Pediatric Emergency

Medicine Course (PEMC)

 DISCLAIMER
Every effort has been made to ensure that the drug doses herein are accurate and in
accordance with the standards accepted at the time of publication. However, the user
is advised to check the doses carefully. The author/publisher shall not be responsible
for any error in this publication. Besides, as new research and experience broaden our
knowledge, changes in treatment and drug therapy occur. Therefore, the reader is
advised to check the product information sheet included in the package of every drug
he or she plans to administer to be certain that changes have not been made in the
recommended dosage or in the contraindications. This is of particular importance in
regard to new or infrequently used drugs. In addition the protocols given in this book
are valid at the time of publication and are subject to constant review.
 Pediatric Emergency
Medicine Course (PEMC)
Excellence in specialized pediatric emergency care
to get kids back on track

Editor
Indumathy Santhanam MD DCH
Assistant Professor
Pediatric Emergency Medicine
Department of Pediatric Emergency Medicine
Institute of Child Health and Hospital for Children
Madras Medical College, Chennai
Tamil Nadu
India

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Pediatric Emergency Medicine Course (PEMC)

© 2008, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any
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This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
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dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2008

ISBN 978-81-8448-279-9
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
 Dedicated
to
All nurses and
physicians who care for the critically ill child
in resource limited settings
Lead me from the untruth to the truth!
Lead me from darkness to light!
Lead me from death to immortality!
Brihadaranyaka Upanishad
800-500 BC
 Contributors
Editor Topics:
Indumathy Santhanam MD General Approach to Shock
Assistant Professor Specific Poisons
Pediatric Emergency Medicine Cyanotic Spell
Department Hypertensive Crisis,
Institute of Child Health and Hospital Scorpion Sting
for Children DKA Protocol
Madras Medical College
Chennai – 600 008 Associate Editor
Suchitra Ranjit MD
Topics: Senior Consultant
Approach to Recognizing Critical Illness, Pediatric Intensive Care Unit
Respiratory Distress and Respiratory Failure, Apollo Hospital
Airway Management Chennai
Stridor
Topics:
Asthma
Dengue Shock and Dengue
General Approach to Shock
Hemorrhagic Syndromes
Septic Shock
DSS Protocol
Anaphylaxis
When to Use Vasoactive Drugs in the ED Associate Editor
Status Epilepticus Thangavelu S MD, MRCP
Cardiogenic Shock Assistant Professor
General Approach to Poisons Pediatric Intensive Care
Non-Traumatic Coma Department
Protocols for the Management of all the Emergencies Institute of Child Health
All Photographs Madras Medical College
Chennai – 600 008
Editorial Board
Topic:
Photograph of Poisons
Associate Editor
Jayanthi Ramesh DNB Janani Shankar DNB
Senior Consultant and Academic Senior Consultant
Officer, Emergency Department Kanchi Kamakoti Childs Trust
Kanchi Kamakoti Childs Trust Hospital
Hospital, Chennai – 600 034 Chennai–600 034
Topic: Topic:
General Approach to Poisons Gastrointestinal Bleeding

Associate Editor M. Jayshree MD

Shanthi S MD Additional Professor
Assistant Professor Pediatric Intensive Care Department
Advanced Pediatric Center
Pediatric Intensive Care Department
PGIMER,
Institute of Child Health
Chandigarh-160012
Madras Medical College
Chennai – 600 008 Topic: Diabetic Ketoacidosis
viii Pediatric Emergency Medicine Course (PEMC)

R Kuzhanthai Kasthuri MD Indira Jayakumar DNB

Director Superintendent Senior Consultant
Institute of Child Health (2007) Pediatric Intensive Care Unit
Madras Medical College Apollo Hospital
Chennai – 600 008 Chennai
Topic: Snake Envenomation Topic:
Laryngeal Mask Airway
B Ramachandran MD
S Giridhar MD
Senior Consultant
Trainee
Pediatric Intensive Care Unit
Neonatology
Kanchi Kamakoti Childs Trust Hospital
PGIMER, Chandigarh
Chennai – 600 034
Topic:
Topic: Multisystem Trauma
Pulse Oximeter
Ramachandran P MD
Assistant Professor SR Kamath DNB
Institute of Child Health and Hospital for Children Consultant
Madras Medical College Pediatric Intensive Care Department
Chennai – 600 008 Mehta’s Hospital
Topic: Cardiogenic Shock Chennai
Topic:
Soonu Udani MD Drowning
Senior Consultant
Pediatric Intensive Care Department The editor, acknowledges with appreciation the
PD Hinduja National Hospital and Medical Research contributions of the following pediatric residents of the
Centre Institute of Child Health—Madras Medical College, in the
Mumbai – 400 016 development of the emergency department protocols for
this resource:
Topic:
Non-traumatic Coma Rajesh Balakrishnan DCH (2005)
Traumatic Brain Injury
N Kumar MD (2006)
Sunit Singhi MD
Professor and Head of Department Rajendran MD (2003)
Department of Pediatric Intensive Care and Emergency
Advanced Pediatric Center Jyothsna S DCH (2003)
PGIMER
Chandigarh-160012 Arun Kumar DCH (2007)

Topic:
Specific Poisons
Iron Poison Protocol
 Foreword
Pediatric emergency medicine is a mature discipline that has been around for over 3 decades.
It is becoming a popular subspecialty for many pediatricians due to the recognition of its
importance in the care of the most vulnerable children. The growth and maturity of the
discipline is fuelled by enlightened emergency medicine practitioners who have shifted the
emphasis to the team concept within the department while also participating in transport
programs for the critically ill, outreach education, and as a resource for community
practitioners. Hospitals are also recognizing the importance of pediatric emergency
departments as the showcase of the hospital, the area where the greatest number of patients
are treated and where there is the potential to do the greatest good.
Like politics, emergency care of children is “local” and depends on adaptation to the
available resources and practice environment. It is therefore appropriate that those who take care of an enormous
volume of patients in a unique environment share their experience and expertise. This is an attempt to do just that.
This book consists of 31 chapters relating to common life-threatening emergencies and procedures that form the
core of emergency medicine. The first chapter is an appropriate launching pad for this valuable text and addresses
the recognition of critical illness in the emergency department. It is then followed by some discussion of common
conditions such as respiratory distress and failure, stridor, asthma, shock, multi-system trauma, and status epilepticus.
These diseases are encountered in children worldwide but the unique contribution of these authors is that they bring
their local perspective to diagnoses and treatment. Other chapters such as poisoning, stings and bites, and fever
syndromes discuss conditions that are unique to patients seen in India. The book also contains practical tips for
common procedures that should be within the armamentaria of the emergency physician and concludes with a
chapter on how to set up an emergency service.
You might ask why another manual in emergency medicine? This book differs from others in that it bears
relevance to countries and situations in which there are limited resources. Chapters are succinctly written and usually
start with a short realistic case scenario. They include flow charts that are easy on the eyes and the key points in
each chapter provide valuable nuggets for those working in similar environments. It has been said that “a picture is
worth a 1000 words”, and the illustrations in this book certainly attest to this aphorism. The illustrations clarify
issues and make relevant points to supplement the text material. One gets the impression that those who are writing
the chapters are experts and spend considerable time practicing in pediatric emergency departments. Therefore, this
is not just another textbook but a unique contribution that provides a perspective that others do not.
This valuable text should be on the shelves of all health care workers who are involved in the emergency care of
the ill and injured child. For those in the developing world it contains useful information to provide care for children
in situations where resources are limited. Those in the developed world can learn useful techniques that are cost
effective and can be easily adapted to their environment.
The ultimate beneficiaries of this book should be the most vulnerable children in resource limited environments.
It provides time sensitive and practical suggestions to treat common problems. The authors have every reason to be
justly proud of their efforts.
Dr. Niranjan “Tex” Kissoon MD, CPE
(President elect of the World Federation of
Pediatric Intensive and Critical Care Societies–2008)
Acute and Critical Care Programs, Department of Pediatrics
University of British Columbia,
Childrens’ Hospital, Rm K4-4480 OAK Street
Vancouver, British Columbia V6H 3V4, Canada
 Preface
“Excellence in specialized pediatric emergency care to get kids back on track”
Few situations in a pediatrician’s practice evoke the anxiety and panic which accompanies the management of an
acutely ill child. The Pediatric Emergency Medicine Course offers a structured approach to handle the crisis using a
time sensitive, goal directed approach during the initial “golden hour” of critical illness.
Conceived by Dr S Krishnan, a pilot course was conducted in 1999 with the collaboration of the emergency and
intensive care physicians of the Kanchi Kamakoti Childs Trust Hospital and the Institute of Child Health, Madras
Medical College, under the auspices of the Indian Society of Critical Care Medicine (ISCCM) - Chennai Chapter.
Since then the content of the course has undergone tremendous changes as international resuscitation guidelines
evolved providing better standards of care. In 2006, this course was formally copy righted to the ISCCM Chennai
chapter.
At the 5th National Pediatric Critical Care Conference, executive body meeting of the Indian Academy of Pediatrics-
Critical Care Chapter held at Surat in October 2003, it was suggested the PEMC manual be re-written with evidence
based guidelines. This was not easy. Most resuscitation guidelines are based on work published in Western centers.
Do these protocols work for us? Evidence is sparse in the Indian context! Using international guidelines as a
prototype, protocols were modified to suit realities of a large volume Emergency Department of a public children’s
hospital with little access to resources and advanced technology. Surprisingly, implementation of these modified
protocols over the last ten years resulted in mortality rates to levels almost on par with developed nations in life-
threatening pediatric emergencies.
This is of special relevance in our country, where the vast majority of critically ill children, do not have access to
appropriate pre-hospital emergency medical services, specialist retrieval teams and advanced intensive care facilities.
Where critical care often evokes thoughts of advanced technology involving expensive resources this message is
of paramount importance.
Emergency medicine also involves the ability to take quick and accurate decisions in life-threatening pediatric
emergencies. To assist novice residents to take acceptable lines of action quickly in critical illnesses, this manual
elucidates a structured method of fitting the findings of the cardiopulmonary assessment into the pediatric assessment
triangle, understanding the physiological status and making the optimal therapeutic decision in the first hour of
resuscitation in the absence of biochemical or radiological support.
While academicians may feel that the methods published in this manual may not have been validated in other
centers, this approach has dramatically improved survival at the ED of the Institute of Child Health, which receives
and resuscitates the largest volume of pediatric emergencies in the planet!

Indumathy Santhanam
 Acknowledgements
It is well known that no one does anything that matters alone. The Pediatric Emergency Medicine Course Manual
and the course are no exceptions. I am grateful for all the talented people who made this journey possible. They have
been great partners and many have become good friends.
Dr Jayanthi Ramesh, provided the spring board from which the PEMC catapulted in to a highly successful
course. Her unswerving ethical stand and guidance even while battling a deadly illness, on the various issues related
to the course have ensured that we grew from strength to strength.
I thank Dr Shanthi Sangareddi for her constant encouragement in conducting this course. Her tireless efforts in
proofing earlier editions while contributing important chapters has played a huge role in improving the content of
this manual.
I am grateful for the intellectual inputs of Dr Suchitra Ranjith, who despite enormous personal commitments
would immediately respond to an urgent call for assistance not only in scientific content but also in patient related
critical care issues of the Institute of Child Health, Chennai.
I feel blessed and grateful to have so many remarkable young critical care physicians, Drs Anjul Dayal, Natwar
Sharma, Narmada Ashok, Shrishu Kamath, Samarth, Shiv Kumar who participate as faculty in this course.
I also thank Dr Rajesh Balakrishnans for his creativity in designing attractive protocols for this manual. My
thanks to all the contributors, Drs Thangavelu S, Janani S, S Singhi, S Udani, M Jayshree, B Ramachandran,
P Ramachandran, Indira Jayakumar who gave their best efforts in making this manual.
I wish to thank Dr Ramakrishnan, Secretary, Dr Mahendran, Treasurer, Indian Society of Critical Medicine –
Chennai Chapter and Dr Ram Rajagopalan, President ISCCM 2006, for endorsing and copy righting the PEMC as
part of the educational activities of the Indian Society of Critical Care Medicine- Chennai Chapter.
I am indebted to Dr R K Kasthuri, Former Head of Department of the Emergency and Intensive Care and Director
of the Institute of Child Health- Madras Medical College, for her unwavering support for the provision of emergency
care of the critically ill child reaching a public children’s hospital.
A physician can save the few lives that he or she encounters during duty hours. But ER friendly policies by
administrators can save the lives of the innumerable critically ill children who reach its threshold. This department
owes its growth in the government sector to the efforts of various Directors and Heads of Department of the Institute
of Child Health over the last decade.
I also wish to thank Dr Shridar, Medical Director and the senior consultants of Kanchi Kamakoti Childs Trust
Hospital for their whole hearted support in conducting the course from its inception. The KKCTH provided an ideal
venue for the course with its state of the art Pediatric Emergency and Intensive Care Departments. Delegates from
the far nooks of the country enjoyed not only its hospitality but also its scientific environment.
Unfortunately, I never had an opportunity to thank Dr Vijayalakshmi Kamath, Head of Department Anesthesia
and Intensive Care, Sri Ramachandra Medical College and Research Institute and Organizing Chairperson of Criticare–
Chennai 2006, National Conference of the Indian Society of Critical Care Medicine, for her generous and outspoken
words of encouragement at the eve of release of the up dated manual in February 2006.
Lessons learnt over the last decade should reach physicians far outside the walls of the ED of The Institute of
Child Health, Chennai. I wish to thank my father, mother, Kichhamma, Subbappa, Subhashini, Ramesh and LG
Varshini for assisting me in achieving this goal.
I am also grateful to Shri JP Vij, CEO, Jaypee Brothers Medical Publishers and Mr Jayanandan for their immense
encouragement in publishing this manual in its current attractive format.
 Contents
1. Recognition of Critical Illness in the Emergency Department ............................................................. 1
2. Approach to Respiratory Distress and Recognition of Respiratory Failure ..................................... 13
3. Stridor ....................................................................................................................................................... 18
4. Asthma ...................................................................................................................................................... 26
5. Airway Management ............................................................................................................................... 33
6. Shock ......................................................................................................................................................... 45
7. When to Use Vasoactive Drugs in the Emergency Department? ........................................................ 57
8. Pediatric Septic Shock ............................................................................................................................ 63
9. Dengue Hemorrhagic Fever and Shock Syndromes ............................................................................ 69
10. Cardiogenic Shock ................................................................................................................................... 76
11. Cyanotic Spell .......................................................................................................................................... 81
12. Hypertensive Emergencies ..................................................................................................................... 84
13. Anaphylaxis .............................................................................................................................................. 89
14. Status Epilepticus .................................................................................................................................... 91
15. Non-traumatic Coma .............................................................................................................................. 99
16. Traumatic Brain Injury ........................................................................................................................ 105
17. Multisystem Trauma ............................................................................................................................. 113
18. Drowning ................................................................................................................................................ 120
19. General Approach to Poisoning ........................................................................................................... 123
20. Specific Poisons ...................................................................................................................................... 130
21. Scorpion Sting ........................................................................................................................................ 137
22. Snake Bite Envenomation ..................................................................................................................... 141
23. Diabetic Ketoacidosis ............................................................................................................................ 145
24. Gastrointestinal Bleeding ..................................................................................................................... 156
25. Chest Tube Placement and Thoracocentesis ...................................................................................... 163
26. Pericardiocentesis .................................................................................................................................. 165
27. Laryngeal Mask Airway ....................................................................................................................... 166
28. Pulse Oximetry ...................................................................................................................................... 169
29. Nebulizer Therapy ................................................................................................................................. 173
30. Central Venous Access .......................................................................................................................... 175
31. Setting up an Emergency Service......................................................................................................... 178
Index ........................................................................................................................................................ 181