Part 08. Acutely ill Child
PART ¥·. The Acutely Ill Child
Chapter 57. Evaluation Of The Sick Child In The Office And Clinic
#
acute febrile illness¸¦ °¡Áø childrenÀÇ
risk¿Í serious illnessÀÇ
cause´Â ³ªÀÌ¿¡ µû¶ó ´Ù¸£´Ù.
#
Identifying the acutely ill child with a serious illness
; careful observation
-
*focus on assessing the child's
response to stimuli
; history
; physical examination
; appreceation of age
; temperature as risk factors
; judicious use of screening
laboratory test
: helpful in identifying the
febrile child at increased risk for common
serious illness
¡ÚFig.
57-1 Acute Illness Observational Scales
Diagnostic Approach
- 3¼¼ ÀÌÇÏÀÇ febrile child¿¡¼
sepsis work-upÀÌ ÇÊ¿ä
Chapter 58. Injury Control
- Injuries : most common cause of death
during childhood > 1st few mo.
most important causes of preventable pediatric morbidity & mortality
Injury Control
¡¦
broadened scope of prevention
+- primary
prevention of the event from occuring in the first place
+-
secondary & tertiary prevention
: appropriate emergency medical services for injured children
Scope Of The Problem
Mortality
;
injuries
- *40% of the death among 1-4 yr old children
/
three times than next leading cause, congenital anomalies
- *70% of the death of rest children & adolescence (< 19 yr)
;
homicide
- *leading cause of injury death for infants under 1yr
- 4th leading cause for age
1-14yr
- 2nd leading cause for age
15-19yr
Table 58-1
Morbidity
; 20-25% of children & adolescents
- medical care for injuries each year in hospital emergency parts
Table 58-2
Trends Over Time
- decreased in
deaths from unintentional injuries
- increased
rates of intentional injuries
Principles Of Injury Control
Table 58-1
¨ç
education
¨è
persuasion
¨é
changes in products
¨ê
modification of environment ( social or physical environment )
Risk Factors For Childhood Injuries
Age
#
Toddlers
; *¡ãrisk for burns,
drowning, falls
#
Young school age
; *¡ãrisk for pedestrian
injuries, bicyle-related injuries(¡ãserious),
motor vehicle occpant injuries, burns, drowning
Sex
- 1-7 yr : M > F
- Boys in all age
groups : higher rates of bicycle-related injuries
Race
:
black > white > asians
4) socioeconomic status
- poverty : one of the
most important risk factor
5) environment
Motor Vehicle Injuries
1) occupants
- peak age : 15-19 yr
- child seat
restraints°¡ À¯¿ë
2) teenage drivers
- alcohol use°¡ Áß¿ä¿øÀÎ
3) bicycle injureis
- use of helmets :
head trauma ¹æÁö
4) pedestrian injuries
- single most common
cause of traumatic death for 5-9 yr ( industrialized country )
- severe nonfatal
injuries
Fire- And Burn-Related Injuries
- 3rd most common
cause of unintentional injury death in U.S.
- 1st decade of life :
highest risk
- flammable fabrics,
scald burns d/t tap water, cigarettes, fireworks injuries,
cigarette
lighters
Poisoning
- decreased
dramatically over the last two decades
Drowning
- diving head first
into water -> spinal cord damage
- alcohol & drug
use
- prevention : fencing
firearm
injuries
- non-intentional
injury
- suicide attempt
- assault
Chapter 59. Emergency Medical Services For Children
(EMS-C)
1) anticipatory gurdiance
¨ç
early recognition & treatment
¨è
education
2) office preparendness
3) staff training and continuing
education
4) policies and procedures
5) resuscitation equipment
6) transport : initial stabilization in
a local community hospital,
but definitive & long-term care in major referred centers
1.
Pediatric prehospital care
1) Access to the EMS system
2) Provider capability
¨ç
first responders
: to provide rapid response and stabilization, pending the arrival of
more highly
trained personnel
¨è
emergency medical technicians (EMTs)
: volunteers or paid professionals who provide the bulk of emergency
medical
response ( in U.S. )
¨é
paramedics ( or EMT-Ps )
: highest level of EMT response, with medical training & supervised
field
experience
3) Response / transport time
Destination
defined by parental preference, provider
preference agency protocol
#
Pediatric Trauma Score ( PTS ) or Revised Trauma Score ( RTS )
-> assess the
severity of injury
¡ÚTable
59-3 pediatric trauma score
#
PTS < 8 or RTS < 11 : should be treated in a designated trauma center
The Pediatric Parent In The Hospital Emergency Department :
Priorities In Pediatric Resuscetation
Table 59-4
A. Airway / Spinal immobilization
B. Breathing
¨ç
pneumothorax
:
dose not improve with supplemental oxygen & positive pr. ventilator
¨è
tension-pneumothorax
+- decreased breath sounds
| hyper-resonance in
the affected hemithorax
| mediastinal shift
| cyanosis
| distended neck vein
+- compromised C.O. (d/t
decreased venous return to heart)
=> insert a needle
or over-the-needle catheter into 2nd ICS at the midclavicular line
C. Circulation
#
¢¾IOI ( Intraosseous infusion )
; alternative to IV line
; indication
-
vascular access is imperative
-
*peripheral iv can't be rapidly
placed in children 6 yr and under
; alternative site
-
distal tibia, distal femur
;
resuscitation drugs, antibiotics, anticonvulsants, continuous infusion of
crystalloid solutions, blood products, vasopressor ÀÌ ¸ðµÎ °¡´ÉÇÏ´Ù.
D. Disability
- rapid assessment of
both cortical & brainstem function ÀÌ Áß¿ä
¡ÚTable
59-5 Glasgow coma scale
AVPU +- is the
patient alert?
+- responsive to voice?
+- responsive to pain?
+- unresponsive?
E. Exposure
- undressing &
exposing the patient -> perform a thorough exam.
but)
prevention of heat loss
Psychosocial / Ethical Issues In Pediatric Resuscitation
- good
physician-parent communicationÀÌ Áß¿ä
- parents´Â ÀÚ½ÄÀ» »ì¸®±â À§ÇØ ÇàÇØÁö´Â ¸ðµç °¡´ÉÇÑ °ÍÀ» ¾Ë±â¸¦ ¿øÇÑ´Ù.
- anger of family
members : reflection fo their sense of guilt & hopeless
Chapter 60. Pediatric Critical Care
;most common life threatening problems
¨çrespiratory distress
¨èimpaired peripheral
perfusion
¨éaltered consciousness
Respiratory Distress
1) Pathogenesis
;blood-gas exchangeÀÇ
disruptionÀÇ process
¨çabn'l
of mechanical function of the lung & chest wall -most common
¨èneuromuscular
abn'l affecting the nerves & muscles of respiration
¨édisturbance
of respiratory control or drive
(1)Mechanical dysfunction
# restrictive lung disease
;lungÁÖÀ§ÀÇ ±¸Á¶¹°(Pleura
rib cage & abd.)ÀÌ volume dependent fashionÀ¸·Î
lungÀÇ
ÆØÃ¢À» Á¦ÇÑ
¡æinterstitiumÀÌ
infilterationµÊ(pulm. edema, inflammation)
alveoli°¡ consolidationµÇ°í
collapseµÊ.
lungÀÌ external source·ÎºÎÅÍ
compressionµÊ(etnse ascites,pneumothorax)
;consequense of
restrictive lung d's(Fig.60-1)
¨çmore
force or muscle effort during inspiration to maintain tidal volume
¨èthe
alveolar volume decrease so the lungs operate at a lower end
expiratory volume
;restrictive
lung disease processµÇ¸é
tachypnea,grunting & signs of increased work³ªÅ¸³ª°í
respiratory rate¿Í
mechanical dysfunction of severityÀÇ indication
# Obstructive lung disease
;lungÀÇ
expansionÀÌ flow dependent fashionÀ¸·Î Á¦ÇÑ
¨çextrathoracic
airway obstr.(epiglottis, croup, FB, T&A)
- ƯÈ÷ inspiration½Ã
narrowµÇ´Â °æÇâÀÌ ÀÖÀ½
¨èintrathoracic
airway obstruction(bronchiolitis,asthma,FB,vascular ring)
- expirationµ¿¾È lung emptyingÀÌ ¾ÈµÇ±â ¶§¹®¿¡ Æä¿ëÀû Áõ°¡(hyperinflation)
¡æexpiratory phase°¡ Áõ°¡,
diffuse wheezingÀÌ ³ªÅ¸³²
(2) Adaption to increased work
;early sign of
resp.muscle farigue(tachypnea)
bobbing of
the head(late signs of fatigue)
¡æbrief
periods of excessive effort preceded & followed by short periods of apnea)
(3) Abn'l of respiratory drive or
neuromuscular function
;Guillain-Barre
SD, muscular dystrophy, Myasthenia gravis
(4) Disruption of Gas exchange
2) Clinical manifastation(Table.60-2)
;evaluation
¨çbrething
frequency
¨èthe
depths of breaths
¨éthe
time for inspiration & expiration
¨êthe
effort by the patient to breathe
¨ëthe
presense of retractions
¨ìuse
of accessory muscles
3) Lab data
4) Initial stsbilization & support
¨çO©ü-
always a safe initial measure
hood(in a small infants)
mask & face tents(in older patients)
nasal cannulae(all ages)
¨ènot
to interfere with the compensatory mechanism of the respiratory system
5) ventilatory support
(1)Modes of ventilatory support
¨çtime
cycled ventilator
-inflationÀÇ extent°¡
insp. floeÀÇ duration¿¡ ÀÇÇØ Á¶Àý
¨èvolume
cycled ventilator
-tidal volume¿¡ ÀÇÇØ Á¶Àý
¨épressure
cycled ventilator
-peak insp. pressure¿¡ ÀÇÇØ Á¶Àý
* +-controlled ventilation
+-assisred
ventilation-IMV,SIMVµî
(2)Complication of ventilatory
support
#Barotrauma
¨çpnemothorax
¨èpneumomediastinum
¨épnemoperitoneum
¨êpneumopericardium
¨ëpulm.
interstitial emphysema
¨ìsubcutaneous
emphysema
#decrease in cardiac output
(3)Discontinuation of ventilatory
support
;based on a rigorous
elevation of all the aspects of the patient's
respiratory function
¨çcontrl
of brearhing
¨ègas
exchange
¨érespiratory
muscle function
6)strategies to improve oxygenation
;arterial oxygenation should
be measured by the adequacy of systemic oxygen
transport (aO2 x CO)
rather than by arterial PO2 or SaO2
;arterial oxygen saturationÀÀ ³ôÀÌ´Â ¹æ¹ý
¨çFiO2 - simplest % quickest mean
¨èshunt
fraction°¨¼Ò
¨émean
airway pressureÁõ°¡
¨êHb
³óµµ Áõ°¡
¨ëCOÁõ°¡
- tissue oxygenationÁõ°¡
2.
Impaired perfusion;all statesin which blood flow to the tissue is
appreciablly decreased
1)Pathogenesis
;shock
- systemic blood flow
is insufficient to sustain vital function
-->progressive dysfunction of multiple organs & signa of severe
tissue ischemia
(1)Regulation of tissue perfusuion
& blood pressure
;blood flow to each
organ is determined by both its perfusion pressure & its vascular
resistance
¨çcarotid
sinus & aortic baroreceptor
¨èsympathetic
stimulation of the adenal gland
(2)Reglation of regional bloos
flow
#Autoregulation
-BP°¡ ¶³¾îÁö´õ¶óµµ brain, heart¿Í °°Àº ±â°ü¿¡¼´Â blood flow¸¦ À¯Áö
neural & hormonal stimulation by the sympatho-adreanl system
#humoral response°¡
CO¸¦ Áõ°¡½ÃŰ´Â mechanism
¨çheart
rateÁõ°¡
¨ècontractilityÁõ°¡(by
the catecholamine stimulation)
¨évenous
returnÁõ°¡(by the venoconstriction)
#renal mechanism -
fluid retention
(3)cause fo inadequate CO
2) CO¿¡ ¿µÇâÀ» ¹ÌÄ¡´Â factor( Table 60 - 4)
¨çend
diastolic or filling volume
¨èejection
fraction
¨éht
rate
3) Assessment
Table 60-5
Fig.60-2
4) Initial stabilization
¨çO©üsupply
¨èHt
rate, cardiac ejection, cardiac filling impair À¯¹« È®ÀÎÇϰí Áï½Ã Ä¡·á
¨éshock
½Ã ventilatory support
60.1 States Of Altered Consciouness
1) Acute global encephalopathy
(1)Toxic - metabolic encephalothy
: circulating toxin or an
alteration in hemostasis interfere with the function
of the brain
# exogenous toxin
¨çopioid
intoxication - hypercapneic hypoventilation associated with small pupil size
¨èsalicylate
poisoning - hyperpnea, resp alkalosis, dehydration
¨éosmotically
active mollecule - unexplained gap between calculated &
measured
osmolarity
# endogenous toxin
- CO©ü,
urea, ammonia
#hupoglycemia
(2)Ischemic - hypoxic
encephalopathy
(3)Infections of the CNS
: meningoencephalitis µî
(4)Seizure
2) Trauma
3) Focal encephalopathy
(1) supratentorial lesion - severe
alteration of the state of consciouness
(2) intracranial HT - tumor, cbr
edema, hyperemia, hrr, hydrocephalus
(3) brain herniation
4) Infratentorial lesion
: earlier onset of the coma,
cranial n. palsy, resp abn'l
2.
general Tx
: assessment of the circulatory
& respiratory functions
¨çcirculatory
deficiency - premotor or motor autonomic center
¨èresp.
dysfunction - pontine & medullary center
¨écareful
neurologic exam - neurologic dysfunction is global or focal
1) Initial Tx of intracranial HT
: hypoxemia ¿Í
hypercarbia ÀÇ ¿¹¹æÀÌ Áß¿ä
¨çmechanical
ventilation
¨èproper
sedation - benzodiazepine, barbiturates, opioid
2) monitoring of intracranial pressure
3) specific tx of intracranial HT
: aimed primarily at
reducing the volume of the cralial contents
¨çosmotic
agent - mannitol, glycerol
¨èloop
diuretics - furosemide
¨éhyperventilation
60.2 Resuscitation
#
¡ÚCause Of Arrest In Child And Infant
; *respiratory arrest
-
sepsis, infections, aspiration of foreign bodies, truama including head injury and
near-drouning, uppper and lower respiratoy tract diaeae, sudden infant death
syndrome, metabolic abnromalies, cardiac diaease ad dysrhythmia distributive,
hypovolimic and cardiogenic shock
Basic Life Support
Airway And Breathing
#
nontraumatized infant or childs
; head tilt-chin lift
maneunver
#
*Traumatized Infants Or Childs
; *jaw thrust
(2) patient's breathing
: mouth-to-mouth ventilation
- under 1yr age : rescuer's
mouth forms a seal over the infant's nose and mouth
over 1yr age or child
: nose is compressed between the rescuer's thumb and
foreginger
while the other habd maintains head position
- beathing may continue at a
rate of 20 breaths/min
mouth-to-mask
ventilation
bag-valve-mask
ventilation
Circulation
#
Assessment of circulation
; *femoral or brachial pulse in infants under 1yr
; carotid pulse in child
#
Location for chest compression for the infant
¡ÚFig.
60-7
; body may be supported along
the rescuer's forearm with the head supported by the rescuer's plam
; head is nor allowed to be
higher than the body
;
index finger just below the intermamillary line
-->
*index finger is raised, and the 3rd
and 4th fingers are used to deliver compressions to the lower one third of the
chest
-->
lower one third of the sternum is compressed one-third to one-half the depth of
the chest, approximately 1/2 - 1 in.
#
Location for chest compression in children
¡ÚFig. 60-8
; middle finger is placed in
the xiphoid notch, and the index finger is place nest to it.
; heel of the hand delivers
compressions at a depth of 1- 1 1¨ö in.
#
*A rate of 5 compression to 1
ventilation is appropriate for both infants and children
; at least 100
compressions/min
Foreign Body Airway Obstruction
- The airway is opened with the head-tilt,
chin-lift maneuver and ventilation is
attempted.
#
under 1yr of age
; *combination of 5 back blows and 5 chest
thrusts
Fig. 60-9
#
over 1yr of age
; *sereies of 5 abdominal thrusts (the Heimlich maneuver)
Fig. 60-10
Advanced Life Support
Assisted Ventilation
- mouth-to-mouth ventilation
: provides only 16-17%
oxygen
- mouth-to-mask ventilation
: protect the rescuer
from contact with patient secretion or vomitus
- Bag-valve mask
: provides variable
amounts of oxygen from room air (21% oxygen) to
approximately 100% oxygen
#
nasopharyngeal airway
; useful in the conscious
child
#
*oropharyngeal airway
; *useful in the unconscious child
Endotracheal Intubation
: protects the airway from aspiration of
gstric contents
allows for control of ventilation
and delivery of adequate oxygen
avoids the gastric distension
resulting from mask or mouth-to-mouth ventilation
permits suctioning of the airway
provides a route for administering
several resuscitation medications
: diameter of the child's little finger -
can be used to estimate endotracheal tube
internal diameter
size.
(1)Tube
size
: internal endotracheal tube diameter
(mm) = (age in yr/4) + 4.
Endotracheal tubes 0.5 mm larger
and 0.5 mm smaller than estimated should also be
available.
: cuffed endotracheal tubes - used for
over 8yr of age
(2)Stylets
: used to stiffen the endotracheal tube
(3)Laryngoscope
blade
:Straight blade - for children up to age
7 or 8yr
size 1 - term newborn
size 2 - child age 2-11yr
size 3 - children age 12 or older
: Child is preoxygenated with 100% FIO©ü
before intubation.
Intubation attempts should last no
longer than 30 sec.
: A properly positioned tube is confirmed
by
symmetric breath sounds,
symmetric chest
movements,
absence of breath
sounds over the stomach,
the presence of
condensation in the endotracheal tube during exhalation.
Noninvasive Respiratory Monitoring
(1)
Pulse oximetry
: excellent method for indicating improvement
or deteriotation of respiratory function
(2)
End-tidal CO©ümonitoring
: helpful adjunct in indicating proper
endotracheal tube placement or dislodgement
and adequacy of chest compression
: low end-tidal CO©ülevels
may indicate
diminished
cellular production,
the inadequacy
of perfusion during resuscitation,
or esophageal
placement of the endotracheal tube.
Vascular Access
#American Heart Association
for children 6yr of age
: If after 90 sec or
three attempts venous access attempts are unsuccessfur, an
intraosseous infusion should be attempted.
3-5 min
have elapsed without vascular access,
appropriate lipid-soluble resuscitation medications may be given via
the
endotracheal tube.
Fluids And Medications
¢ÞTable
60-6
#Volume
infusion
: bolus of 20 mL/kg of isotonic
crystalloid Ringer lactate or normal saline in shock
#Oxygen
: first and most essential medication
#Epinephrine
: drug of choice for cardiac arrest
indicated for asystole,
pulseless or hemodynamically significant bradycardia
: initial strandard epinephrine dose for
asystole or pulseless arrest
--> 0.01mg/Kg
: initial dose of epinephrine given by
an endotracheal tube
--> 0.1mg/Kg
#Atropine
: parasympatholytic medication used for
the treatment of bradycardia.
accelerates heart rate by
enhancing
sinus node automaticity
enhances atrioventricular conduction.
: only possible useful for treatment of
bradycardia associated with hypotension
and poor perfusion.
: indicated for symptomatic bradycardia
resulting from atrioventricular blocks.
: currently recommended dose is 0.02
mg/kg, with a minimum dose of 0.1 mg.
#Soldium
bicarbonate
: possibly effective in cases of metabolic
acidosis and shock
: dose - 1 mEq/Kg
repeated doses - every 10min
#Dopamine
: used for hypotension following
resuscitation
for
the treatment of shock
: low dose - enhanecs flow to renal and
mesenteric blood vessels
moderate dose - increase
contractility(inotropy) and heart rate(chronotropy)
high dose - increase
peripheral vascular resistance
decline in renal and mesenteric blood flow
: dopamine 60mg -+ 1ml/kg/hr --> 10§¶/kg/min
5% 100ml --+
#Dobutamine hydrochloride
: increase contractility and heart rate
used for poor cardiac output
and inadequate myocardial function
side effect - ventricualr
arrhythmia, tachycardia, hypotension
inactivated by sodium
bicarbonate
#Glucose
: indicated hypoglycemia
#Calcium
indicated in hypocalcemia
hyperkalemia
hypermagnesemia
calcium channel blocker overdose
Defibrilation And Caridoversion
: indication : ventricular fibrillation
and pulseless ventricular tachycardia.
Before defibrillation,
acidosis and hypoxia should be treated.
:
initial defibrillation dose 2 jules (J)/kg
--> fibrillation
persists the dose is increased to 4J/kg,
if still unsuccess a 3rd dose
of 4 J/kg is delivered.
: --> epinephrine (0.01 mg/kg
intravenously or intraosseously, or 0.1 mg/kg
endotracheally) and lidocaime 1 mg/kg are administered.
Defibrillation at 4 J/kg is
again attempted 30-60sec after medications are
given.
#Lidocaine
: raise the threshold for ventricular
fibrillation
decreas ventricular ectopy
: initial dose is 1 mg/kg and may be
repeated.
continuous intravenous or
intraosseous infusion of 20-50 §¶/kg/min is used to
suppress ventricular
arrhythmias.
#Bretylium tosylate
: for ventricular fibrillation
begun at a dose of 5mg/Kg
#Synchronized cardioversion
: used to convert ventricular
tachycardia
60.3 Shock
Intravascular Hypovolemia
; loss of intravascular volume
-
*¡ãcommon
- trauma, burns, nephrotic syndrome, vomiting, diarrhea
Intavascular Normovolemia/Hypervolemia
Evaluation
#
Cold shock
; similar with myocardiac
failure
; *systemic hypotension, cold, vasoconstricted extremities with decreased
cardiac index(CI), increased SVR
60.4 Drowning And Near-Drowning
-
Irreversible pansystemic injury occurs very rapidly, often leading to death.
-
Drowning : death within 24hr of submersion
-
Near-drowning : survival greater than 24hr, regardless of whether the victim
dies or
revovers.
Epidemiology
- < 1yr ; traumatic deathÀÇ
7%
- 1 - 4yr ; 19%
- > 5yr ; 12 - 14%
- drowning ; 19yrÀÌÇÏÀÇ ¼Ò¾Æ¿¡¼
4th leading cause of death
5yrÀÌÇÏÀÇ ¼Ò¾Æ¿¡¼ single leading cause
of injury death
- pediatric submersion victim Áß
80%°¡ »ýÁ¸
- »ýÁ¸ÀÚÁß 92%°¡
complete recovery
- intensive care¹Þ´Â µµÁß ´ë·«
30%°¡ »ç¸Á, 10 - 30%°¡
severe brain damage
#
¡ÚPeak Age Group
1) toddlers
2) older adolescent males(15
- 19yr)
-
concomitant medical conditions -> drowningÀÇ ±âȸ Áõ°¡
; children with
epilepsy - 4 - 10 fold increased risk
Pathophysiology
- progressive hypoxemia affects all
organs and tissues, with the severity of injury
dependent on the duration of submersion
Anoxic-Ischemic Injury
- in about 10% of human who drown,
aspiration is absent
- profound hypoxemia and medullary
depression -> terminal apnea
- cardiovascular change ; initial
tachycardia -> severe hypertension with reflex
bradycardia(from catecholoamine release) -> arrhythmias
- duration of hypoxemia°¡
3 - 5minÀ̳»À̸é reversible
- blood flow during anoxic conditions
with ongoing glucose and nutrient delivery
-> anaerobic
metabolism -> cellular lactate¿Í other intermediary
metabolite
concentration ¡è -> glutamate, other excitatory
amino acidÀÇ ºÐºñ¿¡ ÀÇÇÑ neuronal
injury ¡è
- hypoglycemia ; near-drowningÈÄ
initial blood glucose concentration > 300mg/dl
-> die or
survive in a persistent vegetative state compared with normoglycemic
victims
- control of hyperglycemia with insulin
after near-drowning -> not recommended
- neurologic consequences of
hypoxic-ischemic injury
; loss of cerebral
autoregulation and blood brain barrier integrity -> cerebral edema
(À̰ÍÀº initial cytoxic injuryÀÇ
severity¸¦ ¹Ý¿µ)
- other organs¿Í
tissueµµ injury¸¦ ¹ÞÀ½
+- lung - hypoxia,
ischemia, aspiration -> pulm. vascular endothelim¿¡
damage
|
-> vascular permeability ¡è -> noncardiogenic
pul. edema, ARDS
+- heart - myocardial dysfunction,
arrhythmias, infarction
+- kidney - acute
tubular necrosis, acute cortical necrosis
|
(°¡Àå ÈçÇÑ renal complications)
|
vascular endothelial injury, exposing basement membrane
|
-> thrombocytopenia, DIC À¯¹ß
+- GI - bloody
diarrhea with mucosal slouging
+- hepatic
transaminase and serum pancreatic enzyme ¡è
+- violation of normal
mucosal protective barriers -> bacteremia, sepsis
Pulmonary Aspiration
#
drowing victimÀÇ 90%, near-drowning victimÀÇ
80 - 90%¿¡ ¹ß»ý
#
aspirateÀÇ amount¿Í
compositionÀÌ Pt's clinical course¿¡ ¿µÇâ¹Ìħ
;
water salinity, gastric contents, pathogenic organism, toxic chemicals, other
foreign matter
--> lung¿¡
injury, airway obx.
#
Sea water
; hypertonic(´ë·«
3% N/S)
-
*drawing interstitial, intravascular
fluid into the alveoli
; *surfactant¸¦ inactivation -->
alveolar surface tension ¡è --> atelectasis
#
Fresh water
; hypotonic
; *surfactant¸¦ wash out
-->
alveolar instability, collapse
-->
ventilation-perfusion mismatch
-->
hypoxemia, pulm. insufficiency
-->
interpulm. shunting ¡è, lung compliance ¡é,
small airway resistance ¡è
#
profound arterial hypoxemia´Â 2.2ml/kgÁ¤µµÀÇ
aspirationÈÄ¿¡ ¹ß»ý °¡´É
- ±×¿Ü intensive careÁß
mechanical ventilation, barotrauma, pulm. interstitial
emphysema, pneumothorax, pneumomediastinumÀ¸·Î ¹ßÀü °¡´É
Hypothermia
- hypothermia(core temperature < 35¡ÆC)
after submersion -> common event
- ¼Ò¾Æ´Â high body surface area
to mass ratio¿Í decreased subcutaneous fat
insulation¶§ ¹®¿¡
risk ¡è
- < 35¡ÆCÀ̸é
thermoregulation fail, spontaneous rewarmingÀÌ ÀϾÁö ¾ÊÀ½
; moderate
hypothermia(32 - 35¡ÆC) - shivering thermogenesis¿Í
increased sympathetic
tone¿¡ ÀÇÇÑ oxygen consumption¡è
severe
hypothermia(, 35¡ÆC) - shivering cease, cellular
metabolism¡é
moderate
to severe hypothermia 1 progressive bradycardia, impaired myocardial
contractility, loss of vasomotor tone -> hypotension
central
respiration center depression -> hypoventilation, eventual apnea
- < 28¡ÆC - extreme
bradycardia, spontaneous ventricular fibrilation, asystole¡è
- < 25 - 29¡ÆC
- deep coma with fixed and dilated pupil, absent reflex ¿Ã ¼ö ÀÖ´Ù
- temperature aberrationÀÇ
duration°ú severity¿¡ ÀÇÁ¸ÇÏ¿©
systemic adverse consequence¹ß»ý
; ARDS - hypothermic
pulm. endothelial injury¿¡ 2Â÷ÀûÀ¸·Î depressed
hepatorenal
metabolism, perfusion -> drug clearance¡é, hypoglycemia from
glycogen store
exhaustion
altered pancratic insulin release -> hyperglycemia due to
hypercholinergic state,
depressed peripheral glucose utilization
thrombocytopenia, platelet dysfuction, DIC
- Afterdrop ; initial rewarming effortµ¿¾È¿¡
core body temperature°¡ ½ÇÁ¦ÀûÀ¸·Î Áõ°¡µÇÀü ¿¡
dropÇÏ´Â °Í
±âÀü
- cold blood°¡ extremities·Î ºÎÅÍ
warmer central core·Î returnÇÏ´Â °Í¿¡ ´ëÇÑ
2 Â÷ÀûÀ¸·Î ¹ß»ý, ¶Ç´Â warmer core·Î ºÎÅÍ
cooler surface layer·ÎÀÇ heat conduction¿¡ ÀÇÇØ ¹ß»ý
severe
hypothermia ȯÀÚ¿¡¼ÀÇ afterdrop -> cardiac,
respiratory, neurologic functin
À» ÀúÇÏ, arrhythmiaÀ¯¹ß
- Rewarming shock ; body temperatureÀÇ Áõ°¡¿¡ ÀÇÇÑ
additional metabolic requirement¡è¿Í
ÇÔ²² surface rewarming¿¡ ¼ö¹ÝµÇ´Â
vasodilatation°ú blood pressure¸¦ À¯Áö½ÃŰ´Â
external hydrostatic pressureÀÇ removal¿¡ ÀÇÇØ
shockÀÌ ¹ß»ý
Fluid and Electrolyte Change
- sea water¿Í
fresh water·Î »ç¸ÁÇÑ È¯ÀÚÀÇ 15%¿¡¼¸¸
significient E' chagngeº¸ÀÓ
#
Massive Sea Water Ingestion And/Or Aspiration
; *hypernatremia, hypersmolar diuresis, hemoconcentration
#
Fresh Water Intoxication
; hyponatremia, hemodilution
; *sudden hypoosmolarity
-->
*cellular swelling, hemolysis
-->
*hyperkalemia, hemoglobinuria
-->
renal injury
#
±×¿Ü SIADH, IICP µîµµ ¿Ã ¼ö ÀÖÀ½
Clinical Manifestation and Treatment
- significant submersionÈÄ
well-being stateÀÇ childrenÀ̶ó ÇÒ Áö¶óµµ
delayed resp.
decompensationÀÌ ¿Ã ¼ö Àֱ⠶§¹®¿¡ 6-12hrµ¿¾ÈÀº ÁÖÀDZé°Ô °üÂûÇØ¾ß ÇÔ
Initial Evaluation And Resuscitation
- initial out-of-hospital
resuscitation of submersion victim
- rapidly
restoring oxygenation, ventilation, adequate circulation¿¡ ÃÊÁ¡À» µÎ¾î¾ß
ÇÔ
- shockÀÇ
potential indicators ; slow capillary refill, cool extremities, altered
mental status
- IV fluid admistration ;
Non-dextrose-containing, isotonic fluid(Lactated Ringer
solution°ú normal saline)
should be warmed (40 - 43¡ÆC) in the hypothermia Pt.
- Body temperature measure
+- tympanic membrane - best measured
| adequate rectal
temperature ; Àû¾îµµ 10cm insertion
+- oral and axillary temperature ; unreliable
- Rapid assessment of blood
glucose
;
hypoglycemia ; 0.5 - 1.0ml/kg of 5% dextrose -+
2 - 4ml/kg of 10% dextrose -+
*
insulinÀº submersion injuryÈÄ ¹ß»ýÇÑ
hyperglycemia±³Á¤¿¡ »ç¿ëÇØ¼´Â Àý´ë ¾ÈµÊ
Controversial Issues
Hospital Management
Respiratory Managment
- Pt.´Â
atelectasis, pneumonia, pneumothorax, pneumomediastinum, pulm.edema, ARDS·Î Áø
ÇàµÉ ¼ö ÀÖÀ¸¹Ç·Î chest radiography°¡ ¹Ýµå½Ã
obtain
- arterial catheterizaion
- prolonged use of high
inspired oxygen concentraion(>70-80&) -> pulm. injuryÈÄ ´õ ³ª ºüÁú ¼ö ÀÖÀ½
+- endotracheal intubation°ú
PEEP -> the most effective means of reversing hypoxemia
+- CPAP, ECMO
=> PaO2 80 -
120mmHg, PaCO2 30 - 35mmHg À¯Áö
Cardiovascular Management
- continuous ECG monitoring
- fluid resuscitation°ú
inotropic agent
- echocardiography, central
venous pressure monitoring
- Swan-Ganz pulm. artery
catheter placement
Rewarming Measures
- administration of warmed
IV fluid(36 - 40¡ÆC)
- heated humidified inspired
oxygen(40 - 44¡ÆC)
- warmed gastric, bladder,
peritoneal lavage
- more aggressive method ;
hemodialysis, extracorporeal rewarming, cardiopulm. bypass
Neurologic Management
- optimal managementÇÏ¿¡¼
many initially comatous childrenÀº ù 24 - 72hr³»¿¡
dramatic neurologic improvement¸¦ º¸ÀÓ
- conventional
neurointensive therapy
; ICP
monitoring, therapeutic hypothermia, barbiturate therapy(hyperventilation,
osmotic agents, diuretics, fluid restoration, muscle relaxants, steroid)
Other Management Issue
- severe anoxic
encephalopathy - near-drowningÈÄ pediatric intensive care
unit
survivorsÀÇ 10 - 30%¿¡¼ °üÂû
- chronic neurlogic sequelae
after near-drowning
; lowered
mentation, minimal cerebral dysfunction, spastic quadriplegia,
extrapyramidal syndrome, optic and cerebral atrophy, cortical blindness,
peripheral neuromuscular damage, persistent vegetative state
- psychiatric sequelae
Prognosis
#
neurologic exam. and progression during the first 24 - 72hr
; *¡ãindicator of neurologic
outcome
+- 5minÀ̳»ÀÇ submersion time¿¡¼ÀÇ
91%¿¡¼ intact survivor ¶Ç´Â
mild neurologic i
|
impairment
+- 10minÀ̳»¿¡¼´Â 87%¿¡¼ ¹ß»ý
#
CPR ½ÃÇà¹ÞÀº children
; *10minÀÌ»óÀÇ submersion duration½Ã 93%¿¡¼ death or severe neurologic injury
; 25minÀÌ»óÀÎ °æ¿ì
100%¿¡¼ death or severe neurologic injury
#
Glasgow Coma Scale(GCS)
; hospital admission´ç½Ã
-
GCS score > 6 -> good outcome
- *GCS score < 5 ->
higher probability of poor neurologic outcome
60.5 Burn Injuries
- burn injury Pt.ÀÇ
30 - 40% ; < 15yr of age(average 32Mo)
- Scald burns ; total injuryÀÇ
85%
most prevalent in children < 4yr of age
- Flame burns ; 13%
- burn injuryÀÇ ´ë·«
16% ; child abuseÀÇ °á°ú·Î ÀÎÇÔ
- Burn treatmentÀÇ
4 major phases
+- prophylasis
| acute care and resuscitation
| reconstruction and rehabilitation
+- pain relief and
psychosocial adjustment
Prevention
Table 60-8
Acute Care And Resuscitation
- multiple new problems
metabolic
derangements secondary to topical agents, antibiotics, and parenteral
nutrition solutions
translocation of organisms and toxins from the GI tract in the presence
of
hypotensive or shock syndromes
infective
complications that follow necessory monitoring catheters, extensive open
wounds, and parenteral nutritions
- Cx.; wide spectrum of organism,
polymicrobial sepsis, intravascular infections
(thrombophlebitis, infected thrombus, aneurysm formation, osteomyelitis,
septic
arthritis)
Indications For Admission
¡ÚTable
60-9
Emergency care
Table 60-10
First Aid Measure
Life Support Measures
adequate
airway by using humidified oxygens by mask or nasotracheal intubation
intravenous fluid resuscitation
15%
of BSAÀÌ»óÀÇ burn children - IV fluid
resuscitation(10 - 20ml/kg/hr, Lactated
Ringer solution or N/S)
evaluate
for associated injuries
> 15%
of BSA burn ; oral fluid´Â ±ÝÁö (¡ñ
ileus, aspiration ¶§¹®)
Classification Of Burn
1) First degree burn
; only epidermis involve
swelling,
erythema, pain(similar to a mild sunburn)
no blistering,
no residual scars
pain resolve in
48 - 72hr
2) 2nd degree burn
; entire epidermis and a
variable portion of the dermal layer
vesicle and
blister formation
superficial 2nd degree burn ; extremely painful, 7-14ÀÏ¿¡
healing
mid level to deep 2nd degree burn ; pain less than superficial burn
fluid loss and metabolic effect of deep dermal(2nd degree) burn˼
3rd degree
burn°ú À¯»ç
3) Full thickness or 3rd degree burn
; destruction of the entire
epidermis and dermis
no residual
epidermis cell
can heal only by
wound contracture or skin grafting
lack of painful
sensation
Estimation Of Body Surface Area Of Burn
Figure 60-15
Outpatient Management Of Minor Burns
10% BSA ÀÌÇÏÀÇ 1st and 2nd degree
burn
blister´Â intactÇÏ°Ô ³ªµÎ°í
silvadene(silver sulfadiazine cream)À¸·Î Tx.
dressingÀº ÇÏ·ç¿¡ 2¹ø
Fluid Resuscitation
Parkland formula
; 4ml Ringer lactate/kg body
wt./% BSA burned
ù
8½Ã°£¿¡ °ÉÃļ 1/2 IV, ³ª¸ÓÁö
1/2Àº ´ÙÀ½ 16½Ã°£¿¡ °ÉÃļ °°Àº rate·Î
IV
rate of infusion
- Pt's responce to therapy¿¡ µû¶ó ¼öÁ¤
interstitial
edema¿Í muscle cell³»
fluidÀÇ sequestration¶§¹®¿¡
baseline preburn body
wt.¸¦ ³Ñ¾î¼± 20%±îÁö ÁÙ ¼ö ÀÖÀ½
- burnÈÄ second 24hrµ¿¾È
Pt´Â edema fluidÀÇ
reabsorb, diuresis ½ÃÀÛ
- 1st day fluid requirementÀÇ
1/2Àº 5% dextroseÀÎ
lactated Ringer solutionÀ» »ç¿ë
- burnÀÌ 85% total BSAÀÌ»óÀ̸é
colloid replacement°¡ »ç¿ë; burn injuryÈÄ
8 - 24hr¿¡ »ç¿ë
- oral supplementation˼
burnÈÄ °¡´ÉÇÑÇÑ 48½Ã°£¿¡
startÇÒ ¼ö ÀÖ´Ù
- 5% albumine infusion - over 24hr¿¡ °ÉÃļ
; total BSA burn of 30 - 50%
; 0.3ml serum albumin/kg body wt./% BSA burn
burn of 50 - 70% ; 0.4ml ''
burn of 70 - 100 % ; 0.5ml ''
- P/C infusion ; hematocrit < 24%(Hb
< 8g/dL)ÀÏ ¶§
- Sodium supplementation ; 20% BSAÀÌ»çÀÇ
burn, ƯÈ÷ 0.5% silver nitrate solutionÀÌ
topical antibacterial burn dressingÀ¸·Î »ç¿ëµÉ ¶§(serum Na > 130mEq/LÀ¯ÁöÀ§ÇØ)
- Inravenous potassium supplementation ;
serum K > 3mEq/L·Î À¯ÁöÀ§ÇØ
Prevention of Infection
- Prophylactically penicillin therapy -
5 day course
- Erythromycin
- Topical treatment
Nutritional Support
- burn injury´Â
protein°ú fat catabolismÀ» Ư¡ÀûÀ¸·Î
ÇÏ´Â hypermetabolic response¸¦ º¸ ÀÓ
- Calory ; 11/2- 2 times the basal
metabolic rate with 1.5 - 2g/kg body wt of protein
- Multivitamin, ƯÈ÷
vit B group, vit C, vit A¿Í zinc°¡ ÇÊ¿äÇÔ
Topical Therapy
+- 0.5% silver nitrate
+- sulfacetamide acetate
+- silver slufadiazine cream
Cx. ; transient leukopenia
Inhalation Injury
- Respiratory tract¿¡ÀÇ
injury
direct heat(greater problems occure in steam burns)
acute asphyxia
carbon monoxide poisioning
toxic fumes(cyanoides)
- Pulmonary Cx. of burns and inhalation
early carbon monoxide poisoning, airway obstruction, pulmonary edema
ARDS´Â
24 - 48hrÈÄ¿¡ ¹ß»ý
late
Cx. - pneumonia, pulmonary emboli
- Carbon monoxide poisoning
; mild(< 20% HbCO) - slight
dyspnea, decreased visual acuity, higher cebebral
function
moderate(20-40% HbCO) - irritability, nause, dimness of vision,
impaired
judgement, rapid fatigue
severe(40-60% HbCO) - confusion, hallucination, ataxia, collapse, coma
; Tx.- humidified 100%
oxygen
hyperbaric oxygen therapy
Reconstruction and Rehabilitaion
- Physical rehabilitation ; positioning
of Pt, splinting, exercise- active and passive
movement and assistance with activities of daily living and gradual
ambulation
- Pressure therapy ; reduce hypertrophic
scar formation
- Continued adjustments to scarred areas
; scar release, grafting, rearrangement
- Multiple minor cosmetic surgical
procedures
Pain Relief and Psycological Adjustment
Pain management
- Pain˼ depth of burn, stage
of healing, age and stage of emotional development,
cognition, experience and efficiency of treating team, analgesia and
other drug,
pain threshold, interpersional and cultural factor µî¿¡ ÀÇÁ¸
- Opiate analgesia
Oral
morphine sulphate ; 0.3 - 0.6mg/kg body wt. every 4 - 6hr
procedure(dressing changes or debridement)µ¿¾È pain controlÇϱâÀ§ÇØ
procedure 30ºÐÀü¿¡ Åõ¿©
IV bolus
morphine sulfate ; 0.05 - 0.1mg/kg body wt every 2hr
PCA protocolÀ» »ç¿ëÇÏ´Â old Pt¿¡¼ »ç¿ë
procedureÀü Áï½Ã Åõ¿©
morphine
sulfate rectal suppositories ; 0.3 - 0.6mg/kg body wt every 4hr
- Lorazepam ; 0.04mg/kg body wt/dose
every 8hr
School Re-Entry
Special Situation
Electrical Burns
two types +- minor electrical burn
+- more serious category of
elcectrical burn
Lightning burn
Renal Failure In Burn Injury
- ´ëºÎºÐÀÇ case´Â
non-oliguric renal failure¸¦ º¸ÀÓ
- Renal failure´Â 1 - 3ÁÖÈÄ early or lateÇÏ°Ô ¿Ã ¼ö ÀÖ´Ù
Early renal failure
;
subsequent hypovolemia¿Í ÇÔ²² late resuscitationÀÌ ÀÖÀ» ¶§
severe pigment nephropathy(hemoglobinuria, myoglobinuria)°¡ ¹ß»ýÇÒ ¶§
Late
renal failure
; sepsis
or drug toxicity·Î ºÎÅÍ ±âÀεÊ
60.6 Cold Injuries
Pathophysiology
- ice crystalÀÌ
cell»çÀÌ¿¡ Çü¼º -> normal sodium pumpÀÇ
activity ¹æÇØ -> cell membraneÀÇ rupture
- further damage ; red cell or plateletÀÇ
clumping -> microemboli or thrombusÇü¼º
- blood shunting
Etiology
- conduction, convection, radiation¿¡ ÀÇÇØ
body heatÀÇ ¼Ò½Ç
- hypothermia
Clinical Manifestation
Frostnip
- face, ears, extremities¿¡
firm, cold white areaÇü¼º
- ´ÙÀ½ 24 - 72hr¿¡ °ÉÃÄ
blistering°ú peeling ¹ß»ý
- Tx. ; warming
Immersion Foot(Trench Foot)
; feet°¡
damp, wet, pooly ventilated boots¿¡¼ cold¿¡
exposeµÉ ¶§
; pale, edematous, clammy
-->
*tissue maceration, infection,
prolonged autonomic disturbance
/
*increased sweating, hypersensitivity
to pain temperature change
/
¼ö³â°£ Áö¼Ó
; Treatment
-
prophylactic
well-fitting, insulated,
waterproof, nonconstricting footwear»ç¿ë
Frostbite
; *Ãʱ⿡ skinÀÇ stinging or aching
-->
cold, hard white anesthetic and numb area
; *rewarming½Ã blotchy, itchy, red,
swollen, painful
; Tx. ; damaged areaÀÇ
warming
anti-inflammatory agents
analgesics
vasodilating agent(prazocin, phenoybenzamine)
anticoagulant(heparin, dextran)
oxygen supply
Hypothermia
; insidious onset of exteme
lethargy, fatigue, incoordiation, apathy
-->
*memtal confusion, clumsiness,
irritability, hallucination, bradycardia
- prevention ; high priority
- Tx. ; dry clothing
ÇÊ¿ä½Ã CPR
control of fluid, pH, blood pressure, oxygen
gastric or colonic irrigation with warm saline
peritoneal dialysis
Chilblain(Pernio)
; *erythematous, vesicular, ulcerative lesion
; often itchy, painful,
swelling, scabbing
; vascular or
vasoconstrictive origin
; ears, tips of finger, toes,
legÀÇ exposed area¿¡ ¹ß»ý
; ´ë·«
1 - 2ÁÖ°£ Áö¼Ó, ±×·¯³ª ´õ ¿À·¡ Áö¼Ó °¡´É
; Treatment
-
prophylaxis - avoiding prolonged chilling
|
protecting potentially susceptable area
+- prazocin,
phenoxybenzamine
+- local
corticosteroid - itchingÀÌ ½ÉÇÒ ¶§
Cold-Induced Fat Necrosis(Panniculitis)
-
red(less than purple to blue), macular, papular, nodular
-
Tx. ; NSAIDs
10ÀÏ¿¡¼
3ÁÖ°£ Áö¼Ó
60.7 Acute Respiratory Distress Syndrome
- a syndrome recognized as acute
respiratory failure
- Ư¡ ; increased
premeability pulmonary edema
- demonstrated by widespread infiltrates
on chest radiograph, impaired oxygenation and
normal cardiac function(noncardiogenic pulmonary edema)
#
¢¾Definition
;
poor oxygenation (PaO2/FIO2 < 200 regardless of amount of PEEP)
; bilateral infiltrate seen
on frontal chest radiography
;
pulmonary artery occlusion pressure < 18mmHg when measured or no clinical
evidence of Lt. atrial hypertension based on clinical data
- Pediatric PtÀÇ
most common cause of ARDS ; shock, sepsis, near-drowning
±×¿Ü
trauma, drug overdose, aspiration, inhalation injury, intravascular
coagulation
abnormalities
Pathology
- Three distinct stage
exudative
stage : severe capillary congestion
interstitial pulmonary edema(by protein-rich edema fluid)
alveoli´Â
nonhomogenous fluid, blood or aggregated leukocyteÇÔÀ¯
first 6hrµ¿¾È ½ÃÀÛ -> resolution or progessionÀº
72hr±îÁö Áö¼Ó
proliferative phase ; increased density of type II pneumocytes and
fibroblast
injuryÈÄ
1 - 3ÁÖ »çÀÌ¿¡ ¹ß»ý
fibrotic
stage ; ARDS°¡ 3ÁÖÀÌ»ó Áö¼ÓµÉ ¶§ ¹ß»ý
pulmonary fibrosis
Pathogenesis
- multifactorial causes
- endothelum¿¡
injuryÁÖ´Â cellular mediators
; inflammatory cells,
neutrophil, mononuclear phagocytes, eosinophils, platelet,
fibroblast, lymphocyte
- circulating humoral mediators
; complement, endotoxin,
cytokines, oxygen free radical, histamine, serotonin,
proteases, free fatty acid µî
* ARDS´Â neutropenia pt.¿¡¼µµ ¹ß»ý °¡´É
- surfactant systemÀÇ
abnormality -> atelectasis
Clinical Manifestation
- Ãʱ⿡´Â pul. Sx.Àº
minimal, ¡Å ûÁø»ó clear & no X-ray
change
- ´ÙÀ½ 4 - 24hr µ¿¾È
; hypoxemiaÁøÇà
cyanosis, dyspnea, marked tachypnea with diffuse, moist inspiratory
crackles
- gradual recovery °¡´ÉÇϳª ´Ù¼ö°¡
progressive severe hypoxmia or hypercapnia·Î ÁøÇà
Laboratory Finding
- ABGA ; PaO2 < 50mmHg on FiO2 >
0.6%
PaO2/FiO2 ratio < 200´Â QS/QT(intrapulmonary shunt) >
20%¿Í »ó°ü
- Radiographic evidence
; initially, no significant
radiographic abnormality
¼ö½Ã°£ÈÄ,
fine bilateral reticular infiltrate¸¦ º¸ÀÓ
ù
72½Ã°£³»¿¡ cardiomegaly¾øÀÌ
interstitial and alveolar pulmonary edema¹ß»ý
- Cx. ; diffuse interstitial fibrosis¿Í
barotrauma(pneumothorax, pneumomediastinum)
- Poor Px. factors +- pulmonary artery
pressure¡è
+- abnormally high pulmonary artery resistance
Treatment
PEEP ; ¶§¶§·Î
10 - 20cmH2O±îÁö ÇÊ¿ä
supportive Tx. +-
cardiac function À¯Áö
+-
Hct 35 - 40% À¯Áö
+- 2ndary infection ¹æÁö
Prognosis
- mortality rate 50 - 75%
; PEEP > 6cmH2O, FIO2
>0.5 for > 12hr
-
43% mortality
; death
-
*due to initiating event, multisystem
organ involvement
Chapter 61. Anesthesia And Perioperative Care
Preoperative Assessment
Specific Diseases That Impact On Anesthetic
Management
¡ÚTable
61-4
Preanesthetic Preparation And Premedication
Intraoperative Management
- tracheal
intubationÀÇ indication
¨çhead & neck op
¨èintrathoracic,
abdominal, cranial procedure
¨éop. in prone position
¨êmost emergency procedure
1) fluid Tx
2) blood transfusion
*
rapid transfusionÀÇ Indication
- hyperkalemia, ditrate toxicity(ionized hypocalcemia)
arrhythmia, cardiac arrest
3) thermoregulation
*
malignant hyperpyrexia - genetic abnormality of skeletal m.
- tachycardia, tachypnea, hypermetabolism, muscle rigidity, hypercarbia,
acidosis
fever following vapor inhalation anesthetics(halothan, isoflurane) or
succinylcholin.
- Tx : ¨ç¿øÀÎÁ¦°Å
¨èhyperventilation
¨édantrolen(3mg/kg) IV
¨êgeneral care - hyperkalemia,
acidosis±³Á¤
circulatory
suppot
active cooling
urine alkalinization(myoglobinuria)
4) monitoring
5.
Postanesthetic recovery
* general anestheticsÀÇ
sequale
¨ç
postanesthetic excitment
¨è
vomiting
¨é
pain
¨ê
intubationÈÄÀÇ subglottic edema - relieved by
inhalation of aerosolized racemic
epinephrine, corticosteroid
6.
Anesthesia & conscious sedation away from the op. roon
* very brief
procedure(with noxious stimuli)
: midazolam + opioid(fentanyl)
* painless
procedure : pentobarbital or chloral hydrate
Chapter 62. Pain Management
¡ÚMisconception Of Pain
;
children have higher tolerance to pain
;
pain is decreased because of biologic immaturity
;
little memory of a painful experience
;
more sensitive to side effect of analgesics
;
risk for addiction to narcotics
Pathophysiology
# ¡ÚIn
Neonate
; as adult, unmyelinated C fiber transmit nociceptive information peripherally
; nerve pulse transmission in incompletely myelinated A-¥ä fiber
-
*delayed but not blocked
; pattern of autonomic
response to pain
Clinical Manifestation & Assessment
#
assessment in infant
; indirect
; observation of cry, facial
expression, autonomic responses, behavior or motor activity
-
*facial expression : ¡ãvalid indicator
Treatment
table
62-1
(1) post-op pain :
morphin & fentanyl - infant & children
PCA(pt-controlled analgesia) - 6¡18yr
(2) cancer & other
pain syndrome
¨çPCA subcutaneous infusion of
morphin or methadone, fentanyl
opidoid by indwelling epidural or intrathecal catheter
¨èsteroid : wide spread tumor
invasion of bone or n. system
¨étricyclic medication : neuropathic
pain
¨êsickle cell disease or JRA :
acetaminophen, NSAID
Chapter 63. Principles Of Drug Therapy
1.
Influence of Age on Drug Tx
1) Gastrointestinal
absorption. Table 63-1
¨çgastric PH
-
birth - neutrality
- ¼ö½Ã°£ÈÄ - 1.5¡3.0
- 1st 10th day - high
10¡30th day - lowest
- ¼ºÀÎ level : PH 3
¨è Gastric emptyng times &
intestinal motility
- adult level¿¡ À̸£´Â ½Ã±â ; 6¡8mo
¨é
Pancreatic enzyme activity
- full term < premature at level
- lipase activity
34¡36ÁÖ(GA)¼
notice
1wk¿¡ 5¹è
9mo¿¡ 20¹è
- amylase ; 22wk¿¡ detect
- trypsin
¨ê
other processes
- bile salt metabolism
- GIT bacterial colonization
(4¡6day after del.)
2) alternative route
of drug absorption
- IM : water soluble in physiologic PH
- skin : skin dehydrationÁ¤µµ
stratum corneumµÎ²²¿¡ µû¶ó Èí¼ö
3) drug distribution
(1)
binding protein
¨çalbumin
¨è¥á1-acid glycopritein(orosomucoid)
¨élipoproteins
(2)
neonatal period¼ albumin°ú °æÀï
¨çfree
fatty acids
¨èbilirubin
¨é2-hydrozybenzoyl glycine
(3)
bilirubin
¨çindependent to gestational age
¨è5mo - adult level
4) drug metabolism
5) drug excretion
(1)
renal blood flow
¨çbirth
12cc/min
¨èadult level - 5¡12mo
(2)
glomerular filtration rate
¨çfull term - 2¡4cc/min
¨è2¡3day - 8¡20cc/min
¨éadult level - 3¡5mo
2.
Phrmacokinetics
1) basic concepts
¨çdrug absorption &
bioavailability
¨èvolume of distrubution
¨éelimination half-life
t¨ö = (0.693vd)/cl
¨êclearance
¨ëindividulization of drug dose
2) additional
consideration
¨çmethod of drug administration
¨èdrug-drug interaction
¨édrug in hunal milk
¨êprescribing medication
¨ëcompliance with th prescribed
regimen