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Part 08. Acutely ill Child

¹ÚÇö¿ì ¿Ï°áÆÇ

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¯Áö½Ã۴             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) burnÀº 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 supplementationÀº 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

  - PainÀº 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