EMERGENCY

PEDIATRIC

Dr. Idham Jaya Ganda, SpA(K)

PICU Subdiv. Child Health Dept
Medical Faculty, University of Hasanuddin
Dr. Wahidin Sudirohusodo Hospital Makassar
DENGUE SHOCK
SYNDROME
ETIOLOGY
Dengue Virus

PATHOGENESIS
Unclear
The Secondary Heterologous
Infection Hypothesis
 CLINICAL
MANIFESTASION
Fever: acute, high, continuously,
2-7 days
Bleeding manifestation

Liver enlargement

Shock
 LABORATORIUM
Thrombocytopenia ( 100.000/mm3 or
less)
Hem concentration ( Hct 20% or more)
 CLASSIFICATION
WHO CLASSIFICATION OF DHF (1975)
Grade I
Fever, Tourniquet test (+)
Grade II
Grade I + spontaneous bleeding
Grade III
Grade II + Circulatory failure
Grade IV
Profound shock
Grade III & IV DSS
TREATMENT DBD derajat III & IV

1. Oksigenasi (berikan O2 2-4 l/menit)

2. Penggantian volume plasma (cairan kristaloid isotonis)
Ringer laktat/NaCl 0,9 % / Asering
20 ml/kgBB secepatnya (bolus dalam 30 menit)
Evaluasi 30 menit, apakah syok teratasi ?
Pantau tanda vital tiap 10 menit
Catat balans cairan selama pemberian intravena
Syok teratasi
Kesadaran menurun Syok tidak teratasi
Kesadaran membaik
Nadi teraba kuat Nadi lembut / tidak teraba
Tekanan nadi > 20 mmHg Tekanan nadi < 20 mmHg
Tidak sesak nafas sianosis Distres pernafasan / sianosis
Ekstremitas hangat Kulit dingin dan lembab
Diuresis cukup 1 ml/kgBB/jam Ekstremitas dingin
Periksa kadar gula darah
Cairan dan tetesan disesuaikan Lanjutkan cairan
10 ml/kgBB/jam 20 ml/kgBB/jam
Tambahkan koloid/plasma
Evaluasi ketat
Tanda vital Dekstran/FPP
Tanda perdarahan 10-20 (max 30) ml/kgBB/jam
Diuresis Koreksi asidosis
Hb, Ht, trombosit Evaluasi 1 jam
Stabil dalam 24 jam/Ht < 40
Tetesan 5 ml/kgBB/jam Syok belum teratasi
Syok teratasi
Tetesan 3 ml/kgBB/jam Ht turun Ht tetap tinggi/ naik
Tranfusi darah
Segar 10 ml/kgBB Koloid 20 ml/kgBB
Infus stop tidak melebihi 48 jam diulang sesuai kebutuhan
setelah syok teratasi
MONITORING
Vital signs
Hct
SEPTIC SHOCK
DEFINITION
Septic syndrome
Hypotension
Responsive to
treatment
 ETIOLOGY
Neonates: E. coli, Staphylococcus
aureus, Streptococcus group B.
Child: Streptococcus pneumonia, H.
influenzae group B, Salmonella, S.
aureus, Streptococcus group A.
Patofisiologi terjadinya syok septik
Infeksi Bakteri

Endorfin Produk Bakteri Aktivasi Komplemen

mis. endotoksin

Makrofag
Aktivasi PMN.
Faktor Jaringan Sitokin Pelepasan PAF, produk
Arakidonat dan
Substansi toksik lain
Aktivasi Aktivasi
koagulasi kalikreinkinin
fibrinolisis
Vasodilatasi,
Kebocoran kapiler,
Kerusakan endotel Syok Septik
kerusakan endotel
kapiler

Kegagalan Organ Berganda

 CLINICAL
MANIFESTATION
Chilling
Tachycardia
Hyperventilation/tachypnea
Hypotension
Apatetic
Agitation
Bleeding manifestation (petechiae, purpura,
etc)
Neonates with immune disorder: unspecific
(lethargy, vomiting, abdominal pain,
hypotermia/hypertermia)
 DIAGNOSIS
Clinical manifestation
Risk factor
Focus of infection
Laboratory examination (blood
smear/culture)
 TREATMENT
Infection control : ampicillin & aminoglycoside
Blood culture & sensitivity
test
Recovering tissue perfusion : fluid resuscitation,
acid base correction, cardiovascular medicines.
Respiratory function support : oxygen/ ventilator
Renal support : diuretic medicines (furosemide)
Corticosteroid
 DIARRHEA
WITH
DEHIDRATION
 DEFINITION
Watery stool
Frequency 3X/ 24
hours.
 DEHYDRATION TYPES
Isotonic
Na concentration 130-150meq/L or
280 mosm/L
Hypertonic:
Na concentration > 150meq/L or
413 mosm/L
Hypotonic:
Na concentration <130meq/L or
200mosm/L
DEHYDRATION GRADE

Cumulative losses (pwl, cwl, nwl)

Mild : 5%
Moderate : 5-10%
Severe : >10%
Clinical manifestation ( scoring
system)
 Angka Penilaian
Pemeriksaan 1 2 3

Gambaran Klinik
Keadaan umum Baik Lesu/haus Gelisah/renjatan
Mata Normal Cekung Sangat cekung
Mulut Normal Kering Sangat kering
Pernapasan 20-30 per menit 30-40 per menit 40-60 per menit
Turgor Baik Kurang Jelek
Nadi Kuat / kurang 120-140 Lebih 140
120 per menit per menit per menit

Derajat dehidrasi skor 6 skor 7-12 skor 13 / lebih

diare tanpa diare dehidrasi diare dehidrasi
dehidrasi ringan/sedang berat
 TREATMENT

Fluid therapy (Ringer Lactat or

Ringer Asetat)
Antibiotic therapy
Acidosis therapy
 Cara Pemberian
Umur Permulaan Lanjutan

Diare 4 jam pertama 20 jam berikut

Infantil 60 ml/kg 190 ml/kg
- PWL 125 ml
- NWL 100 ml
- CWL 25 ml

250 ml
Kolera 1 jam pertama 7 jam berikut
PWL 100 ml/kg 30 ml/kg 70 ml/kg

PWL 100 ml/kg 1 jam pertama 5 jam berikut

Bayi kurang 30 ml/kg 70 ml/kg
12 bulan jam pertama 2 jam berikut
Anak sama atau lebih 12 30 ml/kg 70 ml/kg
bulan
ASTHMATIC
STATE
 DEFINITIO
N
A severe asthma exacerbation
which is not responsive to drugs
that are usually given for asthma
exacerbation.
ETIOLOGY
Multifactor
Allergen
Restlessness
Emotion
Infection
Inherited
 PATHOGENESIS
Hyper responsiveness &
inflammation process of bronchus
Hyper secretion
Edema
Bronchoconstriction
sification of Severity of Acute Asthma Exacerba
Mild Moderate Severe Respiratory
Parameters Arrest
Imminent
Breathlessness While While talking While at rest
walking

Talks Sentences Phrases Words

Position Can lie Prefers sitting Sits upright

down

Alertness May be Usually Always Confused/

agitated agitated agitated drowsy
Cyanotic - - + +++
Wheeze Moderate, Loud, Extremely loud, Absence of
often only throughout can be heard wheeze
end expiratory without
expiratory inspiratory stethoscope
Breathlessness Minimal Moderate Severe

Use of accessory Usually not Commonly Always

muscles

Retractions Shallow, Moderate, + Deep, + -

intercostals suprasternal flare of alae
nasi

Respiratory rate Increased Increased Increased Decreased

Guide to rates of breathing in awake children:

Age: Normal rate:
< 2 month < 60 / minute
2-12 months < 50 / minute
1-5 years < 40 / minute
6-8 years < 30 / minute
Pulse Normal Tachycardia Tachycardia Bradycardia

Guide to normal pulse rates in children:

Age: Normal rate:
2-12 months < 160 / minute
1-2 years < 120 / minute
3-8 years < 110 / minute
Pulsus None (+) (+) None
Paradoksus < 10 mmHg 10-20 mmHg > 20 mmHg

PEFR or FEV1 (% pedicted ( % best < 40%

-before b.dilator value) value) < 60 %
-after b.dilator > 60% 40-60% respons < 2
> 80% 60-80% jam
SaO2 > 95% 91-95% 90%

PaO2 Normal > 60 mmHg < 60 mmHg

PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg

 CLINICAL
MANIFESTATION
Cough
Wheezing
Tachypnea
Dyspnea
Prolonged
expiration
Retraction
Cyanosis
Tachycardia
 Acute asthma
algorithm
Clinic/ER
Asses attack severity

1st management
nebulitation -agonis 3x, 20 min interval
3rd nebulitation + anticholinergic

Mild attack Severe attack

(nebulization 1x, Moderate attack (nebulization 3x,
complete response) (nebulization 2-3x,
partial response)
persist 1-2 hr: give O2
discharge no response)
asses: Moderate O2 from the start
symptom reappear:
ODC IV line
Moderate attack IV line asses: Severe -

hospitalized
CXR
 One Day Care (ODC) Admission room
Discharge Oxygen therapy Oxygen therapy
give -agonist Oral steroid Treat dehydration and
(inhaled/oral) Nebulized / 2 hour acidosis
routine drugs Observe 8-12 hours, Steroid IV / 6-8 hours
viral infection: if stable discharge Nebulized / 1-2 hours
oral steroid Poor response in 12h, Initial aminophylline IV,
Outpatient clinic in admission then maintenance
24-48 hours Nebulized 4-6x
good response per 4-6 h
If stable in 24 hours
discharge
Poor response ICU

Notes:
In severe attack, directly use -agonist + anticholinergic
If nebulizers not available, use adrenalin SC 0.01 ml/kg/times with maximal dose 0.3 ml/times
Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
Figure. Jet nebulizer

34
Figure. Ultrasonic
nebulizer

35
 Drug dosage for
nebulizer
Nebulizer
Drugs Jet Ultrasound

NaCl 0.9% (ml) 5 10

2-agonist
Alupent sol. 2% (gtt) 35 3-5
Berotec 0.1% (gtt) 5 5
Ventolin nebule (mL) 1 1
Bricasma respule (mL) 1 1
Time (minutes) 10 - 15 3-5

38
TREATMENT IN PICU
Medicines at
ward is
continued
Mechanical
ventilator
ACUTE RESPIRATORY
FAILURE
 DEFINITION

Respiratory system is unable to

maintain its function hypoxia &
hypercapnea.
 ETIOLOGY

Increasing of co2
Ventilated disorder without lungs
dysfunction
Ventilated disorder with lungs dysfunction
Ventilated disorder of death space
 CLINICAL
MANIFESTATION
Symptoms of lungs disorder :
wheezing, grunting, flaring of alae nasi,
retraction, tachypnea, bradypnea, apnea,
cyanosis.
Signs of heart disorder :
bradycardia/tachycardia,
hypotention/hypertention, cardiac arrest.
Symptoms of CNS disorder :
apatic, headache, convulsion, coma.
 TREATMENT
Airway (position, suction, ET)
Breathing (oxygen)
Humidification
Bronchial washing
Physiotherapy
Rehydration
Causal therapy
Specific therapy (mechanical
ventilator)
Acidosis therapy
EPILEPTIC
STATUS
 DEFINITION

Prolonged convulsion attack

(30 minutes or more)
Recurrent convulsion in a short time
as if no recovery
 ETIOLOGY
Febrile convulsion
Idiopathic
Symptomatic
PATHOFISIOLOGY
Compensation
Decompensation
 CLINICAL MANIFESTATION
Age Type of epileptic state Features
Neo- Neonatal epileptic state -subtle, tonic,
nates clonic,
myoclonic, apneic,
Neonatal syndromes fragmentary
epileptic
early infantile epileptic - tonic
encephalopathy - erratic, myoclonic
neonatal myoclonic - clonic
encephalopathy
benign familial neonatal
seizures
Infant & Febrile epileptic state
Child
Infantile spasms (west
syndromes)
State in childhood
myoclonic syndromes
State in benign partial
epilepsy
Child & Tonic-clonic epileptic state
Adult Absence epileptic state
Continue partially epileptic
Myoclonic epileptic state in
coma
Myoclonic epileptic state
syndromes
Complex partial epileptic
state
Epileptic state in mental
retardation
- convulsive or
hemiconvulsive (tonic-
clonic)
- salaam attacks
- myoclonic + absence
- complex partial seizures
- tonic-clonic, subtle
- absence
- simple partial
- myoclonic
- myoclonic
- complex partial
- atypical absence, tonic,
minor motor
 TREATMENT
Initial treatment (stabilization)
Position
ABC
Vital signs monitoring
Blood glucose & electrolyte
Anticonvulsan
Benzodiazepine ( diazepam, midazolam)
Phenytoin
Phenobarbital
Cardiorespiratory & EEG monitoring
Refracted treatment
Barbiturate (Phenobarbital, thiopental)
Propofol & midazolam
INTUSSUSCEPTIO
N
 DEFINITION

A condition where a section of intestine

telescope into its self (proximal
segment telescope into distal segment
of intestine).
PATHOFISIOLOGY
Intussusceptions
 CLINICAL
MANIFESTATION
Colic
Vomiting
Bloody stool , currant jelly stool & terry
stool
Sausage-shaped mass
Pseudoportio
DIAGNOSIS
Clinical
manifestation
Radiology
assessment:
Doughnut sign

Target sign

Cupping sign
TREATMENT
Radiology reduction
Surgery
DIAPHRAGMATIC
HERNIA
 DEFINITION

An abnormal opening in the

diaphragm that allow part of
abdominal organs to migrate into the
chest cavity.
 ETIOLOGY
Improper fusion of the canal of
pleuroperitoneal
Medicines
Abnormal development of thoracic
mysencime
 CLINICAL
MANIFESTATION
Dyspnea
Tachypnea
Cyanosis
Asymmetry of the chest wall
Tachycardia
Scapoid abdomen
Breath sound loosing at
defect side
DIAGNOSIS

Clinical manifestation
Radiology examination
 TREATMENT

Oxygen (ET), position, stop oral

intake
Surgery