Management of Emergencies and Trauma in Children

Clinical Description

All sick children must be triaged upon arrival. This should be done using the ABCCCD approach.

There are three triage categories:

• Emergency: Children must be assessed and treated immediately. Emergency signs include obstructed breathing, central cyanosis, severe respiratory distress, weak or absent breathing, signs of shock (cold hands with capillary refill >3 seconds, weak, fast pulse), slow (<60 bpm) or absent pulse, coma, convulsions, severe dehydration.
• Priority: Children not needing emergency treatment can be prioritized using 3TPRMOB. Tiny baby (<2 months old), temperature (very hot or cold), trauma, pallor, poisoning, pain (severe), respiratory distress (mild-moderate), restlessness, referral (urgent), malnutrition, oedema, burns.
• Queue: Non-urgent cases who can wait to be seen.

EMERGENCY MANAGEMENT IN CHILDREN

AIRWAY:

• Clearing and opening the airway:
• Suctioning:
• Only as far as you can see
• Positioning:
• If no trauma: use a chin lift and head tilt ü <12 months neutral position ü >12 months sniffing position
• If trauma use a jaw thrust. Also remember C-spine immobilization.
• NEVER use neck collars in children.
• Airway adjuncts:
• Oropharyngeal airway
• Nasopharyngeal airway
• Laryngeal mask airway
• Endotracheal intubation

ACUTE UPPER AIRWAY OBSTRUCTION:

Stridor: e.g., croup

• Keep the child calm
• Minimize invasive procedures
• Oxygen
• Steroids
• Prednisolone 2mg/kg PO (maximum 40mg) STAT OR
• Dexamethasone 600 micrograms/kg PO (maximum 12 mg) STAT
• Nebulized Adrenaline 1-2ml of 1:1000 in 2mls of 0.9% saline
• May need intubation

ANAPHYLAXIS:

Often caused by insect stings (bees), drugs and blood products

• Oxygen
• IM Adrenaline: is the PRIORITY; 0.01 ml/kg of 1:1000
• Nebulized Adrenaline 1-2ml of 1:1000 in 2mls of 0.9% saline
• IV Hydrocortisone 4mg/kg 6 hourly
• Chlorpheniramine IV:
• 6 months-6 years: 2.5 mg
• 6-12 years: 5mg
• 12-18 years: 10mg
• Nebulized Salbutamol for wheeze:
• <4 years: 2.5 mg
• >4 years: 5mg
• If also in shock: 10ml/kg 0.9% saline or ringer’s lactate over 20 minutes
• May need PICU admission for respiratory and ionotropic support

CHOKING

Encourage to cough. If ineffective cough and conscious

• 5 back blows
• Followed by 5 chest thrusts (infant), abdominal thrusts (>2 years) or Heimlich maneuver (older child)

If ineffective cough and unconscious

• Open airway, assess breathing, commence BLS

BREATHING:

• Look, listen, and feel: Are they breathing?
• If not breathing commence bag and mask ventilation
• If breathing assess:
• Effort
• Respiratory rate
• Evidence of increased work of breathing
• Efficacy
• Chest expansion
• Auscultation

Effect

• Evidence of cyanosis, oxygen saturations
• Heart rate
• Level of alertness

Detailed review of breathing

• Inspection
• Palpation
• Percussion
• Auscultation