Management of Rare Pediatric Emergencies in the Emergency Department

Introduction:

Health professionals usually come across pediatric emergencies if the underlying condition is left untreated. Assessment of children becomes challenging, as the clinical presentations in many cases may be masked; also, average values of vital signs vary with age, thus requiring adequate knowledge in diagnosing and treatment planning. Many cardiac arrests in pediatric practice follow respiratory failure; hence, meticulous care and timely intervention can prevent fatal outcomes.

What Are the Rare Pediatric Emergencies Encountered and How Are They Managed?

Upper Airway Obstruction:

Airway obstruction happens commonly in children, where foreign objects like coins, marble, food particles, or household stuff get stuck in the child’s throat or upper airways, blocking ventilation, causing suffocation, and making breathing difficult.

Causes:

• Acute laryngotracheobronchitis (croup) (inflammation involving the larynx, trachea, and bronchi - a serious respiratory infection seen in young children).

• Acute epiglottitis (inflammation of the epiglottis- tissue surrounding the windpipe).

• Retropharyngeal abscess (a bacterial infection involving the deep part of the backside of the throat).

• Acute allergic edema due to hair-dye poisoning.

• Diphtheria.

• Foreign body.

Clinical Features:

1. Acute Laryngeotracheobronchiolitis:

• Barking cough.

• Hoarse voice.

• Stridor.

• Congested pharynx.

2. Acute Epiglottitis:

• Fever.

• Drooling of saliva.

• Dysphagia (difficulty in eating).

• Muffled breath sounds.

• Cherry red epiglottis (It is basically a bacterial infection affecting children of two to six years of age, which causes swelling of the epiglottis and gives a fiery red appearance).

3. Retropharyngeal Abscess:

• Neck pain or stiffness.

• Stridor.

• Congested tonsils.

• Peritonsillar abscess (an infection of the tonsils that spreads to the nose and throat, causing accumulation of pus in the region surrounding the tonsils.

• Bulged posterior nasopharynx (swelling of the nasopharynx- the uppermost portion of the pharynx at the level of the soft palate).

4. Acute Allergic Edema Due to Hair-Dye Poisoning:

• Angioedema (swelling of the skin caused due to allergy and is usually painless).

• Stridor (a high-pitched whistling sound, usually heard while taking a breath).

• Dysphagia (difficulty in breathing).

• Woody tongue (a bacterial infection of the tongue causing pain and swelling of the tongue).

5. Diphtheria:

• Low-grade fever.

• Bull-neck, stridor.

• Dysphagia (difficulty in breathing).

• Drooling of saliva.

• Grey membrane over the tonsils.

6. Foreign Body Aspiration:

• Sudden choking.

• Stridor.

• Decreased breathing sounds.

Diagnosis:

Chest X-ray, lateral nasopharynx X-ray, blood culture, blood gas analysis, and urine chromatography are used as diagnostic tools to determine the underlying cause.

Management:

• If the obstruction is due to acute laryngotracheobronchitis (acute viral respiratory infection in infants involving trachea and larynx causing partial or complete obstruction), humidified oxygen of 6 to 8 L/min through a face mask or nasal prongs is administered.

• Lowering body temperature and maintaining adequate hydration, like supportive therapy, is instituted.

• Nebulization therapy using an Epinephrine racemic mixture of 0.05 ml/kg (millilitre per kilogram) to 0.5 ml of 2.25 percent in 2 ml saline is given, or l-Epinephrine (1:1000) of 0.5 ml /kg to 5ml/dose is repeated every 20 to 30 minutes.

• Dexamethasone 0.15 mg /kg six hourly is administered.

• Continuous monitoring is done until the situation comes under control.

• If the upper airway obstruction is due to epiglottitis, a blood culture is advised.

• IV (intravenous) antibiotic therapy like Chloramphenicol of 100mg/kg/day or Ceftriaxone of 100mg/kg/day is administered.

• A tracheostomy is initiated if the obstruction is severe.

• Intubation or mechanical ventilation is initiated if tracheostomy fails to prevent respiratory failure.

• If the obstruction is due to a retropharyngeal abscess, IV Benzylpenicillin (100,000 to 150,000 IU / kg/day is given, and severe cases are indicated for surgical intervention.

• If the obstruction is due to diphtheria, a throat swab is taken to confirm the diagnosis.

• IV Benzylpenicillin, 100,000 to 150,000 IU/kg/day, is given.

• IV or IM (intramuscular) diphtheria antitoxin of 20,000 to 120,000 IU single dose is administered after the skin test.

• If the obstruction is caused because of a foreign body, assistance should be taken in the case of responsive patients.

• For infants less than one year, five black blows and five chest thrusts (with head down are given.

• In children above one year and up to puberty, abdominal thrusts are done.

• In the case of unresponsive patients, advanced care is initiated by CPR (cardiopulmonary resuscitation).

• Every time, the airway has to be opened, and two breaths should be delivered. If the foreign body is seen, care should be taken to remove it.

• If the obstruction is due to hair dye poisoning, immediate hospitalization is required.

• Gastric lavage is initiated.

• Epinephrine and Dexamethasone are given.

• Cricotomy or tracheotomy is initiated as soon as possible if the airway is compromised.

Acute Severe Asthma:

Acute severe asthma or acute exacerbations of asthma are characterized by acute episodes of rapidly worsening shortness of breath, cough, wheezing, chest tightness, or can also be a combination of these symptoms. An acute severe exacerbation of asthma usually does not respond to conventional therapy.

Causes:

• Recurrent viral respiratory tract infections.

• Exposure to allergens.

• Ineffective management of underlying asthma.

Clinical Features:

• Severe respiratory distress.

• Inability to talk or drink.

• Tachypnoea (reduced heart rate).

• Severe tachycardia (increased heart rate).

• Impaired consciousness.

• Pulsus paradoxus (sudden fall of blood pressure by 10 mm of Hg, usually during inspiration).

• Exhaustion.

Diagnosis:

• Lung function tests are advised.

• Reduced FEV1 (forced expiratory volume), which is the amount of air expelled by a person in one second, which is less than 20 percent; reduced PEFR (peak expiratory flow rate) is the volume of air expelled out in one quick exhalation, less than 20 percent and decreased oxygen saturation below 90 percent gives a diagnostic clue.

Management:

• Continuous monitoring is done in I.C.U (intensive care unit).

• Humidified oxygen at 6 to 10 L / minute is administered.

• Continuous nebulization is given by administering Salbutamol of 0.25 mg/kg/hour.

• I.V. Hydrocortisone is given 2 to 4 mg/kg/dose every four hours.

• Ipratropium hydrochloride of 15 mcg in 3 ml saline over five to seven minutes is given every four to six hours.

• Subcutaneous Adrenaline of 0.5 ml (1: 10000) is given every half an hour to one-hour duration.

• I.V. Magnesium sulfate of 50 to 100 mg/kg is given.

• If the airway is compromised, mechanical ventilation is initiated.

Respiratory Failure:

Respiratory failure occurs when adequate oxygen is not supplied from the lungs to the body through the circulatory system and also because of inefficient removal of carbon dioxide from the blood.

Causes:

• Upper airway obstruction.

• Acute severe asthma.

• Bronchiolitis.

• Severe pneumonia.

• Pulmonary edema.

• Drowning.

• Infection of CNS (central nervous system).

• Drug overdose.

• Stroke.

• Traumatic brain injury.

• Sepsis.

Clinical Features:

Type 1 respiratory failure occurs when the lung tissue is damaged, leading to inadequate oxygenation of tissues. Some of the symptoms of type 1 respiratory failure are given below.

• Anxiety.

• Severe tachypnoea (abnormally rapid breathing).

• Tachycardia (increased heart rate).

• Pallor (paleness of the skin, mucosa usually occurs secondary to anemia- lack of hemoglobin).

Type 2 respiratory failure is caused when optimum carbon dioxide excretion is failed due to improper alveolar ventilation. Symptoms include,

• Cyanosis (bluish discoloration of the skin, lips, and nails due to inadequate oxygen levels in the blood).

• Bradycardia (decreased heart rate).

• Altered mental status.

• Cardiac arrest.

Diagnosis:

The diagnosis is based on ABG (arterial blood gas) analysis.

Type I respiratory failure usually presents with the following ABG analysis:

• Pa CO2 (partial pressure of carbon dioxide) less than 40 mm Hg.

• PaO2 (partial pressure of oxygen) less than 80 to 90 mm Hg.

Type II respiratory failure presents with, PaCO2 less than 50 mm Hg, and paO2 less than 60 mm Hg.

Management:

• The patient is admitted to ICU (intensive care unit).

• Intubation and mechanical ventilation are initiated.

• ECMO (extracorporeal membrane oxygenation) is done by perfusing tissues with oxygen, and similarly, carbon dioxide is removed.

• Oxygen therapy is administered.

• IV fluids are given to improve the blood flow to facilitate adequate oxygenation of tissues.

• Underlying conditions which manifest as risk factors for respiratory failure are treated.

Conclusion:

Pediatric emergencies are seldom encountered. However, when they do present, a strong interprofessional collaboration is required to manage the condition effectively. Delivering optimum care, assessing and managing the underlying condition, and effective management of the grave situation by taking adequate steps through the interprofessional approach can ward off critical emergencies.