Common Pediatric Medical Emergencies in Office Practice

General Practitioners frequently see children with medical conditions that may evolve into an emergency if not promptly attended to. The most common emergencies encountered in pediatric office practice are respiratory distress, dehydration, anaphylaxis, seizures and trauma. Assessment of children is sometimes difficult as the signs and symptoms might be subtle and not markedly expressed. Also, normal value of vital signs vary with age, thus their interpretation requires discrete knowledge of age appropriate values. Initial approach to a sick child involves formation of initial impression, doing primary assessment, proper history taking and classifying the condition into following categories: Respiratory distress, Respiratory failure, Compensated shock, Decompensated shock and Primary brain dysfunction. Initial management of any pediatric emergency involves assessment of airway, breathing and circulation and providing relevant adequate support. Majority of cardiac arrests in pediatric practice are secondary to progressive respiratory failure and thus, if intervened timely and effectively, will prevent fatal outcome. In a child with shock, compensated state can rapidly evolve to decompensated state, thus necessitating its early recognition and rapid intervention. Anaphylaxis should be suspected in any child with sudden onset of skin or mucosal symptoms along with respiratory, circulatory or gastro-intestinal involvement and adrenaline should be given by intra-muscular route.     

有创机械通气患儿呼吸评估与治疗进展

机械通气技术的广泛应用使得很多呼吸衰竭患儿得到成功救治。同时,强制通气、肺部正常呼吸生理及呼吸力学的改变会导致呼吸功能减退以及气道廓清能力下降。因此,如何根据儿童自身生理特点进行全面、精准的呼吸功能评估,进行适宜的呼吸功能康复,以尽快拔除气管插管,缩短机械通气时间,是目前儿童重症机械通气有效撤机的研究重点。该文就有创机械通气患儿呼吸功能评估与治疗方法进展进行综述。     

Approach to a Child with Breathing Difficulty

Breathing difficulty and respiratory distress is the most common cause of admission to the Pediatric Emergency. Respiratory distress presents as altered breathing pattern, forced breathing efforts or obstructed breathing, and chest indrawing; respiratory failure is defined as paCO₂ >50 mmHg (inadequate ventilation) and/or a paO₂ < 60mmHg (inadequate oxygenation). Rapid assessment is aimed to ascertain adequacy of airway patency, breathing, and circulation. Immediate care is directed at (a) restoration of airway patency- by positioning (head tilt –chin lift), cleaning the oropharynx, and/or insertion of oropharyngeal airway; (b) supporting breathing- with high flow oxygen and assisted ventilation (with bag and mask or endotracheal intubation and ventilation), and (c) restoration of circulation- using fluid boluses and inotropes, if necessary. Immediate specific management may require endotracheal intubation/tracheostomy for upper airway obstruction; needle thoracotomy and drainage of pneumothorax; and first dose of antibiotic for febrile children. Thereafter meticulous history, focused physical examination, and specific laboratory/radiological investigations are undertaken to identify the underlying cause. At the end of this, one should be able to categorize the child to one of the following: (a) upper airway obstruction, (b) pneumonia (syndrome of cough, fever and breathing difficulty), (c) lower airway obstruction, (d) slow or irregular breathing without pulmonary signs, and (e) respiratory distress with cardiac findings, to initiate specific treatment. Further respiratory support by Continuous Positive Airways Pressure (CPAP) and mechanical ventilation may be required in some cases. All children with respiratory distress must be monitored for early detection of worsening/complications, assessment of response to therapy and rapid documentation of clinical state.     

Definitions and prevention of cardiorespiratory arrest in children

In cardiopulmonary resuscitation ages are divided in neonates (in the inmediate period after the birth), infant (from birth to 12 months) and child (from 12 months to puberty). Respiratory arrest is defined by the absence of spontaneous respiration (apnea) or a severe respiratory insufficiency (agonal gasping) that require respiratory assistance. Cardiac arrest is defined as the absence of central arterial pulse or signs of circulation (movement, cough or normal breathing) or the presence of a central pulse less than 60 lpm in a child who does not respond, not breath and with poor perfusion. After resuscitation the return of spontaneous circulation is defined as the recuperation of central arterial pulse or signs of circulation in a child with previous cardiorespiratory arrest. It is maintained when the duration is longer than 20 minutes. Injuries, sudden infant death syndrome, and respiratory diseases are the most frequent etiologies of cardiorrespiratory arrest in children. The prevention and the formation of citizens in basic cardiopulmonary resuscitation are the most effective measures to reduce the mortality of cardiorespiratory arrest in children.     

Identifying children at risk for cardiorespiratory arrest

Cardiorespiratory arrest in children with severe disease does not usually present suddenly or unexpectedly but is often the result of a progressive deterioration of respiratory and/or circulatory function. Before failure of these functions occurs, there is a series of clinical signs that serve as a warning. Health professionals should not only evaluate clinical signs of respiratory and/or circulatory insufficiency but should also be able to identify these warning signs as early as possible, preferably in the compensation phase, given that the possibility that this process can be reversed by therapeutic measures decreases as the process progresses.     

Basic life support in pediatrics

Basic life support (BLS) is the combination of maneuvers that identifies the child in cardiopulmonary arrest and initiates the substitution of respiratory and circulatory function, without the use of technical adjuncts, until the child can receive more advanced treatment. BLS includes a sequence of steps or maneuvers that should be performed sequentially: ensuring the safety of rescuer and child, assessing unconsciousness, calling for help, positioning the victim, opening the airway, assessing breathing, ventilating, assessing signs of circulation and/or central arterial pulse, performing chest compressions, activating the emergency medical service system, and checking the results of resuscitation. The most important changes in the new guidelines are the compression: ventilation ratio and the algorithm for relieving foreign body airway obstruction. A compression/ ventilation ratio of 30:2 will be recommended for lay rescuers of infants, children and adults. Health professionals will use a compression: ventilation ratio of 15:2 for infants and children. If the health professional is alone, he/she may also use a ratio of 30:2 to avoid fatigue. In the algorithm for relieving foreign body airway obstruction, when the child becomes unconscious, the maneuvers will be similar to the BLS sequence with chest compressions (functioning as a deobstruction procedure) and ventilation, with reassessment of the mouth every 2 min to check for a foreign body, and evaluation of breathing and the presence of vital signs. BLS maneuvers are easy to learn and can be performed by anyone with adequate training. Therefore, BLS should be taught to all citizens.     

Respiratory support in children

Respiratory failure is defined by the inability of the respiratory system to adequately deliver oxygen or remove carbon dioxide from the pulmonary circulation resulting in hypoxemia, hypercapnia or both. A wide variety of disease processes can lead to respiratory failure in children. Multiple interventions can support the paediatric patient with respiratory failure, from simple oxygen delivery devices to high frequency oscillatory ventilation and extracorporeal membrane oxygenation. This article will review available devices to improve oxygenation and ventilation, their advantages and disadvantages, and help guide physicians in the management of children with respiratory failure.     

Recurrent pneumomediastinum and pneumothorax in Langerhans cell histiocytosis

Pneumothorax is an unusual complication of pulmonary Langerhans cell histiocytosis. We report three children who developed recurrent intrathoracic air leaks. In one case, bilateral pneumothoraces may have been precipated by intermittent positive pressure ventilation during general anaesthesia. Chemical pleurodesis was unsuccessful in preventing recurrence of pneumothoraces in two children. The use of extracorporeal membrane oxygenation as an alternative to intermittent positive pressure ventilation in children with respiratory failure from Langerhans cell histiocytosis is discussed. Med. Pediatr. Oncol. 29:139–142, 1997. © 1997 Wiley-Liss, Inc.     

Acute respiratory failure and oxygen therapy

Acute Respiratory Failure (ARF) results in an inability to maintain gas exchange at a rate commensurate with the demands of the body and results in hypoxemia and/or hypercarbia, the mechanisms of which may be different. Hypoxemia commonly occurs due to Ventilation Perfusion (V/Q) mismatching, intrapulmonary shunt, diffusion defect or hypoventilation. Hypercarpnic respiratory failure may also be multifactorial but is usually due to inhibited central respiratory drive or inefficient respiratory muscle pump. Hypercapnia may occur in upper and lower airways obstruction, respiratory muscle fatigue and occasionally due to excess CO₂ production (burns and excessive glucose administration). Issues in management centre around assessment of severity, determining the need for intervention, establishing diagnosis and etiology and institution of specific treatment. Diagnosis of respiratory failure may be made clinically and confirmed by blood gas analysis. Calculation of oxygenation indices will delineate extent of hypoxemia. When evaluating a child with respiratory failure, one should be aware that a child with prominent respiratory symptoms may have non-respiratory disease (i.e. metabolic acidosis, DKA) and conversly, advanced respiratory failure may be present in a child with no respiratory distress (central hypoventilation secondary to drugs, infection) careful assessment of history, complete physical examination and evaluation of lab parameters may clarify the diagnosis. Serial assessment of sensorium, respiratory symptoms, ABG and response to treatment will provide valuable clues to determine the need for intervention. Oxygen, like any drug, must be administered in a prescribed dose, only when indicated with the potential risks borne in mind. A variety of oxygen delivery devices are available; which ever device is used, the resulting FiO₂ and devisable end points must be clearly determined. Hazards of oxygen therapy range from retinal damage in premature infants, damage to the alveolar capillary membrane with resultant hypoxemia) atelectasis and decreased mucociliary activity.     

出血性休克与脑病综合征的干预探讨

目的　 探讨出血性休克与脑病综合征 (HSES)有效的急救措施。 方法 　回顾性分析 12例出血性休克与脑病综合征的临床过程 ,干预措施及对干预的反应。 结果 　HSES的主要危害是脑功能的损害。 结论 　改善和保护脑功能是治疗的重点 ,关键是迅速恢复氧通气、脑灌注 ,即迅速稳定呼吸和循环功能。休克纠正越快 ,预后越好 ;扩容应迅速而大胆。可尽早气管插管和正压通气 ,纠正低氧血症。正压通气、纠酸、抗DIC、抑制炎症反应均有利于循环功能的改善 ,应尽早进行。降颅压并不能改善神经系统功能的预后     

儿童无创通气的局限性及气管插管介入时机选择

近年来,无创通气在儿童呼吸支持领域有了较快发展。无创通气无需气管插管,操作简便,对部分呼吸道疾病有较为满意的疗效。但是,无创通气不能完全替代有创机械通气。在有些疾病无创通气不仅有着较高的失败率,而且会因气管插管的延误导致病情恶化,增加患儿的病死率。在行无创通气之前需评估患儿是否适宜进行无创通气治疗。对于进行无创通气治疗的患儿需严密监护,动态观察生理指标和监测数据的变化,掌握好气管插管的时机,以免造成有创机械通气治疗的延误。     

儿童心力衰竭的诊断与治疗进展

心力衰竭是心脏失去有效泵血或接纳足量静脉回流功能的复杂的临床综合征,从而引起一系列症状,在儿童中的临床表现因年龄而不同。儿童心力衰竭的原因主要是先天性心脏病和心肌病。药物应用在儿童心力衰竭中的治疗进展迅猛,沙库巴曲/缬沙坦于2019年10月由美国食品药品监督管理局(FDA)批准其用于≥1岁儿童伴有症状性左心室收缩功能障碍,标志着儿童心力衰竭药物治疗的新起点。植入型心律转复除颤器和心脏再同步化治疗适用于部分具有指征的患者。机械循环支持是心肺衰竭患者不可缺失的治疗手段,包括体外膜肺氧合和心室辅助装置,作为短期循环辅助-移植等待的重要过渡。儿童心脏移植是心力衰竭终末的治疗方案。     

Veno-venöse ECMO und septischer Schock im Neugeborenenalter Fallbericht

Background. Neonatal septic shock due to streptococcal infection remains a life threatening disease. Veno-arterial ECMO represents a potentially lifesaving therapy even after all other measures have failed. Case report. 2 hours after uncomplicated delivery a mature neonate experienced severe pulmonary and circulatory failure with pulmonary hemorrhage. Despite intensive care with artificial ventilation, inotropes, volume support and antiinfecitve therapy further deterioration occured. Echocardiography revealed myocardial failure and pulmonary hypertension. Pulmonary hypertension decreased after supplementary ventilation with nitric oxide was started, but the child deteriorated hemodynamically. Since conventional medical management was not successful, a modifyed single-needle veno-venous ECMO was installed. Immediately after starting ECMO, pulmonary and circulatory function improved, and the child survived without permanent damage despite a proven streptococci infection. Discussion. A single-needle veno-venous ECMO used during neonatal septic shock despite marked hemodynamic compromise, resulted in a prompt increase in oxygenation, reduced the pulmoarterial resistance and thereby normalized the hemodynamic situation. The pulsatile perfusion of the system remaind stable.     

Inicial care in severe pediatric trauma

OBJECTIVES: To present objectively the therapeutic aspects for the management of child victim of trauma.METHODS: The most relevant articles about the management of acute trauma were selected.RESULTS: Children possess great potential for recovery after a trauma, however, inappropriate resuscitation is the major cause of death preventable.Care in the opening and maintenance of the airways, adequate input of fluid to the child victim of politrauma or burns as well as prompt diagnosis and effective management to internal bleeding has improved prognosis and can reduce mortality considerably. Initial assessment and management of the injured child requires immediate procedures towards respiratory failure, shock and life-threatening thoracic injuries in order to provide efficient ventilation, oxyge-nation and perfusion until definitive treatment is performed. Concomitantly, the cervical spine should be protected against new injuries or progression of established injury.CONCLUSIONS: Effective actions in order to prevent accidents and rigorous laws to protect children and adolescents, associated to training and practice of specific procedures to the politraumatized child could surely reduce the unacceptable morbi-mortality in our country.     

Respiratory failure in the child

OBJECTIVE: To describe the main physiopathologic mechanism of the respiratory failure in the child, as well as to discuss some aspects of the differential diagnosis and treatment. SOURCE OF DATA: The main national and international textbooks and articles about respiratory failure in the child were used as sources of data for this research. RESULTS: Respiratory failure is defined as the incapacity to maintain a paO(2) over 50 mmHg associated or not to a paCO(2) over 50 mmHg in children breathing ambient air at sea level. This failure may be classified as hypoxemic or hypercapnic, or even as acute or chronic. The main alterations may be hypoventilation, ventilation perfusion mismatch and diffusion defect. It may be secondary to a central origin, upper or lower airway compromise, parenchyma disease, or due to pleural or thorax wall affection. The hypoxemia evaluation may be done by hemoglobin saturation, alveolar capillary gradient of oxygen (D[A-a]O(2)) or by the paO(2) / FiO(2) index. COMMENTS: The knowledge of the physiopathologic mechanisms that cause respiratory failure in the child is important to define the more efficient therapeutic strategy for each cause.     

学龄期肾病综合征男童咳嗽1月伴气促半月

患儿,男,6岁11个月,因诊断肾病综合征2年,咳嗽1个月,气促15 d入院。患儿有长期使用激素和免疫抑制剂病史,出现咳嗽和气促后完善胸部CT提示双肺弥漫性磨玻璃影,G试验阳性,呼吸道分泌物检测结果示巨细胞病毒核酸阳性,给予抗真菌及抗病毒治疗后一过性好转,短期内再次加重,肺泡灌洗液六胺银染色发现肺孢子菌。该患儿诊断为（1）重症肺炎（耶氏肺孢子菌、巨细胞病毒感染）,（2）急性呼吸窘迫综合征,（3）肾病综合征。予复方新诺明、更昔洛韦抗感染治疗和呼吸支持治疗,呼吸困难仍进行性加重,并出现张力性气胸,有创呼吸机治疗第13天予体外膜肺氧合（ECMO）支持。ECMO期间经复方新诺明、更昔洛韦、利奈唑胺等抗感染、抗凝、镇静、营养和呼吸道综合管理,于72 d后成功撤离ECMO,住院时间共134 d。出院随访6个月肺部CT明显好转,无脏器功能不全。耶氏肺孢子菌肺炎对免疫低下的患儿是一种潜在的威胁生命的感染,ECMO的应用能有效改善重度呼吸窘迫综合征患儿的预后。     

Post-resuscitation stabilization and transportation

Cardiopulmonary resuscitation does not end with restoration of spontaneous circulation; rather, it must be continued with the application of all the measures that allow organ function to be maintained. The initial goal of hemodynamic treatment is to achieve normal blood pressure for the patient's age by means of fluids and/or vasoactive drugs. The aim of respiratory treatment is to normalize ventilation and oxygenation without causing further lung injury, avoiding hyperoxia and hyperventilation as well as hypoxia and hypercapnia. Neurological stabilization aims to reduce secondary brain damage, by avoiding hypertension and hypotension, maintaining normal ventilation and oxygenation, and treating hyperglycemia, agitation and seizures. Although no specific studies in children are available, data from adults have shown that early moderate hypothermia attenuates brain damage secondary to cardiorespiratory arrest, without increasing complications. After the arrest, the need for analgesia and/or sedation must be considered. The process of transportation to the pediatric intensive care unit (PICU) requires the following steps: stabilizing the patient, checking for and stabilizing fractures and external wounds, ensuring a stable airway and intravenous lines, assessing the need for nasogastric and bladder tubes, taking blood samples for analyses, contacting the PICU and informing the staff about the child's condition, choosing the optimal vehicle for transportation according to the child's condition and the distance, checking pediatric equipment and medications, selecting experienced staff and, finally, maintaining close surveillance and monitoring during transportation.     

Non-invasive positive pressure ventilation: current status in paediatric patients

Non-invasive positive pressure ventilation (NPPV) is a treatment for patients with respiratory dysfunction accomplished by an external interface and a positive pressure ventilator. The goals of NPPV therapy are to decrease the work of breathing and to improve respiratory gas exchange. Children with respiratory dysfunction are increasingly being treated with NPPV with the belief that it is a safe and effective alternative to invasive mechanical ventilation. Reports in support of NPPV are most promising in older children with chronic respiratory failure associated with restrictive pulmonary disorders and neuromuscular weakness. In children with advanced cystic fibrosis and nocturnal hypoxaemia, NPPV appears to be superior to treatment with supplemental oxygen alone in preventing hypoventilation. The role of NPPV in children with acute hypoxaemic respiratory failure is less well defined. Although early reports are encouraging, the question remains unanswered whether early application of NPPV as opposed to standard treatment reduces the likelihood or only delays the need for invasive mechanical ventilation. As young infants may not trigger the inspiratory pressure support feature of bi-level ventilators, application of NPPV with current devices is problematic in patients of this age. The horizon is promising for NPPV in the paediatric population and will likely include novel interfaces and responsive positive pressure devices better suited to the unique mechanical properties of the developing respiratory system.     

Multicenter randomized controlled trial of the effects of inhaled nitric oxide therapy on gas exchange in children with acute hypoxemic respiratory failure

OBJECTIVES AND BACKGROUND: To determine whether inhaled nitric oxide (iNO) therapy can attenuate the progression of lung disease in acute hypoxemic respiratory failure, we performed a multicenter, randomized, masked, controlled study of the effects of prolonged iNO therapy on oxygenation. We hypothesized that iNO therapy would improve oxygenation in an acute manner, slow the rate of decline in gas exchange, and decrease the number of patients who meet pre-established oxygenation failure criteria. STUDY DESIGN: A total of 108 children (median age 2.5 years) with severe acute hypoxemic respiratory failure from 7 centers were enrolled. After consent was obtained, patients were randomized to treatment with iNO (10 ppm) or mechanical ventilation alone for at least 72 hours. Patients with an oxygenation index >/=40 for 3 hours or >/=25 for 6 hours were considered treatment failures and exited the study. RESULTS: Patient age, primary diagnosis, pediatric risk of mortality score, mode of ventilation, and median oxygenation index (35 +/- 22 vs 30 +/- 15; iNO vs control; mean +/- SEM) were not different between groups at study entry. Comparisons of oxygenation indexes during the first 12 hours demonstrated an acute improvement in oxygenation in the iNO group at 4 hours (-10.2 vs -2.7, mean values; P <.014) and at 12 hours (-9.2 vs -2.8; P <.007). At 12 hours 36% of the control group met failure criteria in contrast with 16% in the iNO group (P <.05). During prolonged therapy the failure rate was reduced in the iNO group in patients whose entry oxygenation index was >/=25 (P <.04) and in immunocompromised patients (P <.03). CONCLUSIONS: We conclude that iNO causes an acute improvement in oxygenation in children with severe AHRF. Two subgroups (immunocompromised and an entry oxygen index >/=25) appear to have a more sustained improvement in oxygenation, and we speculate that these subgroups may benefit from prolonged therapy.     

右美托咪定在撤机躁动患儿中的应用

目的探讨右美托咪定在机械通气撤机躁动患儿应用的有效性及安全性。方法采取前瞻性开放性观察性研究，纳入2017年3月至2018年8月入住重症监护室接受机械通气由于躁动导致自主呼吸试验（SBT）失败而应用右美托咪定的病例。将镇静-躁动评分≥5分定义为躁动。观察入组患儿使用右美托咪定0.5、1、2、6、12 h后的镇静情况，拔管前及拔管后1、24、48 h血气分析结果，SBT前、拔管前、拔管后10 min、拔管后60 min、拔管后120 min、拔管后24 h的重要生命体征（心率、呼吸频率、平均动脉压）及使用右美托咪定过程中不良反应发生情况。结果 19例患儿纳入研究。患儿入组时均为躁动状态，使用右美托咪定0.5、1、2、6、12 h后分别有12、17、17、18、18例患儿达到目标镇静状态。拔管前后各时间点的氧合指数、PaCO₂及心率、呼吸频率、平均动脉压差异均无统计学意义（P > 0.05）。所有患儿均未发生严重低血压、呼吸抑制等不良反应，仅1例患儿发生可逆性心动过缓。结论右美托咪定在机械通气撤机躁动患儿中的应用是安全有效的，但尚需前瞻性随机对照试验加以验证。