[PDF] Clinical Manual of Emergency Pediatrics

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ClinicalManualof

EmergencyPediatrics

FifthEdition

ClinicalManualof

EmergencyPediatrics

FifthEdition

Editors

EllenF.Crain

JeffreyC.Gershel

AssociateEditor

SandraJ.Cunningh am

CAMBRIDGEUNIVERSITY PRESS

Cambridge,NewYork ,Melbourne, Madrid,CapeTown,Singapore,

SãoPaulo,Delhi, Dubai,Tokyo, MexicoCity

CambridgeUniversityPress

TheEdinburghBuilding, CambridgeCB28RU, UK

Publishedinthe UnitedStatesof Americaby

CambridgeUniversityPress, NewYork

www.cambridge.org Informationonthistitle:www.camb ridge. org/978052 1736879 #CambridgeUniversityPress2010 Thispublica tionisincopyright.Subjecttos tatutor yexceptio n andtothepr ovisio nsofr elevantcollectivelicensingagreements, norepr oductionofanypartmaytakeplacewit hout thewritten permissionofCambridgeUniversityPress.

Firstpublished 2010

Printedinthe UnitedKingdomat theUniversityPress, Cambridge Acatal ogrecordforthispu blicationisavai lablefromth eBritishL ibrary

LibraryofCongress Cataloging-in-PublicationData

Clinicalmanualof emergencypediatrics/ [editedby]Ellen Crain,

JeffreyC.Gershel. -5thed.

p.;cm.

Othertitle:Emergency pediatrics

Includesbibliographical referencesandindex.

ISBN978-0-521-73687-9 (Paperback)

1.Pediatric emergencies-Handbooks,manuals,etc.

I.Crain,Ellen F.II.Gershel, JeffreyC.III. Title:Emergency pediatrics. [DNLM:1.Emergenc ies-Handbooks.2.Child.

3.Emergency Medicine-methods-Handbooks.4. Infant.

5.Pediatrics -methods-Handbooks.WS 39C6412010]

RJ370.C552010

618.920025-dc222010016794

ISBN978-0-521-73687-9 Paperback

CambridgeUniversity Presshasno responsibilityforthe persistenceor accuracyofURLsforex ternal orthird-partyintern etwebsitesre ferredto inth ispublicatio n,anddoesnotguaranteethatanycont entonsuch websitesis,orwillremain ,accu rateor appropriate . Everyefforthas beenmadeinpreparingth isbook toprovidea ccurateand up-to-dateinformationwhichi sinaccordwithacceptedstandardsa nd practiceatthetimeof public ation.Althou ghcasehist oriesa redrawnfrom actualcases,ever yefforthasbeenmade todisguisetheid entitiesofthe individualsinvolved.Nevertheless, theauthors,editorsandp ublisherscan makenowarr antiestha ttheinformationcontainedher einistotally free fromerror,no tleastbecause clinicalstanda rdsareconstantl ychanging throughresearchandregula tion.Theauthors,editorsa ndpublisher s thereforedisclaimallliabilityf ordirectorconseque ntialdamag esresulting fromtheuseofmaterialcontainedinthisbook.Readersarestronglyadvised topaycar efulatte ntiontoinformation providedbythemanufacturerof anydrugso requipmentthatthey plantous e.

Contents

Listofcontribu torsx

Prefacexv

1.Resuscitation1

WaseemHafeez

Cardiopulmonaryresuscitation

overview1

Emergencydepartmentpriorities 1

Initialmanagement 5

Foreign-bodyairwayobstruction 6

Oxygenation,ventilation,and

intubation8

Rapid-sequenceintubation14

Circulation16

Medicationsandelectricaltherapy in

resuscitation20

Cardioversionanddefibrillation22

Shock23

2.Allergicemergencies30

StephanieR.Lichten

Anaphylaxis30

Angioedema34

Urticaria36

3.Cardiacemergencies 39

MichaelH.GewitzandPaul K.Woolf

Arrhythmias39

Atrialfibrillation 39

Atrialflutter 40

Sinustachycardia 41

Supraventriculartachycardia42

Ventricularpremature

contractions47

Ventriculartachycardia48

Ventricularfibrillation50

Heartblock 50

Pacemakeranddefibrillator

assessment53

Chestpain54

Congestiveheartfailure56

Cyanosis60

Cyanotic(Tet)spells61

Heartmurmurs 62

Infectiveendocarditis64

Pericardialdisease66

Syncope68

4.Dentalemergencies72

NancyDougherty

Dentalanatomy 72

Dentaleruption72

Dentalcaries andodontogenic

infections74

Oraltrauma77

Toothdiscoloration 80

Oralsofttissue lesions82

5.Dermatologicemergencies87

AlexandraD.McCollumand

SheilaF.Fri edlander

Definitionofterms 87

Acne91

Alopecia93

Atopicdermatitis96

Bacterialskininfections 98

Candida100

Contactdermatitis102

Diaperder matitis103

Drugeruptionsand severedrug

reactions107

Erythemaannulare111

Erythemamarginatum111

Erythemamultiforme111

Erythemanodosum112

Granulomaannulare113

Herpessimplex115

Hypopigmentedlesions118

Infestations:lice120

Infestations:scabies122

Neonatalrashes 123

Palpablepurpura126

Pityriasisrosea127

Psoriasis128

Tinea129

Verrucaeandmolluscum132

6.ENTemergen cies135

JeffreyKellerand StephanieR. Lichten

Acuteotitis media135

Cervicallymphadenopathy138

Epistaxis142

Foreignbodies144

Mastoiditis146

Neckmasses147

Otitisexterna 149

Parotitis150

Periorbitalandorbitalcellu litis151

Peritonsillarabscess153

Pharyngotonsillitis154

Retropharyngealabscess156

Serousotitis media157

Sinusitis157

Upperrespiratory infections159

7.Endocrineemergencies 161

JoanDiMart ino-Nardi

Adrenalinsufficiency161

Diabetesinsipidus165

Diabeticketoacidosis:EllenF.Cr ain

andSandra J.Cunningham168

Hypercalcemia:MorriMarkow itz174

Hyperkalemia176

Hypernatremia177

Hypocalcemia:MorriMarkowitz 180

Hypoglycemia183

Hyponatremia186

Thyroiddisorders189

8.Environmentalemergencies194

AnthonyJ.Ciorciar i

Burns194

Drowning199

Electricalinjuries 200

Frostbite203

Heat-excesssyndromes205

Hyperbaricoxygentherapy:

KatherineJ.Chou 207

Hypothermia210

Inhalationinjury212

Leadpoisoning 215

Lightninginjuries217

9.Gastrointestinalemergencies219

TeresaMcCann andJulieLin

Abdominalpain219

Acutepancreatiti s223

Appendicitis225

Assessmentandmanagementof

dehydration:EllenF.Cra inand

SandraJ.Cunningham 228

Colic234

Constipation235

Diarrhea239

Gallbladderandgallstonedisease 244

Hepatomegaly247

Intussusception248

Jaundice249

Liverfailure 253

Lowergastrointestinal bleeding256

Uppergastrointestinal bleeding259

Meckel'sdiverticulum 262

Pyloricstenosis263

Rectalprolapse 265

Umbilicallesions266

Viralhepatitis 268

Vomiting273

10.Emergenciesassociatedwith

geneticsyndromes278

RobertW.Marionand JoySa manich

Congenitalmalformations278

11.Genitourinaryemergencies283

SandraJ.Cunn ingham

Balanoposthitis283

Renalandgenitourinary trauma284

Meatalstenosis288

Paraphimosis288

viContents

Phimosis289

Priapism290

Scrotalswellings 291

Undescendedtestis295

Urinaryretention 296

Urethritis297

12.Gynecologicemergencies300

DominicHollman,Elizabeth M.

Alderman,andAnthony J.Ciorciari

Breastdisorders 300

Dysfunctionaluterinebleeding 304

Dysmenorrhea308

Pregnancyandcomplications310

Sexuallytransmitted diseases314

Vaginaldischargeand

vulvovaginitis325

13.Hematologicemergencies332

MarkWeinblatt

Anemia332

Hemostaticdisorders336

Thrombophilia340

Transfusiontherapy341

Theabnormal CBC342

Infectionandtheimmunocompromise d

host343

Leukemiaandlymphoma345

Lymphadenopathy347

Oncologicemergencies350

Sicklecell disease354

Splenomegaly359

14.Infectiousdiseaseemergencies 362

GlennFennelly andMichaelRosenberg

Botulism362

Catscratch disease363

Dengueviruses365

Encephalitis366

Evaluationofthefebrilechild :

EllenF.Cr ain370

HIV-relatedemergencies374

Infectiousmononucleosisand

mononucleosis-likeillnesses386

Infectiousdiseaseassociated

withexanthems388

Kawasakisyndrome395

Leptospirosis396

Lymedisease 398

Meningitis401

Mycoplasmapneumoniae

infections405

Nontuberculousmycobacteria

diseases407

Parasiticinfections:Christina

M.Coyle408

Pertussis414

Rickettsialdiseases416

Toxicshocksyndrome 420

Tuberculosis423

Diseasestransmitted byexposureto

animals(zoonoses) orarthropod vectors428

15.Ingestions433

StephenM.Blumberg andCarlKaplan

Evaluationofthepoisoned

patient433

Acetaminophen448

ADHDmedications 450

Anticholinergics451

Antidepressants453

Antipsychotics454

Betaagonists456

Betablockers 456

Caffeine458

Calciumchannelbloc kers459

Carbonmonoxide: Katherine

J.Chou 460

Caustics461

Cholinergics462

Clonidine464

Coughandcold medications465

Diabeticagents466

Digoxinandcardiacglycosides 467

Drugsofabuse 469

Ethanol471

Foreign-bodyingestion473

Hydrocarbons474

Inhalants475

Iron476

Contentsvii

Mothballs478

Nonsteroidalanti-inflammatory

drugs479

Ratpoison480

Salicylates481

Toxicalcohols(ethylen eglycol,

methanol,andisopropanol) 483

Tricyclicantidepressants485

16.Neurologicemergencies487

SoeMar

Acuteataxia 487

Acutehemiparesis andstroke491

Acuteweakness 494

Breathholding498

Coma499

Facialweakness502

Headache504

Headtrauma509

Implantabledevices515

Increasedintracranialpres sure516

Seizures518

Sleepdisorders524

Ventriculoperitonealshunts525

17.Ophthalmologicemergencies528

CarolineLederman andMartin

Lederman

Anatomy528

Evaluation528

Decreasedvision529

Excessivetearing530

Eyelidinflammation 533

Oculartrauma535

Theredeye 541

Thewhitepupil (leukocoria) 545

18.Orthopedicemergencies547

SergeyKunkovandJamesMe ltzer

Backpain547

Fractures,dislocations,and

sprains552

Commonorthopedicinjuries557

Limp566

Osteomyelitis571

Splinting:KatherineJ.Chou573

19.Physicalandsexualabuse580

StephenLudwig,MaryMe hlman

andScott Miller

Physicalabuse580

Sexualabuse583

Chartdocumentation inchildabuse:

OlgaJimenez 587

Medicaltestimony andcourt

preparation:OlgaJimen ez591

Abandonmentandphysicalneglect594

20.Psychologicalandsocial

emergencies596

StephenLudwig,MaryMe hlman,

andScottMiller

Deathinthe emergency

department596

Psychiatricemergencies:Daniel

Mason597

Suddeninfantdeathsyndrome599

Suicide:DanielMason601

Munchausensyndromebyproxy602

Interpersonalviolence603

21.Pulmonaryemergencies606

EllenF.Cra inandSerge yKunkov

Asthma606

Bacterialtracheitis613

Bronchiolitis614

Cough616

Croup620

Epiglottitis622

Foreignbodyintheairway 624

Hemoptysis626

Pneumonia629

Pulseoximetry: Sandra

J.Cunningham 633

Respiratorydistressandfailure 634

22.Radiology638

DanBarlev,with RobertAcosta

Orderingradiologicexam inations638

23.Renalemergencies 644

SandraJ. Cunninghamand Preeti

Venkataraman,withBeatrice Goilav

Acuteglomerulonephr itis644

viiiContents

Acutekidney injury647

Hematuria651

Hemolyticuremicsyndrome653

Henoch-Schönleinpurpura655

Hypertension656

Nephrolithiasis660

Proteinuria662

Urinarytractinfect ions664

24.Rheumatologicemergencies668

MichaelGornandSvetlana Lvovich

Acuterheumatic fever668

Arthritis671

Henoch-Schönleinpurpura675

Juveniledermatomyositis677

Systemiclupuserythematosus679

25.Sedationandanalgesia 682

SandraJ.Cunn ingham

Proceduralsedationand

analgesia682

PSAmedications 685

Localanesthesia 691

Topicalanesthesia 692

Regionalanesthesia:Katherine

J.Chou 693

26.Trauma702

AnthonyJ.Ciorciar i

Cervicalspineinjuries702

Handinjuries 705

Multipletrauma710

Pericardialtamponade719

Pneumothorax720

27.Woundcareandmino rtrauma723

AnthonyJ.Ciorciar i

Abscesses723

Bitewounds724

Foreign-bodyremoval726

Insectbitesand stings728

Marinestings and

envenomations729

Rabies731

Scorpionstings733

Snakebites734

Spiderbites 736

Woundmanagement738

28.Specialconsiderations inpediatric

emergencycare745

Thecrying infant:DavidP.Sole 745

Thecritically illinfant:FrankA.

Maffei747

Childrenwithspecial healthcare

needs:JoshuaVova753

Failuretothrive:KirstenRoberts 764

Telephonetriage:LorenYellin768

Index771

CodeCard: WaseemHafeez

Contentsix

Contributors

RobertAcosta,MD

AssistantProfessorofPediatric s,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

ElizabethM.Alderman,MD

ProfessorofClinical Pediatrics,

AlbertEinstein CollegeofMedicine,

Children'sHospital atMontefiore,

Bronx,NY,USA

DanBarlev, MD

AssistantProfessorofRadiology,

StateUniversityofNewYorkatStonyBrook,

WinthropUniversityHospital,

Mineola,NY, USA

StephenM.Blumberg,MD

AssistantProfessorof Pediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

KatherineJ.Chou,MD

AssociateProfessorofCli nicalPediatrics

andClinical EmergencyMedi cine,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

AnthonyJ.Ciorciari,MD

AssociateProfessorof ClinicalEmergency

Medicine,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

ChristinaM.Coyle,MD

ProfessorofClinicalMedi cine,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,Bronx,NY,USA

EllenF.Crain, MD,PhD

ProfessorofPediatrics andEmergency

Medicine,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

SandraJ.Cunni ngham,MD

AssociateProfessorofCli nicalPediatrics

andClinicalEmerg encyMedicine,

AlbertEinst einCollegeofMedicine,

JacobiMedi calCenter,

Bronx,NY,USA

JoanDiMartino -Nardi,MD

ProfessorofClinical Pediatrics,

AlbertEinst einCollegeofMedicine,

NorthernWestc hesterHospitalCenter,

MtKisco, NY,USA

NancyDougherty, DMD,MPH

ClinicalAssociateProfess orofPediatric

Dentistry,

NewYorkUni versityCollegeof Dentistry,

NewYork,NY, USA

GlennFennelly, MD

AssociateProfessorofClinical Pediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

SheilaFallonFrie dlander,MD

ClinicalProfessorof Pediatricsand

Medicine,

UniversityofCaliforniaSanDiego School

ofMedicine,

RadyChildren 'sHospital,

SanDiego, CA,USA

JeffreyC. Gershel,MD

ProfessorofClinicalPediatri cs,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

MichaelH.Gewitz, MD

ProfessorofPediatrics,

NewYorkMedi calCollege,

MariaFareriChildren 'sHospitalat

WestchesterMedicalCenter,

Valhalla,NY,USA

BeatriceGoilav,MD

AssistantProfessorof Pediatrics,

AlbertEinstein CollegeofMedicine,

TheChildren'sHospital atMontefiore,

Bronx,NY,USA

MichaelGorn,MD

PediatricEmergencyMedicine,

St.Joseph 'sRegional MedicalCenter,

Paterson,NJ,USA

WaseemHafeez, MBBS

AssociateProfessorofCli nicalPediatrics,

AlbertEinst einCollegeofMedicine,

TheChildren'sHospital atMontefiore,

Bronx,NY,USA

DominicHollman,MD

AssistantProfessorofPediatric s,

MountSinaiMedical Center,

NewYork,NY, USA

OlgaJimenez, MD

AssistantProfessorofPediatric s,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

CarlKaplan, MD

ClinicalAssistantProfessor ofEmergency

MedicineandPediatrics,

StonyBrookUni versitySchoolofMe dicine,

StonyBrook,NY, USA

JeffreyKeller, MD

AssistantProfessorofOtolaryngo logy/Head

andNeckS urgery,

MountSinaiMedica lCenter,

MtKis coMedicalGroup,

MtKis co,NY,USA

SergeyKunkov, MD,MS

AssociateProfessorofPediatrics,

StonyBrookUnive rsitySchoolofMedi cine,

StonyBrook,NY ,USA

CarolineLederm an,MD

AssistantClinicalProfessor,

ColumbiaUniversity,Edward. S.Harkness

EyeInstitute ofNewYorkPresbyterian

Hospital,

NewYork,NY, USA

MartinLederman, MD

AssociateClinicalProfessor,

ColumbiaUniversity,Edward .S.Harkness

EyeInstitute ofNewYorkPresbyterian

Hospital,NewYork,NY, USA

StephanieR.Lichten,MD

AssistantProfessorof Pediatrics,

AlbertEinst einCollegeofMedicine,

JacobiMedi calCenter,

Bronx,NY,USA

JulieLin,MD

InstructorofP ediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedi calCenter,

Bronx,NY,USA

StephenLudwig,MD

ProfessorofPediatricsand Emergency

Medicine,

UniversityofPennsylvan iaSchoolof

Medicine,

Philadelphia,PA,USA

SvetlanaLvovich,MD

AssistantProfessorofPediatric s,

DrexelUniversityCollege ofMedicine,

Philadelphia,PA,USA

FrankA.Maffei ,MD

AssociateProfessorofPediatrics,

TempleUniversity SchoolofMedicine,

Listofcontributors xi

JanetWeisChildre n'sHos pitalatGeisinger,

Danville,PA,USA

SoeMar,MD

AssistantProfessorinNeurolo gyand

Pediatrics,

WashingtonUniversitySchool ofMedicine,

St.Louis ,MO,USA

RobertW.Marion,MD

Professor,PediatricsandObst etricsand

GynecologyandWomen'sHealth,

AlbertEinstein CollegeofMedicine,

TheChildren'sHospital atMontefiore,

Bronx,NY, USA

MorriMarkowitz,MD

ProfessorofPediatrics,

AlbertEinstein CollegeofMedicine,

Children'sHospital atMontefiore,

Bronx,NY, USA

DanielMason, MD

DepartmentofPsychiatry,

NorthernWestc hesterHospitalCenter,

MtKisco, NY,USA

TeresaMcCann, MD

AssistantProfessorof Pediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedi calCenter,

Bronx,NY,USA

AlexandraD.McCollum,MD

ClinicalResearchFellow,

PediatricandAdolescen tDermatolog y,

RadyChildre n'sHospital,

SanDiego, CA,USA

MaryMehlman, MD

ChiefResidentin Pediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

JamesMeltzer,MD

AssistantProfessorofPediatric s,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

ScottMiller,MD

InstructorinP ediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedi calCenter,

Bronx,NY,USA

KirstenRoberts, MD

AssistantProfessorof Pediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedi calCenter,

Bronx,NY,USA

MichaelRosenberg,MD

AssociateProfessorofCli nicalPediatrics,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

JoySamanich, MD

AssistantProfessor,Pediatri csandObste-

tricsand Gynecologya ndWomen'sHealth,

AlbertEinst einCollegeofMedicine,

TheChildren'sHospital atMontefiore,

Bronx,NY,USA

DavidP.Sole, DO

ClinicalAssistantProfessor ofEmergency

Medicine,

TempleUniversity,

SchoolofMedi cine,

Philadelphia,PA,USA

PreetiVenkataraman, MD

AttendingPediatrician,

JacobiMedical Center,

Bronx,NY,USA

JoshuaVova,MD

AssistantProfessorofPhysica lMedicine

andRehabilitation,

EmoryUniversity SchoolofMedicine,

Atlanta,GA,USA

MarkWeinblatt,MD

ProfessorofClinicalPediatri cs,

StonyBrookUniver sitySchoolofMe dicine,

xiiListof contributors

WinthropUniversityHospita l,

Mineola,NY,USA

PaulK.Woolf, MD

AssociateProfessorofPediatrics,

NewYorkMedi calCollege,

MariaFareriChildren'sHospitalat

WestchesterMedicalCenter,

Valhalla,NY,USA

LorenYellin,MD

AssistantProfessorofPediatric s,

AlbertEinstein CollegeofMedicine,

JacobiMedical Center,

Bronx,NY,USA

Listofcontributors xiii

Preface

Inthisfifth editionofthe ClinicalManualofEmergency Pediatrics,wehave endeavoredto remaintrue toouroriginal intention:to providea dependable,compr ehensive,portable handbookthatoffersco nciseadvice regardingtheapproachto themajorityofconditions seenina pediatricem ergencydepartm ent.Foreachtopic,we haveincludedessentialpoints andpriorities fordiagnosis,management, andfollow-upcare,as wellasindi cationsfor hospitalizationandabibliography toguidefurth erreading. Traditionally,manualssuchasthison ewerewrittenfortrainees, aswell asexperienced pediatricemergencyandem ergencymedicinephysicians,who needed asummaryofthe myriadconditions thatpresenttotheem ergencydepartment andaguideas tohowto differentiateamongthem.Now, however,primary careproviders areexpectedtomanag e acuteillnesses inambulatorysettings.Illchildren arehospitalized lessoften, andthey tend tobedischarg edback totheirprimarycareproviders soonerthaneverbefore. Inadd ition, increasingnumbersofchroni callyillandmedically fragilechild renarereceivingcarein ambulatorysites.Asa resultoftheseshifting practices,physici answorking insettingssuch asprivateoff icesandclinics maybefacedwithpoten tial,or real,pediatric emergencies. Thesecaregivers, aswellasemergencyphysicia ns,canbenefit from apracticalhand book. Sincethepublicat ionofthe firsteditionofthismanual, on-lineandportab leresources havebecome readilyavailable.Howeve r,manyarenotgeared topediatricconditionsor presentations.Itisourobservationthat thereisa lackofdetail, particularlywhen discussing differentialdiagnoses.Our hopeisthatthismanual, whichgatherstheneces saryfactsand managementrecommendationsin auser-friendly,easilyaccessibleman ual,willfaci litate decision-makingandsafecare. Inthefifth edition,we havemaintai nedthebook'suniquefeatures whilemakingmany changesthatincrease itsutility.Because thescopeof childhoodillnessesand injuriesseen in acutecaresetting sis constantlyincreasing,wehav erevised andupdatedeverychapter. We haveaddednew sectionson severalinfecti ousandrheumaticdiseasesthat hadbeen overlookedinprevious editions,along withsectionsonregionalanesthesi a,hyperkalemia, andnephrolithiasis. Theingestionandorthopedic sectionshave beencompletelyrevised andupdated,and thereis specificattention paidtoMRSA, whererelevant. Awordof cautionis inorder.A lthoughamanualforem ergencycare canbevery useful, itmaytem ptphysicians, particularlythosestillintraining ,tolookforautom aticsolutions. Itisno tourintent thatthistextbeusedas aprotocol book.We urgestudents and housestaffnottouse thismanualasasubsti tuteforthe irown criticalthinking and sensitivitywhencaringforchild renandtheir families. Weowe specialthanksto ourassociate editor,SandraJ. Cunningham,MD, forher contributionsanddiligentediting.He rcareful attention todetailgreatly improvedthe qualityofthe book.KatherineJ. Chou,MD ,andAnthony Ciorciari, MD,ourco lleaguesin pediatricemergencymedicine andtheDepartmentofEmergenc yMedicine,respectively, reviewedmuchofthe texttoensurethatrecommen dationswere updatedandevidence - based.Althought hequalityofthisfift hedition reflectsthehardworkof allt hecontributors , thefinalma nuscriptreflec tsourapproachtoanygivenillnessorprob lem,andweare responsibleforthebook'scon tent. Bywhat theyhavetaughtusandby theirexamp leweare especially gratefulto the pediatricemergencydepartment nurses,attendings,andnursepractiti onersattheJacobi MedicalCenter.We havebecomebetterteachersand caregiversby observingthem and theirinteractions withpatientsandfamilies. Weareparti cularlyindebted tothepediatricandemer gencymedicinehouse staffsand thepediatric emergencymedicinefellows attheJacobiMedicalCenter, andthemedical studentsoftheAlbertEins teinCollege ofMedicine whomw ehavehadtheprivilege of teachingandlearningfr omoverthe years.Theirthoughtfulquestion sprovidedtheimpetus forthismanua l. Thisbookis dedicatedtothe memoryofDr. LewisM.Fraad, ourbeloved mentor, whosenamehas beenmemori alizedinthe nameofour department,theLewisM.Fraad DepartmentofPediatricsat JacobiMedical Center.Dayinand dayouthe setanexamp le forallof usbycombi ningintellectual rigorwitha deeprespect forchildrenandtheir families.Hewillalwaysbe withusw henweare atour best.

EllenF. Crainand JeffreyC.Gershel

xviPreface

Chapter

1

Resuscitation

WaseemHafeez

Cardiopulmonaryresuscitationoverview

Cardiopulmonaryarrestin infantsandchildrenisrarely asudden event.Theusualprogres- sionofarres tis respiratoryfailure,cause dbyhypoxia andhypercarbia,whicheventually leadstoasystoli ccardiac arrest.Commonetiologiesthat mayleadto cardiopulmonaryarrest includesuddeninfant deathsyndrome (SIDS),respiratorydisease,sepsis, majortrauma, submersion,poisoning,andmet abolic/electrolyteimbalance.In contrast, primarycardiac arrestisrelativelyrare inthepediatric agegroup andismost frequentlycaus edby congenital heartdisease, myocarditis,andchesttraum awithmyocardialinjury. Althoughasystole and pulselesselectrical activity(PEA) aretheprimaryrhythms inpediatriccard iacarrest, the patientmay alsohaveventricula rtachycardia (VT)orven tricularfibrillation(VF). Theoutcome ofunwitnessedcardiopulmonary arrestininfan tsandchildrenispoo r. Only8.4%of pediatricpatients whohave out-of-hospitalcardiacarrestssurvive todischarg e andmost areneurologically impaired,while thein-hospitalsurvivalrateis 24%,witha betterneurological outcome.Thebestreporte doutcomeshavebeenin childrenwho receive immediatehigh-quality cardiopulmonaryresuscitation(resultinginadequateventilatio n andcoronary arteryperfusion),andin thosewithwitnessedsudden arrest(presentingw ith ventricularrhythmdisturbance) thatrespondstoearlydef ibrillation.

Emergencydepartmentpriorities

Tooptimize outcome,itisessential torecognizeearlysigns andsymptomsof impending respiratoryfailureandcirculatory shockprior tothedeve lopmentoffullcardiopulmonary arrest.Allequipment,supplies, anddrugs mustbeavailableandorganized foreasy access. Itisimperativ ethatthe staffhavetraininginPediatri cAdvanced LifeSupp ort(PALS),and routinelypracticemockpediat ricresuscitations. Pre-calculateddrugsheetsortheBroselowtape andacomprehensiveplantoorganizethe resuscitationteam(Table1-1) willoptimizecare inahigh-stresssituation. Assigna roleto eachteamme mber:teamleade r,airwaymanagement,chest compressions, vascularaccess, obtainingahistory,medi cationadministration, recorder,andrunner.Id entifyateamleader earlywhosesole responsibilityis tooversee theresuscitationandgive instructions.Ideally, a respiratorytherapistwillassist theteam,andaclo ckmust beavailable tofacilitate record keeping.Prepareinadvancethe essentialequi pmentneededfor resuscitation, usingthe mnemonicIMSOAPP.(Tab le1-2).

Rapidcardiopulmonaryassessment

Quicklyperform aprimary evaluation,which focusesontheAppearance,Airway,Breathing andCirculatory(ABCs)status ofthepatien t.Thisinitial examination providesassessm ent ofthepatient 'sacuity, andprioritizestheurgency andaggressivene ssofinterventionin responsetothedegree ofph ysiologiccompromi se.Followingstabilizationof theABCs,the secondaryassessmentincludesa completeexaminationof thepatient,w hilemaintaining normothermiaandnormoglycemia.

Appearance

Assessthegener alapp earanceofthepatient.Evaluate theactivitylevelofthe child,reaction topainful orunfamiliar stimuli,interaction withthecaretaker,consolability,and strength ofthecry, relativetothe patient'sage.

Table1-1.Resuscitationteamrolesand preparation

Roles

Teamleader

Airwaymanagement

Chestcompressions

Vascularaccess

Medicationadministration

Obtainingahistory

Recorder

Runner

Preparation

IV-IO/monitors/suction/O

2 /airwayequipment/medications

Assessweight(in kg)!2"(agein years#4)

Airway(C-collar): headtilt-chinlift;jaw thrust;oxygen;suction

Breathing:rate;air; retractions;O

2 saturation(oximetry);R/O pneumothorax Circulation:pulserate; BP;capillaryrefill; peripheralpulses

IV/IOAccess:NS 20mL/kg "3;pressors;packed RBCs

Disability:AVPU;pupils; neurologicexamination;GCS

Dextrose:D

25

W!2mL/kg; <3mo:D

10

W!5mL/kg

Exposure:logroll; rectalandguaiac

Evaluation:secondaryhead-to-toe examination

Fever:maintain normaltemperature

Fast(trauma):RUQ, sub-xiphoid,cardiac,LUQ, suprapubic Foley:contraindicatedfor highprostate;blood inmeatusor scrotum Gastrictube(NGT): notifthere isamidface injury(useorogastric tube) History:allergies;usual medications;PMH;last mealtime

2Chapter1:Resuscitation

Airway

Airwaypatencyis particularlyprone toearly compromiseinpediatric patients,as the airwaydiam eterandlengtharesmaller thaninadults. Determinew hethertheairway is clear(nointerven tionreq uired),maintainablewithno ninvasiveintervention(positioning, oropharyngealornasopharyngeal airwayplacement, suctioning,bag-maskventilation) or notmaintainable withoutintubation.

Breathing

Ventilationandoxygenati onarereflecte dintheworkofbreathingandcan bequickly assessedbythemnem onicRACE: $Rate:age-dependent (Table1-3).Tachypneaisoften thefirstsign ofrespirato rydistress. $Airentry $Listento breathsoundsin allareas:anteri orandposte riorchest, axillae $Mustruleout pneumothorax: absentbrea thsounds,trachealdeviation $Abnormalsounds:rales,rho nchi,wheezing $Color $Pink,pallid, cyanotic,ormottled $Pulseoximetry:use theO 2 saturationasthefifth vitalsign $Effort/mechanics $"Tripod"position,nasalflaring,grun ting,strido r,headbobbing $Accessorymuscleuse:sternocleidomastoi dprominence $Retractions:suprasternal,subcostal,and /orintercostal Thepresenceof abnormalclinical signsofbreathi ngsuchasgrunting,severe retractions, mottledcolor,useof accessorymuscles, andcyanosisare precursorsto impending respira- toryfailure.

Table1-2.IMSOAPP.mnemonicfor resuscitation

IIVfluids/IV catheter/intraosseousneedle

MMonitors:cardiorespiratory; pulseoximeter; bloodpressure SSuction:tonsil tipped(Yankauer)and flexiblecatheters

O100%Oxygen source

AAirwayequipment

Bag-mask:differentsize masks

Oralairway:nasopharyngeal andoral

Laryngoscopewithassorted blades:Miller,Macintosh

Trachealtube:cuffed anduncuffed,multiple sizes

Stylet

PPharmacy:medications, eitherapre-calculated drugsheetor Broselowtape PPersonnel:call acode,have resuscitationteamavailable

Chapter1:Resuscitation 3

Circulation

Thecirculatory statusreflectstheeffectivenessof cardiacoutput aswell asend-organ perfusion.Therapidassessm entincludes: $Cardiovascularfunction $Heartrate:age-depen dent(Table 1-3) $Centraland peripheralpulses: comparethe femoral,brachial,andradialpulses $Bloodpressure:age- dependent.Use thefollowingguidelinestoestimatethelowe st acceptable(5thpercentile)systoli cBP: $Newborn-1month !60mmHg $1month-1year!70mmH g $1-10years!70mmHg#(2"ageinyear s) $>10years !90mmHg $End-organperfusion(systemi ccirculation) $Skinperfusion: capillaryrefill(<2sec normal),color, extremitytemperatu re (relativetoambienttemperatu re) $Renalperfusion:urinary output!1mL/kgpe rh(ab out30mL/hforanadolesc ent) $CNSperfusion :mentalstatus,level ofconsciousness,irritability,conso lability

Aawake

Vresponsive tovoice

Prespons ivetopain

Uunresponsive

Tachycardiaandtachypneaareearly signsofcardior espiratorycompromise.Observe for centralorperipheral cyanosis andfeeltheskintemperatu reandmoisture.Withthefin gersat thele veloftheheart,appl ypressur etothe nailbeduntilit blanches,then release,timingthe intervaluntilthefingertip "pinksup."Delayedcapillaryre fill(>2sec) ,andcool,clammy

Table1-3.Normalvital signs

RespiratoryPulseSystolic BPDiastolicBP

AgeWeight(kg) Rate/minRate/min10th -90th10th/90th

<1month3 -435-5595-18065 -9035-55

1-11months 5-825-40110 -17085-10545-65

1-3years 10-1520-3090-15090 -10545-65

4-6years 15-2020-2565-13595 -11050-70

7-9years 20-3018-2560-130100 -11550 -70

10-12years30 -4016-2260-110100 -12050-70

13-15years 40-6015-2260-110105 -12555 -70

16-18years60 -7015-2060-100110 -13055-75

>18years>7012-2060-100110 -13565 -85

4Chapter1: Resuscitation

extremitiesareclinicalindicatorsofpoorperfusion.Asystolicbloodpressure<5thpercentile (measuredwithanappropriate -sizecuff),loss ofcen tralpulses,oliguria,andalteredlevelof consciousnessareominoussignsofimpend ingdecompe nsatedcirculator yshock.

Initialmanagement

Airwaymanagement

Airwaymanagement isalwaysthefirstpriority. Immediategoa lsin theEDinclud e reversinghypoxemia,supporting ventilation,maintainingairwaypaten cy,andprotecting theairwayfr omsecretions andvomitus.Toopenthe airway,firstusesimple maneuvers suchasrepositi oningthehead ,suctioningsecretionsfrom themouth, andplacingan oropharyngealornasopharyngeal airway.

Headtilt-chinlift

Opentheairway usingthehead tilt-chinlift techniqueor jawthrustmaneuver.In an unresponsivechild,performthe headtilt-chinliftman euverbyplacing onehandonthe patient'sforehead andgentlytiltingtheheadback intoa neutralposition. Curlthe fingersof theotherhand gentlyunderthe jaw,andlift themandible upwardtoopen theairway .

Jawthrust

Inknownor suspectedtrauma victims,use thejawthrustmaneuverwitho uthead exten- sion.Protect thecervicalspinebyproviding manualinline traction.Perform thejaw thrust bykeeping theheadmidline,placingthefin gersatthe angleofthe jawon bothsides,and liftingthemandi bleupwardand forwardwithoutextendingthe neck.

Suctioncatheters

Suctionsecretions andbloodfromthenasal passages,orophar ynx,and tracheawithflexible suctioncatheters. Thesemustbeavailablein sizessmallenoughto passthrough thesmallest endotrachealtube(ETT).A5 Frcatheter willpassthrough a2.5 mmETT (usually2 "the ETTsize). Largerigid tonsiltipcatheter s(Yankauer)haverounded tipswhichare lesslikely toinjurethe tonsilsandare usefulforclearing bloodandparti culatematter fromthe mouth andhypopharynx. Limitsuctioningtoabout10 seconds,while monitoringthepulse oximeterandheartrate, asvigorous suctioningmay causevagalstimulationresult ingin bradycardiaandhypoxia.

Oropharyngealairway

Theoropharyngeal airwayisanadjunct forventilating anunresponsive patientwithan absentgag reflex.It willkeepthebaseofthe tongueaway fromthe posterior pharyngeal wall,maintai ningairwaypatency.Donotuseit inanawake orobtundedpatientasit can precipitatevomitingandlaryngospasm . Anappropriate lysizedoralairwayextendsfromthecorner ofthe patient'smouth tothe angleofthe jaw.Depress thetonguewith ablade,and inserttheorop haryngealairway with itscurvat urealongthehardpalate. Ininfantsandchildren, avoidinserting anairway thatis toolarge.Do notattemptto inserttheairway inaninverte dposi tionandthen rotateit 180 % , asthis techniquemay damagethepalateandpushthe baseof thetongueposterio rly, occludingtheairway. Theproximal partoftheoralairwayis firmandflat andisdesignedto

Chapter1:Resuscitation 5

beplacedbetw eentheteet htopreventbiting(the tracheal tubeoryourfinger).Ta pethe flangetothe lipstoprevent itfrombeing dislodged.

Nasopharyngealairway

UseanNP airwayinan obtundedpatient withan intactgag reflexwhohas upperairway obstructionsecondarytoa floppytongue.Estimatethe size bymeasuring thedistancefrom thetipof thenoseto thetragusof theear;the appropriate lysizedairway extendsfromthe nostriltothebaseof thetonguew ithoutcompressi ngtheepiglottis. Lubricate thedevice andgentlyinsert italongthe floorofthe nostriltoavoid injuringthe nasalmu cosaor adenoids.Anasopharyngeal airwayisco ntraindicatedinapatientwitha possiblebasilar skullfracture.

Foreign-bodyairwayobstruction

Ifchoking orairwayobstructionfrom aforeignbod yissuspect edandthepatientisawak e andcan speak,makeno attemptstoremov etheobject. Allowthepatien ttocough andclear theairwaywhi leobserving forsignsofcompleteobstructi on(i.e.thevictimisunable to makeasound). Removethe foreignbod yfromthemouthonlyif itis visible.Donot performblindfinger sweepsinany agebecausethe obstructing objectmaybe pushed furtherintothe pharynxand causecomplete airwayobstruction. Ifthepatien tdeteriorates, usetheprocedure sas summarizedinTable1-4.

Infants<1yearofage

Laytheinf antprone overyourthighs,with theheadsup portedina dependentposi tion. Alternatively,holdtheinfantoveryour arm,inthe proneposition,sup portingthe headin yourhand. Deliverfive sharpbackslaps,inrapidsuccession ,betweenthe baby'sscapulae. Turntheinfant overandgive fivechestthru stsusingtwo fingers onthemid-stern um.Look intothemou thtosee whethertheforeignbody isdislodged. Repeatthese maneuversuntil theobjectis expelledorthe infantbecomes unconscious. Donot performabdominalthrus ts ininfantsas thereis riskofinjury totheabdominalorgans.

Unconsciousinfant

Firstopen themouth widebygraspin gthetongueandjaw,and lookforthe foreign bodyin theoralcav ity.Ifan objectisseen,removeit, butdo notperforma blindsweep.If thereis noimprovem ent,begincardiopulmonaryresuscitation(CPR) providingfivecycles(30 compressionsandtwobreathspercycle) over2minutes. Ifbreaths cannotbedelivered, repositiontheheadandtry again,orproce edwitha dvancedairway maneuversuntil respirationshavebeenresto red.

Children>1yearofagetoadolescent

Usethe Heimlichabdo minalthrustmaneuverin thisagegroup.Placethe childinasupine positionandkneelathis orherfeet. Positionthe heel ofthehand inthemid lineofthe epigastriumwiththeother handontop ofthefirst ,thengive arapid seriesofsep arateand distinctupward thrusts.Witheachthrust usesufficientforceto dislodgetheforeignbody. Forasmall child,thehee lofon ehandis sufficient, asoverlyvigorousabdominalthrusts maycause damagetointernalorg ans.Ifthepatientloses consciousness, repositionthehead

6Chapter1:Resuscitation

Table1-4.SummaryofBLS maneuversforinfants, children,andadolescents

ManeuverInfant <1yearChild 1-8years

ofage

Adolescent

Activateemergency

response(lonerescuer)

ActivateEMSafter 5cycles ofCPR

Forsudden,witnessed collapse,

activateafterverifying thatvictim isunresponsive

Activateifvictim found

unresponsive

Ifasphyxialarrest likely,

callafter5 cycles/2 minutesofCPR

A:AirwayHead tilt-chinlift

Suspectedtrauma:use jawthrust.

B:Breathing

Initial2effective breathsat1 second/breath

Rescuebreathingwithout

chestcompressions

12-20breaths/min(approximately

1breathevery 3-5seconds)

10-12breaths/min

(approximately1breath every5-6sec)

Rescuebreathswith

advancedairway

8-10breaths/min (approximately1breath every6-8sec)

Foreign-bodyairway

obstruction

Backslapsand

chestthrusts

Abdominalthrusts

C:Circulation

Pulsecheck( &10sec)Brachial orfemoralFemoral or

carotid

Carotid

CompressionlandmarksJust belownipple

line

Onerescuer:

2fingers

Tworescuers:both

thumbswithhands encirclingthechest

Centerofchest, midsternumbetween

nipples

Onehand:heel ofonehand only

Twohands:heel ofonehand withsecond

ontop CompressiondepthApproximately one-thirdtoone-half the depthofthe chest 1 !-2inches

Compression

ventilationratio

Onerescuer!30:2

Tworescuers !15:2

Oneor two

rescuers!30:2

D:Defibrillation(use AED

forsudden,witnessed collapse) No recommendation forinfants<1year ofageor <10kg

Usechildpads Useadultpads

Unwitnessedarrest

orresponsetime is >4-5min, mayprovide

5cycles/2min ofCPR

beforeshock

F:Foreign-bodyairway

obstruction

Ifunresponsive:remove

visibleobjector startCPR

Fiveback slaps

alternatewith

5chestthrusts

Noabdominal

thrusts

Noblindfinger

sweep

Fiveabdominalthrusts untileffectiveor

patientbecomesunresponsive

Unresponsive:beginCPR for5cycles/2

minutes

Removevisibleforeign body

ActivateEMS

Source:Adaptedwithpermission from:2005AHA GuidelinesforCPR andECC,Part 3:Overviewof CPR.Circulation

2005;112:IV-15.

andattempt tovisualizetheobject. Ifnot visible,beginCPR,prov idingfivecyc lesfor

2minutes.

Aforeign bodymayalsoberemoved underdirectvisuali zationw ithalaryng oscopeand Magillforceps. Onrareoccasions,ifthere istotalobstructi onofthe proximalupperairway, cricothyrotomymaybeneeded.Consultanotolary ngologistto remove moredistaltr acheal orlaryngeal foreignbodiesviaflexible bronchoscopy.

Oxygenation,ventilation,andintubation

Oncetheairway hasbeen stabilizedand thebreathing assessed,theneedfor oxygenation andventilation takespriority.Placepatientswithmild tomoderate respiratory distress onsupplemental oxygen.Reassessbreathing effortbyphysicalexamination andpulse oximetry.Theequipmentfor airwaysupportis describedbelow.

Nasalcannula

Theactualoxygen concentrationdeliv eredbynasal cannulaisunpredictable, sothis methodisappropriate onlyfor patientswhorequireminimal O 2 supplementation.Flow ratesof1 -4L/mindeliver O 2 concentrationsof25-40%.However, flowrates>3L/minare usuallypoorlytolerat edbychildre n,whileflowrates>1-2L/minmay inadvertently administerpositiveairwaypres suretonewbo rnsandinfan ts.

SimpleO

2 mask Thisisthe mostfr equentlyusedmetho dforoxyg endeliveryinspontaneouslybre athing patientsanditismore easilytolerated thannasalcann ula.Theactual O 2 concentration thatthepatien treceives isdependentontheflo wrateandthepatien t'sventilatory pattern,asroomair entersthrough theventilation holesonthe sidesofthe mask.Oxygen flowratesof 6-10L/minwill deliverO 2 concentrationsof35-60%andprevent rebreathing ofexhaled CO 2 . O 2 maskwithreservoir Thissyste mconsistsofasimp lemaskattachedtoa reservoirbag thatis connectedtoanO 2 source.Somemodel scontainone-way valvesattheexhalation portsto preventthe entrainmentofroomair, andasecond valveatthe reservoirbag topreventthe entryof exhaledgasback intothe reservoirbag.Thereservoir bagmustbelargerthanthe patient's tidalvolume(5 -7mL/kg)and remaininf latedduringinspi ration.Oxygenconcent rations upto60% canbe achievedinparti alrebreathing systems,and>90%ispossi bleifthe oxygenflowrateis10 -15L/min,and thereis agoodseal aroundtheface mask.

Ventilation

Forpatientswith respiratory failure,ventilate withabag-maskapparatus,until allthe appropriateequipmentandpe rsonnelforintubationareassem bled.For optimumairway alignment,positionthe patientsothattheauditoryme atusisin linewiththe topof the anteriorshoulder.Usethe "sniffing"positioninan olderchild byplacinga foldedtowel underthehead andelevatingit. Inaninf ant,keepthe headmidline andneckslightly

8Chapter1:Resuscitation

extendedwithapadunder theshoulder. Flexingoroverextend ingthe neckmay inadvertentlyobstructtheairway . Adequateventilationresult sinsymmetricmovement ofthechestwallwith goodbreath soundsheardonauscult ation.Ifthe patientismaking anyrespiratoryeffort,synchro nize thedelivered breathswithhis orhereffor ts.Ifposi tive-pressureventilatio ncauses disten- tionofthe stomach, usegentlepressure onthecricoidcartilage (Sellickmaneuver )to occludetheproximalesoph agusandpre ventairfrom enteringthestomach.However, excessivecricoidpressuremay kinkthetracheaand prevent airfromentering thelungs.

Bagmask

Themostcommo nsystem usedtoventilateanapneic patientconsistsofa self-inflatingbag (AmbuBag),an O 2 reservoir(corrugatedtubing), andmaskwithavalve. Thesebagsdonot needaconstant flowof O 2 torefill;the yentrainroom air.Usingareservoirwith a supplementaloxygenflowrate of10-15L/m indelivers60-95%oxygen tothepatient.

Ifthe baghasa pop-offvalve setat 35-45cmH

2

O,theremu stbe awaytooverrideit, since

ventilatorypressuremaybeinadequat einpatien tswith increasedairway resistanceorpoor lungcompliance. Adequateventilationrequires anappropriate-sizeface mask,onethatextend sfrom the bridgeofthe nosetothe cleftofthe chin.Theminimu mvolu meforthe baginnewbo rns, infants,andsmallchildren is450-500mL; useanadultbagforadolesce nts.Ifthe onlybags availablearelarger thantherecommen dedsize,ventilate infantsandchildre nby usingthe largerbag withaproper-si zefacemas kandadmin isteringonlyenoughvolume tocaus e thechestto rise. UsetheE-C clamptechniqu etoachiev eproperventilationwith abag-maskde vice. Holdthemask snuglytothe facewiththe leftthumband index fingerforming a"C".Apply downwardpress ureoverthemasktoachieve agood seal,while avoidingpressure tothe eyes.Place theremaining threefingersof thelefthand,whichform an"E",onthe mandible toliftthe jaw,avoidingcompr essionofthe softtissuesof thenec k. Usearate of12-20breaths perminuteforan infantorchild (Table1-4)(approximately onebreathevery 3-5seconds). Observethechestrise, listenforbreathsounds, andmonitor theO 2 saturation.Baggingtoorapi dlyorusing excessivepres surecausesinflationofthe stomachandbarotraumato theairways. Ifventilationisdiffi cultorbreath soundsare unequal,repositionthehead ,suctiontheairway, andconsi derforeign-bodyaspirationor pneumothorax.Anoralornasopharyngeal airwaymayhelp tomaint ainapate ntairway duringbag-mask resuscitation,andifthepatient isventilatedformore thanafew minutes, placeanaso gastrictubeto decompressairfromthestomach tomini mizetherisk of aspiration.

Intubation

Trachealintubationisthebes twayto managethe airwayduring cardiopulmonaryresusci- tation.Theindi cationsfortracheal intubationinclude: $Apnea $Excessiveworkofbreathi ngleadingto fatigue $Lackofairway protectivereflex es(gag,cough) $Completeairwayobstructionunre lievedbyfore ign-bodyairwayobstructionmaneuver s $CNSdisorder(increas edintracranial pressure,inadequatecontrolof ventilation)

Chapter1:Resuscitation 9

Beforeattemptingintub ationensure thatallnecessarysupplies (Table1-2),medications, andper sonnelareavailable.Allequipment mustbeavai lableinvariou ssizes alongwith sparelaryngoscope handles,bulbs,andbatte ries.ABroselowtape,whi chaccuratelycorrel- atesweightwith length(for patients&35kg), givesprecisesizesofairwayeq uipment,as wellasappropr iatedrug doses."Straightblades"(Miller)areoften easierto usethan "curvedblades"(Macintosh)ininfantsandyoung children.Estimate laryngoscopeblade sizebythe distancefromthe incisorsto theangleof theman dible.SeeTable 1-5forthe mostpopular age-appropriatebladesizes.

ETTtubes

Estimatethetracheal tubesize bymatching thediameter oftheETTtothe widthof thenail ofthepatien t'sfifthfin gerorthe diameterofthenares. Trachealtube sizesfordifferent age groupsarelisted inTable1-6. Alternatively,usethefollowi ngformulae, butalwayshav e availabletracheal tubes0.5mmlargerandsm allerthanthe calculatedsize: uncuffedETTsize!4#(ageinyears/4) cuffedETTsize!3#(ageinye ars/4). Previously,cuffedtrachealtubeswere indicatedonly inchild ren>8yearsof age.Nowthere arehigh-volume, low-pressurecuffedtrachea ltubesthatmaybeused inallages(except newborns),providedthe cuffinflationpressureiskept <20cmH 2

O.However, cuffedtubes

havesmaller internaldiametersthannon-cuffe dtubes,r esultinginincreasedairflowresist- ance.Insome patientsin whomhighmean airwaypressuresareexpecte d(e.g., status asthmaticus),analternateapproach istouse acuffed tubewiththecuffinitia llydeflated, andinflateon lywhennece ssary. Preparethetracheal tubewitha stylettipplaced 1cmfrom thedistal endofthe tubeand bentina gradualcurveof thedistalthir d.Thetip andcuff ofthetube maybelub ricated withviscous lidocaineorawater-solublegel foreasypassag e.

Table1-5.Laryngoscopebladesize

Premature-newbornMiller0

Onemonth-toddlerMiller1

18months-8yearsMiller 2,Macintosh2

>8yearsMacintosh 3

Table1-6.Trachealtube (ETT)sizeand depth

AgeUncuffedETT CuffedETT Depth

Premature2.5mm - 6-7mm

Newborn3.0-3.5 - 8-10mm

1month-1year3.5 -4.0mm3.0 mm10-11mm

Older4#[(ageinyears)/4] 3#[(ageinyears)/4] 3"ETTsize

10Chapter1:Resuscitation

Intubationprocedure

Inemergency situationsperformoralintub ations,whichareeasier thannasalintubations. Ingeneral, useastraightMillerlaryng oscopebladefor pediatricint ubations.Cricoid pressure(Sellick maneuver)duringintub ationmayhelpvisualizationof theairwayand preventregurgitationofsto machcontents.Haveatonsil tipped suction(Yankauer)andan appropriate-sizeflexiblesuctioncatheterreadilyavail able.Tointubate thepatient ,keepthe headmidlinein the"sniffing"position.If cervicalspine traumaisaconcern,havean assistantmaintainmanualin-line stabilizationduring theintubation,avoidingtraction or movementoftheneck. Continuouslymonito rtheheart rateand pulseoximeterthroug hout theprocedure .Calculateandprepareall ofthemedicationsbefore beginningrapi d sequenceintubation(RSI, seebelow). Placethethum bandindex fingerofthe(gl oved)righ thandintotheri ghtsideofthe patient'smo uth.Placetheindexf ingeronthepat ient'sup perteethandthet humbonthelower teeth,usingthesci ssortechniqueto openthemou thaswideaspossible.Holdth elaryngoscope inthel efthandan dintroducet hebladeintoth erightedg eofthemouth,sweepingthetong ue towardstheleftandoutofthelineofvision.Placeastraightbladeundertheepiglottistoelevate it,butins ertacurved bladeintothevallecu laan dpulltheepiglotti supwards.Anas sistant providingcricoidpressureor retractingtherigh tcornerofthemouthlaterallyma yimprov e visualizationoftheglotticopening.Pullt heh andleofthel aryngoscopeupandawayata 45
% angletothefloo r,inthe directio nofthelongaxisofth ehandle. Iftheblad eisintoodeep, slowlywithdrawitun tiltheglottispopsin toview. Becarefulnottot iltthehandle orblade, whichmayrisk damagin gtheteeth. Oncetheglottis isexposed, takecareto introducethe trachealtubefromtheright sideof themouth (notdownthebarrelofthe blade).Adv ancethe ETTuntil thecuffjust passes beyondthevocal cords.Uncuffed tubesoftenhav eamark atthedistalendof thetube, whichwhenplaced atthelevel ofthecords willpositionthe distaltip inthemid trachea. Thismarkis onlyuse fulifthe tubeistheappropriatesize andthepatienthas anormal- sizedtrachea.A proper-size trachealtube easilypassesthroughthecords. Ifitmeets resistanceinthesubglottic area,replace itwitha smallertube.Holdthetube securely againsttheupperteeth(or gums)andcarefu llywithdrawthe laryngoscope first,and then removethestyletfromthe ETT.

Confirmingposition

Verifyproper tubeplacementbylisteningfor equalbreathsound sandobservingsymm et- ricalriseof thechest.Confi rmthepresence ofexhaled CO 2 fromthetracheal tubew ith eitheraco lorimetricCO 2 detectorora CO 2 analyzer,andusea pulseoximeter tomonitor oxygensaturation.Colorimetr icdevicesareinaccurate ifthepatientdoesnothave a perfusingrhythm(evenw ithappropriatechestcompressi ons)or is<2kg.If breathsound s arelouder overthestomac hthanthe chest,orif itisunclearthat thetubeis inthetrache a, removethetrachealtube andventilat ebybagmask.Anaudibl eairleak isexpected,but if thereisa largeairleak ornoneat all,thetube sizemaybe inadequate ;replace itwithan appropriatelysizedtracheal tube.Onchestradiograph, confirmthatthetipof thetubeis oppositeT2(one fingerbreadthabov ethecari na).Neckextension orheadmovementbrings thetubehigh erwhileneck flexionpushestheETT deeper.Once thetubeposi tionis verified,inflatethecuff toapres sure<20cmH 2

O,andsecu reit tothepatient'sfacew ith

tapeoruse atracheal tubeholder.

Chapter1:Resuscitation 11

Complications

Ifthepatien tdeteriorates afterendotrachealintubation,use themnemonicDOPEto reassess:Displacementofthetubeinto theesophagus ordownthe rightmainstem bronchus, Obstructionofthetube withbloodor secretions,Pneumothorax,orEquipment malfunction.

Alternate/adjunctiveventilationtechniques

Alternateventilationtechniqu esareusefulforsecuring adifficultairwaywhenintub ationis notfeasible orunsuccessful.Thepresence ofcertain congenitalanomalies(Pierre-Rob in, Beckwith-Wiedemann,Downsyndrome),anatomical defects(neckmass, laryngealheman- gioma,subglottic stenosis),ordiseasestates(epiglo ttitis,angioedema,facial/neck trauma) maynece ssitatetheuseofadvanced airwaytechniques. Theseinclude noninvasiveposi tive- pressureventilatio n(NIPPV),heliox,andlaryng ealmaskairways(LMAs).Ot heradvanced airwaytechniques, suchasfiberopticlaryngoscopy, alightedstylet ,needle cricothyrotomy, orsurgical cricothyrotomy,requi retrainingandexperienceto performsuccessfully.

Noninvasivepositive-pressureventilation (NIPPV)

NIPPVprovidesshort-term mechanicalventilatio nwithoutplaceme ntofatrachealtube in stable,spontaneouslybreathing,alert,andcooperativepatients.Althoughtrachealintubation isoftenalife-savingprocedure,NIPPVfunctionstobridgethegapbetweenmaximalmedical managementandintubation.Benefits includedecrea singthework ofbreathing,improving oxygenation,andavoidingcommon complicationsof intubation.Itisimportant tonotethat NIPPVisnot areplacement fortracheal intubationinpatien tswhohavelife-threatening respiratoryfailureor requireairwayprotection.It iscontraindicated inpatientswhoare hemodynamicallyunstable,lethargic,vomiting, orhavecard iacdysrhythmias. Thedecision touseNIPPVisdependentonthepatient(consciousandcooperative),specificdisease(status asthmaticus,bronchiolitis,acute pulmonaryedema,andneurom usculardiseas e),and whetherairwayprotection isrequired. Thetwocommo nmethods ofNIPPVarecontinuouspositive airwaypressure(CPAP) andbilevelposi tiveairway pressure(BiPAP).Theseare deliveredvia anasalorfull-face maskin childrenandby nasalprongsin infants.Strapshold theBiPAP facemaskfirmly to thepatien t'sfaceto createatight seal.Neonates, whoare obligatenos ebre athers,generally donot tolerateBiPAP andmaybenefitmorefromnasal prongCPAP.Typical initial settingsincludeaninspiratory positiveairway pressure(IPAP)of 8-10cmH 2

O,andan

expiratorypositiveairwaypres sure(EPAP)of3-5cmH 2

O.Titrate thesesettingsupwardsin

2cmH 2 Oincrements untilthedesiredeffects areachieved. Monitorthe patientcloselyfor worseningrespiratoryfailurewith seriallungexams,vitalsignsme asurements, andoxygen saturation.Ifthepatient'srespiratory statusworsensordoesnot improve,disconti nue

NIPPVandperf ormtracheal intubation.

Heliox

Heliumisa biologicallyinert gasthatdec reasesturbulentgasflowwhen mixed withoxygen. Helioximproves deliveryofoxygenand aerosolizedmedicationsto constrictedperipheral airways,thusreducingthe workofbreathi ng.Ithasbeenusedin conditions thatare refractorytomedicalmeasures, suchas statusasthmaticus,moderate tosevere

12Chapter1:Resuscitation

bronchiolitis,andseverecroup.Heliox isdelivered inmixtures of80% heliumand20% oxygen(80/20heliox) or70%helium and30%oxygen(70/30 heliox).Itis administered to spontaneouslybreathingpatientsby usingafacemaskandreserv oirbag. Anin-line attachmentcanbeplace dtoadd anebulizer forconcurrentbeta-agonist administration. Improvementofoxygenation andreduction ofrespiratorydistressgenerally occurswithin

1hourof helioxinitiation. Ifthere isnoimprov ementoraworsening ofthepatient 's

clinicalstatus,change toanalternatemeansof ventilation.

Laryngealmaskairway (LMA)

TheLMAis indicatedfor patientswhoreq uireanairwaybutcann otbetrache allyintubated orventilated withabagmaskandit canbeused inpatients withdec reasedairwayreflex es (i.e.obtunded orcomatose).TheLMA consistsof atubeattachedtoa mask,rimmedwith a soft,inflatablecuff. Whenprop erlyplaced,the LMAsitsinthe hypopharynxaroundthe glotticopeningand directsair intothetrachea. Unlikeatrachealtube, itwill notprevent aspirationofgastricconten tsintothe trachea. Selectthe appropriate-size LMAandcheckforpossibleairleaks byinflatingthecuff. HoldtheLMA likea pen,with theindexfinger ofthedominan thandplacedatthejunctio n ofthetube andproximal aspectof themask. Lubricatetheposteriorsurface ofthedeflated mask,andorient itsothat theopeningis directedtowards thetongue .Withone smooth motion,insertthemask firmlyalongthehardpalate andadvance untilresis tanceis encountered.Withthetipof themaskplace dinthe hypopharynx,inflat ethe cuffaccording tothecuff size(Table1-7). Auscultatethe lungstoconfirm correct placement.If endo- trachealintubationissubsequ entlynecessary,inserttheETT blindly throughtheproperly placedLMAas itwillbe directedint othetrachea . Therearenewe rLMAsavailable forspecificsituations.On eversion (ProsealLMA )has aparallel drainagetube attachedtotheairwaytubeto allowpassage ofa nasogastrictube, potentiallydecreasingtherisk ofaspiration.Anothervariation, theintubating LMA(Fas- trachLM A)isdesignedtofacilitate blindtracheal intubationwhileallowingforconti nuous positive-pressureventilation. Table1-7.Laryngealmask airwaysizes(reprodu cedwithpermission fromLMANorth America,Inc.)

MasksizePatient sizeMaximumcuff volume

1Neonates/infantsup to5kg upto4 mL

1 !

Infants5 -10kgup to7 mL

2Infants/children10 -20kgup to10mL

2 !

Children20-30kgup to14mL

3Children30 -50kg upto20 mL

4Adults50 -70kgup to30mL

5Adults70 -100kg upto40 mL

6Adults>100kgup to50mL

Chapter1:Resuscitation 13

Rapid-sequenceintubation(RSI)

Thegoalsof RSIareto createidealintub atingcondition sby attenuatingairway reflexes whileminimizing elevationsofintracranialpressure andmaintainingadequate blood pressure.Rapid-sequenc eintubationisindicatedforpatients whorequireemergency trachealintubationbutare athighriskforpulmonaryaspiration ofgastric contents. In patientswhoare criticallyill,hemodynamicallyunstable,uncoop erative,orwith increased intracranialpressure,attemptingtrachealintub ationwithout sedation islikely tocause significantagitation.This canthenworsenthesympt omsandincr easetherisk ofvom iting andpulmonary aspiration.Patientsincardiacar rest,moribund patients,orbabies withina fewhoursaf terdelivery rarelyrequiremedications tofacilitateintubation. Anticipatethepossibility ofanunsu ccessfulintubationandprepare foralternate airway techniquesbeforeinitiatingsedation. Also,expect adifficultintubationandrequest helpfor patientswithsignificantfacial trauma,restric tedneckextension,orif thetip oftheuvulais notvisiblew henthemouth isopened.Donot usesed ationormu sclerelaxation ifthereis anyconcernthat bag-mask ventilationwill beinadequate.

NEVERsedateor paralyzeapatient

whomyoumay notbeable toventilate!

Procedure

RSIinvolves theuseofpremedicationsto minimizeadv erseevents, preselectedsedativ e/ hypnoticagentswith rapidonsetandshortdu rationofactivity,neurom uscularblocking agents,theapplicationof cricoidpressure topreventaspiration,andgainin gimm ediate controloftheairway, alldonein rapidseq uenceintheaboveorder.

Preoxygenation

Whilepreparing forRSI,havethepatientbreathe 100%oxygenvi aanonrebr eatherf acemask foratleast 3minu tes.Ifthepatie nt isapneicorhasinadequatere spira toryeffo rt,deliver

4-5br eathsbybagmaskin30s econds ,whileappl yingcrico idpres sure.This willestablish

anoxyg enreservethat willlastupto4minut esinaninfantand longerinolde rchildrenand adolescents.Duringtheperiodofpreoxy genation,determinethe likelihoodof adifficult intubation,establishintravenous access,placethepatientoncardi acandpulseoximeter monitors,andassembleallnece ssaryequip mentandpersonnelfortra chealintub ation.

Historyandphysical examination

Nosinglefeatureonphysical examinationaccuratelypredictsadifficultintubation.Therefore, performadetailedpr e-sed ationassessment,includin gtheSAMPLEhistoryandafocused physicalexamination.

SAMPLEhistory:

Signsandsympt oms

Allergy:allergytodrugs,latex, foods

Medications:currentpresc riptionandnon-prescriptiondrugs

14Chapter1: Resuscitation

Pastmedical history:significantpastmedical andsurgicalhistory

Lastmealtime: lastoralintake andtypeof food

Event:recenteventsor historyof presentillne ss

Upperairwayexamination

Askaco operativepatient toopenthemouthas wideaspossible,withthe tonguefully protruded.TheMallampati airwayclassI andII(visiblefaucialpillars anduvula)indi cates relativelyeasierairway management (Figure1-1 ).Usethe"3-3-2rule,"whichisa predictor ofdifficult intubationinadults. Thepatientshouldbeableto placethree fingersbetween theopenincis ors,three fingersfromthementaltubercle ofthemandible tothethyroid (two fingersin children,one fingerininfants),andtwo fingersfrom thelaryngeal prominence tothe floorofthe mouth. Forpre-medicatio ns,sedative/hypnoticsandparalytics,see Table1-8.

Cricoidpressure, BURPmaneuver

Cricoidpressure istheapplicationofpressure onthecricoid cartilage sufficienttoocclude theesophagus withoutcompressingtheairway lumenormovingthe cervicalspine.After thepatient losesconsciousness,haveanassist antapply cricoidpressuretopreven tpassive regurgitationofstomachcontents .Intubate thetracheaoncethepatient isparalyzed.Do notreleasethe cricoidpressureuntil placementof theETThas beenco nfirmedby auscultationofbreathsound s,observation ofchestrise, useofanexhaledCO 2 detector, andpulseoxime try. Ifthel aryngosco picviewislessthanadequate,t rytheB URPmaneuver-firm Backward,Upward,R ightwardP ressureonthethyroidcartilage.Thiswillimprove thelaryng ealview,especiallyinchildr en,inwhomthegl otticopeningishigherand moreanteriorcompared toadults.O ncethevocal cordsare exposed,h avethe assistantmaintain thisviewwithoutreleasingthecric oidpressure .Iftheintubation cannotbe performedwithin20 seconds,ventilatethepatie ntwithabag mask.Change thelaryngoscope blade,ETTsize, patient'sposition,orlaryngoscopistbeforeattempting anotherintubation.R epeatedintubationattemptswillcause edema andbleeding andm akevisualizationmoredifficult.I fthepatientcannotb eintubated orventilated bymask ,insertalaryng ealmaskairwayorcall fo rhelpwithanadvancedairway technique.

Class IClass IIClass III Class IV

Figure1-1.Mallampati

Classification.Withpermissio n

from:Mallampati SR,etal:

Aclinicalsign topredictdifficult

trachealintubation:a prospective study.CanAnaesthSoc J

1985;32:429.

Chapter1:Resuscitation 15

Post-intubationmonitoring

OncetheETT issecured andtheposition isradiographically confirmed,provideadequate sedationand analgesia,andcontin uedmuscle paralysiswith along-actingagent(vecur- oniumorrocuro nium),ifindi cated.Useanalgesicswhenappropr iate.Insert anasogastric tubeassoon aspossibleto decompressthe stomach,esp eciallyininfan tsand children.

Initialmechanicalventilatorsettings

Therearetwo modesof mechanicalve ntilationforemergencyventilation inchild ren.For newbornsandinfants<10kguse pressure-limitedventilators, while volume-limitedventi- latorsareindicated forolder chi

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