NOTE

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor’s consultancy.

 

ABCDs – PRIMARY SURVEY

 

·        Primary survey:

·        On A (airway) we check the airway’s patency. Open the airway. Is airway patent (e.g. the patient talks) or threatened (stridor or ‘snoring’) or obstructed?

 

o       A is also C Spine immobilization (on suspected injury). We open airway with jaw thrust or chin lift (we use jaw thrust on suspected C – spine injury), we do suction (e.g. of vomits), we place an oropharengeal airway (if the airway’s patency is threatened and also if no gag reflex) or nasopharyngeal airway (contraindicated in apnoea, nasal injury, cribiform fracture and basal skull fracture) and we consider soon a permanent airway (e.g. ET endotracheal intubation).

 

o       On A we also check tracheal position and also in older children for JVD (jugular vein distension).

·        Traps on A (airway) are cribiform and face trauma and also base skull fracture with ear or nose leakage of CSF, racoon eyes, blood from the ear and Battle sign with haematoma behind the ears (in the above cases the nasal airway or the nasogastric tube are contraindicated because they may enter to the brain!).

·        On B (breathing) we check RR (respiratory rate), chest expansion (if it is equal bilaterally, otherwise suspect e.g. flail chest on trauma), we ausculate the chest (is breathe sound bilaterally equal? Any wheezing?), we percuss the chest (any tympany?) and take oxygen saturation (SpO2).

 

o       Also we check for central cyanosis (tongue & lips, central cyanosis is always combined with peripheral) or peripheral cyanosis (finger nails – exclude hypothermia). SpO2 is unreliable on methemoglobinemia (may be manifested with asymptomatic cyanosis, it may be caused from drugs) and CO (carbon monoxide) poisoning.

 

o       What is the respiratory effort and depth? Is breathing shallow and laboured? Is oxygen saturation low? Does the child has sub and intercostals recession, xiphoid retraction, nasal flaring, use of assessor muscles (e.g. sternoclidomastoids), head bobbing up and down with each respiration, see – saw (rocking) respiration (movement of the abdomen during inspiration) and grunting (babies)? All the above indicate respiratory distress. 

 

o       Also always give oxygen:

o       On patients WITHOUT significant hypoxia (SpO2 Oxygen saturation) and WITH ADEQUATE breathing we give oxygen with nasal cannula 2 – 4 L/min.

 

o       On patients WITH significant hypoxia but ADEQUATE breathing we give O2 (oxygen) with a non rebreathing face mask with reservoir bag and flow 15 L/min.

 

o       In case of INADEQUATE breathing or APNEA we perform BMV bag mask ventilation with a self inflating bag with reservoir and oxygen supply and flow 15 L/min.

 

o       We keep always SpO2 oxygen saturation > 90%.

 

o       Patients with significantly increased or decreased RR respiratory rate need BMV bag mask ventilation.

 

o       Also on patients with GCS <_ 8 we intubate (we use RSI rapid sequence intubation if GCS is >3).

 

·        Traps on B (breathing) are vulnerable ages (on children rib fractures are rare; if they occur they indicate severe lung injury such as lung contusion). 

·        On C (circulation) we check pulse (radial and carotid on children, brachial and femoral on babies). Is it fast and thready? Is it regular or irregular? BP and pulse pressure (SBP systolic BP – DBP Diastolic BP). BP will fall with > 40% volume loss.

 

o       We obtain vascular (IV/IO) access (2 wide IV lines on trauma). On hypovolemia (from trauma or dehydration) we give NS (normal saline) or RL (Ringers - Lactated), reassess and also consider early to transfuse blood (if not type available give Group O Rh negative). On trauma fluids should be warm (39 degrees C)! On hypovolaemic children we give 20 ml/kg fluids bolus over 5 – 20min. If no response, we repeat 20 ml/kg and if shock still remains we give 15 ml/kg packed red blood cells PRC to 10 ml/kg crystalloids or we give 10 ml/kg whole warmed blood. On hypovolaemic newborns we give10 ml/kg fluids over 5 – 10 min (in arrest).

 

o       After IV access we also take blood for Labs (including pregnancy test on child bearing age women, toxicology, coagulation and blood type and crossmatch – we ask blood units for transfusion).

 

o       Signs of shock:

o       On children, on < 25% of circulating blood volume loss, there is mildly increased HR heart rate, moderate increased RR respiratory rate, normal or increased (!) peripheral pulse volume, normal or increased capillary refill time, cool/pale skin and mild agitation. Οn shock, systolic BP will fall if more than 40% of circulation blood volume is reduced on children!

 

o       Ο C we also look the color and temperature of the skin (a cold clammy mottled or pale or with cyanosis skin may indicate shock, however exclude low ambient temperature!), the peripheral pulses, the capillary refill time (normal is when < 2 sec, on 5 sec finger nail pressure or on the babies on sternum pressure), the LOC (level of consciousness) and also for babies the interaction with the parents or the presence of uncontrolled cry. 

 

o       We also check the preload with JVD (jugular vein distension). In case of JVD, we need to exclude heart failure, pulmonary embolism (rare), cardiac tamponade and tension pneumothorax). We also check for leg and pulmonary oedema (both are rare on children) and liver distension (that is more significant sign on children!). 

 

o       We also connect to a monitor, and – if indicated (e.g. arrhythmia or heart contusion on trauma) we take a 12 lead ECG. If there is time, we may also take ABGs (arterial blood gases) to check e.g. for acidosis.

·        On D (disability) we check AVPU (Alert, responds to Voice, responds to Pain, Unresponsive), or if there is time (and always on trauma) we check GCS (Glasgow comma scale). We also check pupil’s size & reaction to light and also for abnormal postures of flexion (decorticate) or extension (decerebrate). On GCS <_ 8 intubate (use paralytics – anaesthetics if GCS > 3). On AVPU, response only to pain indicates GCS about 8. Check then the GCS.

·        Traps on D (disability) are: lucid interval on epidural hematoma, brain’s vasoconstriction from hyperventilation and also increasing ICP during intubation (prevent it with lidocaine and etomidate – the last is contraindicated on hypotension – in that cases stabilize first the patient with fluids).

·        Οn E (Expose, Environment) we expose the patient (from his/her clothes) and check the skin for clues (wounds, rash, belt sign on car accident etc). We also perform log roll and check the back. Next we prevent hypothermia e.g. with blankets. E is also to call Expert!

·        Traps on E are hypothermia which complicates clotting.

·        We also check the kid’s temperature! 

·        Aids on ABCDs are ABGs (arterial blood gases), SpO2 (oxygen saturation), CO2 detector (capnographer or oesophagal detector) after intubation), Foley, Levine (nasogastric tube), ECG and FAST/ ultrasound.  DPL (diagnostic peritoneal lavage) is unreliable on children.

·        Secondary survey οn trauma is the examination from head to toes. We check pulses and also check for lacerations, edema, deformity, paleness, tenderness, crepitation, surgical (subcutaneous) emphysema, joints mobility, sensory examination, reflexes and neurological examination etc. We use X’ Rays, Doppler, CT etc.

·        The emergency needs to be transferred to the nearest APROPRIATE (trauma) medical centre/ hospital.

·        TRIAGE is based to factors such as ABCs, the available means (personnel and devices), if we have a mass destruction, the number of victims, the time and distance for definite care, the severity of the injury and the bigger chance for survival (in case of a patient with a very serious injury that is not compatible with life, or in a case of no pulse, we go on with the rest patients and ‘flag’ this patient with black color – or blue in some countries, i.e. expectable to die). Triage is continuing (dynamic).

·        On trauma we do not forget log roll.

·        On secondary survey always we ask AMPLE (Allergy, Medication, Past medical history, Last meal and Environment/Events). Some prefer to ask it from the very first.

 

 

·        Commonly the reason of arrest on children is from respiratory insufficiency which manifests with bradycadia (!) and commonly ends up (unfortunately) to asystoly.

·        On bradycardia treat hypoxia. On tachycardia exclude hypovolemia.

·        Reversible causes to be excluded and corrected in arrest are the 6 Hs & 6 Ts.

o       The 6 Hs include Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypoglycemia and Hypothermia.

o       The 6 Ts include Toxins/Tablets (poisoning), Tamponade cardiac, Tension pneumothorax, Thrombosis coronary, thrombosis pulmonary and Trauma. 

·        On a compensated respiratory failure we assess ABCD including RR respiratory rate, chest auscullation & percussion, chest expansion, oxygen saturation, pulses, HR, BP, skin color and temperature, capillary refill time, preload (especially we check for liver enlargement), peripheral pulses, LOC (level of concioussness), and TEMPERATURE. We give oxygen with a NON THREATENING way (e.g. with an oxygen tube supply on the child’s mouth and nose and the mother holding the baby). We also establish IV/IO access (better under topical anesthesia) and provide specific therapy.

·        We establish IO access after 3 failures of IV access or failure after 1.5 min of trying to establish it. This is important especially on trauma, critical ill children and arrest.

·        We check ABCDs for response to treatment. We also assess urine output and LOC (level of consciousness). However on hypovolaemia with hypotension we check first if BP has improved.

·        On epiglottitis: oxygen administration, X’ Rays, IV access, attempting to the child’s throat and intubation (from non expert) may appear very threatening to the child and deteriorate it dramatically. Avoid any of these and generally any aggressive manipulation. Just give oxygen with a tube supply on the child’s mouth and nose (the baby on its mother hug) and immediately call experts (anesthesiologist & ENT doctor) for defenit care. Antibiotics are given once the airway is secured! Epiglottitis is caused by haemophilus influenza type B, usually seen on children 1 – 6 years old and manifests with abrupt high fever. The child is usually sitting immobile with its mouth open, its chin raised and may have excessive drooling.

·        Croup (laryngotracheitis) is a situation caused 95% by viruses (usually parainfluenza virus, also from RSV, adenovirus etc). It manifests with inspiratory stridor, barking cough, hoarseness and various degrees of respiratory distress. Treatment is with oxygen (on respiratory distress call an ENT doctor and an anesthetist, in case of intubation use a smaller than predicted ET tube because of the edema), steroids and other supportive measurements.

·        On a child with a clean diper on the morning, exclude dehydration and shock.

·        Dehydration may be indicated from a history of prolonged diarrhea and/or vomiting. Check if skin turgor is decreased and if tongue/mouth is dry. On older children check for orthostatic hypotension.  Also check if the kid has lost weight (this may indicate water loss).

·        On BLS (basic life support) we don’t forget to close the child’s nose during mouth to mouth rescue breaths (on babies we cover with our mouth their mouth and nose).

·        On an emergency we check safety first.

·        To check if a child responds and is conciouss we hold with our 1 hand its forehead and with our other hand we sheak its arm and ask the child ‘are you Ok’?

·        Rescue breaths ventilations (e.g. on arrest) need to last 1 – 1.5 sec each.

·        On infants (<1 year) old many prefer chest compressions with their 2 fingers vertically on the child’s chest and on newborn/ neonates with their thumbs crossed on the baby’s chest.

·        Children and especially the younger have larger head than adults. So on infants (<1 year old) and newborn/ neonates establish neutral position with a folded towel behind the baby’s shoulders. On older children establish sniffing position with the head in bigger extension than in neutral position.

·        On a child that chokes from a foreign body:

If the kid is conscious and the cough is effective, we encourage it to cough.

 

If the kid is conscious and the cough isn’t effective, on children > 1 years old we give with our palm (thenar) 5 back blows between its scapulae and 5 abdominal thrusts (Heimlich maneuver). On infants (<1 years old) we perform 5 chest compressions (like the ones on CPR). We reassess. If ventilations are absent or not effective we call for help. With our fingers we remove any VISIBLE foreign body from the victim’s mouth with A SINGLE try. We never do blind sweeping.   

 

In case the kid is unconscious, we give 5 rescue breaths. If no effective ventilations, we go on with CPR for 1 min and reassess. If still absent or not effective ventilations, we call EMT (Emergency medical team)/ blue code.

·        Oxygen masks with reservoir bags are the 1^st choice on a spontaneously breathing child. During inspiration with 1 way valves bilaterally, oxygen is provided only by the reservoir and the oxygen source. During expiration 1 way valves allow exhalation and prevent rebreathing. Self inflating bags should have reservoir as well.

·        On arrest initially you can perform ‘Quick Look’ with the defibrillator’s paddles and check on the monitor the rhythm. 

·        On asystole check if Leads have been detached, increase the GAIN and sensitivity of the monitor and also check another lead.

·        On asystole and PEA exclude reversible causes (see above).

·        On arrest with VF/ pulseless VT (both rhythms are shockable and need defibrillation as soon as the defibrillator is available) the 1^st defibrillation energy is 2 J/Kg and the next ones are 4 J/Kg.

·        Epinephrine (adrenaline) dose on arrest is 0.1 ml/kg IV/IO of 1: 10.000 solution. The ET rout is 100mcg/ kg (0.1 ml/kg) of 1:1000 solution. However the ET absorption is unpredictable, so is less prefered.

·        Amiodarone dose on arrest is 5 mg/kg IV/IO (diluted in D5W 5% dextrose) bolus.

·        Dextrose dose on hypoglecemia is 5 – 10 ml/kg of 10% dextrose. On neonates the dose is 2.5 ml/kg. Never give it via ET (endotracheal tube). Alos, don’t mix it with blood. On newborn dextrose may be useful on arrest.

·        Naloxone dose is 100 mcg /kg (0.1 mg/kg) IV/IO/IM for kids < 5 years old and 2 mg for children > 5 years old. Avoid it on a newborn of a chronic opioid abuse mother because it may manifest withdrawal syndrome (in this case call expert).

·        Bicarbonate dose on arrest is 1mEq/kg (1 mMole/ kg) of 8.4 % solution IV/IO. On newborn use 4.2% solution. Don’t mix them in the same line with epinephrine (adrenaline) or other sympathiticomimetics such as dopamine. At least clean with saline the line.

·        Atropine dose is 20 mcg/kg IV/IO/ET for arrest with asystole with P waves or suspected vagotony. Max dose is 1mg on children and 2 mg on adolescent. Min dose is 0.1 mg.

·        Bradycardia is HR < 60 on children > 1 years old and HR < 80 on infants (< 1 years old).

·        Tachycardia is HR > 160 on children > 1 years old and HR > 180 on infants (< 1 years old).

·        On SVT (supraventricular tachycardia) the HR is > 180 on children > 1 years old and > 220 on infants (< 1 years old). Contrary, on sinus tachycardia the HR is < 180 on children > 1 years old and < 220 on infants (< 1 years old).

·        An SVT is abrupt, there are no P waves and also it is no specific.

·        A sinus bradycardia may be caused by fever, hypovolaemia (hemorrhage or dehydration), anemia, pain, stress/ fear, respiratory failure etc.  The only therapy is to correct the cause!

·        On synchronized shock for an unstable wide or narrow complex tachyarrhythmia we perform electrical cardioversion after sedation on a non unconcious child. The 1^st shock dose is 1 J/Kg. We check monitor and for pulse (to exclude PEA). If no response, we repeat with 2 J/Kg. Next, we give amiodarone 5 mg/kg IV/IO (diluted in D5W 5% dextrose), over 20 – 60 min, and continue with the 3^rd shock.

·        Babies < 6 months old are nasal breathers, so nasal obstruction may cause respiratory distress!

·        In case we have adult paddles we place them 1 anteriorly and 1 posteriorly.

·        On IO access we do not initially forget to take blood for Labs!

·        We don’t apply IO access on a fractured limb or a limb with infection.

·        IO rout is the 1^st choice on PEA (pulseless electrical activity) or asystole on children!

·        On newborn IV access is via umbilical vein. If it fails, perform IO access. Don’t use ET (endotracheal) rout.

·        There is insufficient evidence for using AED (automated external defibrillator) on infants (< 1years old).

·        On children 1 – 8 yaers old use AED with paediatric attenuation. However, if unavailable, use a standard AED.

·        Don’t forget to press ‘syncronized’ button on cardioversion of an unstable tachyarrhythmia, otherwise you may cause R on T phenomenon and induce VF (ventricular fibrillation)!

·        Remove oxygen mask/ nasal cannula/and any oxygen supply at least 1 meter away andclose the ventilator during defibrillation.

·        Oropharengeal airway is placed without 180 degrees rotation, but with the concave side down, with the help of a tongue depressor.

·         The oropharengeal airway’s proper length is estimated by fitting to the distance between the mouth’s angle (incisors) and the angle of the mandible.

·        The nasopharyngeal airway’s proper length is estimated by fitting to the distance between the tip of the nose and the tragus of the ear. Alternatively, the proper size fits to the patient’s little finger.

·        On infants use a 500 ml self inflating bag with reservoir for BMV (bag mask ventilation).

·        Intubation has to be performed on max 30 sec or the max hold of our breath. If 3 fails occur, call expert!

·        On suspected cervical injury, immobilize the head during intubation. In case the intubation is impossible, then increase a little bit the head’s extension (you may cause an injury, however without established airway and breathing the kid will die). 

·        Before you place the cervical colar check the trachea (deviated, late, in tension pneumothorax) and for JVD (jugular veins distension – see above).

·        On trauma, burns, bites (human or animal), frostbites, electrocution and stings don’t forget tetanus immunization.

·        Remove wet clothes.

·        On newborn intubate if insufficient bag mask ventilation, or if prolonged ventilation is needed, or if there is meconium with the baby compromised or in case of congenital diaphragmatic hernia.

·        Suction should be applied max for 5 sec. The suction tube length on newborn is 12 – 14 Fr and negative pressure max 100 mmHg. 

·        On a newborn firsts we do suction of the mouth and next suction of the nose. 

·        In case of thick meconium we perform suction on a newborn with HR< 100, absent or insufficient breaths and not vigorous – with poor muscular tone. We do suction of the hypo-pharynx under direct vision. Then we intubate, we perform suction again – we aspirate the meconium found under the vocal cords. Next, we remove the suction tube with the ET tube (together; the meconium is stuck on the ET tube!) continuing suction of the oropharynx. If after the extubation HR is < 100 and > 60 we perform again intubation and suction. If HR is < 60 we perform the newborn arrest algorithm.

·        On newborn arrest, for the first few breaths the inflation pressure is kept 30 cmH2O (20 – 25 cm H2O for preterms) and each rescue breath is applied 5 times, 2 – 3 sec each.

·        On newborn arrest, compressions & rescue breaths are perform synchronized (and not simultaneously) and with 3:1 rhythm.

·        During CPR, keep the newborn on neutral position (see above).

·        The compressions on newborn are 120/min and on children are 100/min. The ventilations on newborn are 30/min and on children are 12 / min.

·        CPR rate on children is 15: 2. On BLS (basic life support) it is 30:2 with a single non professional rescuer.

·        ET (endotrachel tubes) should be uncuffed on children < 8 years old. Also the laryngoscope’s blade should be straight on infants (< 1 years old).

·        To prevent hypothermia on a very preterm newborn, wrap it (e.g. with a plastic food grade wrapper) – without drying it before with a towel – and place it under the radiant warmer.

·        Many do not start ALS on very preterm babies (< 23 weeks), babies with trisomy 13 or 18, anencephaly and DNAR. Check your local policy.

·        On trauma PR (per rectum) digital examination should be performed better by the surgeon that will operate the child.

·        ET tube is easily displaced on children.

·        Hypoplastic chin, laryngomalacia, Pierr Robin’s syndrome, inhalation burns, foreign bodies, diphtheria, epiglottitis and croup may all compromise airway.

·        HOOD (oxygen tent) may supply oxygen but has the disadvantage of not easy access to the airway.

·        Respiratory failure on newborn occurs with PaCO2 > 60 – 65 mmHg and Pa O2  < 40 – 50 mmHg. On older children occurs with PaCO2  > 55 – 60 mmHg (or if it increases fast > 5 mmHg) and PaO2   < 50 – 60mmHg. However, don’t rely on the above values, but consult an anesthetist.

·        Arrhytmia on children may be ought to congenital heart disease, cardiomyopathy, myocarditis (usually from viruses such as enteroviruses), drugs (!) and operated heart disease.

·        Vagotony (with parasympathetic stimulation) –manifested with bradycardia – may be caused by intubation. That’s why we premedicate with atropine before intubation. ˆ

·        TCP (transcutabeous pacemaker) is indicated in unstable bradycardia caused by 2^nd degree AV block type Mobitz II,  complete AV block, (suspected) vagotony, and sick sinus syndrome. It is also indicated in asystole with P waves.

·        On children QRS are considered wide if their width is > 0,08 sec (2 small squares). 

·        On a stable narrow complex tachycardia initially try vagotonic stimulation e.g. with ipsilateral carotid massage (in older children), or by placing a cold ice pack on the child’s cheek or with  Valsava maneuver (e.g. by blowing the plunger of a syringe).

·        On an intubated child we perform compressions and ventilations asynchronized. This is not the case for CPR on a  newborn.

·        Tachypnea (increased RR respiratory rate) on children < 30 days (neonates) is RR > 60min. on children 2 – 12 months old (infants)  is RR > 50/min. on children 1 – 4 years old is RR > 40/min. 

·        On severe asthma we give methyl–prednisolone 2mg/kg IV/IM/IO.

·        Asthmatic crisis may be caused by a viral infection.

·        Except ABCDs, another indication for intubation is the prevention of respiratory exchaustion.

·        Oxygen saturation 88 – 90 % means that oxygen concentration is about 60 mmHg.

·        On a child that was found near drowned in a pool, on ALS we consider hypothermia as a reversible cause during resuscitation (especially on asystole or PEA).

·        On anaphylaxis we can give nebulized adrenaline and IV/IM/IO methyl-prednisolone (2mg/kg). However the mainstem of therapy is immediately an IM injection of epinephrine (adrenaline) and also fluids on hypotension (IV or alternatively IO).

·        Epinephrine dose in arrest on children is 10 mcg/kg (0.1 ml/kg) 1:10.000 solution IV/IO. In case you have 1:1000 solution and you need 1 ml adrenaline then take from this solution 1 ml, dilute it in 10 ml normal saline and from the new solution (which is now 1:10.000) take the 1 ml.

·        Administration of medications (such as adrenaline) on peripheral lines on emergencies should be followed immediately by flush with normal saline (2 – 5 ml on children) and elevation of the extremity for 10 – 20 sec to facilitate drug delivery to the central circulation.

·        Suspect airway obstruction by a foreign body on achild with stridor and sudden respiratory distress. Ask history. Was the baby eating nuts? Was it playing with small toys? 

·        On airway obstruction from a foreign body if all the measurements of the algorithm fail and also the removal with a Magill’s forceps fails as well perform needle cricothyroidotomy.

·        Hypovolaemia may be caused by hemorrhage, dehydration (prolonged diarrhea and/or vomiting, osmotic diuresis/ DKA diabetic ketoacidosis, decreased fluid intake – exclude also hypokalaemia), burns (usually late!), loss in 3^rd space (e.g. pancreatitis) etc.

·        Distributive shock may be septic or anaphylactic or neurogenic.

·        Obstructive shock may be ought to tension pneumothorax, cardiac tamponade, PE (pulmonary embolism). All may have JVD.

·        Dehydration is characterized by tachycardia (early sign), mucus membranes dryness (check if the tongue is dry) and increased urine density.  Dehydration with > 10% volume loss is also characterized by decreased urine output and decreased skin turgor. Also check if the kid has lost weight (this may indicate water loss).

·        Severe dehydration may cause shock.

·        Excessive NS normal saline administration may cause hypernatremia and hyperchloraemic acidosis.

·        On hypovolaemia give loading dose of fluids.

·        Maintenance dose of fluids is for children with body weight 1 – 10 Kg: 100 ml/kg/24 h, for 11 – 20 Kg: 1000 ml + 50 ml/kg and for 21 – 80kg: 1500ml + 20 ml/kg. Alternatively follow the rule of 4/2/1 and for children <_ 10Kg give 4 ml/kg/h; for children 10 – 20 Kg give 2 ml/kg/h and for any extra Kg of body weight give 1 ml/kg/h. However it is suggested not to follow the above rules, but to check your local protocol.

·        Poisoning is an emergency that often occurs on children. Contamination may be oral or via the conjuctiva or via the skin or via inhalation or even IV. Older kids may be addicted to substances of abuse (such as glue sniffing) and also may take illicit drugs.

·        On poisoning start from ABCDs. Check especially RR (respiratory rate), ausculate the chest, check SpO2 (oxygen saturation), give oxygen (!), check pulse/ HR, BP, connect to monitor, obtain IV/IO access and take blood for Labs (including medicine levels – such as aspirin and acetaminophen, toxins, heavy metals and illicit drugs of abuse), check the LOC (level of consciousness), the pupils (size & reaction) and also the urine output. Also check for xerostomy (dry mouth), lacriomation, check the skin, the muscle tone, exclude mucal and especially inhalational burns. Exclude abuse and also iatrogenic poisoning (e.g. wrong drug dose)! Take as soon as possible a glucose finger stick to exclude hypoglycemia. Blind antidotes (e.g. on coma or seizures) are naloxone and glucose. Check also the electrolytes.

·        Perform gastric lavage if the victim arrives < 1 h after the poisoning conjestion. However it is contraindicated in poisoning from petroleum products & corrosives, such as acids, alkali, hydrocarbonates, gasoline, bleach, descalers, oesophagal erosions. In case of a compromised airway (e.g. coma) and seizures, intubate first! Gastric lavage is ineffective for insecticise, hydrocarbonates, acids, alkali, alcohols, iron and lithium. 

·        You can perform whole bowel irritation (with an osmotic carbohydrate such as Golytelx) on iron, lithium and slow release tablets. Always check the electrolytes after.

·        Other therapies for poisoning include dialysis, hemofiltration, hemoperfusion, alcalic diuresis (e.g. with sodium bicarbonate on aspirin OD overdose), peritoneal dialysis etc.

·        Active charcoal absorbs many toxins and in many cases repeated doses are used. However, other poisons/ toxins, such as lithium and iron, aren’t absorbed.

·        On poisoning consult poisoning center for therapy and specific antidotes (e.g. desferoxamine on iron poisoning or hyperbaric therapy for severe CO carbon monoxide poisoning).

·        Pain therapy includes initially paracetamol (acetaminophen, give it every 8 h, contraindicated in liver failure). If pain is not relieved, we add NSAIDs (e.g. ivuprofen). If pain is still not relieved we add an opioid. Morphine is on opioid that can be administered by IV/IM/Sc rout and has SE (side effects) that include CNS depression. It may also compromise respiration (especially on infants < 3 months old) and cause hypotension. Also it may cause (transiet – for 15 – 20 min) broncospasm (thus contraindicated in asthma) and nausea (add an antiemetic such as metoclopramide).

·        Analgesics for children include also fentanyl patch (however it needs 3 days to reach the desired levels, so the first 3 days we add another analgesic) and lolypop with fentanyl. Naloxon is the antidote that will revers the opioids action. For sedation, an expert could also administer midazolam. Fentanyl is a strong analgesic. One of its side effects is the chest hard that makes chest compressions on CPR difficult (then we administer muscle relaxative agent).

·        Etomidate may cause hypotension and may increase hypotension on shock. Stabilize first the patient e.g. with fluids (and also perhaps with operation)!

·        Etomidate is preferred as an anesthetic on increased ICP (intracranial pressure) e.g. on head trauma. On head trauma on RSI (rapid sequence intubation), premedication with lidocaine is indicated. Another drug used on increased ICP (without hypotension!) are barbiturates (‘barbiturate coma’), but these can cause respiratory failure and hypotension and must be given by an expert.

·        On hypotension midazolam and ketamine seem safer (however midazolam is less safe because it may still cause hypotension and compromise respiration), however on shock the priority is to correct BP with fluids (and – if indicated – with surgery).Ketamine hasn’t got the cardiovascular adverse effects of other anesthetics.

·        Ketamine may cause hallucinations, so it may be combined with a benzodiazepine such as midazolame. It may also increase bronchial secretions that may be prevented with atropine. It is contraindicated in increased ICP such as in head trauma, increased eye pressure (glaucoma) and pulmonary infections. 

·        Avoid propofol out of ICU because it may cause severe hypotension.

·        On children with a small needle (e.g. insulin’s) you may administer a topical anesthetic in order to establish an IV access. Children shouldn’t suffer from pain during medical procedures. 

·        ENTONOX (NO – Oxygen 50% : 50%) is an alternative analgesic (in many countries is used in obstetrics). It is contraindicated in respiratory distress/ failure, on pneumothorax, on bowel obstruction, on decreased LOC (level of consciousness) and on severe facial or chest injuries.

·        Flumazeline is an antidote for benzodiazepine OD (overdose). It reverses their action. However, avoid it on seizures (call expert) because then seizures may be intractable and not respond to benzodiazepines such as diazepam or lorazepam. Also avoid it on TCA (tricyclic antidepressants) overdose (call expert).

·        Burns may cause secondary respiratory injury (such as pulmonary edema) manifested even > 24 h later.

·        Don’t count 1^st degree burns (erythema like the one in sunburn) when you estimate the BSA (Body Surface Area).

·        2^nd degree burns (partial thickness) are painful and may accompanied with blisters. Skin remains pink or slightly mottled.

·        3^rd degree (full thickness) burns are painless and have grey/ white/ charred (burned) color.

·        Admit at the hospital if burns are > 10% for partial thickness or > 20% for full thickness, if you suspect respiratory burn and also on burns that involve face, perineum, hands and legs.

·        On facial or suspected inhalational burn, intubate early.

·        Circumferential burns on the chest, that limit chest’s movement compromising respiration, need promptly escharotomy. With diathermy or a scalpel perform incision on the mid axillary line. 3^rd degree burns are painless, so don’t give analgesia.

·        For burns >_ 10% the maintenance fluid formula is: % BSA x body weight (Kg) x 4 ml/day. The half of the dose is administered the first 8 h from the burn (not the arrival to the ER/ ED emergency room/ department) and the rest at the next 16 h. In case the first 8 h since the burn have lapsed, then give the fluids over 2 h.

·        On burns check also urea and electrolytes.

·        Urine output is the mainstem to assess response on fluid therapy on burns.

·        Burns on limbs may cause edema that may cause compartment syndrome.

·        On burns remove any jewerely or watch.

·        Suspect inhalational (respiratory) burn on black sputum, singed (burned) nasal hair, stridor, voice hoarseness, decreased LOC (level of consciousness), facial burn and also when the victim was inside a close room.

·        On burns prevent hypothermia.

·        Suspect cyanide poisoning in case of burns of foamable plastic  furniture. Then breathing may smell almond (wild bitter almonds may also cause cyanide poisoning)!

·        Kid’s palm is 1% BSA.

·        On the burn unit silver sulfadiazine is used in burns. On facial burns many apply bacitracine ointment and on eye burns tobramycin eye drops.

·        Don’t forget tetanus immunization on burns!

·        On burns don’t break the blisters.

·        On burns don’t forget analgesia.

·        On burns if IV access on intact skin is imposible, then do it on burned area. 

·        Decreased LOC (level of consciousness) may occur from hypoxia/ischemia, hypovolaemia (trauma or dehydration), epilepsy (status epilepticus may rarely occur without seizures or may have fine seizures on isolated muscles – perform EEG!), infection (e.g. meningitis or meningoencephalitis), poisoning/ toxins, metabolic causes (check FBC/ CBC full/ complete blood count, electrolytes, glucose, BUN blood urea nitrogen, creatinine and LFT liver function tests etc) and vascular causes. Check glucose on finger stick before the official Lab test.

·        For hypoglycemia give 5 – 10 ml/kg of 10% dextrose (2.5 ml/kg on newborn). Don’t give it via ET (endotracheal tube) and also don’t mix it with blood. 

·        Give antibiotics (such as ceftriaxone) as soon as possible on suspected meningitis. Give acyclovir on suspected encephalitis (it may help if is caused by HSV). Also give dexamethasone (prevents deafness) on meningitis.

·        CI (Contraindications) to LP (lumbar puncture) are suspected intracranial mass lesion, papilloedema, focal neurological signs & signs of increased ICP, trauma, local infection (you may do it on a higher level), middle ear pathology, major coagulopathy (you can correct coagulopathy e.g. give Vitamin K or FFP as indicated), and septemic signs of meningitis with shock, hypotension, rash (initially may have decreased capillary refill >2sec and cold hands & feet). Be aware of the above contraindications, because if you perform a LP the patient may die from herniation! On suspected meningitis, if a LP may be delayed (e.g. for performing a CT), then give antibiotics, otherwise it would be a malpractice.

·        Pinpoint pupils may occur from opioids and pupil constriction (mysis) from organophosphate poisoning. Pinpoint pupils may also occur from pontine hemorrhage.

·        Abrupt onset of comma may indicate poisoning or CVA (cerebrovascular accident).

·        On DKA (diabetic ketoacidosis) give fluids for the dehydration, also administer insulin plus dextrose and correct potassium. DKA may manifest with kussmaul’s breathing pattern.

·        On history on emergencies always ask AMPLE (Allergy, Medication, Past medical history, Last meal and Environment/Events).

·        If time ask also about persons in family with the same symptoms, recent travel abroad (specially at the tropics – exclude elonosia), hobbies, animals, family medical history, alcohol and illicit drugs etc.

·         Increased ICP (intracranial pressure) – e.g. from head trauma –may cause decrease of GCS >_2, non reactive pupils, pupil dilation (anisokoria), hemiplegia, hemiparesis and Cushing triad (increased BP, decreased HR and irregular breathing). It may result to herniation. Treatment of increased ICP and impending herniation is with bed elevation (max 30 degrees, don’t do it in hypotension), mannitol and perhaps Lasix (don’t give any of them on hypotension but treat first hypotension e.g. with fluids and perhaps with surgery). Check and correct glucose abnormal levels and also control (with fluids) mean arterial pressure and keep PaCO2 at normal levels (eucapnia, normocapnia). However, controlled hyperventilation may be justified on impending herniation.  On head trauma, on RSI use lidocaine on premedication and as anesthetic use etomidate (if not hypotension). 

·         Head injury is not a cause of hypotension. Exclude hypovolaemia e.g. from abdominal or chest hemorrhage.

·         Methanol poisoning may be suspected by increased osmolar gap metabolic acidosis. It is treated with fomepizole or (if unavailable) with ethanol. Methanol poisoning may cause blindness and even death.

·         A normal X’ Ray may not exclude a spinal cord injury. SCIWORA is Spinal Cord Injury WithOut Radiological Abnormality! In strongly suspected spinal cord injury perform a CT or better a MRI.

·         Parents who shake their baby may cause the ‘shake baby syndrome’ with cervical spine injury and even with brain contusion.

·         Usually C (cervical) – spine injury occurs on C1, C2 and C3 vertebrae.

·         C (cervical) – spine X’ Rays include PA/ AP, lateral, odoid view & ‘swimmer’s’ view.

·         On trauma initially on secondary survey perform lateral C (cervical) – spine X’ Ray and AP X’ Ray of chest and pelvis.

·         Neurogenic shock (on spinal cord injury) is manifested with hypotension, bradycardia (!) and warm skin.

·        Spinal ‘shock’ is not really a shock, but the absence of reflexes after a spinal cord injury, soon after the injury. However it may not be permanent. 

·        Decreased rectal tone may indicate a complete or not complete spinal cord injury.

·        A spinal cord injury may complicate the examination of the abdomen (e.g. the bowel sounds may be absent and the abdomen may appear shoft). Also the absence of pain may mask a compression syndrome!

·        Rule out a hypovolemic shock before attributing shock to be neurogenic.

·        On absent psoas shadow on X’ Ray exclude retroperitoneal hemmorhage.

·        On a high diaphragm on chest X’ Ray exclude subdiaphragmatic fluid.

·        On air under diaphragm on CXR exclude bowel perforation.

·        On suspected urethral injury (e.g. hematuria) perform IV pyelography / ureteralvesicography.

·        ‘TREAT FIRST WHAT KILLS FIRST’!

·        ‘TREAT AS YOU GO’!

·        On head trauma, III cranial nerve palsy is indicated by unilateral pupildilation.

·        Midbrain lesion cause mid position fixed pupils.

·        Pontine lesion cause pinpoint pupils.

·        On increased ICP do not obtain jugular vein access.

·        On head trauma and also on stroke don’t give D5W (5% dextrose) fluids.

 

 

 

 

 

 

APPENDIX

 

I)      GCS

 

Eye Opening (E4)

4  0 – 1 years old: spontaneously; > 1 years old: spontaneously

3  0 – 1 years old: to shout; > 1 years old:  to verbal command (not 

 necessarily to ‘open your eyes’)

2  all ages: to pain

1  all ages: no response  

Response to pain is checked by pressing the patient’s nail’s bed with a pen. If not response, try supraorbital pressure and sterna pressure. 

 

Best Verbal Response (V5)

5  0 – 2 years old: appropriate cry, smiles;  2 – 5 years old: appropriate words and phrases; > 5 years old: oriented, converses

4  0 – 2 years old: cries; 2 – 5years old: inappropriate words; > 5 years old:  confused

3  0 – 2 years old: inappropriate cry; 2 – 5 years old: cries, screams; > 5 years old:  inappropriate words

2  0 – 2 years old: grunts; 2 – 5 years old: grunts, sounds; > 5 years old:  incomprehensible e.g. moans

1  all ages: no response

 

Best Motor Response (M6)

6  0 – 1 years old: moves spontaneously and adequately; > 1 years old:  obeys command

5  all ages: localizes pain  

4  all ages: flexion withdrawal

3  all ages: decorticate (stereotypical flexion)

2  all ages: decerebrate (stereotypical extension) 

1  all ages: no response 

 

Motor response may be e.g. ‘raise your hand’. It is the better response of any limb. Decorticate posture is characterized by flexion of upper extremities. Decerebrate posture is characterized by internal rotation of shoulder & arm pronation and limb extension.

 

 

Score: min 3, max 15. If GCS<_8 the patient needs intubation (RSI rapid sequence intubation if GCS > 3). GCS <_8 severe injury, GCS 9 –12 moderate injury, GCS 13–15 minor injury. 

 

 

II)    Normal vitals:

 

a)   RR (respiratory rate)

Neonates (until 6^th week) min 30/min and max 50/min.

Infants until preschool age min 20/min and max 30/min.

Teenagers min 12/min and max 20/min.

  

b)  HR (heart rate)

 Neonates min 100bpm and max 150 bpm.

 Infants min 80 bpm and max 120 bpm.

   Preschool age until school age min 60 bpm and max 110  

 bpm.

 Teenagers/adults min 60 bpm and max 100 bpm.

 

c)   Systolic BP:

 

Neonates until preschool age min is 70 mmHg.

School age and adolescents min is 80 – 90 mmHg.

Adults 90mmHg

 

d)  Urine Output

Infants 2 ml/kg/hour.

Children 1ml/kg/h.

Adults 0.5 ml/kg/h.

 

  e) Weight on children

W (Kg)= (age (years) + 4 ) x 2.

 

 

III) Paediatric orotracheal intubation.

 

The tube size is

for pre-term neonates 2.5 – 3 mm ID (internal diameter) or gestational weeks/10. 

For term neonates it is 3 – 3.5 mmID.

For infants < 1 year old it is 4 – 4.5 mmID.

For children > 1 year old use the formula: (age (years)/4 ) +4 e.g. for 8 years old kid use a size 8/4 + 4 = 6mmID.

 

Use uncuffed tubes on children < 8 years old (up to 5.5 mmID). To estimate the length of the tube, use the formulas: oral tube length (cm) = (age (years)/2) + 12. Nasal tube length (cm) = age (years)/2 + 15.

On RSI use atropine (to prevent bradycardia).

About the laryngoscope, use a straight blade (No 0 or 1) for infants (< 1year old) and neonates. On children and adolescents use curved blades (No 0, 1, 2 for infants and children; No 3 or 4 for adolescent& adults).

Don’t forget Sellick maneuver (cricoid pressure). Nasotracheal intubation is not applicable for children < 3 years old.

Neonatal orotracheal intubation. The insertion depth at the upper lip (cm) = Weight (Kg) + 6 cm.

Use an uncuffed straight blade (size0 for premature and size 1 for term newborn).

About the tracheal tube size use the below guidance. GA is gestational age.

 

Tracheal tube size 2.5 mmID, Weight <1000gr, GA <28 weeks,  Insertion depth 6.5 – 7cm

Size 3 mmID, Weight 1000 – 2000 gr,  GA28 – 34 weeks,  Insertion depth 7 – 8 cm

Size 3 – 3.5 mmID, Weight  2000 – 3000 gr, GA 34 – 38 weeks, Insertion depth  8 – 9 cm

Size 3.5 – 4 mmID, Weight  >3000 gr, GA >38 weeks, Insertion depth >9 cm

 

Tracheal tube size (mm)= gestational age (weeks)/10.

Insert the tube about 1.5 – 2 cm into the larynx, so that the black mark on the tip of the tube is just visible thru the cords.

·        DOPES (Displacement of the tube – accidental extubation or tube in the right main bronchus, Obstruction of the tube, Pneumothorax, Equipment failure, Stomach distension) should be checked if respiratory distress occurs on an intubated patient.

The first thing is to extubate the patient and ventilate him/her for a while with BMV (Bag Mask Ventilation) until you figure out the reason of the respiratory compromise. About the Equipment failure check Oxygen, bag mask, ventilator etc. Stomach distension happens frequently on children, pregnant and patients (e.g. neonates) with diaphragmatic hernia.

 

 

 

APPENDIX: SIGNS OF HYPOVOLAEMIC SHOCK

Signs of hypovolaemic shock (haemorrhage - external or internal blood loss; or severe dehydration e.g. on severe diarrhea or vomiting) include: tachycardia (if not on β' blockers or pacemaker!), fast thready pulse, narrowed pulse pressure (Systolic BP - diastolic BP), weak peripheral pulses, tachypnea, decreased level of concioussness (LOC), decreased urine output (adults < 0.5 ml/kg/h, children 1ml/kg/h, infants 2 ml/kg/h), decreased capillary refill time (>2 sec), hypotension (late, with > 30% volume loss on adults and > 40% on children), cool pale skin, diaphoresis (not on dehydration); also decreased skin turgor (unreliable on the elderly) and dry mucus membranes (e.g. dry tongue) on dehydration.

NOTE

Some information in this text is empirical and its reliability can't be ascertained. It is suggested to search official medical articles, books and guidelines in order to ascertain the medical information of this text.

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor's consultancy.

 

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7) Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

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11) ALSO (Advanced Life Support in Obstetrics), American Academy of Family Physicians, 4th edition (revised), 2006.

12) Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw – Hill, 16th edition, 2005.

13) Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

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16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2^nd edition, Jones and Bartlett Publishers, 2007.