrers... 170 1. Hypothyroidism... 170 2. Hyperglycaemia... 171 3. Diabetes mellitus... 172 4. Diabetes insipidus... 175 5. Weight management... 178 18. Malnutrition... 183 19. Procedures... 187
1. Analgesia and sedation... 187
2. Lumbar puncture... 190 3. Suprapubic aspirate... 195 4. Needle thoracocentesis... 197 20. Appendices... 200 1. Appendix I... 201 2. Appendix II... 212 3. Appendix II... 217 4. Appendix IV... 224
Table of Contents
STANDARD : CLINICAL GOVERNANCE DEPARTMENT : CLINICAL SERVICES PROTOCOL NO. : CGP/CS/PRO/2
PROTOCOL : STANDARD TREATMENT GUIDELINES
AUTHOR : DRUGS AND THERAPEUTICS COMMITTEE
OWNER : HEAD CLINICAL SERVICES
VERSION : 2
ACTIVE DATE : DECEMBER 1, 2009
REVIEWED DATE : JUNE, 2010
NEXT REVIEW : JUNE, 2011
NOTES Approval:
This protocol has been approved for use by the Head of Clinical Services who is herein identified as the protocol owner. This he has done in consultation with the Drugs and Therapeutics Committee. Author:
Whereas the Drugs and Therapeutics Committee appears as the protocol author, the actual development was done by a number of people as acknowledged in the document. The Drugs and Therapeutics Committee coordinated the development. The Drugs and Therapeutics Committee is a sub-committee of the Medical Advisory Committee.
Accountability:
The Head of Clinical Services is accountable for the implementation of this protocol
Description:
This protocol contains standard treatment guidelines to be used in the management of the described diseases/conditions as will be encountered at Gertrude’s Children’s Hospital.
1. RESUSCITATION GUIDELINES
CARDIORESPIRATORY ARREST
● Signs of shock, cyanosis, bradycardia / tachycardia, apnoea or increasing tachypnoea are warning signs and an indication for urgent resuscitation.
● The majority of arrests in children are due to hypoxia, hypotension and acidosis. The most common dysrhythmias are severe bradycardia, pulseless electrical activity or asystole. Ventricular arrhythmias (Ventricular fibrillation (VF) and
pulseless ventricular tachycardia (VT)) are seen with pre-existing cardiac disease (cardiomyopathies, hereditary prolongation of QT interval, congenital heart disease), poisoning (e.g. tricyclic antidepressants) and low voltage electrocution (less than 1000 volts), and may occur during resuscitation. SVT may cause shock in newborn infants.
Assessment A - Airway
● Position the head - neutral position (<1 year old), or sniffing position (1 year of age)
● Open airway – head tilt or chin lift or jaw thrust ● Use Oropharyngeal airway if required.
B - Breathing
● Signs of respiratory inadequacy
● If respiration is adequate, administer oxygen by face mask at 10 L/min. Do not use self-inflating bags in spontaneously breathing
patients. They are designed to deliver O2 only if squeezed.
Artificial Ventilation
● Select the appropriate sized resuscitator bag ○ Infant up to 2 years - 500 mL bag
○ Child > 2 years - 2 litre bag ● Select an appropriate sized mask. ● Obtain an airtight seal
● O2 flow rate of 10-15 l/min and attachment of a reservoir
assembly will give nearly 100% O2.
● An Oropharyngeal airway will facilitate maintenance of the airway.
● Brief suction of the mouth and pharynx if needed, using a yankeur sucker under direct vision
● Ventilate to have normal chest rise and fall. Do not over ventilate
● Intubation should only be attempted by those credentialed and skilled to do so
Endotracheal Intubation Select the correct tube size: Correct endotracheal tube size
Age Weight (Kg) Tube size (mm) Length at lip (cm)
Newborn 3.5 3.0 8.5
2 months 5 3.5 9
6 months 8 4.0 10
1 year 10 4.0 11
Older than 1 year: Tube size (mm) = (age in yr/4) + 4 Length at lip (cm) = (age in yr/2) + 12 C - Circulation
● If there are no signs of circulation, i.e. no pulse, slow pulse (<60) or you are not sure, commence external cardiac
compression and determine the cardiac rhythm - attach an ECG monitor and display the ECG
● Signs of circulatory inadequacy Initial Management
Assessment and Management of the airway and breathing are the initial priorities
Initial Assessment and Management
Call for help
Stimulate and assess response
Airway opening manoeuver Check breathing
Bag valve mask ventilation
Assess for pulse and signs of circulation
Table 1
External cardiac compression
● DO NOT interrupt except for defibrillation.
● Place the child on a firm surface. If on a bed, place the cardiac massage board under the patient, not under the mattress ● Apply massage to the lower half of the sternum in all patients
including newborns
● Compress sternum one third the depth of the chest. ● Use the hand technique that allows you to achieve this.
1. With large children use the “heel” of one hand with the other superimposed.
2. For small children use the heel of one hand 3. For infants use two fingers.
4. For newborn infants the best technique is a two-handed hold (encirclage) in which both thumbs compress the sternum. ● Gain IV or IO access as soon as possible - at least the second
dose of adrenaline should be given via this route
● Frequent changes of personnel (every few minutes) is desirable ● During resuscitation do not stop to check for a pulse unless for
defibrillation or the ECG shows an organised rhythm.
● After DC shock, continue CPR for 2 minutes prior to checking rhythm.
During resuscitation
Correct treatable causes (6H, 4T) ● Hypoxaemia ● Hypovolaemia ● Hypo/hyperthermia ● Hypo/hyperkalaemia ● Tamponade ● Tension pneumothorax ● Toxins/poisons/drugs ● Thrombosis
Other drugs to consider
Atropine
For persistent asystole / bradycardia (20mcg/Kg) (Minimum 100mcg, Maximum 600mcg)
Amiodarone
Used for shock refractory ventricular fibrillation
Dose 5mg/Kg over 1 to 2minutes, may repeat up to 20mg/Kg maximum 300mg
If patient responds, start an infusion at 10 to 15mg/Kg/ day
Lignocaine
Never give lignocaine after Amiodarone. Amiodarone is the preferred agent
Same indications as Amiodarone. Dose (1mg/Kg) (0.1mL/Kg of 1% Lignocaine)
Magnesium Sulphate
For hypomagnesaemia or for polymorphic VT (torsade de pointes) 50% solution: 0.05-0.1mL/Kg (0.1-0.2mmol/Kg) (Maximum 2 g) Infuse over 5 mins.
Sodium bicarbonate, calcium and high doses of adrenaline (>10mcg/Kg/ dose) have no place in routine resuscitation.
Other issues
Blood gas analysis
● It is not a priority in initial resuscitation attempts and
obtaining a sample should not distract from other resuscitation manoeuvres.
● Arterial (and to some extent venous) blood gas analysis can help determine degree of hypoxaemia, adequacy of ventilation, degree of acidosis and presence of electrolyte abnormalities such as of Sodium and Potassium.
Diagram 1.
Co
ntinuous CPR
Pr e i nt ub at io n • ~ 10 0 c om pr es si on s/ m in ut e • 1 5 c om pr es si on s t he n 2 b re at hs • Pa us e c om pr es si on s f or each breath Obtain IV or I O ac ce ss Assess rhythm fo r m ax im um of 10 seconds Shockabl e VF or pulsess VT Non-Shockabl e Asystole o r Pu ls el es s E le ct ric al Activity A drenaline - # 0.1mls/Kg 1:10,000 IV or IO Co nt in ue C PR f or 2 m in ut es A ss es s rh ythm fo r m ax im umof 10 seconds One DC Shoc
k 4 J /K g ( Ad ul t 2 00 j) Im m ed ia tl y r es um e C PR and gi ve A drenaline - # 0.1mls/K g 1:10,000 IV or IO Co nt in ue C PR f or 2 m in ut es Sh oc ka bl e VF or pulseless VT One DC Shoc k 2m ls/ Kg ( Ad ul t 2 00 J) Im m ed ia tl y r es um e CP R f or 2 m in ut es # - A drenalin e 0.1 mls/Kg of 1:10,000 IV or IO Adults: 1mg (1ml 1:10,000) ET T adrenaline may be used fo r
1st dose if IV or IO access not read
ily o bt ai ne d. I t is not the pref er re d r ou te . 0. 1 m ls /K g 1 :1 00 0 d ilu te d t o 3 m l A dults: 5mg (5ml 1:1000) A m io da ro ne 5mg/kg (max 300mg) afte r 3 rd D C
shock and adrenalin
Age Length (cm) Weight (kg) Pulse Resp. BP mmHg (systolic) BP mmHg (diastolic) Temp. (ºC) ET tube (mm)
ET depth (cm tip to tip) Laryng Blade LMA NG Tube Suction Catheter Pre-term 1 - 2 100–180 40 – 60 50 - 60 35 – 45 34.0 – 38.0 2.5 6 + WT (kg) 0 1 5 5 – 6 Term Newborn 50 3 - 4 100–180 40 – 60 60 – 90 40 - 45 34.0– 38.0 3.0 6 + WT (kg) 1 1 5 – 8 6 – 8 6months 67 7 100–160 30 – 60 83 - 105 40 - 45 34.0 – 38.0 3.5 11 1 1.5 8 8 1 year 75 10 80 – 110 26 – 34 95 – 105 50 - 65 34.0 – 38.0 4.0 11 – 12 1 2 10 8 – 10 3 years 95 15 70 – 110 24 - 26 96 – 110 55 - 75 36.1 – 37.8 4.5 13 – 14 2 2 10 10 5 years 110 18 70 – 110 20 – 24 96 – 110 55 – 75 36.1 – 37.8 5.0 14 – 15 2 2 12 10 6 years 115 20 65 – 110 20 – 24 97 - 112 65 - 80 36.1 – 37.8 5.5 15 – 16 2 2.5 12 10 8 years 127 25 65 – 110 20 – 24 97 – 112 65 – 80 36.1 – 37.8 6.0 17 – 18 2 3 14 10 12 years 150 40 60 –100 12 – 20 112 - 128 70 - 85 35.9 – 37.6 6.5 19 – 20 3 3 – 4 14 12 16 years > 50 60 –100 12 – 20 112 - 128 70 – 85 35.9 – 37.6 7.0 20 – 24 3 3 – 4 18 12 Adult Female 50 – 75 60 – 100 12 – 20 112 - 130 70 - 90 35.9 – 37.6 7.5 22 – 24 3 – 4 3- 4 18 14 Adult Male 75- 100 60 – 100 12 – 20 112 - 130 70 - 90 35.9 – 37.6 8.0 22 - 24 3 – 4 4 - 5 18 14
Appropriate internal diameter (mm) of ET tube = (Age in years/ 4) + 4; NB: For ET tube size, you choose a size larger and a size smaller in addition to the indicated size. Appropriate length of Oral tube (cm) = Newborn = 6 + weight (kg); In infant and child = (Age in years/2) + 12 or three times internal tube diameter Appropriate length of Nasal tube (cm) = (Age in years/ 2) + 15
ADRENALINE
Newborn: 0.1 – 0.3 mL/kg of 1:10,000 IV/ IO
Child: 0.1 mL/kg of 1:10,000 IV/ IO; 0.1 mL/kg of 1:1,000 ET Adult 10 mL of 1:10,000 IV/ IO; 2.0-2.5 mL of 1:1,000 ET
Age Endotracheal Intravenous Anaphylaxis (IM)
1:1,000 1:10,000 1:1000 Pre-term 0.5 mL (1:10,000) 0.2 – 0.mL 0.15 mL (150 mcg) Term NB 1 mL (1:10,000) 0.5 – 1 mL 0.15 mL (150 mcg) 6 months 0.7 mL 0.7 mL 0.15 mL (150 mcg) 1 year 1 mL 1 mL 0.15 mL (150 mcg) 3 years 1.5 mL 1.5 mL 0.15 mL (150 mcg) 5 years 1.8 mL 1.8 mL 0.15 mL (150 mcg) 6 years 2 mL 2 mL 0.30 mL (300 mcg) 8 years 2.5 mL 2.5 mL 0.30 mL (300 mcg) 12 years 2.5 mL 4 mL 0.30 mL (300 mcg) 16 years 2.5 mL 5 mL 0.50 mL (500 mcg) Adult 2 – 2.5 mL 10 mL 0.5 0mL (500 mcg)
IM or slow IV/ IO CHLORPHENIRAMINE HYDROCORTISONE
< 6 months 250 mcg/kg 25 mg
6 months – 6 Years 2.5mg 50 mg
6 - 12 years 5 mg 100 mg
Adult or child >12 years 10 mg 200 mg
AMIODARONE: 5mg/kg IV/ IO; rapid bolus for pulseless VF/ VT; over 20-60min for perfusing tachycardia. MAXIMUM SINGLE DOSE: 300 mg. May repeat to MAX DOSE= 15 mg/kg/Day (2.2g/Day). DO NOT combine with procainamide.
(Adult: 300mg rapid bolus for VF/VT; may repeat 150mg after 3-5min prn; 150mg over 10minutes for perfusing tachycardia; may repeat. Follow both by an infusion. MAX DOSE = 2mg/day)
ATROPINE: 0.02 mg/Kg IV/ IO or ET (MINIMUM DOSE =0.1mg; MAX SINGLE DOSE = 0.6mg for child and 0.9 mg for adolescent); May repeat x 1
(Adult: 0.5-1.0mg; may repeat Q3-5min to MAX TOTAL= 3mg) LIDOCAINE: 1.0-1.5mg/kg IV /IO or ET; follow by an infusion.
(Adult: 1.0- 1.5mg/kg IV/ IO; repeat 0.5-0.75mg/kg q 5-10min if needed up to MAXIMUM TOTAL DOSE = 3mg/kg. ET dose = 2-4 mg/kg)
ELECTRICITY
DEFIBRILLATION: 4 Joules/kg (monophasic or biphasic waveform) should be used for all shocks. The MAXIMUM DOSE for the first shock is 360 J (monophasic) or 150 – 200 J (biphasic) and subsequent shocks is 360 J (monophasic) or 200 J (biphasic)
(Adult: 200 joules; then 200 – 300 joules; 360 joules thereafter)
Table 3
Table 4
Post resuscitation care
● Ensure airway and breathing are managed effectively including intubation if not already performed. Do not extubate. Use adequate sedation and analgesia.
● Ventilate to normal carbia
● Circulation - maintain adequate blood pressure with use of inotropes as needed. Monitor for further arrhythmias.
● Aim for core temperature of 35 degrees (do not actively warm if core temp >32 degrees)
● Ongoing anti arrhythmic drugs ● Ensure normal glycaemia
CARDIOVERSION: 0.5 joules/kg; increase to 1 joule/kg if needed
(Adult: 50 Joules for SVT or atrial flutter; 100 Joules for monomorphic VT or A-fib; 200 joules for polymorphic VT; increase to 300 and 360 joules if needed)
CRYSTALOID FLUID CHALLENGE
Choose an ISOTONIC, non-glucose-containing solution (Ringer’s lactate, Hartman’s solution, Normal Saline 0.9%)!
Newborn: 10 mL/kg;
Infant or child: 20 mL/kg; repeat as needed
(ADULT; 500-1,000 mL or 10-20 mL/kg; titrate to effect) BOLUS MEDICATIONS
ADENOSINE: 0.1mg/kg rapid IV/ IO push; increase to 0.2mg/kg if needed; MAXIMUM SINGLE DOSE = 12mg
(Adult: 6mg; increase to 12mg if no effect; may repeat 12 mg x 1) CALCIUM CHLORIDE: 20mg/kg (= 0.2 mL/kg of 10% solution) IV/ IO GIVE slowly IV / IO over 5 – 30minutes; may repeat after 10 minutes (Adult: 2 – 10 mL; may repeat q 10minutes)
CEFOTAXIME or CEFTRIAXONE: 50mg/kg IV/ IO/IM (Adult: 2gms)
DEXTROSE: Infant/ child 10mL/kg IV/ IO (Newborn: 5 mL/kg) of 10 % solution. (Adult: 1 mL/kg up to 50 mL of 50% solution)
ADRENALINE, IM or SQ: (for anaphylaxis): 0.01 mL/kg of 1:1,000 solution up to max of 0.5 mL (Adult: 0.3- 0.5 mL of 1: 1,000 solution)
FENTANYL: 2mcg/kg IM or slow IV/ IO push; consider increase to 5 – 10mcg/kg for better analgesia (Adult: 2 – 10 mcg/kg)
PHENYTOIN: 15 – 20 mg/kg IV/ IO push at max rate of 100mg/min or IM; then 2 -3 mg /kg q 12 hours (Adult: same as child)
MIDAZOLAM: 0.05 – 0.15 mg/kg slow IV/ IO push with prn repeat upto MAXIMUM TOTAL DOSE = 6mg for child < 5 years, 10 mg for older child; Intramuscular dose for seizures: 0.2mg/kg IM up to MAXIMUM DOSE 7mg
(Adult: 1.0 – 32.5 mg; repeat prn to MAXIMUM TOTAL = 10 MG) NALOXONE: 0.1 mg/kg for newborn – 5 years (MAXIMUM 2mg) 2mg for older child; IV/ IO, IM, or ET
(Adult: 0.2 – 2.0 mg; may repeat to total of 10mg) PROCAINAMIDE: 15mg/kg over 30-60 minutes
(Adult: 20 mg/ minute until endpoint or 17 mg/kg TOTAL DOSE)
SALBUTAMOL: (0.5% solution): 0.10- 0.15mg/kg in 3 mL Normal Saline via nebulizer; MINIMUM DOSE = 0.5mL/2.5 mg; MAXIMUM DOSE = 1.0 mL/5mg
2. EMERGENCIES
1). ACUTE UPPER AIRWAY OBSTRUCTION
Description
The signs of partial acute upper airway obstruction are: ● Stridor
● Increased work of breathing as evidenced by suprasternal, intercostal and subcostal retraction along with an increased use of accessory muscles of respiration.
Management
• Allow child to settle quietly on parent’s lap in the position the child feels most comfortable.
• Observe closely with minimal interference. • Treat specific cause
• Call ICU if worsening or severe obstruction.
• Oxygen may be given while awaiting definitive treatment.
This can be falsely reassuring because a child with quite severe obstruction may look pink in oxygen.
Notes
• Intravenous access should be deferred – upsetting the child can cause increasing obstruction.
• Lateral cervical soft tissue x-rays do not assist in management.
• In severe airways obstruction x-rays cause undue delay in definitive treatment and may be dangerous (positioning may precipitate respiratory arrest).
2). ANAPHYLAXIS
Description
Anaphylaxis is a multi-systemic allergic reaction characterised by: ● At least one respiratory or cardiovascular feature and
● At least one gastrointestinal or skin feature.
For reactions which do not fulfill this definition, see Urticaria guidelines
Management
• Supplemental oxygen
• Intra-muscular adrenaline 0.01mL/Kg of 1/1000 (maximum 0.5mL), into lateral thigh is the treatment of choice for anaphylaxis which should be repeated after 5 minutes if patient not improving - Do not use subcutaneous adrenaline as absorption is less reliable than the
intramuscular route. Do not use IV bolus adrenaline unless cardiac arrest is imminent.
• An adrenaline infusion should be considered if repeated doses of IM adrenaline are required at 0.05 - 1 mcg/Kg/min • In addition to adrenaline, repeated 10-20 mL/Kg boluses of
0.9% saline may be required for shock
• Nebulised adrenaline is not recommended as first-line therapy but may be a useful adjunct to IM adrenaline if upper airway obstruction is present.
• If airway oedema is not responding to parenteral and nebulised adrenaline, early intubation is indicated. • Corticosteroids or antihistamines should never be relied
upon as first line treatment of anaphylaxis
• ICU should be notified if children require 2 adrenaline doses or 30 mL/Kg fluid bolus for the management of anaphylaxis or if ongoing airway concerns.
Other therapies to consider
● Nebulised salbutamol is recommended if the patient has respiratory distress with wheezing.
● Anti-histamines may be given for symptomatic relief of pruritus. Second generation anti-histamines are preferred (promethazine can cause hypotension).
● Corticosteroids may be considered at the discretion of the treating physician especially for bronchospasm although the limited evidence available does not support their use. Admission
All children with anaphylaxis should be admitted. At least 6-12 hours observation is recommended and overnight admission should be considered if any of the following circumstances apply:
● Greater than one dose of adrenaline (including nebulised adrenaline) required.
● A fluid bolus required
● The child lives a long distance from medical services Discharge Plan and Follow up
● Outpatient follow up is recommended. Reference
1. Advanced Paediatric Life Support: A practical approach. Advanced life support group. Fourth ed. London: Blackwell Publishing, 2005.
3). HEREDITARY ANGIOEDEMA
(C1 Esterase Inhibitor Deficiency, HAE) Description
● HAE causes recurrent episodes of angioedema in the upper respiratory, gastrointestinal tract or in subcutaneous tissues. ● Acute episodes of angioedema may be triggered by infection,
stress, menstruation, surgery, dental work, trauma and some
medicines (including oestrogen-containing contraceptives and ACE-inhibitors) or may have no clear trigger.
● HAE is a rare autosomal dominant condition in which C1 esterase inhibitor levels are reduced (HAE type I) or poorly functional (HAE type II). HAE is diagnosed by the finding of low C1 esterase inhibitor level or function. C4 level is also low during episodes of angioedema.
Management
Mild/moderate angioedema episodes Treatment is conservative:
● Hospital admission is not usually required
● Other causes of abdominal pain may need to be excluded and abdominal ultrasound may help by showing intestinal wall oedema or ascites in HAE-related angioedema.
● A 3 day course of tranexamic acid may be considered to shorten the duration of symptoms (12-25mg/Kg/dose (max 1.5g) 3-4 times per day)
Severe angioedema episodes
Severe angioedema episodes can be fatal. Management includes: ● Hospital admission for all severe angioedema episodes ● If upper airway obstruction is present, notify a colleague
experienced in endotracheal intubation
● Intravenous C1 esterase inhibitor concentrate should be administered (see below for dosing)
Planned Surgery or Oropharyngeal Procedures
Surgery or any traumatic procedure of the oropharyngeal area such as dental work should be carefully planned. The use of a prophylactic agent prior to such procedures reduces the risk of precipitating angioedema.
● For planned procedures, Danazol is the first choice of
prophylactic agent, (10mg/Kg/day for 5-10 days before and 2-5 days after the procedure).
● For emergency or high-risk procedures, C1 esterase inhibitor concentrate (25units/Kg infusion given 1 hour prior to the procedure)
● Due to the risk of precipitating laryngeal oedema, oropharyngeal procedures should usually involve general anaesthesia with endotracheal intubation
Notes
Antihistamines and Corticosteroids
● Antihistamines and corticosteroids have no role in the management of HAE related angioedema.
● The role of adrenaline in the treatment of HAE is not well established.
● There are anecdotal reports of efficacy using nebulised or intramuscular adrenaline to treat upper airway angioedema, however C1 esterase inhibitor is the treatment of choice for airway angioedema caused by HAE.
4). NEAR DROWNING
All children should receive full resuscitative efforts after an episode of immersion or near drowning.
Assessment and management
● Rapidly assess airway, breathing, circulation and level of consciousness
● If child is in cardiorespiratory arrest proceed immediately with cardiopulmonary resuscitation
Airway and breathing (protect cervical spine if any possibility of injury)
● If spontaneously breathing, administer 100% oxygen by face mask.
● Intubate and ventilate if: ○ Inadequate respiration
○ Falling arterial Oxygen concentration (PaO2) despite increased fractional inspired Oxygen
○ Persisting depressed level of consciousness
● Monitor Oxygen saturation and perform arterial blood gas ● Do a chest x-ray
Circulation
● Assess pulse rate and volume, blood pressure and capillary refill.
● Insert intravenous line.
● Perform Haemogram, serum glucose, electrolytes and creatinine.
● If circulation is inadequate give fluid bolus of 20 mL/Kg Ringers Lactate.
● Consider early ionotropic support Cerebral support
● Avoid any further episodes of hypoxia and hypercarbia. ● Optimise circulation as best possible.
● Once shock is reversed restrict fluids to 75% of maintenance. ● Monitoring and control of intracranial pressure is occasionally
required. Temperature
● Actively rewarm children slowly to a core temperature of 34 degrees.
● Passively rewarm over 34 degrees. General
● Admit to appropriate inpatient unit. ● Corticosteroids are not recommended.
Adverse Prognostic Factors ● Immersion time > 10 minutes. ● Rectal temperature < 30°C.
● Absence of any initial resuscitative efforts.
● Arrival in hospital with CPR in progress or in coma ● Requirement of cardiopulmonary resuscitation ● Initial serum pH < 7.0
5). FLUID MANAGEMENT
1. Composition of IV Fluids
Fluid Na Cl K Ca Lactate Osmolality
Normal Saline (0.9% ) 154 154 _ _ _ 308 ½ Strength Normal Saline 77 77 _ _ _ 154 ¼ Strength Normal Saline 38.5 38.5 _ _ _ 77 Ringers Lactate 130 109 4 3 28 275 Half strength Darrows 62 17 _ _ 25 170 5%Dextrose - - - - - 253 Table 6
2. Body Weight Method of Calculating Maintenance Fluid Volume
Body weight (Kg) Fluid Therapy per Day (mL)
0-10 100 mL /Kg
11- 20 1000 mL + 50 mL/Kg for each Kg greater than 10 Kg
>20Kgs 1500mL+ 20 mL/Kg for each Kg greater than 20Kg
3. Maintenance Electrolyte Requirements ● Sodium: 2-3 meq /Kg/24hr ● Potassium 1-2 meq/Kg/24hr ● Calcium 1-2mmol/Kg/24hr ● (Glucose 4-6mg/Kg/Min) 4. Types of Dehydration 1. Hypernatremic dehydration a. Restore intravascular volume
If in shock, administer Normal Saline 20 mL / Kg over 20 minutes. Repeat until out of shock
b. Determine time for correction based on the initial sodium concentration
145 – 157 meq/L: 24 Hours 158 – 170 meq/L: 48 hours 171 – 183 meq/L : 72 Hours 184 – 196 meq/L: 84 Hours
c. Administer fluid at constant rate over the time for correction ● Typical fluids 5% dextrose + ¼ strength normal saline or 5%
dextrose + ½ normal saline (both with 20 Meq/l potassium chloride unless contraindicated)
● Typical rate: 1.25 -1.5 times maintenance ● Monitor serum sodium concentration 4 hourly
d. Adjust fluid based on clinical status and serum sodium concentration:
Signs of volume depletion: Administer normal saline (20 mL/Kg) If Sodium decreases too rapidly,
1. Increase sodium concentration of IV fluids 2. Decrease IV fluids infusion rate
If Sodium decreases too slowly,
1. Decrease sodium concentration of IV fluids 2. Increase IV fluids infusion rate
3. Replace ongoing losses as they occur Fluid replacement in shock
● Fix an IV line
● Draw blood for analysis
● Infuse 20 mL /Kg of isotonic fluid (normal saline or ringers lactate)
● Reassess after 1st infusion: If no improvement, repeat 20 mL/ Kg as quickly as possible
● Reassess after 2nd infusion: If no improvement, repeat 20 mL/ Kg as quickly as possible
● Reassess after 3rd infusion: if no improvement, consider giving blood 20 mL/Kg over 30 minutes
● Reassess after 3rd infusion
6). ENDOCRINE EMERGENCIES
1). DIABETIC KETOACIDOSIS
Assessment
Degree Of Dehydration - (often overestimated) ● Mild (<4%) No clinical signs
● Moderate (4-7%) easily detectable dehydration - reduced skin turgor, poor capillary return
● Severe (>7%) poor perfusion, rapid pulse, reduced blood pressure - in shock
Investigations
● Blood glucose, urea, and electrolytes ● Arterial or capillary acid/base status ● Urine - Ketones, microscopy, culture
● Check for precipitating cause e.g. Infection (Urine, Full Haemogram, blood cultures; consider Chest x-ray)
● Islet cell antibodies, insulin antibodies, GAD antibodies, Total IgA, antiendomysial IgA antibody and Thyroid function test for all newly diagnosed patients
Management
● Airway, Breathing and Circulation - ABCs Fluid Requirements
● If in shock, give Normal Saline at 10-20mL/Kg stat
● Repeat until perfusion is re-established (warm, pink extremities with rapid capillary refill).
Commence rehydration with Normal Saline as below Fluid rates (mL/hour) including deficit and maintenance fluid requirements, to be given evenly over 48 hours
Fluid volumes for the subsequent phase of rehydration
Weight(Kg) mL/24 h
Give maintenance plus 5% of body weight per 24hours
mL/24hr mL/hr 4 325 530 22 5 405 650 27 6 485 790 33 7 570 920 38 8 640 1040 43 9 710 1160 48 10 780 1280 53 11 840 1390 58 12 890 1490 62 13 940 1590 66 14 990 1690 70 15 1030 1780 74 16 1070 1870 78 17 1120 1970 82 18 1150 2050 85 19 1190 2140 89 20 1230 2230 93 22 1300 2400 100 24 1360 2560 107 26 1430 2730 114 28 1490 2890 120 30 1560 3060 128 32 1620 3220 134 34 1680 3360 140 36 1730 3460 144 38 1790 3580 149 40 1850 3700 154 45 1980 3960 165 50 2100 4200 175 55 2210 4420 184 60 2320 4640 193 65 2410 4820 201 70 2500 5000 208 75 2590 5180 216 80 2690 5380 224
Table 8 After initial resuscitation and assuming 10% dehydration, the total amount of fluid should be given over 48 hours. The above table gives volumes for maintenance and rehydration per 24 hours and per hour. If fluid has been given for resuscitation, the volume should not be subtracted from the amount shown in the table. Fluids given orally (when patient has improved) should be subtracted from the amount in the table. The table is based on maintenance volumes according to Darrrow. For body weights >32 kg, the volumes have been adjusted so as not to exceed twice the maintenance rate of fluid administration.
Keep nil by mouth (except ice to suck) alert and stable. Insert a nasogastric tube if patient is comatose or has recurrent vomiting; leave on free drainage.
Rehydration may be completed orally after the first 24 - 36 hours if the patient is metabolically stable.
Bicarbonate
This is usually not necessary if shock has been adequately corrected. Continuing acidosis usually means insufficient resuscitation. In extremely sick children (with pH < 6.9 with or without HCO3 < 5mmol/L), small amounts may be given after discussion with the endocrinologist.
HCO3 dose (mmol) = 0.15 x body weight (Kg) x base deficit. Give over 30 min with cardiac monitoring. Reassess acid base status. Remember risk of hypokalaemia
Admission to ICU
● Admit to ICU if age < 2 years, coma, cardiovascular compromise, seizures.
Ward Transfer Instructions ● Strict fluid balance
● Check all urine for Ketones
● Hourly observations: pulse, BP, respiratory rate, level of consciousness and pupils
● Hourly glucose (Glucometer) while on insulin infusion; other biochemistry as clinically indicated
● 4-hrly temperatures Inpatient Treatment Insulin
Note: Beware the rare entity of hyperglycaemic-hyperosmolar non-ketotic coma: Insulin should ONLY be used after discussion with endocrinologist
Add 50 units of clear/rapid-acting insulin (Actrapid HM or Humulin R) to 49.5 mL 0.9% NaCl (1 unit/mL solution). Ensure that the insulin is clearly labeled.
Start at 0.1 units/Kg/hr in newly diagnosed children, and those already on insulin who have glucose levels > 15 mmol/L. Children who have had their usual insulin and whose blood sugars are < 15 mmol/L should receive 0.05 units/Kg/hour. Adjust the concentration of dextrose to keep blood glucose 10-12 mmol/L. Adequate insulin must be continued to clear acidosis (Ketonaemia). Insulin dose may be halved for children < 5yrs of age
The insulin infusion can be discontinued when the child is alert and metabolically stable (blood glucose < 10-12 mmol/L, pH > 7.30 and HCO3 > 15)The best time to change to SC insulin is just before meal time. The insulin infusion should only be stopped 30 minutes after the first SC injection of insulin.
● Potassium
Start Potassium Chloride after initial fluid at a concentration of 40 mmol/L of fluid infusion if body weight less than 30Kg, or 60 mmol/L of fluid infusion if 30 Kg or more. Measure levels 2 hours after starting therapy and 2-4 hourly thereafter. Specimens should in general be arterial or venous. Give no Potassium if the serum level is > 5.5 mmol/L or if the patient is anuric
● Fluids
If the blood sugar falls very quickly, i.e. within the first few hours, change to Normal Saline with 5% dextrose. When the blood sugar reaches 12-15 mmol/L, use 0.45% Normal Saline with 5% dextrose.
Aim to keep the blood sugar at 10-12 mmol/L
If the blood glucose falls below 10-12 mmol/L and the patient is still sick and acidotic, increase the dextrose in the infusate to 7.5-10%. Do not turn down insulin infusion
Hazards
● Hypernatraemia
Measured serum sodium is depressed by the dilutional effect of the hyperglycaemia. To "adjust" sodium concentration, use the following formula:
Adjusted (i.e. actual) sodium = measured sodium + 0.3 (glucose - 5.5) mmol/L ie 3 mmol/L of sodium to be added for every 10 mmol/L of glucose above 5.5 mmol/L
If Na is > 160 mmol/L, discuss with the Endocrinologist. Sodium should rise as the glucose falls during treatment. If this does not happen or if hyponatraemia develops, it usually indicates overzealous volume correction and insufficient electrolyte replacement. This may place the patient art risk of cerebral
oedema.
● Hypoglycaemia
If blood glucose < 2.2 mol/L give IV 10% dextrose 5 mL/Kg. Do not discontinue the insulin infusion. Continue with a 10% dextrose infusion until stable. Insulin infusion may be reduced to 0.05Units/ Kg/hour
● Cerebral Oedema
Some degree of subclinical brain swelling is present during most episodes of diabetic ketoacidosis. Clinical cerebral oedema occurs suddenly, usually between 6 and 12 hours after starting therapy (range 2 - 24 hr). Mortality or severe morbidity is very high without early treatment
● Prevention
Slow correction of fluid and biochemical abnormalities. Optimally, the rate of fall of blood glucose and serum Osmolality should not exceed 5mmol/L/hr, but in children there is often a quicker initial fall in glucose. Patients should be nursed head up
Warning signs
● First presentation, long history of poor control, young age (< 5 yr)
● No sodium rise as glucose falls, hyponatraemia during therapy, initial adjusted Hypernatraemia
● Headache, irritability, lethargy, depressed consciousness, incontinence, thermal instability
● Very late - bradycardia, increased BP and respiratory impairment.
Treatment
● Mannitol 20% 0.5 g/Kg IV stat. Give immediately when the clinical diagnosis is made - do not delay for confirmatory brain scan
● Severely reduce fluid input ● Nurse head up
● Transfer immediately to ICU
2). ADRENAL CRISIS
An adrenal crisis is a physiological event caused by an acute relative insufficiency of adrenal hormones
It should be considered in patients with: ● Congenital adrenal hyperplasia
● Hypopituitarism on replacement therapy
● Those previously or currently on prolonged steroid therapy.
It may occur in previously undiagnosed adrenal/pituitary insufficient patients, or acutely in a previously well patient Assessment
History and physical examination – look for:
● Glucocorticoid deficiency: weakness, anorexia, nausea and/or vomiting, hypoglycaemia, hypotension (particularly postural) and shock
● Mineralocorticoid deficiency: dehydration, hyperkalaemia, hyponatraemia, acidosis and prerenal renal failure
Investigations
● Immediate blood glucose using a Glucometer ● Serum glucose, urea, sodium and potassium ● Arterial or capillary acid base
Where the underlying diagnosis not known, collect at least 2 mol of clotted blood for later analysis (cortisol and 17-hydroxyprogesterone and ACTH)
Management
Susceptible patients who present with vomiting but who are not otherwise unwell should be considered to have incipient adrenal crisis. To attempt to prevent this from developing further:
● Administer IV/IM Hydrocortisone 2 mg/Kg
● Give oral fluids and observe for 4–6 hours before considering discharge
● Discuss with endocrinologist For all other children:
Give intravenous fluids
Shock or severe dehydration:
● Normal Saline 20 mL/Kg IV bolus. Repeat until circulation is restored
● Administer remaining deficit plus maintenance fluid volume as Normal Saline in 5% dextrose evenly over 24 hours
● Check electrolytes and glucose frequently
● After the first few hours, if serum sodium is greater than 130 mmol/L, change to half Normal Saline
● 10% dextrose may be needed to maintain normoglycaemia Moderate dehydration:
● Normal Saline 10 mL/Kg IV bolus. Repeat until circulation is restored
● Administer remaining deficit plus maintenance fluid volume as Normal Saline in 5% dextrose evenly over 24 hours
Mild or no dehydration: ● No bolus
● 1.5 times maintenance fluid volume administered evenly over 24 hours
Hydrocortisone
Administer Hydrocortisone intravenously. If IV access is difficult, give IM while establishing intravenous line.
● Neonate: 25 mg stat and then 10–25 mg, 6 hourly ● 1 month – 1 year: 25 mg stat, then 25 mg, 6 hourly
● Toddlers (1–3 years): 25-50 mg stat then 25–50 mg, 6 hourly ● Children (4–12 years): 50–75 mg stat, then 50–75 mg, 6 hourly ● Adolescents and adults: 100 – 150 mg stat, then 100 mg, 6
hourly
When stable reduce IV Hydrocortisone dose, then switch to triple dose oral Hydrocortisone therapy, gradually reducing to maintenance levels (10–15 mg/m2/day).
In patients with mineralocorticoid deficiency start Fludrocortisone at maintenance doses (usually 0.1 mg daily) as soon as the patient is able to tolerate oral fluids
Treat hypoglycaemia
Hypoglycaemia is common in infants and small children. Treat with IV bolus of 2- 5 mL/Kg 10% dextrose. Maintenance fluids should contain 5–10% dextrose
Treat hyperkalaemia
Hyperkalaemia usually normalises with fluid and electrolyte replacement.
If potassium is above 6mmol/L perform an ECG and apply cardiac monitor as arrhythmias and cardiac arrest may occur.
If potassium is above 7 mmol/L and hyperkalaemia ECG changes
are present (e.g. peaked T waves, wide QRS complex), give 10% calcium Glucometer 0.5 mL/Kg IV over 3–5 mins. Commence infusion of insulin 0.1units/Kg/hr IV together with an infusion of 50% dextrose 2 mL/Kg/hr
If the serum Potassium is above 7 mmol/L with a normal ECG, give Sodium bicarbonate 1–2 mmol/Kg IV, over 20 mins with an infusion of 10% dextrose at 5 mL/Kg/hr
Identify and treat potential precipitating causes such as sepsis. Admit to appropriate inpatient facility.
Prevention
Prevention of a crisis if possible, is essential and may involve: ● Anticipating problems in susceptible patients
● Giving triple normal oral maintenance steroid dose for 2–3 days during stress (e.g. fever, fracture, laceration requiring suture) ● Giving intramuscular Hydrocortisone when absorption of oral
medication is doubtful like in vomiting or severe diarrhoea ● Increasing parenteral Hydrocortisone (1–2 mg/Kg) before
anaesthesia, with or without an increased dose postoperatively
3). PHAEOCHROMOCYTOMA CRISIS
Crisis is caused by the action of unopposed high circulating levels of catecholamines acting at adrenoreceptors: α-receptors cause a pressor response with increases in blood pressure, while α-receptor activation has positive inotropic and chronotropic effects, any patient presenting with acute hypertension and tachycardia should be considered at risk of Phaeochromocytoma, especially if young or in an at risk group
Risk factors Spontaneous
Associated conditions:
● Multiple Endocrine Neoplasia type 2. ● Neurofibromatosis type 1.
● Von Hippel-Lindau syndrome. ● Ataxia telangiectasia. ● Tuberous sclerosis. ● Sturge-Weber syndrome. Precipitating factors ● Spontaneous
● Haemorrhage into Phaeochromocytoma ● Other
○ Exercise.
○ Pressure on abdomen. ○ Urination.
○ Drugs: Guanethidine, glucagon, Naloxone, Metoclopramide, ACTH, cytotoxics, tricyclic antidepressants
Clinical features
● Hypertension, palpitations, sweating, pallor, pounding headache, anxiety and tremulousness, pulmonary oedema, feeling of impending death, hyperhydrosis, nausea and vomiting, abdominal pain (tumour haemorrhage), paralytic ileus, hyperglycaemia, altered consciousness (hypertensive encephalopathy), myocardial infarction, and stroke
● Flushing is not a feature of Phaeochromocytoma. ● The attacks last between 15 60 minutes.
● Signs of end organ hypertensive damage; hypertensive retinopathy and papilloedema, left ventricular hypertrophy, renal impairment, and proteinuria
Biochemical diagnosis
Biochemical diagnosis is made by:
● Collecting urine into acidified bottles for estimation of 24-hour free catecholamines and metanephrines
● Plasma metanephrines and catecholamines are also increasingly be used for this diagnosis.
Treatment
● Should not wait for biochemical confirmation
● Phenoxybenzamine (alpha blocker) is the drug of choice, with a starting dose of 0.25-1.0mg/kg orally three times a day, increasing to a maximum dose of 240 mg/24 hour. Doses above 40 mg three times a day are seldom required. Dose titration is performed every 48 hours until control of blood pressure is achieved
● After the first 48 hours addition of Propranolol 0.5-4 mg/kg/ day PO/ divided every 8hours; not to exceed 60 mg/day orally three times a day may be added
Important pharmacological issues in treatment
● It is vital that 48 hours of a-blockade precede β-blockade to avoid exacerbating a crisis through the unopposed action of
catecholamines at α-receptors
● Alpha-antagonists such as doxazosin, and calcium channel antagonists, while increasingly used for maintenance therapy before operation for Phaeochromocytoma, are not recommended for management of crisis.
● Labetalol is not recommended as this has relatively greater β-blocking action compared to its α-blocking action, and hence can even precipitate or worsen Phaeochromocytoma crisis.
4). ACUTE HYPERCALCAEMIA
● Causes of hypercalcaemia ○ Endocrine
○ Hyperparathyroidism (adenoma, hyperplasia, carcinoma) ○ Multiple endocrine Neoplasia
○ PTH related protein production by solid tumours ● Neoplastic
○ Carcinoma and bone invasion. ○ Myeloma.
● Granulomatous ○ Sarcoidosis ○ Tuberculosis ○ Berylliosis ● Iatrogenic ○ Vitamin D toxicity ○ Thiazides ○ Vitamin A ● Renal failure ○ Tertiary hyperparathyroidism. ○ Aluminium toxicity ● Miscellaneous
○ Paget’s disease of bone
○ Familial hypocalciuric hypercalcaemia. ○ Hypophosphataemia.
History
History of polyuria and polydipsia, and there can be dehydration, bone pain, confusion, anorexia, and constipation. Relevant drug and family histories must be taken
The cornerstone of differential diagnosis is the measurement of serum parathyroid hormone (PTH)
Investigations at presentation should include; ● Parathyroid Hormone, PTH
● Serum total protein with immunoglobulin electrophoresis for myeloma, Albumin, Phosphate, Magnesium
● Erythrocyte sedimentation rate, full blood count ● ECG
● Chest radiography
● Fractional excretion of Calcium
Treatment
● Any precipitating drugs should be stopped
● The mainstay of treatment is adequate volume repletion with intravenous Normal Saline
● Loop diuretics such as Frusemide, which has calciuretic effects, should only be used after initial volume expansion
● Intravenous bisphosphonates, such as sodium pamidronate at a dose of 30–90 mg are extremely effective in the treatment of hypercalcaemia of malignancy, with duration of action that lasts days to weeks
● It is important to remember that serum PTH will rise after an acute fall in serum calcium induced by such treatment and hence it is vital that the initial sample for PTH is obtained before bisphosphonate treatment
● Cases of primary Hyperparathyroidism should be referred to endocrine surgeons
● Corticosteroids (Prednisolone 1-2mg/Kg each day) are the drugs of choice If granulomatous diseases such as Sarcoidosis, or vitamin A or D intoxication are considered
● In subcutaneous fat necrosis, intravenous fluids, diuretics, and corticosteroids should be used
5). THYROID STORM
Precipitating factors General
● Infection
● Non-thyroidal trauma or surgery ● Psychosis
● Parturition
● Myocardial infarction or other acute medical problems Thyroid specific
● Radioiodine
● High doses of iodine-containing compounds (for example, radiographic contrast media)
● Discontinuation of antithyroid drug treatment ● Thyroid injury (palpation, infarction of an adenoma) ● New institution of Amiodarone therapy
Cardinal features
Include severe tachycardia, fever (usually 38.5˚C), gastrointestinal dysfunction (vomiting, diarrhoea, and occasional jaundice), agitation, confusion, delirium, or coma. Congestive heart failure may occur, particularly in the elderly, and most patients have systolic hypertension
Biochemical features
Include hyperglycaemia, leucocytosis, high free T3 and T4, low TSH, mild hypercalcaemia, and abnormal liver function tests. Adrenal reserve may be impaired
Treatment
● Carbimazole/Methimazole 0.5-1mg/kg/day orally in 2 or 3divided doses, or Propylthiouracil in a dose of 5-7 mg/Kg/day is given. They inhibit thyroid hormone synthesis and conversion of thyroxine to tri-iodothyronine
● One hour after starting any of the above medications, iodide (like, eight drops of Lugol’s iodine every six hours) is given to inhibit thyroid hormone release
● High doses of b-blocker should be given, and Propranolol at a dose of 2-4mg/Kg/day every six hours is recommended
● Cholestyramine, 4 g every 6–12 hours, binds thyroid hormone in the gut and thus interrupts the modest enterohepatic circulation of thyroid hormone; its use will lead to a more rapid lowering of circulating thyroid hormones
● In exceptional cases, peritoneal dialysis or plasmapheresis may be needed
● Treatment of any underlying illness follows the usual lines
● Supportive treatment includes the use of external cooling, possibly supplemented by chlorpromazine, cautious intravenous fluids, or Oxygen as determined by appropriate assessment and empirical administration of intravenous Hydrocortisone 100 mg every eight hour
6). MYXOEDEMA COMA
Precipitating factors ● Hypothermia
● Infections especially pneumonia
● Myocardial infarction or congestive heart failure ● Cerebrovascular accident
● Respiratory depression due to drugs (for example Anaesthetics, sedatives, tranquillizers)
● Trauma or gastrointestinal blood loss Clinical features
The three main features are:
● Altered mental state ranging from poor cognitive function through psychosis to coma
● Hypothermia (as low as 23˚C) or absence of fever in spite of severe infection (prognosis worsens as the core temperature fall)
● The presence of a precipitating event. Other features
● The physical signs of hypothyroidism are usually obvious and most patients have respiratory depression secondary to a decreased hypoxic ventilatory drive and an impaired response to hypercapnia: the more severe the latter, the more likely coma is ● Cardiac enlargement, bradycardia, decreased ventricular
contractility, hypotension, and ECG changes (low voltage, non-specific ST wave changes and sometimes torsades des pointes with a long QT interval) are common
● Many patients have anorexia, abdominal pain and distention, and constipation and these changes may rarely lead to paralytic ileus and megacolon
Biochemical abnormalities include:
● Hyponatraemia, normal or increased urine sodium excretion, ● Raised creatine phosphokinase and lactate dehydrogenase ● Hypoglycaemia
● Normocytic or macrocytic anaemia
● Thyroid stimulating hormone values may only be modestly raised (and will be normal or low in secondary hypothyroidism) but free thyroxine levels are usually very low
Treatment
The three principles of management are;
● Rapid institution of thyroid hormone replacement ● Treatment of the precipitating cause
● Provision of ventilatory and other support Thyroxine institution may be done in two ways:
1. High dose replacement thus;
○ Intravenous thyroxine can be given as a bolus of 300–500 mcg, followed by 50–100 mcg daily
○ Intravenous dose of tri-iodothyronine is 10–20 mcg initially, followed by 10 mcg every four hours for 24 hours, then 10 mg every six hours
2. Give 200 mcg thyroxine with 10 mcg tri-iodothyronine
initially, and then tri-iodothyronine 10 mcg every 12 hours and thyroxine 100 mcg every 24 hours, until the patient resumes normal thyroxine orally
Oral treatment with similar doses is also possible
The ‘‘low dose’’ approach would suggest 25 mcg of thyroxine daily for a week, or 5 mcg of tri-iodothyronine twice daily with a gradually increasing dose.
Treatment of the underlying precipitant is usually straightfor-ward
All patients should be admitted to intensive care or the HDU: most patients require ventilatory support for 1–2 days
Hypothermia should be treated with space blankets, since active rewarming leads to circulatory collapse
Cautious volume expansion using intravenous saline usually suffices, but hypertonic saline may need to be considered if the serum sodium is very low (< 120 mmol/L) and intravenous glucose may be required for hypoglycaemia
There is often a degree of temporarily impaired adrenal function, and most authorities advocate routine intravenous administration of 50–100 mg Hydrocortisone every eight hours until recovery
7). ACUTE PITUITARY APOPLEXY
Causes
Acute pituitary apoplexy occurring in
● 0.6%–9.1% of all surgically treated pituitary tumours, but is potentially life threatening
● Haemorrhagic infarction of a pituitary tumour ● Normal pituitary gland
Risk factors include ● Spontaneous
● Anticoagulation—pre-existing haemodialysis, cardiac surgery ● Hypertension
● Raised intracranial pressure
● Dynamic pituitary testing—insulin tolerance test, thyroid releasing hormone test, gonadotrophin releasing hormone test, corticotrophin releasing hormone test
● Drugs—oestrogens, Bromocriptine, Aspirin. ● Pituitary radiotherapy
Treatment
If pituitary apoplexy is suspected
● Hydrocortisone 2mg/kg IV/IM stat, then 100mg/m2 in 4-6hrly doses intramuscularly six hourly, or 4 mg/hour intravenously should be administered without delay and continued until the crisis is over
● Before administration bloods should be drawn for cortisol, prolactin, follicle stimulating hormone, luteinising hormone, oestradiol (women), testosterone (men), sex hormone binding globulin, free thyroxine, thyroid stimulating hormone, insulin-like growth factor-1, and preferably ACTH (needs immediate cold centrifugation and freezing at -220˚C), urinary and plasma Osmolality blood glucose should be monitored and treated accordingly
● Standard cardiopulmonary supportive measures are needed ● Early neurosurgical intervention is associated with improved
neuro-ophthalmic outcome
8). PITUITARY CRISIS
Causes
● Not matching Glucocorticoid dose to stress in known patient with pituitary deficiency
● Undiagnosed Hypopituitarism
○ Pituitary adenomas or other intrasellar and parasellar tumors ○ Inflammatory and infectious destruction
○ Surgical removal and traumatic brain injury (TBI) ○ Radiation-induced destruction of pituitary tissue ○ Subarachnoid hemorrhage
○ Postpartum agalatasia pituitary necrosis (Sheehan syndrome) Clinical presentation;
Weakness, fatigue, or altered mental status without a clear diagnosis,
Hypotonia, bradycardia, decreased skin and nipple pigmentation, muscle weakness, vomiting, nausea, constipation, hypothermia, and hypoventilation
A postpartum galactic is often the first sign of Sheehan's syndrome Investigations
● TBC, serum electrolytes ● Cortisol level, prolactin level
● Evaluate the hypothalamic-pituitary-adrenal axis -corticotropin stimulation test
● Assess thyroid function- serum thyrotropin (TSH) and thyroxine (T4)
● 24hour fluid balance then a water deprivation test and an aqueous vasopressin stimulation test
Radiologic
● A lateral skull film can delineate contours of the sella turcica ● Both MRI and CT scans should be obtained with intravenous
contrast to increase sensitivity of the tests. Treatment
● Standard resuscitation with IV fluids, Vasopressors ● Hypoglycemia must be sought and treated
● Electrolyte imbalance is corrected following the usual guidelines Hormone replacements
● Hydrocortisone – high dose ● Thyroxine
● ADH analogues Note
Do not start on thyroxin therapy before confirmation of normal cortisol levels, or Hydrocortisone replacement
3. POISONING GUIDELINES
POISONING MANAGEMENT
The management of acute poisoning is discussed in detail in the Gertrude’s Children’s Hospital Poisoning Management Guidelines. Below is summary guideline. The actions below are not necessarily outlined in any particular order of implementation.
1. Manage patients as per general guidelines below and specific management as per the Gertrude’s Children’s Hospital Poisoning Management Guidelines
2. Refer to the Gertrude’s Children’s Hospital Poisoning Management Guidelines
3. Call the Gertrude’s Drug and Poison Information unit on extension 237/240 or 020 7206237/ 0207206240 for information support
4. Consult consultant on call 5. Admit patient
General Management ● Maintain adequate airway ● Provide adequate oxygenation
● Treat convulsions in any and make efforts to establish the etiology of the seizures so that appropriate treatment can be administered
● Treat coma if patient is in coma. It is important to consider other causes of depressed sensorium, including ruling out structural lesions such as subdural haematoma. The following agents can be utilized in the poisoned patient with altered level of consciousness:
○ 100% oxygen in suspected cases of poisoning with carbon monoxide, hydrogen sulphide, cyanide and asphyxiants ○ Thiamine to prevent Wernicke’s encephalopathy in an alcohol
intoxicated patient: Dose is 100 mg IV
○ Glucose to reverse the effects of drug-induced hypoglycaemia: Dose is 25 mL of glucose 50% solution in adults or 0.5-1g glucose/kg body weight in children (e.g. 5-10 mL/kg of 10% glucose)
○ Naloxone in cases of possible opioid toxicity ○ Flumazenil in cases of coma known to be caused by
benzodiazepines ALONE (because of the risk of provoking convulsions or arrhythmias, flumazenil should not be given when the patient is suspected of having taken other drugs as well).
● Correct metabolic abnormalities. The following metabolic abnormalities should be corrected:
○ Hypokalaemia ○ Hyperkalaemia ○ Hypomagnesaemia ○ Hypothermia ○ Hyperthermia ○ Hypoglycaemia ○ Hypocalcaemia
○ Acid-base abnormalities, particularly metabolic acidosis ● Prevent absorption of poisons by gut decontamination using
single-dose activated charcoal or gastric lavage as may be indicated if a patient has taken a potentially toxic amount of a poison up to one hour following ingestion. Avoid emesis. Wash off skin and/or eye exposure of poisoning if indicated.
● Enhance elimination of poison through multiple activated charcoal doses if indicated.
● Provide supportive care as will be indicated
○ Monitor vital signs (blood pressure, heart rate, respiratory rate, temperature)
○ Monitor fluid input and output
○ Monitor level of consciousness, pattern of breathing and regularity of the heart rate
○ Monitor oxygen saturation using a pulse oximeter
○ Administer intravenous fluids for maintenance and fluid loss replacement
○ Carry out intensive nursing care to avoid aspiration or the development of bed sores
○ Treat metabolic disturbances such as electrolyte abnormalities, hypoglycaemia and metabolic acidosis ○ Manage underlying illnesses that may be aggravated by
existing problem of poisoning ● Use specific antidotes if indicated
4. GASTROINTERSTINAL DISEASE
1). ACUTE VOMITING
Description
Vomiting of abrupt onset Management
● Oral rehydration: oral: child 1month- 1yrs;
● 1-1.5times usual feed volume. Child 1-12yrs; 200mLs after every loose motion. Child 12-18yrs; ORS 200-400mLs after every loose motion.
● NB: After reconstitution, the oral rehydration solution should be discarded in an hour after preparing or after 24hrs if stored in the refrigerator
● Use IV fluids if necessary
● Investigate cause and manage appropriately
2). DIARRHEA
Diarrhoea is defined as increased fluidity and frequency of stool. There is a significant variability in stooling frequency among babies and children. Breastfed babies usually stool more frequently. Types of diarrhoea presentation
● Acute diarrhoea with severe, some and no dehydration ● Severe persistent diarrhoea with and without malnutrition ● Non severe diarrhoea with and without malnutrition Acute diarrhea with severe dehydration
Description
● Diarrhea of abrupt onset associated with frequent passage of loose or watery stools, fever, chills, anorexia, vomiting and malaise
● Diarrhea associated with two or more of the following signs present
• Lethargy or unconsciousness
• Sunken eyes/unable to drink or drinks poorly • Skin pinch goes back very slowly (> 2 seconds) Management
● Administer oral rehydration fluids while setting up drip
● Administer IV fluids immediately Hartman’s solution or Normal saline (0.9% Nacl) if Hartman’s is not available: This should be given at a dose of 100ml/kg as follows
Rehydration fluid volume and duration
First give 30 ml/kg in: Then , give 70 ml/kg in:
<12 months 1 hour* 5 hours
≥ 12 months 30 minutes* 2 ½ hours
*Repeat again if radial pulse is still very weak or not detectable
● Reassess the child after every 15 – 30 minutes. If rehydration status is not improving, give the IV drip more rapidly.
● Give ORS at 5ml/kg/hour as soon as the child can drink ● Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration and treat appropriately
● A normally breastfed child should be breastfed regularly ● Zinc supplementation when able to tolerate orally:
• <6 months – 10mg elemental Zinc per day for 10 – 14 days • ≥ 6 months - 20mg elemental zinc per day for 10- 14 days Diarrhea with Some Dehydration
Description
If the child has two or more of the following signs, the child has some dehydration
● Restlessness/irritability ● Thirsty and drinks eagerly ● Sunken eyes
● Skin pinch goes back slowly
If a child has any one of the above signs and one of the signs of severe dehydration, then that child has some dehydration Management
● In the first 4 hours, administer ORS at a dose of 75ml/kg: If the child wants more ORS, this is given
● Show the mother how to give the ORS solution, a teaspoonful every 1-2 minutes if the child is under 2 years, frequent sips from a cup for an older child
● If the child vomits, wait 10 minutes, then resume ORS more slowly
● If the child becomes puffy, stop ORS and give plain water or breast milk
● Advice breast feeding mothers to continue breastfeeding whenever the child wants
● Reassess the child after 4 hours, checking for signs of dehydration
● Discharge on zinc supplementation:
• < 6 months – 10mg elemental zinc per day for 10 – 14 days • ≥ 6 months - 20mg elemental zinc per day for 10- 14 days Feeding
● In the first 4 hours, do not give any food except breast milk ● Breastfed children should continue to breastfeed frequently
throughout the episode of diarrhea
● After 4 hours, if the child still has some dehydration, continue and give food every 3 – 4 hours
Diarrhea with no Dehydration Description
Should be diagnosed if the child does not have two or more of the following signs:
● Restlessness/irritability ● Lethargy or unconsciousness
● Not able to drink or drinks poorly ● Thirsty and drinks eagerly ● Sunken eyes
● Skin pinch goes back slowly Persistent Diarrhea
Severe persistent diarrhea without malnutrition Description
● Diarrhea, with or without blood which begins acutely and lasts for 14 days or longer
● When there is some or severe dehydration, persistent diarrhea is classified as severe
Management
● Assess the child for signs of dehydration and manage with fluids appropriately
● Investigate for intestinal infections and treat appropriately ● Investigate for non – intestinal infections such as pneumonia,
sepsis, urinary tract infections, oral thrush and Otitis media and treat appropriately
● Give multivitamins plus micronutrients supplementation for 2weeks
● Treat persistent diarrhea with blood in the stool with an oral antibiotic effective for Shigella
Feeding
Feeding is essential for all children with persistent diarrhea Non – severe Persistent Diarrhea without Malnutrition Description
Children with diarrhea lasting 14 days or longer who have no signs of dehydration and no severe malnutrition
Management
● Treat as outpatient
● Give multivitamins plus micronutrients for 14 days. Prevent dehydration
● Give fluids as for acute diarrhea with no dehydration (ORS) ● Identify and treat specific infections
Persistent Diarrhea with Malnutrition – Refer to section on malnutrition
3). CHOLERA
Description
An acute infectious disease caused by Vibrio cholera.
Characteristics include severe diarrhea with extreme fluid and electrolyte depletion, muscle cramps and prostration. Vomiting may be a feature
Usual course:
Acute; chronic; relapsing
Cholera should be suspected in children over 2 years with acute watery diarrhea and signs of severe dehydration, if cholera is occurring in the local area
Management
● Assess and treat dehydration as for other acute diarrhea ● Give an oral antibiotic guided by culture and sensitivity ● Zinc supplementation when able to tolerate orally:
• <6 months – 10mg elemental Zinc per day for 10 – 14 days • ≥6 months - 20mg elemental Zinc per day for 10- 14 days
4). DYSENTERY
● Usually of infective cause.
