06 Emergency Kuliah Emergency

8/8/2019 06 Emergency Kuliah Emergency

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EMERGENCYEMERGENCY

PEDIATRICPEDIATRIC

Dr. Idham Jaya Ganda, SpA(K)Dr. Idham Jaya Ganda, SpA(K)

PICU Subdiv. Child Health Dept

Medical Faculty, University of Hasanuddin

Dr. Wahidin Sudirohusodo HospitalMakassar
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DENGUE SHOCKDENGUE SHOCK

SYNDROMESYNDROME


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ETIOLOGYETIOLOGY

Dengue VirusDengue Virus

UnclearUnclear

The Secondary HeterologousThe Secondary Heterologous

Infection HypothesisInfection Hypothesis

PATHOGENESISPATHOGENESIS


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CLINICALCLINICAL

MANIFESTASIONMANIFESTASION Fever: acute, high, continuously,Fever: acute, high, continuously,

2-7 days2-7 days Bleeding manifestationBleeding manifestation

Liver enlargementLiver enlargement

ShockShock


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LABORATORIUMLABORATORIUM

Thrombocytopenia ( 100.000/mm Thrombocytopenia ( 100.000/mm33 oror

less)less)

Hem concentration ( Hct 20% or more)Hem concentration ( Hct 20% or more)


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CLASSIFICATIONCLASSIFICATION

WHO CLASSIFICATION OF DHF (1975)WHO CLASSIFICATION OF DHF (1975)

Grade IGrade I

Fever, Tourniquet test (+)Fever, Tourniquet test (+) Grade IIGrade II

Grade I + spontaneous bleedingGrade I + spontaneous bleeding Grade IIIGrade III

Grade II + Circulatory failureGrade II + Circulatory failure Grade IVGrade IV

Profound shockProfound shock

Grade III & IVGrade III & IVDSSDSS


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TREATMENT DBD derajat III & IV

1. Oksigenasi (berikan O2 2-4 l/menit)

2. Penggantian volume plasma (cairan kristaloid isotonis)

Ringer laktat/NaCl 0,9 % / Asering

20 ml/kgBB secepatnya (bolus dalam 30 menit)

Evaluasi 30 menit, apakah syok teratasi ?

Syok teratasiSyok tidak teratasi

Kesadaran membaik

Nadi teraba kuat

Tekanan nadi > 20 mmHg

Tidak sesak nafas sianosis

Ekstremitas hangat

Diuresis cukup 1 ml/kgBB/jam

Kesadaran menurun

Nadi lembut / tidak teraba

Tekanan nadi < 20 mmHg

Distres pernafasan / sianosis

Kulit dingin dan lembab

Ekstremitas dingin

Periksa kadar gula darahCairan dan tetesan disesuaikan

10 ml/kgBB/jam

Pantau tanda vital tiap 10 menit

Catat balans cairan selama pemberian intravena

Lanjutkan cairan

20 ml/kgBB/jam

Evaluasi ketatTanda vital

Tanda perdarahan

Diuresis

Hb, Ht, trombosit

Tambahkan koloid/plasma

Dekstran/FPP

10-20 (max 30) ml/kgBB/jam

Stabil dalam 24 jam/Ht < 40

Tetesan 5 ml/kgBB/jam

Syok teratasi

Syok belum teratasi

Koreksi asidosis

Evaluasi 1 jam

Ht turun Ht tetap tinggi/ naikTetesan 3 ml/kgBB/jam

Infus stop tidak melebihi 48 jam

setelah syok teratasi

Tranfusi darah

Segar 10 ml/kgBB

diulang sesuai kebutuhan

Koloid 20 ml/kgBB


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MONITORINGMONITORING

Vital signsVital signs HctHct


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SEPTIC SHOCKSEPTIC SHOCK


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DEFINITIONDEFINITION

Septic syndromeSeptic syndrome

HypotensionHypotension

Responsive toResponsive to

treatmenttreatment


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ETIOLOGYETIOLOGY Neonates:Neonates: E. coliE. coli,, StaphylococcusStaphylococcus

aureusaureus,, Streptococcus group BStreptococcus group B.. Child:Child: Streptococcus pneumonia, H.Streptococcus pneumonia, H.

influenzae group B, Salmonella, S.influenzae group B, Salmonella, S.aureus Stre tococcus rou A.


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Patofisiologi terjadinya syok septik

Infeksi Bakteri

Endorfin Produk Bakteri

mis. endotoksinAktivasi Komplemen

Makrofag

SitokinFaktor Jaringan

Aktivasi PMN.

Pelepasan PAF, produkArakidonat dan

Substansi toksik lainAktivasi

koagulasi

fibrinolisis

Aktivasi

kalikreinkinin

Vasodilatasi,

Kerusakan endotel

kapiler

Syok SeptikKebocoran kapiler,

kerusakan endotel

Kegagalan Organ Berganda


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CLINICALCLINICAL

MANIFESTATIONMANIFESTATION ChillingChilling TachycardiaTachycardia Hyperventilation/tachypneaHyperventilation/tachypnea

HypotensionHypotension ApateticApatetic AgitationAgitation Bleeding manifestation (petechiae, purpura,Bleeding manifestation (petechiae, purpura,

etc)etc) Neonates with immune disorder: unspecificNeonates with immune disorder: unspecific

(lethargy, vomiting, abdominal pain,(lethargy, vomiting, abdominal pain,h otermia h ertermiah otermia h ertermia


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DIAGNOSISDIAGNOSIS Clinical manifestationClinical manifestation

Risk factorRisk factor Focus of infectionFocus of infection

Laboratory examination (bloodLaboratory examination (bloodsmear culture


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TREATMENTTREATMENT

Infection control :Infection control : ampicillin & aminoglycosideampicillin & aminoglycoside

Blood culture & sensitivity testBlood culture & sensitivity test

Recovering tissue perfusion :Recovering tissue perfusion : fluid resuscitation, acidfluid resuscitation, acid

base correction, cardiovascular medicines.base correction, cardiovascular medicines. Respiratory function support :Respiratory function support : oxygen/ ventilatoroxygen/ ventilator

Renal support :Renal support : diuretic medicines (furosemide)diuretic medicines (furosemide)

CorticosteroidCorticosteroid


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DIARRHEA WITHDIARRHEA WITHDEHIDRATIONDEHIDRATION


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Watery stoolWatery stool

FrequencyFrequency 3X/ 243X/ 24

hours.hours.


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DEHYDRATION TYPESDEHYDRATION TYPES

IsotonicIsotonic

Na concentration 130-150meq/L orNa concentration 130-150meq/L or

280 mosm/L280 mosm/L

Hypertonic:Hypertonic:

Na concentration > 150meq/L orNa concentration > 150meq/L or

413 mosm/L413 mosm/L

Hypotonic:Hypotonic:

Na concentration


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DEHYDRATION GRADEDEHYDRATION GRADE

Cumulative losses (pwl, cwl, nwl)Cumulative losses (pwl, cwl, nwl)

Mild : 5%Mild : 5%

Moderate : 5-10%Moderate : 5-10%Severe : >10%Severe : >10%

Clinical manifestation ( scoring system)Clinical manifestation ( scoring system)


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Pemeriksaan

Angka Penilaian

1 2 3

Gambaran Klinik

Keadaan umum

Mata

MulutPernapasan

Turgor

Nadi

Baik

Normal

Normal20-30 per menit

Baik

Kuat / kurang

120 per menit

Lesu/haus

Cekung

Kering30-40 per menit

Kurang

120-140

per menit

Gelisah/renjatan

Sangat cekung

Sangat kering40-60 per menit

Jelek

Lebih 140

per menit

Derajat dehidrasi skor 6

diare tanpa

dehidrasi

skor 7-12

diare dehidrasi

ringan/sedang

skor 13 / lebih

diare dehidrasi

berat


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TREATMENTTREATMENT

Fluid therapy (Ringer Lactat orFluid therapy (Ringer Lactat or

Ringer Asetat)Ringer Asetat)

Antibiotic therapyAntibiotic therapy

Acidosis therapyAcidosis therapy


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Umur

Cara Pemberian

Permulaan Lanjutan

Diare

Infantil

- PWL 125 ml

- NWL 100 ml

- CWL 25 ml250 ml

Kolera

PWL 100 ml/kg

4 jam pertama

60 ml/kg

1 jam pertama

30 ml/kg

20 jam berikut

190 ml/kg

7 jam berikut

70 ml/kg

PWL 100 ml/kg

Bayi kurang

12 bulan

Anak sama atau lebih 12

bulan

1 jam pertama

30 ml/kg

jam pertama

30 ml/kg

5 jam berikut

70 ml/kg

2 jam berikut

70 ml/kg


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ASTHMATICASTHMATIC

STATESTATE


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A severe asthma exacerbationA severe asthma exacerbation

which is not responsive to drugswhich is not responsive to drugs

that are usually given for asthmathat are usually given for asthma

exacerbation.exacerbation.


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ETIOLOGYETIOLOGY

MultifactorMultifactor

AllergenAllergen

RestlessnessRestlessness

EmotionEmotion

InfectionInfection

InheritedInherited


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PATHOGENESISPATHOGENESIS

Hyper responsiveness &Hyper responsiveness &

inflammation process of bronchusinflammation process of bronchus

Hyper secretionHyper secretion EdemaEdema

BronchoconstrictionBronchoconstriction


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fication of Severity of Acute Asthma Exacerb

Parameters

Mild Moderate Severe Respiratory

Arrest

Imminent

Breathlessness Whilewalking

While talking While at rest

Talks Sentences Phrases Words

Position Can liedown Prefers sitting Sits upright

Alertness May beagitated

Usually

agitated

Always

agitated

Confused/

drowsy

Cyanotic - - + +++

Wheeze Moderate,often only

end

expiratory

Loud,

throughout

expiratory

inspiratory

Extremely loud,

can be heard

without

stethoscope

Absence of

wheeze


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Breathlessness Minimal Moderate Severe

Use of accessory

muscles

Usually not Commonly Always

Retractions Shallow,intercostals

Moderate, +

suprasternal

Deep, +

flare of alae

nasi

-

Respiratory rate Increased Increased Increased Decreased

Guide to rates of breathing in awake children:Age: Normal rate:

< 2 month < 60 / minute2-12 months < 50 / minute

1-5 years < 40 / minute

6-8 years < 30 / minute


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Pulse Normal Tachycardia Tachycardia Bradycardia

Guide to normal pulse rates in children:

Age: Normal rate:

2-12 months < 160 / minute

1-2 years < 120 / minute3-8 years < 110 / minute

Pulsus

Paradoksus

None

< 10 mmHg

(+)

10-20 mmHg

(+)

> 20 mmHg

None

PEFR or FEV1

-before b.dilator-after b.dilator

(% pedicted

value)> 60%

> 80%

( % best value)

40-60%60-80%

< 40%

< 60 %respons < 2

jam

SaO2 > 95% 91-95% 90%

PaO2 Normal > 60 mmHg < 60 mmHg

PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg


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CLINICALCLINICAL

MANIFESTATIONMANIFESTATION

CoughCough

WheezingWheezing

Tachypnea

Tachypnea

DyspneaDyspnea

Prolonged expirationProlonged expiration

RetractionRetraction

CyanosisCyanosis

TachycardiaTachycardia


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algorithmClinic/ER

Asses attack severity

1st managementnebulitation -agonis 3x, 20 min interval

3rd nebulitation + anticholinergic

Moderate attack(nebulization 2-3x,partial response)

give O2 asses: Moderate

ODC IV line

Mild attack(nebulization 1x,

complete response)

persist 1-2 hr:discharge

symptom reappear:Moderate attack

Severe attack(nebulization 3x,

no response)O2 from the startIV lineasses: Severe -

hospitalized CXR


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One Day Care (ODC)

Oxygen therapy Oral steroid Nebulized / 2 hour Observe 8-12 hours,if stabledischarge

Poor response in 12h,

admission

Admission room

Oxygen therapy Treat dehydration andacidosis

Steroid IV / 6-8 hours Nebulized / 1-2 hours Initial aminophylline IV,

then maintenance Nebulized 4-6x good response per 4-6 h

If stable in 24 hours discharge Poor response ICU

Dischargegive -agonist(inhaled/oral)

routine drugs viral infection:oral steroid

Outpatient clinic in24-48 hours

Notes:In severe attack, directly use -agonist + anticholinergic If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/timesOxygen therapy 2-4 l/min should be early treatment in moderate

and severe attack


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Figure. Jet nebulizerFigure. Jet nebulizer


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Figure. UltrasonicFigure. Ultrasonic

nebulizernebulizer


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DDrug dosage forrug dosage fornebulizernebulizer

DrugsNebulizer

Jet Ultrasound

NaCl 0.9% (ml) 5 10

2-agonist Alupent sol. 2% (gtt) Berotec 0.1% (gtt) Ventolin nebule (mL)

Bricasma respule (mL)

3 5

5

1

1

3-5

5

1

1

Time (minutes) 10 - 15 3 - 5


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TREATMENT IN PICUTREATMENT IN PICU

Medicines atMedicines at

ward isward is

continuedcontinued

MechanicalMechanical

ventilatorventilator


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ACUTE RESPIRATORYACUTE RESPIRATORY

FAILUREFAILURE


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Respiratory system is unable toRespiratory system is unable to

maintain its function hypoxia &maintain its function hypoxia &

hypercapnea.hypercapnea.


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ETIOLOGYETIOLOGY

Increasing of coIncreasing of co22

Ventilated disorder without lungs dysfunctionVentilated disorder without lungs dysfunction Ventilated disorder with lungs dysfunctionVentilated disorder with lungs dysfunction

Ventilated disorder of death spaceVentilated disorder of death space

C CCLINICAL


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CLINICALCLINICAL

MANIFESTATIONMANIFESTATION Symptoms of lungs disorderSymptoms of lungs disorder ::

wheezing, grunting, flaring of alae nasi,wheezing, grunting, flaring of alae nasi,

retraction, tachypnea, bradypnea, apnea,retraction, tachypnea, bradypnea, apnea,

cyanosis.cyanosis. Signs of heart disorderSigns of heart disorder ::

bradycardia/tachycardia,bradycardia/tachycardia,

hypotention/hypertention, cardiac arrest.hypotention/hypertention, cardiac arrest.

Symptoms of CNS disorderSymptoms of CNS disorder ::

apatic, headache, convulsion, coma.apatic, headache, convulsion, coma.


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TREATMENTTREATMENT

Airway (position, suction, ET)Airway (position, suction, ET) Breathing (oxygen)Breathing (oxygen) HumidificationHumidification

Bronchial washingBronchial washing PhysiotherapyPhysiotherapy RehydrationRehydration Causal therapyCausal therapy Specific therapy (mechanicalSpecific therapy (mechanical

ventilator)ventilator)


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EPILEPTIC STATUSEPILEPTIC STATUS


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Prolonged convulsion attackProlonged convulsion attack

(30 minutes or more)(30 minutes or more)

Recurrent convulsion in a short timeRecurrent convulsion in a short time

as ifas ifno recoveryno recovery


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ETIOLOGYETIOLOGY Febrile convulsionFebrile convulsion

IdiopathicIdiopathic

SymptomaticSymptomatic


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PATHOFISIOLOGYPATHOFISIOLOGY CompensationCompensation

DecompensationDecompensation


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Age Type of epileptic state Features

Neo-

nates

Neonatal epileptic state

Neonatal syndromesepileptic

early infantile epilepticencephalopathy

neonatal myoclonicencephalopathy

benign familial neonatalseizures

- subtle, tonic,

clonic,myoclonic,apneic,fragmentary

- tonic- erratic, myoclonic- clonic

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION


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Infant &

Child

Febrile epileptic state

Infantile spasms (westsyndromes)State in childhoodmyoclonic syndromesState in benign partial

epilepsy

- convulsive or

hemiconvulsive (tonic-clonic)

- salaam attacks- myoclonic + absence- complex partialseizures

Child &Adult

Tonic-clonic epileptic stateAbsence epileptic stateContinue partially epilepticMyoclonic epileptic state in

comaMyoclonic epileptic statesyndromesComplex partial epilepticstateEpileptic state in mental

retardation

- tonic-clonic, subtle- absence- simple partial- myoclonic

- myoclonic- complex partial- atypical absence, tonic,minor motor


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TREATMENTTREATMENT

Initial treatment (stabilization)Initial treatment (stabilization) PositionPosition ABCABC

Vital signs monitoringVital signs monitoring

Blood glucose & electrolyteBlood glucose & electrolyte

AnticonvulsanAnticonvulsan Benzodiazepine ( diazepam, midazolam)Benzodiazepine ( diazepam, midazolam)

PhenytoinPhenytoin

PhenobarbitalPhenobarbital

Cardiorespiratory & EEG monitoringCardiorespiratory & EEG monitoring

Refracted treatmentRefracted treatment Barbiturate (Phenobarbital, thiopental)Barbiturate (Phenobarbital, thiopental)

Propofol & midazolamPropofol & midazolam


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INTUSSUSCEPTIONINTUSSUSCEPTION


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A condition where a section oA condition where a section of

intestine telescope into its selintestine telescope into its self(proximal segment telescope into(proximal segment telescope intodistal se ment of intestine .

PATHOFISIOLOGYPATHOFISIOLOGY


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PATHOFISIOLOGYPATHOFISIOLOGY

IntussusceptionsIntussusceptions


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CLINICALCLINICAL

MANIFESTATIONMANIFESTATION ColicColic

VomitingVomiting Bloody stool , currant jelly stool & terryBloody stool , currant jelly stool & terry

stoolstool

Sausage-shaped massSausage-shaped mass

Pseudo ortioPseudo ortio


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DIAGNOSISDIAGNOSIS ClinicalClinical

manifestationmanifestation

RadiologyRadiologyassessment:assessment:

Doughnut signDoughnut sign

Target signTarget sign Cu in si nCu in si n


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TREATMENTTREATMENT

Radiology reductionRadiology reduction

SurgerySurgery


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DIAPHRAGMATICDIAPHRAGMATIC

HERNIAHERNIA


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An abnormal opening in theAn abnormal opening in the

diaphragm that allow part odiaphragm that allow part of

abdominal organs to migrate into theabdominal organs to migrate into the

chest cavit .chest cavit .


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ETIOLOGYETIOLOGY Improper fusion of the canal ofImproper fusion of the canal of

pleuroperitonealpleuroperitoneal MedicinesMedicines

Abnormal development of thoracicAbnormal development of thoracicm sencime

CLINICALCLINICAL


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CLINICALCLINICAL

MANIFESTATIONMANIFESTATION DyspneaDyspnea

TachypneaTachypnea

CyanosisCyanosis

Asymmetry of the chest wallAsymmetry of the chest wall

TachycardiaTachycardia

Scapoid abdomenScapoid abdomen

Breath sound loosing at defectBreath sound loosing at defectsideside


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DIAGNOSISDIAGNOSIS Clinical manifestationClinical manifestation

Radiology examinationRadiology examination


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TREATMENTTREATMENT

Oxygen (ET), position, stop oralOxygen (ET), position, stop oral

intakeintake SurgerySurgery


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06 Emergency Kuliah Emergency