Part 08. Acutely ill Child

PART Ⅷ. The Acutely Ill Child

Chapter 57. Evaluation Of The Sick Child In The Office And Clinic

# acute febrile illness를 가진 children의 risk와 serious illness의 cause는 나이에 따라 다르다.

# 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

★Fig. 57-1 Acute Illness Observational Scales

Diagnostic Approach

  - 3세 이하의 febrile child에서 sepsis work-up이 필요

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

      ① education

      ② persuasion

      ③ changes in products

      ④ modification of environment ( social or physical environment )

Risk Factors For Childhood Injuries

Age

# Toddlers

    ; *▲risk for burns, drowning, falls

# Young school age

    ; *▲risk for pedestrian injuries, bicyle-related injuries(▲serious), 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 restraints가 유용

  2) teenage drivers

     - alcohol use가 중요원인

  3) bicycle injureis

     - use of helmets : head trauma 방지

  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

      ① early recognition & treatment

      ② 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

      ① first responders

         : to provide rapid response and stabilization, pending the arrival of more highly

            trained personnel

      ② emergency medical technicians (EMTs)

            : volunteers or paid professionals who provide the bulk of emergency medical

              response ( in U.S. )    

      ③ 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

★Table 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       

     ① pneumothorax

        : dose not improve with supplemental oxygen & positive pr. ventilator

     ② 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

# ♥IOI ( 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 이 모두 가능하다.

D. Disability

     - rapid assessment of both cortical & brainstem function 이 중요

★Table 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 communication이 중요

     - parents는 자식을 살리기 위해 행해지는 모든 가능한 것을 알기를 원한다.

     - anger of family members : reflection fo their sense of guilt & hopeless

Chapter 60. Pediatric Critical Care

  ;most common life threatening problems

  ①respiratory distress

  ②impaired peripheral perfusion

  ③altered consciousness

Respiratory Distress

  1) Pathogenesis

    ;blood-gas exchange의 disruption의 process

    ①abn'l of mechanical function of the lung & chest wall -most common

    ②neuromuscular abn'l affecting the nerves & muscles of respiration

    ③disturbance of respiratory control or drive

 

   (1)Mechanical dysfunction

    # restrictive lung disease

      ;lung주위의 구조물(Pleura rib cage & abd.)이 volume dependent fashion으로 lung의

       팽창을 제한

       →interstitium이 infilteration됨(pulm. edema, inflammation)

          alveoli가 consolidation되고 collapse됨.

          lung이 external source로부터 compression됨(etnse ascites,pneumothorax)

      ;consequense of restrictive lung d's(Fig.60-1)

       ①more force or muscle effort during inspiration to maintain tidal volume

       ②the alveolar volume decrease so the lungs operate at a lower end

         expiratory volume

      ;restrictive lung disease process되면

          tachypnea,grunting & signs of increased work나타나고 respiratory rate와

          mechanical dysfunction of severity의 indication 

    # Obstructive lung disease

      ;lung의 expansion이 flow dependent fashion으로 제한

       ①extrathoracic airway obstr.(epiglottis, croup, FB, T&A)

         - 특히 inspiration시 narrow되는 경향이 있음

       ②intrathoracic airway obstruction(bronchiolitis,asthma,FB,vascular ring)

         - expiration동안 lung emptying이 안되기 때문에 페용적 증가(hyperinflation)

         →expiratory phase가 증가, diffuse wheezing이 나타남

   (2) Adaption to increased work

      ;early sign of resp.muscle farigue(tachypnea)

       bobbing of the head(late signs of fatigue)

       →brief 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

    ①brething frequency

    ②the depths of breaths

    ③the time for inspiration & expiration

    ④the effort by the patient to breathe

    ⑤the presense of retractions

    ⑥use of accessory muscles

 

 3) Lab data

 

 4) Initial stsbilization & support

    ①O₂- always a safe initial measure

           hood(in a small infants)

           mask & face tents(in older patients)

           nasal cannulae(all ages)

    ②not to interfere with the compensatory mechanism of the respiratory system

 5) ventilatory support

   (1)Modes of ventilatory support

      ①time cycled ventilator

         -inflation의 extent가 insp. floe의 duration에 의해 조절

      ②volume cycled ventilator

         -tidal volume에 의해 조절

      ③pressure cycled ventilator

         -peak insp. pressure에 의해 조절

  * +-controlled ventilation

    +-assisred ventilation-IMV,SIMV등

   (2)Complication of ventilatory support

    #Barotrauma

      ①pnemothorax

      ②pneumomediastinum

      ③pnemoperitoneum

      ④pneumopericardium

      ⑤pulm. interstitial emphysema

      ⑥subcutaneous 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

     ①contrl of brearhing

     ②gas exchange

     ③respiratory 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 saturation응 높이는 방법

     ①FiO2   - simplest % quickest mean

     ②shunt fraction감소

     ③mean airway pressure증가

     ④Hb 농도 증가

     ⑤CO증가 - tissue oxygenation증가

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 

      ①carotid sinus & aortic baroreceptor

      ②sympathetic stimulation of the adenal gland

   (2)Reglation of regional bloos flow

     #Autoregulation

       -BP가 떨어지더라도 brain, heart와 같은 기관에서는 blood flow를 유지

        neural & hormonal stimulation by the  sympatho-adreanl system

     #humoral response가 CO를 증가시키는 mechanism

      ①heart rate증가

      ②contractility증가(by the catecholamine stimulation)

      ③venous return증가(by the venoconstriction)

     #renal mechanism - fluid retention

   (3)cause fo inadequate CO

  2) CO에 영향을 미치는 factor( Table 60 - 4)

      ①end diastolic or filling volume

      ②ejection fraction

      ③ht rate

 

  3) Assessment      

      Table 60-5

      Fig.60-2

 

   4) Initial stabilization

     ①O₂supply

     ②Ht rate, cardiac ejection, cardiac filling impair 유무 확인하고 즉시 치료

     ③shock 시 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

     ①opioid intoxication - hypercapneic hypoventilation associated with small pupil size

     ②salicylate poisoning - hyperpnea, resp alkalosis, dehydration

     ③osmotically active mollecule - unexplained gap between calculated &

       measured osmolarity

    # endogenous toxin

      - CO₂, urea, ammonia

    #hupoglycemia

 

   (2)Ischemic - hypoxic encephalopathy

 

   (3)Infections of the CNS

     : meningoencephalitis 등

 

   (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

    ①circulatory deficiency - premotor or motor autonomic center

    ②resp. dysfunction - pontine & medullary center

    ③careful neurologic exam - neurologic dysfunction is global or focal

 

  1) Initial Tx of intracranial HT

    : hypoxemia 와 hypercarbia 의 예방이 중요

    ①mechanical ventilation

    ②proper 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

    ①osmotic agent - mannitol, glycerol

    ②loop diuretics - furosemide

    ③hyperventilation

60.2 Resuscitation

# ★Cause 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

★Fig. 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

★Fig. 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 1½ 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% FIO₂ 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 CO₂monitoring

 : helpful adjunct in indicating proper endotracheal tube placement or dislodgement

   and adequacy of chest compression

 : low end-tidal CO₂levels 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

㉿Table 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

    - *▲common

    - 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 death의 7%

  - 1 - 4yr ; 19%

  - > 5yr ; 12 - 14%

  - drowning ; 19yr이하의 소아에서 4th leading cause of death

               5yr이하의 소아에서 single leading cause of injury death

  - pediatric submersion victim 중 80%가 생존

  - 생존자중 92%가 complete recovery

  - intensive care받는 도중 대략 30%가 사망, 10 - 30%가 severe brain damage

# ★Peak Age Group

    1) toddlers

    2) older adolescent males(15 - 19yr)

- concomitant medical conditions -> drowning의 기회 증가

     ; 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 hypoxemia가 3 - 5min이내이면 reversible

  - blood flow during anoxic conditions with ongoing glucose and nutrient delivery

      -> anaerobic metabolism -> cellular lactate와 other intermediary metabolite                concentration ↑ -> glutamate, other excitatory amino acid의 분비에 의한 neuronal          injury ↑

  - hypoglycemia ; near-drowning후 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         (이것은 initial cytoxic injury의 severity를 반영)

  - other organs와 tissue도 injury를 받음

     +- lung - hypoxia, ischemia, aspiration -> pulm. vascular endothelim에 damage

     |         -> vascular permeability ↑ -> noncardiogenic pul. edema, ARDS

     +- heart - myocardial dysfunction, arrhythmias, infarction

     +- kidney - acute tubular necrosis, acute cortical necrosis

     |           (가장 흔한 renal complications)

     |           vascular endothelial injury, exposing basement membrane

     |            -> thrombocytopenia, DIC 유발

     +- GI - bloody diarrhea with mucosal slouging

     +- hepatic transaminase and serum pancreatic enzyme ↑

     +- violation of normal mucosal protective barriers -> bacteremia, sepsis

Pulmonary Aspiration

# drowing victim의 90%, near-drowning victim의 80 - 90%에 발생

# aspirate의 amount와 composition이 Pt's clinical course에 영향미침

  ; water salinity, gastric contents, pathogenic organism, toxic chemicals, other foreign matter

    --> lung에 injury, airway obx.

# Sea water

    ; hypertonic(대략 3% N/S)

        - *drawing interstitial, intravascular fluid into the alveoli

    ; *surfactant를 inactivation --> alveolar surface tension ↑ --> atelectasis

# Fresh water

    ; hypotonic

  ; *surfactant를 wash out

           --> alveolar instability, collapse

       --> ventilation-perfusion mismatch

           --> hypoxemia, pulm. insufficiency

           --> interpulm. shunting ↑, lung compliance ↓, small airway resistance ↑

# profound arterial hypoxemia는 2.2ml/kg정도의 aspiration후에 발생 가능

  - 그외 intensive care중 mechanical ventilation, barotrauma, pulm. interstitial                 emphysema, pneumothorax, pneumomediastinum으로 발전 가능

Hypothermia

  - hypothermia(core temperature < 35°C) after submersion -> common event

  - 소아는 high body surface area to mass ratio와 decreased subcutaneous fat insulation때        문에 risk ↑

  - < 35°C이면 thermoregulation fail, spontaneous rewarming이 일어나지 않음

     ; moderate hypothermia(32 - 35°C) - shivering thermogenesis와 increased sympathetic           tone에 의한 oxygen consumption↑

       severe hypothermia(, 35°C) - shivering cease, cellular metabolism↓

       moderate to severe hypothermia 1 progressive bradycardia, impaired myocardial                contractility, loss of vasomotor tone -> hypotension

       central respiration center depression -> hypoventilation, eventual apnea

  - < 28°C - extreme bradycardia, spontaneous ventricular fibrilation, asystole↑

  - < 25 - 29°C - deep coma with fixed and dilated pupil, absent reflex 올 수 있다

  - temperature aberration의 duration과 severity에 의존하여 systemic adverse consequence발생

     ; ARDS - hypothermic pulm. endothelial injury에 2차적으로 depressed hepatorenal                 metabolism, perfusion -> drug clearance↓, 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 effort동안에 core body temperature가 실제적으로 증가되전        에 drop하는 것

      기전 - cold blood가 extremities로 부터 warmer central core로 return하는 것에 대한 2 차적으로 발생, 또는 warmer core로 부터 cooler surface layer로의 heat conduction에 의해 발생

 

      severe hypothermia 환자에서의 afterdrop -> cardiac, respiratory, neurologic functin           을 저하, arrhythmia유발

  - Rewarming shock ; body temperature의 증가에 의한 additional metabolic requirement↑와         함께 surface rewarming에 수반되는 vasodilatation과 blood pressure를 유지시키는             external hydrostatic pressure의 removal에 의해 shock이 발생

Fluid and Electrolyte Change

  - sea water와 fresh water로 사망한 환자의 15%에서만 significient E' chagnge보임

# 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

# 그외 SIADH, IICP 등도 올 수 있음

Clinical Manifestation and Treatment

  - significant submersion후 well-being state의 children이라 할 지라도 delayed resp.             decompensation이 올 수 있기 때문에 6-12hr동안은 주의깁게 관찰해야 함

Initial Evaluation And Resuscitation

    - initial out-of-hospital resuscitation of submersion victim

       - rapidly restoring oxygenation, ventilation, adequate circulation에 초점을 두어야             함

    - shock의 potential indicators ; slow capillary refill, cool extremities, altered               mental status

    - IV fluid admistration ; Non-dextrose-containing, isotonic fluid(Lactated Ringer                 solution과 normal saline)

           should be warmed (40 - 43°C) in the hypothermia Pt.

    - Body temperature measure +- tympanic membrane - best measured

                               |  adequate rectal temperature ; 적어도 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     -+

        * insulin은 submersion injury후 발생한 hyperglycemia교정에 사용해서는 절대 안됨

Controversial Issues

Hospital Management

Respiratory Managment

    - Pt.는 atelectasis, pneumonia, pneumothorax, pneumomediastinum, pulm.edema, ARDS로 진          행될 수 있으므로 chest radiography가 반드시 obtain

    - arterial catheterizaion

    - prolonged use of high inspired oxygen concentraion(>70-80&) -> pulm. injury후 더 나          빠질 수 있음

    +- endotracheal intubation과 PEEP -> the most effective means of reversing hypoxemia

    +- CPAP, ECMO

     => PaO2 80 - 120mmHg, PaCO2 30 - 35mmHg 유지

Cardiovascular Management

    - continuous ECG monitoring

    - fluid resuscitation과 inotropic agent

    - echocardiography, central venous pressure monitoring

    - Swan-Ganz pulm. artery catheter placement

Rewarming Measures

    - administration of warmed IV fluid(36 - 40°C)

    - heated humidified inspired oxygen(40 - 44°C)

    - warmed gastric, bladder, peritoneal lavage

    - more aggressive method ; hemodialysis, extracorporeal rewarming, cardiopulm. bypass

Neurologic Management

    - optimal management하에서 many initially comatous children은 첫 24 - 72hr내에                 dramatic neurologic improvement를 보임

    - 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-drowning후 pediatric intensive care unit                  survivors의 10 - 30%에서 관찰

    - 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

    ; *▲indicator of neurologic outcome

  +- 5min이내의 submersion time에서의 91%에서 intact survivor 또는 mild neurologic i         |     impairment

  +- 10min이내에서는 87%에서 발생

# CPR 시행받은 children

  ; *10min이상의 submersion duration시 93%에서 death or severe neurologic injury

    ; 25min이상인 경우 100%에서 death or severe neurologic injury

# Glasgow Coma Scale(GCS)

    ; hospital admission당시

        - GCS score > 6 -> good outcome

    - *GCS score < 5 -> higher probability of poor neurologic outcome

60.5 Burn Injuries

  - burn injury Pt.의 30 - 40% ; < 15yr of age(average 32Mo)

  - Scald burns ; total injury의 85%

                  most prevalent in children < 4yr of age

  - Flame burns ; 13%

  - burn injury의 대략 16% ; child abuse의 결과로 인함

  - Burn treatment의 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

★Table 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 BSA이상의 burn children - IV fluid resuscitation(10 - 20ml/kg/hr, Lactated                                              Ringer solution or N/S)

       evaluate for associated injuries

       > 15% of BSA burn ; oral fluid는 금지 (∵ ileus, aspiration 때문)

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, 7-14일에 healing

         mid level to deep 2nd degree burn ; pain less than superficial burn

          fluid loss and metabolic effect of deep dermal(2nd degree) burn은 3rd degree               burn과 유사

  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 이하의 1st and 2nd degree burn

  blister는 intact하게 나두고 silvadene(silver sulfadiazine cream)으로 Tx.

  dressing은 하루에 2번

Fluid Resuscitation

  Parkland formula

    ; 4ml Ringer lactate/kg body wt./% BSA burned

      첫 8시간에 걸쳐서 1/2 IV, 나머지 1/2은 다음 16시간에 걸쳐서 같은 rate로 IV

      rate of infusion - Pt's responce to therapy에 따라 수정

      interstitial edema와 muscle cell내 fluid의 sequestration때문에 baseline preburn body           wt.를 넘어선 20%까지 줄 수 있음

 

  - burn후 second 24hr동안 Pt는 edema fluid의 reabsorb, diuresis 시작

  - 1st day fluid requirement의 1/2은 5% dextrose인 lactated Ringer solution을 사용

  - burn이 85% total BSA이상이면 colloid replacement가 사용; burn injury후 8 - 24hr에 사용

  - oral supplementation은 burn후 가능한한 48시간에 start할 수 있다

  - 5% albumine infusion - over 24hr에 걸쳐서

    ; 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)일 때

  - Sodium supplementation ; 20% BSA이사의 burn, 특히 0.5% silver nitrate solution이             topical antibacterial burn dressing으로 사용될 때(serum Na > 130mEq/L유지위해)

  - Inravenous potassium supplementation ; serum K > 3mEq/L로 유지위해

Prevention of Infection

  - Prophylactically penicillin therapy - 5 day course

  - Erythromycin

  - Topical treatment

Nutritional Support

  - burn injury는 protein과 fat catabolism을 특징적으로 하는 hypermetabolic response를 보        임

  - Calory ; 11/2- 2 times the basal metabolic rate with 1.5 - 2g/kg body wt of protein

  - Multivitamin, 특히 vit B group, vit C, vit A와 zinc가 필요함

Topical Therapy

  +- 0.5% silver nitrate

  +- sulfacetamide acetate

  +- silver slufadiazine cream

  Cx. ; transient leukopenia

Inhalation Injury

  - Respiratory tract에의 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

        ARDS는 24 - 48hr후에 발생

        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

  - Pain은 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 등에 의존

  - Opiate analgesia

       Oral morphine sulphate ; 0.3 - 0.6mg/kg body wt. every 4 - 6hr

         procedure(dressing changes or debridement)동안 pain control하기위해

         procedure 30분전에 투여

       IV bolus morphine sulfate ; 0.05 - 0.1mg/kg body wt every 2hr

         PCA protocol을 사용하는 old Pt에서 사용

         procedure전 즉시 투여

       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

  - 대부분의 case는 non-oliguric renal failure를 보임

  - Renal failure는 1 - 3주후 early or late하게 올 수 있다

        Early renal failure

       ; subsequent hypovolemia와 함께 late resuscitation이 있을 때

         severe pigment nephropathy(hemoglobinuria, myoglobinuria)가 발생할 때

        Late renal failure

       ; sepsis or drug toxicity로 부터 기인됨

60.6 Cold Injuries

Pathophysiology

  - ice crystal이 cell사이에 형성 -> normal sodium pump의 activity 방해 -> cell membrane의       rupture

  - further damage ; red cell or platelet의 clumping -> microemboli or thrombus형성

  - blood shunting

Etiology

  - conduction, convection, radiation에 의해 body heat의 소실

  - hypothermia

Clinical Manifestation

Frostnip

 - face, ears, extremities에 firm, cold white area형성

 - 다음 24 - 72hr에 걸쳐 blistering과 peeling 발생

 - Tx. ; warming

Immersion Foot(Trench Foot)

    ; feet가 damp, wet, pooly ventilated boots에서 cold에 expose될 때

    ; pale, edematous, clammy

         --> *tissue maceration, infection, prolonged autonomic disturbance

                   / *increased sweating, hypersensitivity to pain temperature change

                   / 수년간 지속

    ; Treatment

           - prophylactic

         well-fitting, insulated, waterproof, nonconstricting footwear사용

Frostbite

    ; *초기에 skin의 stinging or aching

           --> cold, hard white anesthetic and numb area

    ; *rewarming시 blotchy, itchy, red, swollen, painful

    ; Tx. ; damaged area의 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

         필요시 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, leg의 exposed area에 발생

    ; 대략 1 - 2주간 지속, 그러나 더 오래 지속 가능

    ; Treatment

           - prophylaxis - avoiding prolonged chilling

          |               protecting potentially susceptable area

      +- prazocin, phenoxybenzamine

      +- local corticosteroid - itching이 심할 때

Cold-Induced Fat Necrosis(Panniculitis)

- red(less than purple to blue), macular, papular, nodular

- Tx. ; NSAIDs

        10일에서 3주간 지속

60.7 Acute Respiratory Distress Syndrome

  - a syndrome recognized as acute respiratory failure

  - 특징 ; increased premeability pulmonary edema

  - demonstrated by widespread infiltrates on chest radiograph, impaired oxygenation and         normal cardiac function(noncardiogenic pulmonary edema)

# ♥Definition

  ; 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 Pt의 most common cause of ARDS ; shock, sepsis, near-drowning

     그외 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)

                         alveoli는 nonhomogenous fluid, blood or aggregated leukocyte함유

                         first 6hr동안 시작 -> resolution or progession은 72hr까지 지속

       proliferative phase ; increased density of type II pneumocytes and fibroblast

                             injury후 1 - 3주 사이에 발생

       fibrotic stage ; ARDS가 3주이상 지속될 때 발생

                        pulmonary fibrosis

Pathogenesis

  - multifactorial causes

  - endothelum에 injury주는 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 등

  * ARDS는 neutropenia pt.에서도 발생 가능

  - surfactant system의 abnormality -> atelectasis

Clinical Manifestation

  - 초기에는 pul. Sx.은 minimal, ∴ 청진상 clear & no X-ray change

  - 다음 4 - 24hr 동안 ; hypoxemia진행

                         cyanosis, dyspnea, marked tachypnea with diffuse, moist                                      inspiratory crackles

  - gradual recovery 가능하나 다수가 progressive severe hypoxmia or hypercapnia로 진행

Laboratory Finding

  - ABGA ; PaO2 < 50mmHg on FiO2 > 0.6%

           PaO2/FiO2 ratio < 200는 QS/QT(intrapulmonary shunt) > 20%와 상관

  - Radiographic evidence

    ; initially, no significant radiographic abnormality

      수시간후, fine bilateral reticular infiltrate를 보임

      첫 72시간내에 cardiomegaly없이 interstitial and alveolar pulmonary edema발생

  - Cx. ; diffuse interstitial fibrosis와 barotrauma(pneumothorax, pneumomediastinum)

  - Poor Px. factors +- pulmonary artery pressure↑

                     +- abnormally high pulmonary artery resistance

Treatment

     PEEP ; 때때로 10 - 20cmH2O까지 필요

     supportive Tx. +- cardiac function 유지

                    +- Hct 35 - 40% 유지

                    +- 2ndary infection 방지

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

★Table 61-4

Preanesthetic Preparation And Premedication

Intraoperative Management

      - tracheal intubation의 indication

         ①head & neck op

         ②intrathoracic, abdominal, cranial procedure

         ③op. in prone position

         ④most emergency procedure

     1) fluid Tx

     2) blood transfusion

        * rapid transfusion의 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 : ①원인제거

                ②hyperventilation

                ③dantrolen(3mg/kg) IV

                ④general care - hyperkalemia, acidosis교정

                                 circulatory suppot

                                 active cooling

                                 urine alkalinization(myoglobinuria)

 

     4) monitoring

 

5. Postanesthetic recovery

   * general anesthetics의 sequale

      ① postanesthetic excitment

      ② vomiting

      ③ pain

      ④ intubation후의 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

★Misconception 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

# ★In Neonate

    ; as adult, unmyelinated C fiber transmit nociceptive information peripherally

    ; nerve pulse transmission in incompletely myelinated A-δ 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 : ▲valid indicator

Treatment   

table 62-1

     (1) post-op pain : morphin & fentanyl - infant & children

                       PCA(pt-controlled analgesia) - 6∼18yr

 

 

 

     (2) cancer & other pain syndrome

          ①PCA subcutaneous infusion of morphin or methadone, fentanyl

            opidoid by indwelling epidural or intrathecal catheter

          ②steroid : wide spread tumor invasion of bone or n. system

          ③tricyclic medication : neuropathic pain

          ④sickle 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

         ①gastric PH

            - birth - neutrality

            - 수시간후 - 1.5∼3.0

            - 1st 10th day - high

              10∼30th day - lowest

            - 성인 level : PH 3

         ② Gastric emptyng times & intestinal motility

            - adult level에 이르는 시기 ; 6∼8mo

         ③ Pancreatic enzyme activity

            - full term < premature at level

            - lipase activity

                34∼36주(GA)서 notice

                1wk에 5배

                9mo에 20배

            - amylase ; 22wk에 detect

            - trypsin

         ④ 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 dehydration정도

                    stratum corneum두께에 따라 흡수

 

     3) drug distribution

        (1) binding protein

          ①albumin

          ②α1-acid glycopritein(orosomucoid)

          ③lipoproteins

        (2) neonatal period서 albumin과 경쟁

           ①free fatty acids

           ②bilirubin

           ③2-hydrozybenzoyl glycine

        (3) bilirubin

           ①independent to gestational age

           ②5mo - adult level

     4) drug metabolism

     5) drug excretion

        (1) renal blood flow

           ①birth 12cc/min

           ②adult level - 5∼12mo

        (2) glomerular filtration rate

           ①full term - 2∼4cc/min

           ②2∼3day - 8∼20cc/min

           ③adult level - 3∼5mo

 

2. Phrmacokinetics

     1) basic concepts

          ①drug absorption & bioavailability

          ②volume of distrubution

          ③elimination half-life

               t½ = (0.693vd)/cl

          ④clearance

          ⑤individulization of drug dose

     2) additional consideration

          ①method of drug administration

          ②drug-drug interaction

          ③drug in hunal milk

          ④prescribing medication

          ⑤compliance with th prescribed regimen