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IAP Speciality Series on Pediatric Intensive Care
Praveen Khilnani, Krishan Chugh, Soonu Udani, Deepak Ugra
1:
Recognition and Stabilization of Critically Ill Child
INTRODUCTION
APPEARANCE OF THE CHILD
Airway
Breathing
Respiratory Rate
Work of Breathing
Air Entry
Skin Color and Temperature
Circulatory Status
Heart Rate
Pulse
Skin Perfusion
Organ Perfusion
Pulse Oximetry
Stabilization
Airway
Breathing
Circulation
CNS Support
SUMMARY
2:
Predictors of Outcome of Critical Illness in PICU
THE SCORING SYSTEMS
PRISM SCORE
Organ Specific Scoring System
How to Use the Score?
3:
Oxygen Therapy
INDICATIONS FOR OXYGEN SUPPLEMENTATION
Indications for Intervention
HOW TO DETERMINE OXYGENATION
Clinical Markers of Hypoxia
Measuring Oxygenation
Arterial Blood Gases (ABG)
Pulse Oxymeter
Drawbacks of SpO2
Advantages of SpO2
Precautions
TRANSCUTANEOUS OXYGEN MONITOR (TcO2)
TO DETERMINE TISSUE OXYGENATION
HUMIDIFICATION OF OXYGEN
HOW TO GIVE OXYGEN
Oxygen Sources and Flow Regulators
Low Flow Devices
High Flow Devices
DOSE OF OXYGEN
HOW TO START OXYGEN
PRACTICAL GUIDELINES
WHEN AND HOW TO WEAN AND STOP OXYGEN
HAZARDS OF OXYGEN
FIELD FOR RESEARCH
COST OF OXYGEN
4:
Upper Airway Diseases
INTRODUCTION
PATHOPHYSIOLOGY
Common Causes of Upper Airway Diseases (Table. 4.1)
HISTORY
PHYSICAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
RADIOLOGY
X-rays
CT/MRI
ENDOSCOPY
Precautions
OTHERS
MONITORING
MANAGEMENT
Initial Management
Airway Management
Choanal Atresia
Laryngomalacia
Laryngeal Webs, Stenosis or Tumors
Vascular Impingement on Trachea
Bronchomalacia and Intrathoracic Tracheomalacia
LTB
Epiglottitis
Bacterial Tracheitis
Peritonsillar Abscess
Retropharyngeal Abscess
Laryngeal Papillomatosis
Vocal Cord Paralysis
Intrathoracic Mass Lesions Causing Respiratory Obstruction
Trauma
Post-extubation Stridor
Acquired Laryngotracheal (subglottic) Stenosis
Foreign Body Aspiration
Traumatic Injury to the Airway
Angioedema
SUMMARY
KEYPOINTS
Things not to do
5:
Pediatric Airway Management
ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS
APPROACH TO AIRWAY MANAGEMENT
Oxygen Administration
Masks
Nasal Cannulae
Oropharyngeal and Nasopharyngeal Airways
BAG MASK VENTILATION
Equipment Required
Suction Devices
Procedure of Bag and Mask Ventilation
Problems during Bag and Mask Ventilation (Table. 5.1)
Endotracheal Intubation
Indication for Intubation
DIFFICULT AIRWAY
CHECK EQUIPMENT
Larygoscope (Fig. 5.6)
Preparation for Intubation
Positioning of Patient (Fig. 5.8)4
The Intubation Technique
Precautions
Confirmation of Tracheal Tube Placement
RAPID SEQUENCE INTUBATION4
INDICATION
CONTRAINDICATIONS
ALTERNATIVE APPROACHES TO AIRWAY MANAGEMENT
TRACHEOSTOMY
LARYNGEAL MASK AIRWAY (Fig. 5.10)
Indications and Usage
Contraindications
CRICOTHYROTOMY AND RETROGRADE INTUBATION
6:
Resuscitation
INTRODUCTION
BASIC LIFE SUPPORT (BLS)
CARDIOPULMONARY RESUSCITATION (CPR)
POSITIONING THE CHILD
RAPID ASSESSMENT (BEGINNING CPR)
OPENING THE AIRWAY
Method
BREATHING
RESCUE BREATHS
BAG-AND-MASK TECHNIQUE AND RESCUE BREATHING.
PULSE CHECK
CHEST COMPRESSIONS
WHEN TO ACTIVATE THE EMERGENCY RESPONSE SYSTEM
CPR FOR INFANTS (FLOW CHART 6.1)
AVOIDING HYPERVENTILATION DURING CPR
ADVANCED AIRWAY CONSIDERATIONS
AUTOMATED EXTERNAL DEFIBRILLATORS
RELIEF OF CHOKING IN CHILDREN AND INFANTS
DISCONTINUATION OF LIFE SUPPORT
7:
Pediatric Mechanical Ventilation
INTRODUCTION
BASIC PHYSIOLOGY3
Ventilation
Oxygenation
Gas Exchange
Time Constant
Indications of Mechanical Ventilation4
Commonly used Nomenclature
Modes of Ventilation
Control Modes
IMV Modes
SIMV: Ventilator Synchronizes IMV “breath” with Patient's Effort
Support Mode
BASIC FUNDAMENTALS OF VENTILATION
Pressure vs Volume Control6
Pressure Limited Ventilation
Volume Limited Ventilation
Trigger/Sensitivity
Advanced Modes
Pressure Regulated Volume Control(PRVC)7
Volume Support
Initial Ventilator Settings
Control Every Breath (Assist control) or some SIMV
Choose the Mode
Usually Based on Blood Gases and Oxygen Saturations
Gas Exchange Related Problems
Inadequate Oxygenation
High PaCO2
Measures for high PaCO2:
Sedation and Muscle Relaxation During Ventilation
Routine Ventilator Management Protocol
Respiratory Care Protocol
Respiratory Care during Ventilation10
Humidification
Aerosol Therapy
Mucolytics
Endotracheal Suctioning
Eye Care
Weaning from Mechanical Ventilation46
How do we know if the condition is improving?
Weaning Methodology
Following weaning guidelines can be followed
Extubation
Disease Specific Ventilation
Initiation of Ventilation
Ventilation Strategies
Use of PEEP
Controlled hypercapnia9
Case Scenario 1
Ventilation for Acute Respiratory Distress Syndrome (ARDS)
Goals of Ventilation in ARDS
Case Scenario 2
Airleak Syndrome
Case Scenario 3
Neonatal Ventilation54
Conventional Neonatal Ventilation56, 57
Case Scenario 4
Alternative Modes of Neonatal Ventilation
Case Scenario 5
Inhaled Nitric Oxide (INO)
SUMMARY
8:
Respiratory Monitoring in PICU
PHYSICAL EXAMINATION
NON-INVASIVE RESPIRATORY MONITORING
History
How Pulse Oximeter Works?
Limitations of Pulse Oximetry
Capnography
What is Capnography?
Types of CO2 Monitors2
CLINICAL APPLICATIONS OF CO2 MONITORING
PaCO2-EtCO2 Gradient
Limitations
Indications for Capnography are:
Microstream Technology
Advantages
PULMONARY FUNCTION TESTS
Clinical Relevant Tests
Research Tests…(examples)
X-ray
Invasive Monitoring
Arterial Blood Gas Analysis
Basic Concepts
Systematic Analysis of Arterial Blood Gases
Basic Introduction of Arterial Blood Gases
Systematic Analysis of Arterial Blood Gases
Stepwise Approach to Diagnosing Acid-Base Disorders
Steps in Acid-base Analysis
KEY MASSAGES
SUMMARY
9:
Acute Severe Asthma
FIRST LINE THERAPY IN THE EMERGENCY DEPARTMENT
Oxygen
Inhalation Therapy with β Agonists
Continuous or Intermittent Nebulization
MDI V/S Nebulizers
Treatment for Incomplete Response
Key Points
Corticosteroids
Anticholinergics
High Dose IV Salbutamol in Bolus Form7
Intravenous Terbutaline in Acute Severe Asthma
Use of Ketamine in Acute Asthma10
BTS Guidelines for use of Aminophyllines in Patients with Acute Asthma1
Heliox11
Magnesium Sulphate12
Antileukotriene Agents
Ventilation in Asthma13
Supportive Treatment
Prognosis
SUMMARY
KEY MESSAGES
10:
Pulmonary Edema
INTRODUCTION
PATHOPHYSIOLOGY OF PULMONARY EDEMA15
Increased Pressure Edema
Mechanisms
Increased Permeability Edema (and Acute Lung Injury)10–12
DIAGNOSIS
TREATMENT6, 15
11:
Acute Renal Failure in Pediatric Intensive Care Unit
INTRODUCTION
DEFINITION
INCIDENCE
ETIOLOGY AND CLASSIFICATION
INVESTIGATIONS
TREATMENT
Modalities of RRT
Peritoneal Dialysis
Continuous Renal Replacement Therapies (CRRT)
Hemodialysis SLEDD
CONCLUSION
12:
Acute Heart Failure
INTRODUCTION
DEFINITION
FACTORS AFFECTING CARDIAC OUTPUT
FACTORS AFFECTING MYOCARDIAL PERFORMANCE
PATHOPHYSIOLOGY BASED ETIOLOGY OF AHF
PATHOPHYSIOLOGY OF SYMPTOMS IN AHF
Left Ventricle (LV) Failure
Right Ventricle (RV) Failure
CLASSIFICATION AND ETIOLOGY OF AHF
Low Output Failure
AHF IN POSTOPERATIVE CONGENITAL HEART DISEASE
Systemic Ventricular Failure
RV Failure
CLINICAL PRESENTATION
INVESTIGATIONS
Radiography
Electrocardiography
Echocardiography
Pulse Oximetry
Blood Gas and Electrolytes
Miscellaneous Tests
Cardiac Catheterization
MANAGEMENT
Optimize Preload
Increase in Myocardial Performance
Dopamine
Dobutamine
Epinephrine
Isoproterenol
Inodilators
Vasodilators
Digoxin
ACE Inhibitors
Beta-blockers
RECENT ADVANCES
Levosimendan
Neseritide
MECHANICAL AFTERLOAD REDUCTION
Intra-aortic Balloon Pump (IABP)
ECMO (Extracorporeal Membrane Oxygenation)
VAD (Ventricular Assist Device)
Adjunctive Therapy
Position
Oxygen
Positive Pressure Ventilation
PGE1
Diet
Treatment of Underlying Condition
Predictors of Mortality
CONCLUSION
13:
Intensive Care and Emergency Room Management of Arrhythmia in Children
INTRODUCTION
NORMAL RHYTHM DISTURBANCES
Sinus Arrhythmia
Sinus Bradycardia
Extrasystoles
PATHOLOGICAL RHYTHM DISTURBANCES
TACHYARRHYTHMIAS
Hyperdynamic Cardiac Activity (Sinus Tachycardia)
True Arrhythmias (Supraventricular and Ventricular Tachycardias)
Supraventricular Tachycardia (Fig. 13.1)7,8
Atrial Fibrillation and Atrial Flutter (Figs 13.2 and 13.3)
Ventricular Tachycardia (VT) (Fig. 13.4)9,10
MANAGEMENT OF TACHYARRHYTHMIAS
Tachycardia with Hemodynamic Instability
Narrow-Complex (<0.08 Second) Tachycardia
Vegal Stimulation
Chemical Cardioversion
Electrical (Synchronized) Cardioversion
Other Antiarrhythmic Drugs
Wide-Complex (>0.08 Second) Tachycardia
Electrical (Synchronized) Cardioversion
Atrial Fibrillation or Flutter
Tachycardia with Hemodynamic Stability
BRADYARRHYTHMIAS
Sinus Bradycardia
Impulse Conduction Disturbances
a. First Degree AV Block (Fig. 13.5)
b. Second Degree AV Block (Fig. 13.6)
c. Third Degree AV Block
MANAGEMENT OF BRADYARRHYTHMIAS
COLLAPSE RHYTHM (PULSELESS ARREST)11,12
MANAGEMENT OF COLLAPSE RHYTHM (SEE FLOW CHARTS 13.1 TO 13.3)
Shockable Rhythm (VF/Pulseless VT)16
Torsades de Pointes (Fig. 13.7)7
Nonshockable Rhythm (Asystole/PEA)
ANTIARRHYTHMIC DRUGS FOR ACUTE CARE
Adenosine
Amiodarone
Atropine
Calcium
Epinephrine
Lidocaine
Magnesium
Procainamide
DEFIBRILLATORS
Paddle Size
Paddle Position
Interface
Energy Dose
Automated External Defibrillators (AEDs)
Defibrillation Sequence
TRANSCUTANEOUS PACING
CONCLUSION
14:
Vasodilators and Antihypertensives
ANTIHYPERTENSIVE DRUGS: A GENERAL APPROACH (FLOW CHART 14.1)
PHARMACOLOGY OF ANTIHYPERTENSIVE DRUGS
Diuretics
Angiotensin-Converting Enzyme Inhibitors
Angiotensin Receptor Blockers (ARBs)
Adrenergic Inhibitors
β-Adrenergic Receptor Blockers
α-Blockers
Combined α- and β-Blockers
Peripheral Adrenergic Inhibitors
Central α-Agonists
Calcium Channel Blockers
Direct Vasodilators
Vasopeptidase Inhibitors (VPIs)
Vasodilators in Pediatric Practice
15:
Hypertensive Crisis
INTRODUCTION
PATHOPHYSIOLOGY
ETIOLOGY
EVALUATION
TREATMENT
HYPERTENSIVE EMERGENCY
HYPERTENSIVE URGENCY
SPECIAL SITUATIONS
CONCLUSION
16:
Physiology of Fluids and Electrolytes
INTRODUCTION
Certain Useful Definitions1
WATER METABOLISM
REGULATION OF WATER
Differences between Children and Adults
ELECTROLYTES METABOLISM
FUNCTIONS OF ELECTROLYTES
Sodium (Normal Range 135–145mEq/L)
Potassium (Normal Range 3.5–5.0 mEq/L)
Calcium (Normal Range 8.8–10.4 mg/dl)
Magnesium (Normal Range 1.7–2.3 mg/dl)
Phosphates (Normal Range 2.2–4.4 mg/dl)
Chloride (Normal Range 98–108mEq/L)
REGULATION OF ELECTROLYTES
Maintenance Requirement of Fluids and Electrolytes
Parenteral Fluids (Table. 16.2)
SUMMARY
KEY MESSAGE
17:
Inotropes and Vasopressors
DEFINITIONS
BASIS FOR USE OF INOTROPIC SUPPORT
THE CHOICE OF INOTROPES AND VASOPRESSORS
DOPAMINE
Clinical Pharmacology
Therapeutic Use
Pharmacokinetics
Preparation and Administration
Adverse Effects and Contraindications
Drug Interactions
DOBUTAMINE
Clinical Pharmacology
Therapeutic Uses
Septic Shock
Pharmacokinetics
Preparation and Administration
Adverse Effects
Drug Interactions
EPINEPHRINE
Clinical Pharmacology
Cardiac Effects
Blood Pressure
Vascular Effects
Effects on Smooth Muscles
Respiratory Effects
Metabolic Effects
Therapeutic Use
Pharmacokinetics
Preparation and Administration
Adverse Effects
Central Nervous System
Cardiovascular System
Metabolic Effects
Drug Interactions
MILRINONE
Mechanism of Action
Clinical Pharmacology
Therapeutic Use
Use after Cardiac Surgery
Use in Septic Shock
Use in CHF
Pharmacokinetics
Preparation and Administration
Dose
Adverse Effects
Drug Interactions
NOREPINEPHRINE
Clinical Pharmacology
Therapeutic Use
Pharmacokinetics
Preparation and Administration
Adverse Effects
Drug Interactions
VASOPRESSIN
Clinical Pharmacology
Clinical Use
Pharmacokinetics
Dosing, Preparation and Administration
Drug Interactions
Adverse Effects
DIGOXIN
Mechanism (s) of Action
Practical Aspects
Adverse Effects
SUMMARY
Guidelines
18:
Multiorgan Dysfunction Syndrome
EPIDEMIOLOGY
DEFINITION
ETIOLOGY
PATHOPHYSIOLOGY
ENDOTHELIAL ACTIVATION/INJURY
APOPTOSIS
Two Hit Theory
Altered Coagulation (Flow chart 18.2)
Monitoring and Laboratory Tests
Treatment Guidelines of MODS
PROGNOSIS
19:
Noninvasive and Invasive Hemodynamic Monitoring in the PICU
HEMODYNAMIC MONITORING
CLINICAL HEMODYNAMIC PARAMETERS
HEMODYNAMIC MONITORS
Electrocardiography Monitoring (ECG)
Blood Pressure Monitoring
Noninvasive BP Monitoring (NIBP)
Invasive BP Monitoring (IBP)
DETERMINANTS OF CARDIAC OUTPUT
Preload Assessment
Pulmonary Artery Catheter
Contractility Assessment
Echocardiography
METABOLIC INDICATORS OF TISSUE PERFUSION AND O2 DELIVERY
20:
Septic Shock
INTRODUCTION
Development of Consensus for Application of Pediatric Sepsis Guidelines in India
Definitions
SIRS (Systemic Inflammatory Response Syndrome)
Infection
Sepsis
Severe Sepsis
Septic Shock
Rapid Cardiopulmonary Assessment and Clinical Examination of a Patient in Shock
Emergency Management (Golden Hour of Sepsis Management)
Priorities of Treatment
GUIDELINES
Initial Resuscitation
Preload and Volume Replacement
Choice of Fluid for Volume Replacement
Hypocalcemia and Hypoglycemia
Early Antibiotics
Inotropic and Vasoactive Agents
15 to 60 Minutes
Recognition of Fluid Refractory Shock is Important
Dopamine
Dobutamine
Adrenaline (Epinephrine)
Noradrenaline (Norepinephrine)
60 Minutes
Recognize Catecholamine Resistant Shock
Further Management in PICU
60 Minutes
60 Minutes
Vasopressin
60 Minutes
DOSING, PREPARATION AND ADMINISTRATION
THERAPEUTIC END POINTS
CONCLUSION
21:
Choice of Empiric Antibiotics in Severe Sepsis and Septic Shock
22:
Blood Components in Intensive Care Practice
INTRODUCTION
Why not whole blood and why components?
Which components?
Storage and Shelf Life
ABO and Rh Compatibility
Whole Blood
Indications
Packed Red Blood Cells (PRBC)
Indications
Platelet Transfusions
Types of Platelets
RDP
SDP
Criteria to Transfuse
Indications
Granulocytes
Leukodepleted Blood Components
Why Leukodepletion?
Fresh Frozen Plasma (FFP)
Cryoprecipitate
23:
Evaluation of a Comatose Child
INTRODUCTION
PATHOPHYSIOLOGY OF COMA
Clinical Evaluation of a Comatose Child
HISTORY
Examination
GCS (Table. 23.1)
Anatomical and Etiological Localization (Tables 23.2 and 23.3)
INVESTIGATIONS
MANAGEMENT
Outcome and Predictors
Investigations Predicting Outcome
SUMMARY
KEY MESSAGES
24:
Pathophysiology of Intracranial Pressure
25:
Head Injury in Children
OBJECTIVES
Assessment
What is the level of coma?
Minor Head Injury (Table. 25.2)
Assessment and management of moderate and severe head trauma:
Blood Pressure in Head Injury
Cervical Spine Immobilization
Other Associated Injuries
Surgically Amenable Lesions (Table. 25.5)
Medical Management
Specific Measures
OSMOTIC DIURETICS
The Columbia Stepwise Protocol for ICP Management21 (Modified)
Post-traumatic Seizures
SUMMARY OF RECOMMENDED PRACTICES
Decrease Intracranial Pressure
Supportive Measures
Decrease Cerebral Metabolic Rate
26:
The Neuromuscular Diseases in Critically Ill Children
INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL FEATURES
FEATURES OF COMMON DISEASES THAT PRESENT WITH NEUROMUSCULAR WEAKNESS TO THE PICU
Guillain Barré Syndrome (GBS)
Spinal Muscular Dystrophy (SMA)
Myasthenia Gravis
Acute Poliomyelitis
Diphtheria
Organophosphates
Botulism
Axonal Neuropathy
Acute Intermittent Porphyria (AIP)
Tick Paralysis
Diseases of Muscle
Muscular Dystrophy
Periodic Paralysis
Dermatomyositis and Polylmyositis
Critical Illness Neuromuscular Disease
MANAGEMENT OF RESPIRATORY FAILURE IN CHILDREN WITH NEUROMUSCULAR DISORDERS
Respiratory Management
Other Considerations
SUMMARY
27:
Trauma in Children
MANAGEMENT OF A SEVERELY INJURED CHILD
Size and Shape
Skeleton
AIRWAY MANAGEMENT
Anatomic Peculiarities in Child
Management
VENOUS ACCESS
RESUSCITATION PHASE
SECONDARY ASSESSMENT
CHEST TRAUMA
Salient Points in Chest Trauma
SUMMARY
ABDOMINAL INJURIES
Salient Points in Abdominal Injury Management
Pelvic Fractures and Extremity Injuries
Salient Points in Extremity Injuries
Treatment in Compartment Syndrome
SUMMARY
28:
Adrenal Insufficiency in Critical Illness
INTRODUCTION
NORMAL PHYSIOLOGY
Stressed HPA Axis and Cortisol Response during Critical Illness (Fig. 28.2)
Implications of the above Disturbances in the HPA Axis
Mechanism of Adrenal Insufficiency in Critical Illness
Diagnosing Adrenal Insufficiency in Critical Illness
Clinical Diagnosis
Laboratory Diagnosis
Confounding and Conflicting Factors
Treatment
Dose11
Duration12
CONCLUSION
29:
Diabetic Emergencies
INTRODUCTION
DEFINITION OF DKA
Biochemical Criteria
FREQUENCY OF DKA
At Disease Onset
In Children with Established TIDM
MORBIDITY AND MORTALITY OF DKA IN CHILDREN
MANAGEMENT OF DKA (FLOW CHART 29.1)
General Issues
Care in PICU
Monitoring
Headache
Confirm the Diagnosis
Immediate Investigation
General Resuscitation A, B, C
Fluids and Salt
Proceed with urgency but with caution
Insulin
Potassium
Phosphate
Acidosis
CEREBRAL EDEMA
Management of Cerebral Edema
SUPPORTIVE THERAPY
OTHER COMPLICATIONS
30:
Endocrine Emergencies in PIcu
INTRODUCTION
When to Suspect Pediatric Endocrine Problem in ICU Setting
POINTERS TO THE DIAGNOSIS OF ENDOCRINE DISEASE
Laboratory Indicators
Clinical indicators
SELECT ENDOCRINE EMERGENCIES
Hypoglycemia2
Introduction
Etiology
Clinical Features
Investigations
Blood Tests
Urine Tests
Approach to Diagnosis of Hypoglycemia
Treatment
Hypocalcemia
Hypocalcemia in the Neonatal Period
Hypocalcemia Beyond the Neonatal Period
Investigations
Parathyroid Hormone
Management
Addisonian Crisis
Clinical Features
Investigations
Management
Thyroid Storm3
Pheochromocytoma4
Perioperative Management of Diabetes Insipidus5–8
Syndrome of Inappropriate ADH
Cerebral Salt Wasting9
31:
Abdominal Surgical Catastrophy
EVALUATION OF CHILD
Initial management
Appendicitis (Fig. 31.1)
Intussusception (Fig. 31.2)
Mesenteric Lymphadenitis
Acute Pancreatitis
Volvulus (Fig. 31.3)
Torsion of Ovarian Cyst or Ovary (Fig. 31.4)
Constipation and Hirschsprung's Disease
Urinary Tract Infection
32:
Severe Acute Pancreatitis
INTRODUCTION
ETIOLOGY (TABLE 32.2)
PATHOPHYSIOLOGY9
CLINICAL PICTURE7
DIAGNOSTIC TESTS
Lab Investigations
Radiological Findings
MANAGEMENT
Fluid Resuscitation and Rehydration
COMPLICATIONS
Local Complications
Systemic Complications
PROGNOSIS
SUMMARY
KEY MESSAGES
33:
Burn Inhalation and Electrical Injury
INTRODUCTION
INHALATION INJURY
Types of Inhalation Injury
Carbon Monoxide (CO) Poisoning
Upper Airway Obstruction
Parenchymal Dysfunction
Management of ARDS
ELECTRICAL INJURY
Fluid Resuscitation in Burns
34:
Pain Management in the PICU
SOME DEFINITIONS
Issues in Pain Management in the PICU and during MV
Sedation Goals
Assessment of the Adequacy (Usually Inadequacy) of Sedation and Analgesia
Sedatives
How to Give: Continuous vs Intermittent
Some Newer Aspects
CONCLUSION
35:
Envenomation
SNAKE BITE
PATHOPHYSIOLOGY
Clinical Features
Snake Bites with no Clinical Effects
Local Effects of Snake Bite
Systemic Effects
SPECIAL SITUATIONS
Envenomation without Bite
Bite by Killed Snake
Snake Bite to a Lactating Mother
Laboratory Diagnosis
Management
First Aid
Rapid Assessment and Resuscitation
Specific Therapy
Indications of ASV
Dose of ASV
Administration
Timing of Administration
Supportive Therapy
KEY MESSAGES
EPIDEMIOLOGY
PATHOPHYSIOLOGY
CLINICAL FEATURES
Temporal Relationship of Various Clinical Features
Local Pain
Systemic Manifestations
INVESTIGATIONS
MANAGEMENT
Unhelpful or Harmful Therapies
KEY MESSAGES
36:
Management of Poisoning
CLINICAL PRESENTATION
TOXIDROMES
ADMISSION IN PICU
PRINCIPLES OF MANAGEMENT
TREATMENT
Initial Stabilization
HYDROCARBONS
Pulmonary Effects
Gastrointestinal Effects
CNS Effects
Cardiac Effects
ORGANOPHOSPHATES AND CARBAMATES
Exposure
Clinical Effects
Acute Effects
Treatment of Organophosphate Intoxication
Clinical Presentation
Care
Surgical Care
IRON
EVENTS IN IRON POISONING
Dose of Ingested Iron
Early Clinical Assessment and Simple Laboratory Screening
Decontamination
Iron Chelation Therapy
Life Support Measures
Clinical and Laboratory Manifestations
Lab Studies
CARBON MONOXIDE POISONING
METHANOL AND ETHYLENE GLYCOL
Methanol and Ethylene Glycol Treatment
CALCIUM CHANNEL BLOCKERS
Tricyclic Antidepressants
SUMMARY
37:
Nutritional Support in the Critically Ill Child
GENERAL PRINCIPLES, PHILOSOPHIES AND CALORIE DELIVERY
MACRONUTRIENTS
VITAMINS AND MINERALS
Optimal Route of Nutritional Delivery
Who can be fed enterally in the NICU and PICU ?
Concept of “Immunonutrition”
Special Nutritional Requirements in Specific Situations
rhuman Growth Hormone in the ICU
CONCLUSION
38:
Transport of Critically Ill Child
HISTORY OF TRANSPORT MEDICINE
REASONS FOR TRANSPORT
MODES OF TRANSPORT
PREPARATION FOR TRANSPORT
PERSONNEL AND TRAINING
STABILIZATION DURING TRANSPORT
HANDING OVER THE PATIENT
COMMUNICATION
RISK MANAGEMENT
SYSTEMS ERROR
AIR TRANSPORT
Need for Organized Transport Process
SUMMARY
KEY LEARNING POINTS
39:
Critically Sick Child with Human Immunodeficiency Virus Infection
INTRODUCTION AND EPIDEMIOLOGY
TRANSMISSION
Perinatal Transmission
Sexual Transmission
Blood Transfusion
NATURAL HISTORY OF PEDIATRIC HIV
CLINICAL FEATURES
THE SPECTRUM OF DISEASES IN THE PICU
Respiratory Diseases Complicating HIV Infection
Pneumocystis Jiroveci Pneumonia (PCP)
Bacterial Pneumonia
Mycobacterial Infection
Lymphoid Interstitial Pneumonitis
Fungal Infections
Immune Reconstitution Syndrome (IRS)
Cardiac Dysfunction
Septic Shock
Renal Failure
Neurological Complications
HIV TESTING AND DISCLOSURE IN THE ICU
THERAPY
40:
Doses of Drugs Used in Emergency Situations
EPINEPHRINE
Newborn
Child
Adult
Atropine
Dextrose
Defibrillate
Cardioversion
ENDOTRACHEAL (ET) INTUBATION
GLASGOW COMA SCALE
ANALGESIA AND SEDATION
REVERSAL AGENTS
ANTIBIOTICS
ASTHMA, ANAPHYLAXIS, STRIDOR
CARDIAC MEDICATION AND DRIPS
ENDOCRINE
HYPERKALEMIA
MALIGNANT HYPERTENSION
SEIZURES
INCREASED INTRACRANIAL PRESSURE
RAPID SEQUENCE INTUBATION
HEAD INJURY
MISCELLANEOUS DRUGS
INDEX
TOC
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