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Pediatric Emergencies for Rural Pediatrics

Pediatric Emergencies for Rural Pediatrics. Ron Kaplan, MD, FAWM Clinical Associate Professor Of Pediatrics Division of Emergency Medicine University of Washington School of Medicine Seattle Children’s Hospital. Pediatric Emergencies for Rural Pediatrics.

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Pediatric Emergencies for Rural Pediatrics

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  1. Pediatric Emergencies for Rural Pediatrics Ron Kaplan, MD, FAWM Clinical Associate Professor Of Pediatrics Division of Emergency Medicine University of Washington School of Medicine Seattle Children’s Hospital

  2. Pediatric Emergencies for Rural Pediatrics • Many pediatric emergencies can be managed initially in the remote setting • Principles may be applied in the tertiary care setting

  3. Pediatric Emergencies for Rural Pediatrics • Dehydration associated with acute GI illness • Status asthmaticus • Status epilepticus

  4. Objectives Provide rehydration and symptomatic treatment for the child with acute GI illness without an IV Provide emergency treatment for the child with status asthmaticus without power Manage the child with status epilepticus without an IV

  5. Dehydration

  6. Dehydration: Background • 2.5 million childhood deaths annually worldwide • In the US: • >200,000 hospitalizations • >1.5 million outpatient visits • 300 deaths • Estimated costs >1 billion dollars

  7. Oral Rehydration Therapy • Steady decline in mortality over the last few decades • Decrease in ED visits, hospitalizations and cost • Established guidelines by WHO, CDC, AAP • Two meta-analyses of RCTs document efficacy

  8. Oral Rehydration Therapy • Two meta-analyses comparing ORT to IVT in children younger than 15 with gastroenteritis • 16 trials from 1988-2003 • 1545 children • 11 countries • One-half in developing countries • 18 studies from 1982-2005 • 1811 patients • One-half in developing countries

  9. Oral Rehydration Therapy • Across all 16 trials, ORT failure rate 4% • Reduced hospital stay with ORT in three trials in developed countries • No difference in frequency of stools, duration of diarrhea or weight gain • IVT more expensive • No significant difference in major adverse events

  10. Oral Rehydration Therapy • Across18 studies slightly more treatment failures with ORT • One failure for every 25 patients with ORT compared to IVT • Reduced hospital stay with ORT in 6 trials • No difference in weight gain, duration, total fluid intake, hypo- or hypernatremia

  11. Oral Rehydration Therapy • ORT is as effective as IVT in children with mild to moderate dehydration caused by diarrhea • ORT IS THE TREATMENT OF FIRST CHOICE

  12. Oral Rehydration Therapy • Standard commercial ORS • Treatment divided into two phases • Rehydration • Maintenance

  13. Oral Rehydration Therapy: Rehydration Phase • Fluid deficit replaced over 3-4 hours • Frequent small amounts by spoon, syringe, NG tube • 5 ml every 1-2 minutes = 150-300 ml/hr • 50 ml/kg over 4 hours for mild dehydration • 100 ml/kg over 4 hours for moderate dehydration • Continue breastfeeding

  14. Oral Rehydration Therapy: Maintenance Phase • Ongoing losses replaced with ORS • 10 ml/kg per diarrheal stool • 2 ml/kg per emesis • Rapid return to unrestricted diet

  15. Oral Rehydration Solutions • Total osmolality 200-310 mmol/L • Equimolar concentrations of glucose and sodium • Glucose concentration < 20g/L (111 mmol/L) • Sodium concentration 60-90 meq/L

  16. ORT: Physiologic Basis

  17. Oral Rehydration Solutions • Standard commercial ORS • WHO ORS, Pedialyte, etc. • Sports drinks, juice, soft drinks, Jell-O, popsicles? • Too much sugar, too little sodium • Chicken soup??? • Too much sodium

  18. Oral Rehydration Solutions

  19. Oral Rehydration Solutions

  20. Dehydration: Symptomatic Treatment • Antiemetics? • Antidiarrheals? • Antibiotics? • Probiotics?

  21. Dehydration: Antiemetics • Meta-analysis of 11 trials of antiemetics in gastroenteritis • Ondansetron • Decreases further vomiting • Reduced need for IV fluids • Decreases hospitalization rates • Others • No evidence of efficacy • Potentially dangerous

  22. Dehydration: Ondansetron • 2 mg for 8-15 kg • 4 mg for 15-30 kg • 8 mg for >30 kg

  23. Dehydration: Diarrhea • Antidiarrheals • Avoid in general • ? antimotility agent with antibiotics for severe travelers’ diarrhea • Antibiotics • Ditto • Probiotics • Lactobacillus GG

  24. Dehydration: Summary • ORT is as effective as IV hydration in mild-moderate dehydration • ORT is the treatment of first choice in these patients • Ondansetron is useful for vomiting • Avoid antibiotics and antidiarrheals except some travelers’ diarrhea • Lactobacillus GG couldn’t hurt • Remember the NG tube!

  25. Status Asthmaticus

  26. Status Asthmaticus • Treatment aimed at reversing airflow obstruction due to bronchospasm and airway inflammation • Inhaled beta agonists • Systemic glucocorticoids • Other • Treatment principles are the same in the remote setting as in the ICU

  27. Inhaled Beta Agonists • MDI vs Nebulizer • MDI convenient, cost-effective • High rate of lost drug with neb • Lower risk of bacterial contamination with MDI • MDI technique-dependent • Clinical trials and meta-analyses suggest MDI is at least as effective as neb

  28. MDI with Spacer • Spacer corrects for poor MDI technique • Can be used in very small children • Spacer can be made from a 500 ml plastic bottle

  29. Homemade Spacer

  30. MDI with Spacer: Technique • Assemble, shake • Place in mouth or apply mask • Breathe normally • Actuate MDI at start of inspiration • One puff at a time • Deep breath, hold for 10 seconds • For small child, 6 breaths per puff • Wait 30-60 seconds between puffs

  31. Albuterol MDI: Dosing • Four puffs = 2.5 mg neb • Standard dose 4-8 puffs • 30 mg/hr neb = 48 puffs!!!

  32. Asthma: Steroids • Effects within 2-4 hours • NAEPP guidelines: oral preferred to IV • Effects are equivalent • Less invasive • Consider IM if oral dose vomited • Prednisone vs. Dexamethasone • ? Inhaled steroids

  33. Asthma: Steroids • Prednisone 2 mg/kg initial dose • Half-life 18-36 hours • Dexamethasone 0.6 mg/kg • Half-life 36-72 hours • 4 mg tablets convenient, crush and mix with food

  34. Asthma: Steroids • Single dose of IM dex as effective as 5 days of PO pred • Single dose of PO dex similar to 5 days of BID prednisolone • Two doses of PO dex similar to 5 days of PO pred with improved compliance, fewer side effects

  35. Asthma: Treatment • Inhaled steroids: mixed results, not routinely recommended • Ipratropium MDI • Don’t use if peanut or soy allergy • Subcutaneous epinephrine or terbutaline

  36. Status Asthmaticus: Summary • Albuterol MDI with spacer at least as good as nebs • Don’t be shy with dosing • Oral steroids as good as IV • Dex convenient, long acting, better compliance • Consider subcutaneous epi or terb • Ipratropium MDI if no peanut/soy allergy • Inhaled steroids if you don’t have PO

  37. Status Epilepticus

  38. Status Epilepticus • Many seizure meds may be given without an IV • IV access may be delayed or impossible even if available • Strict EMS/ED protocols may result in unnecessary IV therapy in many children • Unnecessary IV therapy may cause excessive sedation and respiratory depression

  39. Status Epilepticus • Alternative routes of administration • Oral • Intramuscular • Transmucosal • Rectal • Buccal • Intranasal

  40. Seizure Medications: Oral • Oral loading may be possible if the child is conscious and not actively seizing • Phenobarbital • Phenytoin • Valproic acid • Oxcarbazepine • Levetiracetam

  41. Seizure Medications: Intramuscular • Benzodiazepines • Fosphenytoin • Barbiturates • Paraldehyde

  42. Seizure Medications: Transmucosal • Safe, effective, well tolerated, absorbed quickly • Avoids treatment delays related to transport and IV access • Allows earlier treatment at home or in the field

  43. Seizure Medications: Rectal • Diazepam • Paraldehyde • Anything available as an oral suspension • Clonazepam • Carbamazepine, Oxcarbazepine • Valproate • Levetiracetam

  44. Seizure Medications: Rectal Diazepam • Effective and safe • Rectal gel in prefilled syringe • Long shelf life • Does not require refrigeration • Respiratory depression extremely rare

  45. Seizure Medications: Rectal Diazepam • Round dose to 2.5, 5, 7.5, 10, 12.5, 15, 17.5 and 20 mg/dose • Diastat® 2.5 mg rectal gel • Diastat Accudial® • 10 mg [delivers a 5mg, 7.5mg, or 10mg dose] • 20 mg [delivers a 10mg, 12.5mg, 15mg, 17.5mg, or 20mg dose]

  46. Diastat Accudial®

  47. Seizure Medications: Buccal Midazolam • At least as effective as rectal diazepam • More socially acceptable • Shorter time to treatment with buccal midazolam compared to IV diazepam • Similar risk of respiratory depression

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