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Pediatric Medical Emergencies continued…
Common summer-related pediatric emergencies to look out for are anaphylaxis and vehicular hypothermia. Anaphylaxis is a disorder characterized by the acute onset of skin or mucosal area involvement (hives or swollen lips), respiratory symptoms and/or reduced blood pressure. Either of the following may be considered anaphylaxis:
- Acute onset with skin or mucosal area involvement (hives or swollen lips) and respiratory symptoms or reduced blood pressure
- Reduced blood pressure after exposure to a known allergen
The most common triggers for children are food allergies (peanuts, tree nuts, shell fish, etc.), medications or bee stings. As a clinical diagnosis, testing is not required and immediate treatment is necessary. So, if your patient meets the criteria, IM epinephrine is the treatment of choice. Delays in IM epinephrine treatment have been associated with death and “biphasic” reactions — getting no better and no worse.
IM epinephrine should be administered into the lateral thigh. Doing so intramuscularly gets the medicine into the body faster than other methods, including SQ. Other available treatments include:
- Antihistamines – Combined H1 and H2 blockers have been found to be superior when treating mild allergic reactions
- Aerosolized medications – Symptoms of wheezing can be treated with beta agonists or stridor, with racemic epinephrine
- Corticosteroids – Prednisone is often given to decrease the risk of a biphasic reaction. However, evidence regarding steroids for anaphylaxis is not clear; APLS recommends the use of steroids
- Other therapies – If the patient has low blood pressure, give fluid boluses of 10–20mL/kg
- Monitoring – Anaphylaxis can get better, but it can also get and worse. It’s important to monitor the patient carefully, including all of the vital functions of airway, breathing and circulation
Vehicular hyperthermia is an awful and preventable cause of heat stroke in young children. With the positioning of children in the back seat, out of sight, caregivers may forget that the child is in the car. The inside temperature of the car rises quickly and dramatically. The air temperature inside a vehicle parked in the sun increases by 20 degrees every 10 minutes, so by minute 20, the inside temperature could be 29 degrees higher than the ambient temperature. Meaning, in an hour’s time, the inside temperature could be 140–180° F.
Heat stroke is the most severe heat illness, resulting in a core body temperature greater than or equal to 104˚ F as well as neurologic dysfunction (disorientation, delirium, seizures, or coma). When encountered, rapid cooling and treatment of the dehydration and/or shock is immanent. This is known as, immediate acute resuscitation.
Resuscitation focuses on stabilization of the ABCs and rapid cooling. Airway support, such as a bag-valve mask, may be required. This depends on the degree of hyperthermia and altered mental status. Supplemental oxygen, however, should be provided to all hyperthermic patients and intravenous access should be established. An initial fluid bolus of 20 mL/kg of either chilled or tepid isotonic crystalloid is appropriate. For any child with an altered mental status, a point-of-care blood glucose is needed to rule out hypoglycemia.
When responding, core temperature should be measured as soon as possible. Temperature is best measured in the rectum, as other methods — axillary, oral and tympanic — are not accurate enough. The child should be removed from the vehicle immediately, exposing bare skin and cooling core temperature to 100° F.
Small trials and expert consensus suggest that evaporative cooling is the most rapid cooling method when responding to a child in the field. Using room temperature water is effective and should be sprayed while fanned either manually or with a fan. Ice packs placed in the axilla, groin and around the neck may also be beneficial. To prevent hypothermia, however, temperature should be monitored and cooling should be stopped once a core temperature of 100° F has been reached.
Mild hyperthermia, without mental status changes, may be managed by moving the child to a cooler environment and correcting dehydration with fluids. While antipyretics do not have a role in treating environmental hyperthermia, shivering should be actively managed as it slows the rate of cooling. Medications, such as Midazolam, can be given for shivering or seizures.