The H's
Treatment for hypovolaemia
1. Fluid balance assessment (think dehydration table!)
2. IV or IO crystalloid (e.g. 0.9% Sodium Chloride) may be used initially for resuscitation as a bolus of 10 mL/kg. Additional boluses should be titrated against the response.
3. Document in/out and ongoing loss (fluid balance chart)
Treatment hypoglycaemia
If conscious/can tolerate orals = <25kg 15g glucose gel or 125ml orange juice (>25kg double dose)
If unconscious:
1. IV access
2. Glucose - 10% 2ml/kg IV bolus
3. Fluid maintenance + slow-release carbohydrates *eg sandwich
4. Repeat BGL in 15-30mins // consult if not resolving
5. Find cause - RCH has great pathway!
Treatment Toxins
1. Supportive care
2. Poisons hotline
3. Antidote if available
4. Close monitoring (including serum levels)
Drowning
1. Primary survey
2. Respiratory support if SpO2 >95%, or poor resp effort
3. Consider hypothermia - remove wet clothes *consider therapeutic hypothermia if hypoxic brain injury
4. Observe 8hrs once stable
5. Water safety info to parents // referral to social work if deemed appropriate
*adverse prognostic factors - submersion time >5mins, BSL onset >10mins, GCS<5, rectal temo <30, arterial blood pH <7.1
Treatment for hypokalaemia
1. If < 3.0 mmol (or 3.5 w S+S) = replace K
*Oral dosing preferred unless ECG changes
oral dose = 1-2mmol/kg oral (max 5mmol/kg/daily)
IV dose = 02/-0.4mmol/kg/hour over 3hrs
*Infusions should only be given by infusion pumps and frequent (every 30 to 60 minutes) serum monitoring with continuous electrocardiogram (ECG) monitoring.
Treatment cardiac tamponade
1. Recognition (Becks triad)
2. Imaging - bedside echo
3. Needle pericardiocentesis
Sepsis
1. Vascular access - bloods // consider urinalysis +/- LP
2. Empirical abx // benpen & cefotaxime/ceftriaxone (RCH)
3. IV fluid within 30mins
4. Inotrop/vasopressor support within 60mins // adrenaline inf (RCH)
*consider resp support (there is a hihg risk of CA with use of induction agents in children w septic shock)
Treatment for hyperkalaemia
If >5.5mmol-6mmol = salbutamol nebs, bicarbonate if met acidosis, resonium PR/oral if moderate to severe
If 6.1-7.0+mmol = add cardiac monitoring + calcium IV +insulin & dextrose
*Calcium gluconate 10%: 0.15 mmol/kg, maximum 6.6 mmol. (0.68 mL/kg, max 30 mL), slow IV/intraosseous injection over 2-5 minutes if unstable, 15-20 minutes if stable. (RCH)
Treatment thrombosis
Compared to the adult population, there is less evidence defining paediatric populations at risk of thrombosis and even less evidence informing optimal treatment protocols.
Primary prophylactic anticoagulation is recommended for the following conditions:
- Prosthetic Valves
- Pulmonary Hypertension
- Cardiomyopathy
- Children admitted with major (>30%) burns who have a central venous line insitu.
anticoagulation = Unfractionated heparin 20 units/kg/hour
*RCH from Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease: A Scientific Statement From the American Heart Association
Trauma
*Massive haemorrhage is a common cause of TCA.
1. Primary survey
2. Stop bleeding - The initial treatment for external massive bleeding is direct pressure (if possible, using haemostatic dressings). Depending on the site, external bleeding may be appropriately managed with application of a tourniquet. Consider TXA.
2. Replacement of bloods/fluids
3. Paeds surg
*Note TWELVE-C for airway ax in trauma survey
*Regardless of the need for airway support, all spontaneously breathing patients should have high-flow oxygen applied (typically 10-15 L via non-rebreather mask) (RCH)
Treatment hypothermic arrest
Actively rewarm (aim >32degree) - escalation:
1. bair hugger, warm blankets, thermal mattress -> warm IV fluids -> gastric/blagger lavage w 40degree NACL -> Ventilate w humidified gas heated to 42degrees -> pleural/pericardial lavage -> ECMO
*warm no faster than 2degrees p/hr + inspect skin for thermal injury
(*PCH guideliens)
Treatment (tension) pneumothorax
Request a portable chest X-Ray
In intubated children, insert an orogastric tube to prevent gastric dilatation which can impair effective ventilation
Types of pneumos:
Congenital Heart Disease
Biggest concern...
Pulmonary hypertension - up to 10% of all congenital heart disease (AHA)
Standard PALS techniques may be ineffective in cardiac arrest in children with pulmonary hypertension.
1. Reversible causes of increased pulmonary vascular resistance (cessation of usual medication, hypoxia, hypercarbia, cardiac arrythmias, cardiac tamponade, drug toxicity) should be sought and treated. Treatment with pulmonary vasodilators should be considered in combination with CPR.
2. Start ECMO ASAP - ANZCOR suggests that, in children who develop signs of pulmonary hypertensive crisis, low cardiac output, or right ventricular failure despite optimal medical therapy, extracorporeal membrane oxygenation (ECMO) may be considered before cardiac arrest or for refractory cardiac arrest as a bridge to recovery or as a bridge to the evaluation for organ replacement and transplantation in very select cases.
3. Paediatric surg consult!!!