UMANAND PRASAD SCHOOL OF MEDICINE

& HEALTH SCIENCES

PAEDIATRIC CASE WRITEUP

SIGATOKA PERIPHERY

CASE 4

NAME: SHAKSHI RAINA

ID: 20170017
COURSE CORDINATOR: DR DENNIS BUENAFE
CASE WRITEUP

GENERAL DATA

Name: Lavenia Tawake DOB: 28/05/2017

Sex: Female DOA: 1/8.2022

Race: Itaukei DOD: 5/8/2022

NHN: 990398534 Informant: Grandmother

Presenting complaint:

- Cough x 3/7
- Shortness of breath x 1/7

History of presenting illness:

- child developed cough from Saturday, productive in nature

- Yesterday she developed shortness of breath and presented last night to
sigatoka district hospital, received nebs and then sent back home on
antibiotic.

Review of system:

(+) fever

(+) shortness of breath

(+) vomiting

(+) cough
Decreased appetite

- passing urine
- bowel output

Paediatric history

- delivered via NVD in New Zealand

- grandparents taking care of baby from 3 months
- immunization up to date

Past medical history:

- admitted in Lautoka hospital with asthma

- multiple admission in Lautoka and sigatoka hospital
- last admission was in this month
- history of asthma

Drug history:

- NIL

Social history:

- Lives in Udu settlement

- Mum is also asthmatic
- No one else is sick at home

Birth history:
 - NVD at term
- No birth complications

Upon examination:

- In respiratory distress, speaking in one word.

Vitals: T- 36.2 P- 150 SP02- 86% RR- 61

HEENT:

- (+) nasal flaring

- (+) tracheal tug
- No lymphadenopathy

Chest:

- Bilateral wheeze with crepitations on right side and left lower zone
- S1S2 regular, no murmur

Abdomen:

- Soft and non tender

Extremities:

- Good volume pulse

- Capillary refill <2 seconds
- No edema
-
Assessment:

1. Severe acute exacerbation of bronchial asthma

2. Bronchiolitis

Plan:

1. Admit

2. Do bloods (FBC, UECR, BC)

3. Start meds – Crystalline penicillin 750,000 IV Q6H

- Gentamicin 75mg IV OD

- Ventolin Nebs x 3

- Hydrocortisone 8mg/kg IV stat

Follow up:

Bloods – FBC

NOT UPDATED

UECR

 Urea – 4.3
 Creatinine- 27
 Potassium- 4.0
 Sodium- 138

Blood culture- No growth in 48 hours

Discharge medications:

- Amoxicillin 250mg PO Q8H

- Paracetamol 250mg PO Q6H

Follow up:

- Ward review in 1 week

Learning issues:

Status Asthmaticus

Introduction
Asthma is a chronic inflammatory disease of the airways characterized by
recurrent/reversible airway obstruction and bronchospasm. Early recognition and
acute management of severe or life-threatening disease is of vital importance.
Status asthmaticus is defined as an acute severe exacerbation of asthma that
remains unresponsive to initial treatment with bronchodilators.

Clinical Presentation

ASESSEMENT OF SEVERITY
The criteria used here for assessment of the severity of an acute asthma
exacerbation have been separated into two categories:

- Primary features - which are reliable indicators of severity and

- Secondary features - which provide useful information but are variable and
less reliable.
Severity of exacerbation Primary Features Secondary Features
Mild normal mental state, O2 saturation > 95% in
subtle or no accessory room air, able to talk
muscle use or recession normally, normal heart
rate, expiratory wheeze

Moderate normal mental state, mild O2 saturation 92 - 95% in

accessory muscle use or air, some limitation of
recession ability to talk, tachycardia,
expiratory and inspiratory
wheeze

Severe agitated or distressed, O2 saturation < 92% in

moderate to marked air, marked limitation of
accessory muscle use or ability to talk, tachycardia,
recession wheeze audible without
stethoscope
Critical (Life-Threatening) Confused or drowsy, O2 saturation < 90% in
maximal accessory muscle air, inability to talk,
use or recession and marked tachycardia,
exhaustion wheeze audible without
stethoscope or chest may
be silent

Management:

Consider consultation with paediatric team when:

a) Assessed as moderate or severe asthma
b) Poor response to inhaled salbutamol
c) Oxygen requirement
Consider transfer when:
a) Severe or critical asthma requiring intravenous treatment or respiratory
support
b) Children with escalating O2 requirement
c) Children poorly responsive to salbutamol or unable to wean salbutamol
d) Children requiring care above the level of comfort of the local hospital

Management of mild – severe asthma

Management of Critical or Life-threatening Asthma

- Call for assistance – request for urgent review with PICU senior
registrar/consultant
- Oxygen – use high flow via Oxygen mask (15 L/min)
- Continuous nebulized salbutamol: use 0.5 % undiluted respirator solution
(5mg/ml). Put 6 ml of 0.5 % solution in the nebulizer (and refill when about
2 ml remain). Use oxygen 8-10L/min AND
- Add Ipratropium Bromide (250 mcg per dose for children who weigh < 20
kg,

500 mcg per dose for children who weigh ≥ 20 kg) to salbutamol in the first
nebulizer dose and every 20 minutes for 3 doses, then every 4 hours
- IV access
- Give Hydrocortisone IV initial 8 – 10 mg/kg (maximum 300 mg) IV as soon
as possible then 4 mg/kg 6 hourly
- If the child has severe asthma and other signs of anaphylaxis, use
Adrenaline 0.01 ml/kg of 1:1000 (maximum 0.5 ml) IM, into lateral thigh
which should be repeated after 5 minutes if the child is not improving.

IV Magnesium sulphate bolus:

- Use Magnesium sulphate 50% for intravenous administration. Give 0.1

ml/kg (approximate 50 mg/kg, Max dose 2 g) over 20 minutes (dilute to 50
mls with normal saline and infuse via syringe pump).
- If infusion is needed then 0.06 mls/kg/hr (30 mg/kg/hr)

- IV Salbutamol infusion:
 -
o Dose: 5 -10 mcg/kg/min for 1 hour then reduce to 1 - 2 mcg/kg/min

o If Patient Weight < 16 kg: Add 3 mg/kg of IV salbutamol solution (1 mg/ml) to a

50 ml syringe and make up to 50 ml with 5 % Dextrose (1 ml/hr = 1 mcg/kg/min)

o If Patient Weight > 16 kg: Draw up undiluted IV salbutamol solution (1 mg/ml)

into a 50 ml syringe

- Rate (ml/hr) = 0.06 x weight (kg) x dose (mcg/kg/min). For example if you
have a 20 kg child and want to infuse salbutamol at 5 mcg/kg/min then set
rate at 0.06 x 20 x 5 = 6 ml/hr.

- Aminophylline bolus - If the child is already on oral theophylline, do not

give IV Aminophylline loading dose.

- Loading Dose: give 10 mg/Kg IV (maximum dose 500 mg) over 1 hour.
Dilute to 50 ml with either NSS, D5% or D10%.

- Ensure cardiac monitoring for arrhythmias.

- If inadequate response to bolus therapy then start IV Aminophylline

infusion (Refer to Annex III for Aminophylline Infusion).

- Use separate IV lines for IV Salbutamol and Aminophylline

- There is a role for non-invasive ventilation (CPAP or high-flow) in life

threatening asthma and this should be considered as an additional
treatment modality.
PICU Monitoring:
o Continuous cardiac monitoring
o Non-invasive blood pressure, oxygen saturation, and respiratory rate
o UECs, Mg+, Ca++, baseline CBGs and ABGs at least 6 hrly

 NOTE:

o Blood gas extraction is distressing and can cause further respiratory

compromise. It is not usually required and the child's clinical state is more
important in guiding treatment.
o Electrolytes for potassium levels may be indicated.
o Chest x-ray is not generally required (discuss with senior doctor)
o Spirometry is NOT required in the assessment of acute asthma in children.
o If child is improving, therapy can be stepped down at any stage.
o Avoid rapid cessation of treatment just before discharge to the ward.
o Do not sedate an un-intubated child with asthma.

Ventilation in Asthma

Indication for ventilation:

a) Severe hypoxia
b) Severe exhaustion
c) Rapid deterioration in mental state
d) Hypoxemia despite provision of high concentrations of oxygen or noninvasive
positive pressure ventilation (NPPV, partial pressure of oxygen [pO2] <60 on 100
% oxygen)
e) Worsening ABG with hypercarbia and clinically deterioration
f) Cardiopulmonary arrest

Induction
o Induce with Ketamine 2 mg/kg or Fentanyl 3 mcg/kg or Vecuronium 0.1 mg/kg
or Pancuronium 0.1 mg/kg
o Thiopentone/Midazolam/Propofol are other alternatives
o Sedate with Ketamine 10 – 20 mcg/kg/min.
o DO NOT use Morphine (causes Histamine release)

Ventilator Mode
o Child 1 - 9 yrs: ventilate with Pressure Control mode at VR 16 - 20, IE ratio 1:5,
PEEP 3 – 5 cm H2O. Aim for a pCO2 of 60 – 100 mmHg with pH 7.10 -7.20.
o For older children: no preferable mode of ventilation. At the comfort of treating
physician.
o Observe chest movement carefully.

Criteria for transfer out of PICU

a) Successful weaning from invasive or noninvasive positive pressure ventilation
(NPPV).
b) Successful weaning/cessation of intravenous bronchodilators.
c) Requirement of aerosolized bronchodilators at a frequency that can be safely
delivered in the general pediatric ward.
d) Oxygen requirement within the range of what can be safely and locally
appropriate to deliver in the general pediatric ward.

Discharge Guideline

Patients may be discharged when:

 Their asthma symptoms and signs are considered mild.
 Each child should have a written Asthma Action plan

REFERENCE:

- Pediatric intensive care unit clinical practice guideline.