Paediatric emergencies

Poisoning
It is the ingestion, inhalation or injection of the toxic substance or in excessive amount of
substance
Poisoning is common from one year to four years of age.
Accidental poisoning occurs due to lack of supervision and carelessness
Emergency medical care
Common poisons may be drugs, cleaning agents , detergents, insecticides, pesticides, paint
solvent, kerosene, corrosives, cosmetics and adulterated food.
Clinical manifestation
• Nausea, vomiting,diarrhea, stomach pain, unusual drooling etc.
•Sore throat, trouble breathing, cyanosis, sternal retraction and grunting
•Shock and collapse
•Lip or mouth burns or blisters
•Strange odors from child’s breath
•Drowsiness, irritability, convulsions or unconsciousness
•Unusual stains on child’s clothing
Management
Identification of poison
• Check poison containers to determine what was swallowed
• Ask the time and amount of swallow
Removal of poison
◦ If the substance is still in child’s mouth, make child to spit it out or remove it
with fingers
◦ Vomiting is induced immediately to prevent further absorption of poison
◦ Ipecac syrup with water given to induce vomiting
◦ Gastric lavage done to empty stomach poison
◦ Vomiting and gastric lavage are
contraindicated in
◦ Child in severe shock
◦ Child in coma
◦ Loss of gag reflex
◦ Corrosive and mineral oil poisoning
Decontamination of stomach
Stomach is decontaminated with activated charcoal
It is used after vomiting and with in one hour of poisoning
Dilution of poison
• Dilution of substance such as corrosive agents
Prevention
Educate the parents regarding safe storage of all substance
Teach the children the hazards of ingesting non food items
Keep drugs and medicines out of reach of children
Avoid storing poisonous substance in food storage container
Keep the poisonous substance in safety storage container
under lock and key
Drowning
Drowning is defined as death resulting from suffocation within 24 hours of
submersion in a liquid medium
Near-drowning: Near-drowning, as survival of (even with severe medical therapy) at
least 24 hours after an episode of suffocation caused by submersion in a liquid
medium
Dry-drowning:
Due to a sudden immersion into water, largyngospasm leading to asphyxia resulting
with alveoli without water
Wet-drowning: Drowning due to water in the alveoli
Secondary drowning: Any secondary disease (Heart disease, epilepsy, alcohol use
etc) leading to loss of consciousness in water, thereby drowning
Risk Factors
Age: Youth 40% under 4 years old
Location: Pools, bathtubs, lakes, rivers
Sex: Male 3:1 Time of year: Warm months
Chain of events
Increase
d
Breath intracran
holding ial
Aspiratio
voluntari Cardiac pressure,
Unvolunt n of
ly and arrest Hypoxic Cytotoxic decrease
arily water
with due to damage cerebral d
point of and/or
panic on-going of brain odema cerebral
cession laryngos
Struggle hypoxia blood
pasm
of the flow
victim Herniatio
n and
death
Immediate Treatment
A-B-C should be applied Mouth –to-mouth breathing should be
started in water
Subdiaphragmatic pressure may be effective for draining water from
the lungs
Manual and mechanical ventilation with ETT Standart CPR SpO2
should tried to be kept at 90%
Management at hospital
ETT and mechanical ventilation if needed

Fluid replacement with appropriate solution Inotropic support to treat

hypoglycemia and hypocalcemia
Thermoregulation -Wet clothes should be removed Especially in
children heat loss is very fast
Heat the patient slowly with blankets and light

Iv fluids and O2

Foreign Bodies in the Ear, Nose, and Throat
An infant or young child may put an object in his or her ears,
nose, or mouth.
Objects in the mouth may be swallowed or breathed
(aspirated) into the lungs.
Objects in the ears and nose can make it hard to hear or
breathe and can cause infection
Foreign bodies in the ear

Foreign bodies in the ear canal can be anything a child can push into his
or her ear. Some of the items that are commonly found in the ear canal
include:
 Food
 Insects
 Toys
 Buttons
 Pieces of crayon
 Small batteries
Symptoms
Some objects placed in the ear may not cause symptoms.
Other objects, such as food and insects, may cause pain in
the ear, redness, or drainage.
Hearing may be affected if the object is blocking the ear
canal.
Treatment
The treatment for foreign bodies in the ear is prompt removal of the object
It can be removed by
 Instruments such as long, thin tweezers or forceps may be put in the ear to grab
and remove object.
 Magnets are sometimes used to remove the object if it t is metal.
 The ear canal may be flushed with water.
 A machine with suction may be used to help pull the object out.
After removal of the object, re-examine the ear to determine if there has been
any injury to the ear canal. Antibiotic drops for the ear may be prescribed to treat
any possible outer ear infections.
Foreign bodies in the nose

Objects that are put into the child's nose are usually soft things. These would include:
 Tissue
 Clay
 Pieces of toys
 Erasers
Sometimes, a foreign body may enter the nose while the child is trying to smell the object.
.
Symptoms
The most common symptom of a foreign body in the nose is
nasal drainage.
The drainage appears only on the side of the nose with the
object and often has a bad odor.
In some cases, the child may also have a bloody nose.
Treatment
Treatment of a foreign body in the nose involves prompt removal of the
object
Sedating the child is sometimes needed to remove the object successfully.
The following are some of the techniques :
 Suction machines with tubes attached may be used.
 Instruments may be inserted in the nose.
 The object may be "blown" out of the nose.
 After removal of the object, nose drops or antibiotic ointments can be
used to treat any possible infections
Foreign bodies in the throat

A foreign body in the throat can cause choking and is a medical emergency
that needs immediate attention.
 The foreign body can get stuck in many different places within the airway.
According to the American Academy of Pediatrics, death by choking is a
leading cause of death and injury among children younger than 4 years of age
 Children under the age of 4 years are in the greatest danger of choking on
small objects, including: Seeds, Toy parts, Grapes, Hot dogs, Pebbles, Nuts,
Buttons and Coins
Children need to be watched very closely to prevent a choking emergency
Symptoms
Foreign body ingestion needs immediate medical attention. The following are the most common symptoms
that may mean a child is choking:
 Choking or gagging when the object is first inhaled
 Coughing at first
 Wheezing (a whistling sound, usually made when the child breathes out)
Although the initial symptoms listed above may resolve, the foreign body may still be blocking
the airway. The following symptoms
•Stridor (a high-pitched sound usually heard when the child breathes)
 Cough that gets worse
 Child unable to speak
 Pain in the throat area or chest
 Hoarse voice
 Blueness around the lips
 Not breathing
 The child becoming unconscious
Treatment
Treatment of the problem varies with the degree of airway blockage.
If the object is completely blocking the airway, the child will be unable to
breathe or talk and his or her lips will become blue.
This is a medical emergency and you should seek emergency medical
care.
Do basic life support treatment for choking .
Sometimes, surgery is needed to remove the object.
Children who are still talking and breathing but show other symptoms
also need to be evaluated by a healthcare professional immediately
Prevention
•Cut foods into small pieces
•Never let small children run, play, or lie down while eating
•Keep coins and small items out of reach of your children
•Read warning labels on toys
•Learn first aid for choking
Burns
Burn is a type of injury to the flesh caused by heat, electricity,
chemicals, fire, radiation or friction.
 A common cause of preventable injury, especially in children
 Most affect only the skin, but sometimes deeper structures are
affected.
 Children ≤ 2yrs more affected
 Boys more affected than girls
 Scalds are burns caused hot liquids
Classification of Burns
 Can be classified in various ways:
Cause of burn
Depth of burn
Surface area
Severity
Cause of injury
 Heat
 Electrical
 Chemical
 Fire
 Radiation
 Friction
 Lightning
Depth of burns
1. First degree Epidermis- Redness (erythema) Dry,Painful,1week or less
2. Second degree (Partial thickness) Extends into the dermis, Superficial -
Clear blisters, Deep - Red or white with bloody blisters. Moist,Painful
3. Third degree Third degree (Full thickness) Involves all layers, including
appendages Leathery and white/brown Dry, leathery Painless Requires
excision and grafting
4. fourth degree - Extends beyond the skin to the muscles and bone.
Appears black and charred.
Severity
 Based on a number of factors, including total body surface area burnt, the
involvement of specific anatomical zones, age of the person and associated
injuries.
 Minor burn (Can be managed as out patient)  First degree burn  Partial
thickness burn involving <10% of total body surface area
 Major Burn (Requires hospital admission)  Partial thickness burn involving
>10% of total body surface area  Any full thickness burn  Burns involving the
hands, face, feet, or perineum  Burns that cross joints  Circumferential burns 
Electrical burns  Burns associated with inhalational injury, fractures or other
trauma  Burns in infants  Burns in persons at high-risk of developing
complications
Rule of nine in infant
Rule of Nines for Infant (Age < 1 year)
Rule of 9 in children

Role of Nines for Children (Age 1-14 years)

Emergency management
  First, remove cause of burn if still present
  Airway  Facial burns with upper airway involvement require early
intubation b/c it usually worsens over time
  Breathing  Rapid assessment of respiratory effort, chest expansion,
breath sound  Pulse oximetry, Arterial blood gases  100% O 2
mandatory for severe burns
  Circulation  Quick assessment of circulation- pulses, extremities,
CRT, heart rate, mental status,  Initial fluid resuscitation for all severe
burns (see below)  Secondary survey  Look for associated injury 
Investigation  FBC, coagulation profile, CXR (may be delayed),
ECG etc.
Outpatient management
 Minor burns can be managed as an outpatient
Clean with warm saline or soap water
Leave blisters intact
Apply topical antibacterial agent eg. Silver sulfadiazine, bacitracin,
mafenide, aqueous silver nitrate
Light dressing
Twice daily dressing  Analgesic (NSAID)  Daily follow up
 All major burns must be managed in the hospital
  Fluid Therapy Parkland’s formula  1 st 24hrs: crystalloids(Ringer’s lactate) at
4ml/kg /% burn surface area  ½ given over 8 hrs and ½ over remaining 16hrs 
Calculation of time starts from time of burn Colloids(albumin, plasma) may be
introduced at this point  Dextrose may be added in the 1 st 24hrs in younger
children
 Monitor Urine output closely and adjust fluid as indicated.  1ml/kg body
weight/hr is adequate urine output , monitor electrolyte closely.
  Antibiotic therapy -Topical and systemic antibiotics  Frequent examination of
injury for signs of infection  Regular culture of wound swabs
 Pain management  Reduction of pain is very important to make child calm  Cover
with clean sheet as even cool air movement increases pain.  Adequate anlgesia  IV
analgesic more effective than IM and oral  Anxiolytic may be added to the analgesic
Other management considerations  Tetanus toxoid boster  ATS for the
unimmunized  Temperature regulation  Blood glucose monitoring
Snake bite
It results in punctured wounds caused by the fangs of a snake
3 million bites and 1,50,000 deaths/year from venomous snake
worldwide.
Bites highest in temperate and tropical regions.
3000 species of snakes, out of them only 10-15% of snakes are
venomous
97% of all snake bites are on the extremities
Common Snakes - INDIA
Cobras(nagraj) –Neurotoxicity

Common krait – Neurotoxic

Saw scaled viper- Hemotoxic

Non Poisonous Snakes
Head - Rounded
Fangs - Not present
Pupils - Rounded
Anal Plate - Double row
Bite Mark - Row of small teeth.
Poisonous Snakes
Head – Triangle
Fangs – Present
Pupils - Elliptical pupil
Anal Plate - Single row
Bite Mark - Fang Mark
 Clinical manifestations
History of bite
Two wounds produced by snake fangs
Moderate envenomation
Severe pain
Edema spreading towards trunk
Petechiae and ecchymosis limited area
Nausea,vomiting,giddiness

Mild temperature
Severe envenomation
◦ Within 12 hours edema spreads to the extremities and part of trunk.
◦ Petechiae and ecchymosis may be generalized
◦ Tachycardia
◦ Hypotension
◦ Subnormal temperature
Envenomation very severe
◦ Sudden pain rapidly
◦ Progressive swelling which leads to ecchymosis all over trunk
◦ Bleb formation and necrosis
◦ Systemic manifestations within 15 min after the bite
◦ Weak pulse, vertigo
◦ Convulsions, coma
Management
First aid
Reassurance
Immobilization of affected limb
Transfer to medical facility
Tourniquets should be never be left in place too long
for fear of distal avascular necrosis
Clean the area with saline and sterile dressing
Specific therapy
Antivenom – if severe envenomation present
Dose – 50 ml for mild
100ml for moderate
150ml in severe case
Timing – best effect within 4 hours of bite
can give up to 48 hours
Supportive therapy
Blood transfusion in case of bleeding
Dopamine in case of shock
Mechanical ventilation in case of respiratory failure
Dialysis in case of renal failure
Antibiotic therapy
Immunoglobulin
TT