Protocolos Clínicos en Pediatría

1. General Emergency 1 Jayanta Bandyopadhyay, Jaydeep Choudhury Approach to a Child in Pediatric Emergency Department 1 • Warning symptoms in history 1 • Warning signs in examination 1 • Decision-making in pediatric emergency 2 – Normal vital signs 2 – Things to be done in emergency room 3 Early Assessment and Emergency Triage 4 • Priority 1—Severe life-threatening emergency 4 • Priority 2—Acute medical problems or distress 4 • Priority 3—Semiurgent acute medical problems 4 • Priority 4—Nonurgent acute medical problems 5 • Priority 5—Condition is stable and will not deteriorate as a result of waiting 5 2. Resuscitation 6 Jayanta Bandyopadhyay, Joshi Anand Karketta, Jaydeep Choudhury, Mahasweta Chaudhuri, Sudipta Sekhar Das Cardiopulmonary Resuscitation 6 • Airway 6 • Breathing 7 – To minimize gastric inflation 8 • Circulation 8 – Characteristics of good chest compressions 8 – Recommended chest compression : ventilation ratio 9 • Vascular access 9 – Fluids 9 – Drugs 10 Coma 13 • Neurological examination 13 – Level of consciousness 13 – Attitude and posturing 13 – Respiration 14 – Brainstem function 14 • Investigations 15 • Management 16 – Airway 16 – Breathing 16 – Circulation 17 Clinical Protocols in Pediatrics xiiPrelims – Hypoglycemia 17 – Hyperglycemia 17 – Drugs 17 – Specific therapy 17 – Emergency management of raised intracranial pressure 17 – Antiseizure medications in coma 19 – Choice of empiric antimicrobials 19 – Prognosis 19 Anaphylaxis 21 • Management 21 – Airway, Breathing and Circulation (A, B and C) 21 – Treatment of choice 21 – Hypotension 21 – Antihistaminics 21 – Systemic corticosteroid 21 – Salbutamol 22 Fluid and Electrolyte Balance 24 • General guidelines for rehydration 24 • Rehydration in Acute Gastroenteritis 24 – Principles 25 – Hypovolemia or shock 25 – Deficit replacement 25 – Maintenance requirements 26 – Volume 26 – Ongoing loss 26 • Hyponatremic Dehydration 27 – Asymptomatic hyponatremia 27 – Symptomatic hyponatremia 28 – Factitious hyponatremia 28 • Hypernatremic Dehydration 29 – Hypovolemic hypernatremia 29 – Euvolemic hypernatremia 29 – Clinical features 29 – Management 30 • Hyperkalemia 30 – Etiology 31 – Clinical features 31 – ECG changes 31 – Management 31 • Hypokalemia 31 – Etiology 32 – Clinical features 32 – ECG changes 32 – Management 32 • Hypocalcemia 32 – Clinical features 32 – ECG changes 32 – Management 32 Blood Component Transfusion 34 • Red blood cell 35 – Indications 36 • Platelets 36 – Indications 36 Contents xiii Prelims • Plasma 37 – Indications 37 • Complications of transfusion 38 • Miscellaneous 40 3. Sedation, Analgesia, Intubation and Procedures 41 Jayanta Bandyopadhyay, Mahasweta Chaudhuri Basics of Intubation 41 • Indications for intubation 42 • Equipment 43 – Selection of laryngoscope blade 43 – Endotracheal tube size 43 – Pharmacological control over intubation 44 • Preparing for the Procedure 45 • Positioning the patient 45 • Procedure 45 4. Neonatal Emergencies 47 Jaydeep Choudhury, Jayanta Bandyopadhyay Neonatal Emergencies 47 • Severe Hypothermia 47 – Temperature range 47 – Management 48 • Seizures 48 – Management 48 • Hypoglycemia 49 – Management 49 • Neonatal Hemorrhage 49 – Management 49 • Neonatal Apnea 50 – Management 50 • Air Leak 51 – Management 51 Bleeding Neonate 53 • Baseline investigations 53 • Management 53 – Supportive care 53 – Neonate in shock 53 – Neonate not in shock 53 – Specific treatment 53 Neonatal Collapse 56 • Management 56 5. Respiratory Emergencies 58 Jayanta Bandyopadhyay, Jaydeep Choudhury, Saheli Misra Respiratory Distress and Noisy Breathing 58 • Nonrespiratory causes of respiratory distress 58 • Noisy Breathing 58 – Approach to noisy breathing 58 Croup 60 • Management 60 Acute Epiglottitis 62 • Management 62 Clinical Protocols in Pediatrics xivPrelims • Recommended Antibiotics 62 – Chemoprophylaxis recommended 63 – Chemoprophylaxis not recommended 63 Bronchiolitis 64 • Management 64 Acute Severe Asthma 66 • Management 66 • Good response group 67 • Signs of high risk 68 • Poor response group 68 – Improvement at the end of 6 hours 68 – Condition unchanged 69 – Clinical deterioration 69 • First attack of status asthmaticus 69 6. Cardiovascular Emergencies 70 Mahasweta Chaudhuri, Jaydeep Choudhury, Jayanta Bandyopadhyay, Joshi Anand Karketta, Amitabha Chattopadhyay, Biswajit Bandopadhyay Cyanotic Spell 70 • Management 70 – Acute care 70 – Ongoing care 72 Heart Failure 73 • General management 73 • Specific Management 73 • Important Considerations 73 Abnormal Pulse Rate or Rhythm 76 • General management of arrhythmia 76 – Airway 76 – Breathing 76 – Circulation 77 • Bradycardia 77 • Tachycardia 78 – QRS complexes 78 – Narrow complex tachycardias 78 • Supraventricular Tachycardia 80 – Management 80 • Wide-complex Tachycardia 83 – Approach to a child with VT 83 • Defibrillator for Cardioversion 84 – Paddle size 84 – Interface 86 – Energy dose 86 – Technique 86 7. Gastrointestinal Emergencies 87 Jaydeep Choudhury, Jayanta Bandyopadhyay Acute Abdominal Pain 87 • Important Considerations 87 Upper Gastrointestinal Bleeding 89 • Management 89 – Immediate 89 Contents xvPrelims – Restore and maintain intravascular volume 90 – Re-establish a normal oxygen carrying capacity 90 – Determination of source and site of bleeding 90 – Treatment options available for acute variceal hemorrhage 92 Fulminant Hepatic Failure 93 • Management 93 – Follow-up and monitoring 95 – Temporary hepatic support 95 8. Renal Emergencies 96 Jaydeep Choudhury, Saheli Misra, Jayanta Bandyopadhyay Acute Renal Failure 96 • Assessment of severity 96 • Determination of underlying cause 96 – Baseline Investigations 96 • Management 97 • Diet 98 • Infection 100 • Indications of dialysis in ARF 100 Hypertensive Crisis 101 • Common Causes 101 • Management 101 Hematuria 106 • Management 106 – Important Considerations 106 9. Neurological Emergencies 108 Jayanta Bandyopadhyay, Jaydeep Choudhury Status Epilepticus 108 • Management 108 – Initial control of seizure 109 – Stage I 109 – Stage II 109 – Stage III 110 – Stage IV (ICU) 110 Rapid Onset Limb Weakness 112 • Management 112 – Immediate management 112 – Specific management 112 – Long-term management 113 10. Endocrinal Emergencies 115 Jaydeep Choudhury, Joshi Anand Karketta, Jayanta Bandyopadhyay Diabetic Ketoacidosis 115 • Treatment 115 – Fluid 115 – Electrolytes 116 – Monitoring initial progress 117 • Complications during treatment 118 – Cerebral edema 118 – Treatment of suspected cerebral edema 118 – Further care 118 Clinical Protocols in Pediatrics xviPrelims Hypoglycemia in Neonates and Children 120 • Management 120 – Management for refractory hypoglycemia 120 – Tapering 120 – Drugs causing hypoglycemia 121 11. Environmental Problems 124 Tapan Kumar Ghosh, Jaydeep Choudhury, Jayanta Bandyopadhyay Animal Bites 124 • WHO classification of bites 124 – Management 125 – The steps of management 125 • Rabies immunoglobulin (RIG) 126 • Antirabies vaccines 127 – Types of antirabies vaccines 127 – Intramuscular (IM) regimen of cell culture antirabies vaccine 127 – Intradermal (ID) regimen of cell culture antirabies vaccine 127 – ID Vaccine Regimen 128 • Pre-exposure Schedule 128 – Schedule of pre-exposure vaccination 128 Snake Bite 130 • Management 130 – First aid 130 – Local wound management 131 – Optimize ABC (Airway, Breathing and Circulation) 131 – Specific treatment 131 – Indications 131 – Skin test 131 – Pretreatment 131 – Antivenin 132 • Neuroparalysis 132 • Supportive treatment 132 Near Drowning 133 • Prehospital intervention 133 • Emergency department management 133 • Hospital admission criteria 134 • Hypothermia 134 • Cerebral edema 134 • General measures for management 135 Burn 136 • First aid: To be Done at the site of burn 136 • Life support 136 • Degree of burn 136 • Admission criteria for pediatric burns patients 136 • Fluid resuscitation 137 – Parkland formula 137 – Sedation 137 – Infection 137 – Stress ulcer 138 – Topical treatment 138 – Complications 138 Contents xvii Prelims 12. Poisoning 139 Jayanta Bandyopadhyay, Jaydeep Choudhury, Joshi Anand Karketta General Management Principles and Approach to Unknown Poisoning 139 • Management 139 • ABC 139 – Surface decontamination 139 – Gastrointestinal decontamination 140 – Enhanced elimination 140 – Antidotes 140 Various Poisonings 141 • Paracetamol 141 – Management 141 • Iron 142 – Management 142 • Organophosphorus Compound 144 – Management 144 13. Foreign Body 146 Jayanta Bandyopadhyay, Jaydeep Choudhury Airway Foreign Body 146 • Management 146 • Management of partial airway obstruction 146 – Important Consideration 146 Button Battery Ingestion 151 • Mode of action 151 • Treatment 152 – Battery in the nose or ear 154 14. Psychiatric Behavioral and Social Issues 155 Jaydeep Choudhury Psychiatric Assessment for Nonpsychiatrists 155 • Mental state examination 155 15. Trauma and Orthopedics 157 Jayanta Bandyopadhyay, Jaydeep Choudhury, Anirban Chatterjee Head Trauma 157 • Immediate priority 157 – Airway 157 – Circulation 158 – Cervical spine 158 – Assess 158 Acute Neck Stiffness 161 • Life-threatening conditions 161 • Causes of acute stiff neck 161 – Diagnosis of acute stiff neck 161 Acute Painful Hip 163 • Transient synovitis 163 – Management 163 • Septic arthritis 163 – Management 163 Clinical Protocols in Pediatrics xviiiPrelims • Acute osteomyelitis 164 – Management 164 • Slipped upper femoral epiphysis (SUFE) 164 – Management 164 • Other conditions 164 Spinal Cord Injury and Spinal Cord Injury without Radiographic Abnormality (SCIWORA) 166 • Initial assessment 166 – Management 166 Blunt Trauma 168 • Basic principles of trauma management 168 • Management 168 • Abdominal trauma 168 – Liver trauma 168 – Splenic trauma 169 – Pancreatic trauma 170 – Renal trauma 170 Fractures: Initial Stabilization and Management 171 • Management goals 171 • Injuries in the appendicular skeleton: common upper extremity injuries 171 – Fall on the outstretched hand 171 – Fall directly on the elbow 173 – Immobilization methods and optimum position for injuries to the upper limb 175 – Injuries in the appendicular skeleton: common lower extremity injuries 175 – Immobilization methods and optimum position for injuries to the lower limb 177 – Injuries to the axial skeleton 177 16. Otolaryngological Emergencies 178 Jaydeep Choudhury Otolaryngological Issues 178 • Acute Otitis Externa 179 – Management 179 – Prevention 180 • Acute Otitis Media (AOM) 180 – Management 180 • Foreign Body in the Nose and Ear 181 – Management 181 • Epistaxis 181 – Management 182 • Sinusitis 182 – Acute Bacterial Sinusitis 182 • Oral Cavity Lesions 182 – Herpetic Gingivostomatitis 183 – Herpangina 183 Contents xixPrelims 17. Dermatological Emergencies 184 Mahasweta Chaudhuri, Jayanta Bandyopadhyay, Amiya Kumar Mukhopadhyay Fever with Rash 184 • Different forms of skin rash 185 • Distribution 185 • Management 186 – Unwell child with fever and petechiae/purpura 186 – Principles in the management of meningococcal disease 187 Urticaria and Angioedema 189 • Management 190 • Moderate to mild urticaria 190 • Chronic urticaria 190 Stevens-Johnson Syndrome (SJS) 192 • Management 192 Toxic Epidermal Necrolysis 194 • Management 195 18. Infections 196 Jayanta Bandyopadhyay, Jaydeep Choudhury Fever without Focus 196 • Stabilization 196 – Approach 196 Severe and Complicated Malaria 199 • Management 199 – Supportive 199 – Antimalarial chemotherapy 199 • Management of complications 200 – Severe anemia 200 – Hypoglycemia 201 – Cerebral malaria 201 – Hyperpyrexia 201 – Hyperparasitemia 201 – Lactic acidosis 201 – Circulatory collapse 201 – DIC 202 Dengue 203 • Management 203 Community-acquired Pneumonia 205 • Management 205 Acute Meningitis 208 • Management 208 • Antibiotic therapy 208 – Full term neonates <1 week 208 – 1 week to 3 months 208 – Children >3 months 208 – Add vancomycin 208 Clinical Protocols in Pediatrics xxPrelims – Duration of antibiotics 208 – Supportive care and monitoring 209 • Prophylaxis 209 Urinary Tract Infection 210 • Treatment 210 – Indication for admission 210 • Antibiotic therapy 210 – Duration of therapy 210 – Prophylactic antibiotics 212 19. Toxic Shock Syndrome 213 Mahasweta Chaudhuri, Jayanta Bandyopadhyay Toxic Shock Syndrome 213 • Management 213 – Staphylococcal toxic shock syndrome 213 – Streptococcal toxic shock syndrome 215 20. Medicolegal Issues 216 Jaydeep Choudhury Medicolegal Issues in Emergency Room 216 • Documentation in emergency ward 216 • Consent in emergencies 217 • Medical negligence 217 • Informing the police 217 • Breaking bad news 218 • Death certificate 218 – Child brought dead who was under treatment at the hospital 218 – Child brought dead by the parents 218 – Child brought dead by a mob 218 Index 221