PEDIATRIC EMERGENCY CONDITIONS

1. PEDIATRIC EMERGENCY CONDITIONS Unit 2 Module 2

2. REFERENCES C290- Nelson’s Essentials of Pediatrics C 277- Toronto Notes C306- Toronto Sick Kids Manual C291- Primary care for the PA Toronto Sick kids – Pediatric emergency Clinical Practice Guidelines, March 2000

3. OUTLINE Assessment /Management of Pediatric Multi-trauma Shock in Infants /Children Pediatric Burns Poisonings /Overdoses Anaphylaxis Discussion Injury Prevention

4. NUANCES OF PEDIATRIC TRAUMA Multisystem injury is the rule rather than the exception The priorities of pediatric trauma management are the same for children as for adults Because of smaller body mass, energy from linear forces (e.g., fenders, bumpers, falls) results in greater force applied per unit body area

5. NUANCES OF PEDIATRIC TRAUMA Children have less fat, less elastic connective tissue and close proximity of organs, which leads to more multisystem organ injuries The skeleton is incompletely calcified and more pliable If bones are broken, assume that a massive amount of energy was applied Internal organs may be damaged without evidence of overlying bone fractures Children's have unique anatomic characteristics that require special considerationsChildren's have unique anatomic characteristics that require special considerations

6. NUANCES OF PEDIATRIC TRAUMA The young child’s ability to interact and cooperate with parents or caregivers is limited, which makes history-taking and physical examinations difficult Children have a large body surface area in relation to their weight, relatively thin skin and a lack of insulating fat.These characteristics lead to increased loss of water and heat Appropriate measures must be taken to ensure that injured children do not become hypothermic (e.g., thermal blankets, warmed IV fluids) Appropriate measures must be taken to ensure that injured children do not become hypothermic (e.g., thermal blankets, warmed IV fluids)

7. NUANCES OF PEDIATRIC TRAUMA Normal" systolic blood pressure can be estimated by adding 80 to two times the child's age in years Normal diastolic blood pressure is roughly two-thirds of the systolic pressure Because of children's excellent capacity for physiologic adaptation, shock may go unrecognized in its early stages

8. NUANCES OF PEDIATRIC TRAUMA AIRWAY INJURY The smaller the child, the greater the disproportion between the size of the cranium and the size of the midface. This produces a greater propensity for the posterior pharyngeal area to buckle as the relatively large occiput forces passive flexion of the cervical spine

9. NUANCES OF PEDIATRIC TRAUMA CHEST TRAUMA The child's chest wall is very compliant, which allows energy to be transferred to the intrathoracic soft tissues, frequently without any evidence of external chest wall injury Consequently, pulmonary contusions and intrapulmonary hemorrhage are common The mobility of the thoracic structures makes the child more sensitive to tension pneumothorax and flail segments

10. NUANCES OF PEDIATRIC TRAUMA HEAD TRAUMA Children are particularly susceptible to the secondary effects of brain injury produced by hypoxia, hypotension, seizures and hyperthermia Young children with open fontanels and mobile cranial suture lines are more tolerant of expansion of intracranial mass lesions, decompensation may not occur until the mass lesion has become large Shock resuscitation and avoidance of hypoxia are critically important to a favorable outcome A bulging fontanel or a widened suture is an ominous sign Shock resuscitation and avoidance of hypoxia are critically important to a favorable outcome A bulging fontanel or a widened suture is an ominous sign

11. NUANCES OF PEDIATRIC TRAUMA SPINAL CORD INJURY Children may sustain spinal cord injury without radiographic abnormality (known by the acronym SCIWORA) This situation occurs because the pediatric spine is so much more elastic and mobile than the adult spine Spinal precautions must be maintained The interspinous ligaments and joint capsules are more flexible, the facet joints are flatter, and the relatively large size of the head allows for more angular momentum to be generated during flexion and extension, which in turn results in greater energy transferThe interspinous ligaments and joint capsules are more flexible, the facet joints are flatter, and the relatively large size of the head allows for more angular momentum to be generated during flexion and extension, which in turn results in greater energy transfer

12. GENERAL APPROACH TO THE CHILD WITH TRAUMA  ABCs are your first priority Primary survey and resuscitation are followed by: Secondary survey Definitive care

17. PEDIATRIC TRAUMA SCORE See handout attached -*NB: Lecturer Please See Article handout attached to power point presentation-*NB: Lecturer Please See Article handout attached to power point presentation

18. PRIMARY SURVEY ABC’s C-spine precautions Pediatric Glasgow Coma Scale Vital signs including rectal temperature Check for signs of obvious trauma Check for S&S of raised ICP

19. SECONDARY SURVEY The secondary survey serves to identify any potentially life-threatening cardiopulmonary injuries that were not immediately evident in the primary survey It consists of a head-to-toe evaluation, including - vital signs - a complete history and physical examination - a complete neurologic evaluation - paediatric Glasgow coma score Secondary survey History :The SAMPLE mnemonic is useful in obtaining the history from a conscious child/caregiver –    S for symptoms –    A for allergies –    M for medications –    P for past medical history –    L for last meal time - E for events and environment related to the injury - Look for external evidence of trauma - Skull/scalp/ facial injury - Anterior Fontanelle – in infants - Eyes - Fundi( retinal hemorrhages), oculomotor movements, (Racoon eyes/Panda bear sign) - Ears (Battle sign, CSF drainage, hemotypanum, nose, throat - Neck - Breathing patterns, chest trauma( pulmonary/cardiovascular injury) - Abdominal trauma - Limb trauma/ Motor responses ( focalizing/lateralizing signs - Spine/back - Genital/rectal - CNS – detailed exam incgluding GCS ( not as reliable in children as adults) - Pediatric trauma scoringSecondary survey History :The SAMPLE mnemonic is useful in obtaining the history from a conscious child/caregiver –    S for symptoms –    A for allergies –    M for medications –    P for past medical history –    L for last meal time - E for events and environment related to the injury - Look for external evidence of trauma - Skull/scalp/ facial injury - Anterior Fontanelle – in infants - Eyes - Fundi( retinal hemorrhages), oculomotor movements, (Racoon eyes/Panda bear sign) - Ears (Battle sign, CSF drainage, hemotypanum, nose, throat - Neck - Breathing patterns, chest trauma( pulmonary/cardiovascular injury) - Abdominal trauma - Limb trauma/ Motor responses ( focalizing/lateralizing signs - Spine/back - Genital/rectal - CNS – detailed exam incgluding GCS ( not as reliable in children as adults) - Pediatric trauma scoring

20. DEFINITIVE CARE Resuscitative measures initiated earlier are continued (e.g., airway, IV therapy, oxygen) Identified conditions should be managed according to their priority Ensure that airway is protected in an unconscious child Apply suction as needed Administer high concentrations of supplemental oxygen, even if breathing appears adequate Administer high concentrations of supplemental oxygen, even if breathing appears adequate

21. DEFINITIVE CARE Treat hypotension aggressively with IV fluid replacement Insert nasogastric tube and apply suction (if not already done), unless the child has facial fractures or a suspected basal skull fracture Insert Foley catheter (if no contraindications and not already done)

22. Not all tests may be done, patient presentation specificNot all tests may be done, patient presentation specific

23. PEDIATRIC SHOCK History- Infant - May become combative initially, then lethargic - Poor feeding - Decreased responsiveness to parents or caregivers - History of trauma - History of symptoms of an underlying illness (e.g., cough indicating pneumonia) Trauma is the single largest cause of death in all childhood age groups, except the first year of life. To reduce morbidity and mortality rates in the critical early hours after trauma has occurred (the “golden period”), early resuscitation and rapid transport to hospital are key. Trauma is the single largest cause of death in all childhood age groups, except the first year of life. To reduce morbidity and mortality rates in the critical early hours after trauma has occurred (the “golden period”), early resuscitation and rapid transport to hospital are key.

24. PEDIATRIC SHOCK History- Older Child - Nausea - Light headed , feeling faint - Thirst - Altered level of consciousness - Other symptoms depending upon underlying cause - Trauma

25. PEDIATRIC SHOCK Physical Findings - Remember: ABCs are the priority The physical findings are variable, depending on whether the child is in compensated or decompensated shock It is generally assumed that any child who is hypotensive secondary to hypovolemia has lost at least 25% of total circulating blood volume - Persistent tachycardia is the most reliable indicator of shock in children Do not rely on blood pressure readings. In children, blood pressure is preserved by compensatory vasoconstrictive mechanisms until very late in shock. Appearance, breathing and perfusion are more reliable clinical indicators of shock. Prolonged capillary refill (>2 seconds) is a sign of decreased tissue perfusion and is more beneficial as a sign of shock in children than in adults. Do not rely on blood pressure readings. In children, blood pressure is preserved by compensatory vasoconstrictive mechanisms until very late in shock. Appearance, breathing and perfusion are more reliable clinical indicators of shock. Prolonged capillary refill (>2 seconds) is a sign of decreased tissue perfusion and is more beneficial as a sign of shock in children than in adults.

26. PEDIATRIC SHOCK Compensated Shock - Appearance: alert, anxious - Breathing: tachypnea or hyperpnea - Circulation: tachycardia, cool or pale skin, decreased peripheral pulses

27. PEDIATRIC SHOCK Decompensated Shock - Appearance: altered mental status, reduced level of consciousness - Breathing: tachypnea or bradypnea - Circulation: tachycardia or bradycardia, mottled or cyanotic skin, peripheral pulses absent

28. PEDIATRIC SHOCK Management: - Assess and stabilize ABCs - Ensure that airway is patent and ventilation is adequate - Insert oral airway and ventilate with Ambu bag (using oxygen) as needed - Control any external bleeding: use direct pressure to control bleeding from external wounds - Place in head-down position - Give oxygen at 12–15 L/min by non-rebreather mask with reservoir; keep oxygen saturation >97% or 98%

29. PEDIATRIC SHOCK Management: - Start 2 large-bore IV lines with normal saline (or Ringer’s lactate) - Give 20 mL/kg IV fluid rapidly as a bolus over 20 minutes - Reassess for signs of continuing shock - If shock persists, continue to administer fluid in 20 mL/kg boluses, and reassess after each bolus - Adjust IV rate according to clinical response If unable to achieve IV access after 90 seconds, go to interosseous access I f still in shock After 3 bolus’ of IV crystalloid, need to go on to blood products After resuscitation other measures include: - Insert indwelling urinary catheter - Insert nasogastric tube prn Monitoingr ABCs, vital signs (including pulse oximetry, if available) and level of consciousness as often as possible until condition is stable Frequent reassessment for continuing blood loss is important Monitor hourly intake and urine output Identify and manage underlying cause of shock (e.g., manage sepsis with IV antibiotics) Assess stability of pre-existing medical problems (e.g., diabetes mellitus) If unable to achieve IV access after 90 seconds, go to interosseous access I f still in shock After 3 bolus’ of IV crystalloid, need to go on to blood products After resuscitation other measures include: - Insert indwelling urinary catheter - Insert nasogastric tube prn Monitoingr ABCs, vital signs (including pulse oximetry, if available) and level of consciousness as often as possible until condition is stable Frequent reassessment for continuing blood loss is important Monitor hourly intake and urine output Identify and manage underlying cause of shock (e.g., manage sepsis with IV antibiotics) Assess stability of pre-existing medical problems (e.g., diabetes mellitus)

30. PEDIATRIC BURNS Risk Factors - Excess sun exposure - Hot water heaters set too high - Exposure to chemicals or electricity - Young children with thin skin are more susceptible to injury - Carelessness with burning cigarettes - Inadequate or faulty electrical wiring Burns are common in children and can cause significant morbidity and mortality. They constitute the leading cause of accidental death in children. Open flames and hot liquids are the most common cause (heat usually 15°C to 45°C or greater) . In children <3 years old, scald burns from spilled hot liquids are the most common type of burn Electrical burns to the mouth can occur in toddlers who chew electrical cords Specific Paediatric Issues Body surface area is proportionately high for weight in younger children The relative contribution of various body parts to body surface is different in children than in adults (e.g., head relatively larger, legs relatively smaller) Burns are common in children and can cause significant morbidity and mortality. They constitute the leading cause of accidental death in children. Open flames and hot liquids are the most common cause (heat usually 15°C to 45°C or greater) . In children <3 years old, scald burns from spilled hot liquids are the most common type of burn Electrical burns to the mouth can occur in toddlers who chew electrical cords

31. PEDIATRIC BURNS Intentional Burn Injuries - A form of child abuse that can sometimes be recognized by specific burn patterns - Consider child abuse when a child presents with hot-water burns - Observe distribution of burns - Pay attention to straight-line burns, especially if bilateral Accurate diagnosis requires a careful history, physical examination and assessment of the child’s developmental capabilities, Accurate diagnosis requires a careful history, physical examination and assessment of the child’s developmental capabilities,

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37. Complications - Hypoglycemia (may occur in children because of limited glycogen storage) - Burn wound sepsis (usually gram-negative organisms) - Decreased mobility, with possibility of future flexion contractures - Gastroduodenal ulceration Complications - Hypoglycemia (may occur in children because of limited glycogen storage) - Burn wound sepsis (usually gram-negative organisms) - Decreased mobility, with possibility of future flexion contractures - Gastroduodenal ulceration

38. PEDIATRIC BURNS Management - Stabilize ABCs - Primary survey - Establish airway and assist ventilation as required -- Give oxygen so as to keep oxygen saturations >97% to 98% - Fluid Resuscitation Calculate fluid resuscitation from time of burn, not from time treatment begins Start IV therapy with normal saline or Ringer’s lactate Initiate IV therapy if more than 10% of child’s body surface area has been burned Replace fluid losses Rule of thumb for fluid replacement in children with major burns: 4 mL × body weight (kilograms) × % of body surface area burned Half of this volume is given in the first 8 hours, a quarter in the second 8 hours and the last quarter in the third 8 hours This quantity is given in addition to maintenance fluids and is adjusted according to urine output and vital signs Burn shock usually takes hours to develop. If shock is evident on initial presentation, look for other causes of volume loss, such as major injury elsewhere in the body. See “Shock,” in chapter 20, “General Emergencies and Major Trauma.” Calculate fluid resuscitation from time of burn, not from time treatment begins Start IV therapy with normal saline or Ringer’s lactate Initiate IV therapy if more than 10% of child’s body surface area has been burned Replace fluid losses Rule of thumb for fluid replacement in children with major burns: 4 mL × body weight (kilograms) × % of body surface area burned Half of this volume is given in the first 8 hours, a quarter in the second 8 hours and the last quarter in the third 8 hours This quantity is given in addition to maintenance fluids and is adjusted according to urine output and vital signs Burn shock usually takes hours to develop. If shock is evident on initial presentation, look for other causes of volume loss, such as major injury elsewhere in the body. See “Shock,” in chapter 20, “General Emergencies and Major Trauma.”

39. Source: Health Canada, First Nation’s Inuit health branch,Pediatric Clinical Practice Guidelines for Nurses in Primary CareSource: Health Canada, First Nation’s Inuit health branch,Pediatric Clinical Practice Guidelines for Nurses in Primary Care

40. POISONINGS AND OVERDOSES Ingestion of a potentially toxic substance, including a drug, a household or industrial chemical, plant material or waste products Initial Evaluation - ABCs are the first priority! - Ensure that the child’s condition is stable - If not, take steps to stabilize before obtaining the history, performing the physical examination and instituting management OVERDOSES, POISONING AND TOXIDROMES One of the unique features of poisoning during childhood is its two very different scenarios. The first involves the young child between 1 and 5 years of age who accidentally ingests a small amount of a substance that may or may not have pharmaceutical properties. The second involves the teenager who intentionally ingests a large amount of one or more substances, usually pharmaceutical. Although the latter situation can and does result in significant morbidity, it is quite uncommon in young children. In the younger age group, less than 10% of those who ingest a potentially toxic substance are actually poisoned, either because the ingested substance is inherently non-toxic or because the amount ingested is too small to cause toxic effects. OVERDOSES, POISONING AND TOXIDROMES One of the unique features of poisoning during childhood is its two very different scenarios. The first involves the young child between 1 and 5 years of age who accidentally ingests a small amount of a substance that may or may not have pharmaceutical properties. The second involves the teenager who intentionally ingests a large amount of one or more substances, usually pharmaceutical. Although the latter situation can and does result in significant morbidity, it is quite uncommon in young children. In the younger age group, less than 10% of those who ingest a potentially toxic substance are actually poisoned, either because the ingested substance is inherently non-toxic or because the amount ingested is too small to cause toxic effects.

42. POISONINGS AND OVERDOSES History- Determine: - Circumstances of ingestion - What and how much was taken - The time of ingestion - When the symptoms began, if any - Whether symptom intensity has decreased, increased or remained the same HISTORY Typically the young child is brought to the healthcare provider very soon after the discovery of the accidental ingestion. In most situations, there has not been enough time for symptoms to have occurred. Make inquiries about the circumstances of the ingestion: –   How did the child get at the container? –   Was the container left within easy reach? –   Was the child-resistant closure left disengaged? This information is useful for preventive counselling at the end of the encounter. Although most childhood poisonings are accidental, always be on guard for purposeful administration by a parent or caregiver. This should be considered especially in children <1 year old and in any child with repeated ingestion of a potentially toxic substance, particularly if the various incidents involve the same compound. A careful history is the most important part of the assessment, as there may be no clinical signs at the time of presentation. HISTORY Typically the young child is brought to the healthcare provider very soon after the discovery of the accidental ingestion. In most situations, there has not been enough time for symptoms to have occurred. Make inquiries about the circumstances of the ingestion: –   How did the child get at the container? –   Was the container left within easy reach? –   Was the child-resistant closure left disengaged? This information is useful for preventive counselling at the end of the encounter. Although most childhood poisonings are accidental, always be on guard for purposeful administration by a parent or caregiver. This should be considered especially in children <1 year old and in any child with repeated ingestion of a potentially toxic substance, particularly if the various incidents involve the same compound. A careful history is the most important part of the assessment, as there may be no clinical signs at the time of presentation.

43. POISONINGS AND OVERDOSES Physical Examination - ABCs are the priority - Vital signs: temperature, heart rate, respiratory rate, depth of respiration, blood pressure - Level of consciousness - Closely examine cardiovascular, respiratory and central nervous systems Signs vary with the type of poison. The main systems involved in poisoning are the cardiovascular, respiratory and central nervous systems, but in certain situations there is a need to focus on other systems (e.g., the mouth and the esophagus after ingestion of caustic alkali).Signs vary with the type of poison. The main systems involved in poisoning are the cardiovascular, respiratory and central nervous systems, but in certain situations there is a need to focus on other systems (e.g., the mouth and the esophagus after ingestion of caustic alkali).

44. POISONINGS AND OVERDOSES Diagnostic Investigations to Consider: Specific drug levels Serum osmolality ABG’s Rapid bedside glucose blood Urinalysis, Urine pregnancy test ( adolescents) Pulse oximetry EKG CXR Abdominal X-ray for radiopaque tablets

45. POISONINGS AND OVERDOSES Management Stabilize ABCs as required Give oxygen as necessary - Start IV therapy with normal saline (if there is evidence of compromise in circulation or significant dehydration); run at a rate sufficient to maintain vital signs and hydration

46. POISONINGS AND OVERDOSES Management - Nasogastric tube may be necessary for a child who is unconscious and who cannot or will not drink - Administer charcoal therapy - Insert Foley catheter (in child with altered level of consciousness) GI Tract Decontamination Activated charcoal is now recommended as the sole therapy and should be given for ingestion of any toxic material, except iron, hydrocarbons, alcohols and caustic agents. GI Tract Decontamination Activated charcoal is now recommended as the sole therapy and should be given for ingestion of any toxic material, except iron, hydrocarbons, alcohols and caustic agents.

47. POISONINGS AND OVERDOSES Pharmacologic Interventions – specific poisons If opiate poisoning is suspected: naloxone (Narcan) 0.1 mg/kg by IV push If Acetaminophen poisoning: N-acetylcysteine( Mucomyst)is started within 8 hours If Iron overdose: deferoxamine(desferal) Acetaminophen This is the most common drug overdose at all ages. Despite the tens of thousands of reported ingestions by children <6 years old, there have been only a few cases of significant toxic effects, primarily because small children usually ingest pediatric formulations. Ingestions of greater than 150 mg/kg should be a cause for concern, but remember that this figure also incorporates a safety factor, such that significant toxic effects actually manifest at a somewhat higher dose. The organ at risk is the liver, with toxic effects occurring a few days after the ingestion. Toxic effects can be prevented if the antidote N-acetylcysteine is started within 8 hours after the overdose. Although the antidote becomes less effective beyond 8 hours, it is still worthwhile to initiate therapy between 8 and 24 hours after ingestion. In medical facilities, administration of this antidote is determined by acetaminophen blood level, which is unavailable in the nursing station Iron Iron poisoning can be quite serious. It usually results from ingestion of a prenatal supplement or other adult dosage form. The toxic effects depend on the amount of elemental iron ingested (ferrous sulfate is 20% elemental iron, ferrous fumarate is 33% elemental iron, and ferrous gluconate is 12% elemental iron). Therefore, for example, a 300-mg tablet of ferrous sulfate contains 60 mg of elemental iron. With greater amounts ingested, degree of toxic effects also increases. At 20 mg of elemental iron, expect GI symptoms, such as vomiting and diarrhea, with the possibility of blood in the emesis or stool. At 60 mg/kg of elemental iron, there is significant risk of GI hemorrhage, shock and acidosis. Coma occurs late in the overdose and is a consequence of shock and acidosis Acetaminophen This is the most common drug overdose at all ages. Despite the tens of thousands of reported ingestions by children <6 years old, there have been only a few cases of significant toxic effects, primarily because small children usually ingest pediatric formulations. Ingestions of greater than 150 mg/kg should be a cause for concern, but remember that this figure also incorporates a safety factor, such that significant toxic effects actually manifest at a somewhat higher dose. The organ at risk is the liver, with toxic effects occurring a few days after the ingestion. Toxic effects can be prevented if the antidote N-acetylcysteine is started within 8 hours after the overdose. Although the antidote becomes less effective beyond 8 hours, it is still worthwhile to initiate therapy between 8 and 24 hours after ingestion. In medical facilities, administration of this antidote is determined by acetaminophen blood level, which is unavailable in the nursing station Iron Iron poisoning can be quite serious. It usually results from ingestion of a prenatal supplement or other adult dosage form. The toxic effects depend on the amount of elemental iron ingested (ferrous sulfate is 20% elemental iron, ferrous fumarate is 33% elemental iron, and ferrous gluconate is 12% elemental iron). Therefore, for example, a 300-mg tablet of ferrous sulfate contains 60 mg of elemental iron. With greater amounts ingested, degree of toxic effects also increases. At 20 mg of elemental iron, expect GI symptoms, such as vomiting and diarrhea, with the possibility of blood in the emesis or stool. At 60 mg/kg of elemental iron, there is significant risk of GI hemorrhage, shock and acidosis. Coma occurs late in the overdose and is a consequence of shock and acidosis

48. ANAPHYLAXIS Causes Vaccines - Drugs Insect sting (e.g., bee) Food Latex Venoms Idiopathic Anaphylaxis usually begins a few minutes after injection of the offending substance and is usually evident within 15 minutes

49. ANAPHYLAXIS The symptoms may include the following Sneezing Coughing - Itching "Pins-and-needles" sensation of the skin - Flushing of the skin - Facial edema (perioral, oral or periorbital urticaria)

50. ANAPHYLAXIS The symptoms may include the following Anxiety Palpitations - Nausea, vomiting - Early respiratory difficulties (e.g., wheezing, dyspnea, tightness of the chest) - Hypotension, which may progress to shock and collapse

51. ANAPHYLAXIS Management: - Place the child in a recumbent position (elevating the feet if possible) Establish and maintain oral airway if necessary - Give oxygen by mask, 10-12 L/min by non-rebreather mask; keep oxygen saturations > 97% to 98% - Start IV therapy with normal saline to keep vein open, unless severe anaphylaxis and signs of shock are evident

52. ANAPHYLAXIS Management: Administer - Aqueous epinephrine 1:1000, 0.01 mL/kg (maximum dose 0.3 mL) SC or IM in the limb opposite that in which the original injection was given - A single SC injection is usually sufficient for mild or early anaphylaxis - Epinephrine can be repeated twice at 15- 20 minute intervals, if necessary. In severe reactions it may be necessary to give these repeat doses at shorter intervals (10–15 minutes) If the vaccine causing anaphylaxis was given subcutaneously, an additional dose of 0.005 mL/kg (maximum dose 0.3 mL) of aqueous epinephrine (1:1000) can be injected at the vaccination site to slow absorption of the vaccineIf the vaccine causing anaphylaxis was given subcutaneously, an additional dose of 0.005 mL/kg (maximum dose 0.3 mL) of aqueous epinephrine (1:1000) can be injected at the vaccination site to slow absorption of the vaccine

53. Source: Health Canada , FNIHB Clinical Practice Guidelines for Nurses in Primary CareSource: Health Canada , FNIHB Clinical Practice Guidelines for Nurses in Primary Care

54. ANAPHYLAXIS Management (Cont’d) - If hypotensive after epinephrine , Start IV N/S 20 cc/Kg bolus over 20 minutes - Diphenhydramine 1-2 mg/kg IM or IV, up to 50 mg q4-6h - Hydrocortisone 5-10 mg/Kg up to 500mg Q4-6h - Ranitidine 12.5-50 mg IV q6-8h - Monitor Vital signs frequently - Salbutamol via MDI for persistent bronchospasm - Observe for 6-8 hours minimum with rapid response - If protracted course monitor for 24 hours Source: Toronto Sick Kids Hospital –Pediatric Emergency Clinical Practice GuidelinesSource: Toronto Sick Kids Hospital –Pediatric Emergency Clinical Practice Guidelines

55. PREVENTING ALLERGIC REACTIONS Take a careful patient and family history of allergies Be prepared with emergency response Monitor child for 20 minutes after injection

56. INJURY PREVENTION Prevention - Information obtained during the initial history is often very helpful for post-encounter preventive counseling Poison prevention as well as accident prevention counseling should be a regular part of your follow-up and a regular part of well-baby visits beginning after the child reaches 6 months of age Encourage parents to have local poison control center phone number visible and accessible in case of accidental ingestion Caregivers and child’s school should be alerted to child’s allergies especially if potential life threatening allergies are present