PREM Triangle: Decision Making Tool for Resuscitation

INTERVENTION INTERVENTION

dLOC: Correct hypoxia, shock, DISABILITY AIRWAY Unstable: Head tilt-chin lift, suction,
cardiac dysfunction, NCSE LOC: Alert Stable, obstructed, NG decompression
Metabolic: Dextrose, insulin, Decreased-LOC unstable, obstructed Stable or obstructed: Position of comfort
electrolyte correction Convulsive SE BREATHING (avoid noxious stimuli, supine position or
CSE, NCSE: Anti-convulsant Non-convulsive SE Normal separating from mum)
ICP: Anti-oedema measures ↑Intra-cranial Effortless tachypnea Croup: O2 + Epinephrine neb + steroid
pressure Respiratory distress Asthma: O2 + Bronchodilators
Impending respiratory failure Respiratory distress, failure: O2 + CPAP
Relative bradypnea Apnea: O2 + BVM Ventilation, ETT
Apnea
REASSESS

REASSESS

CIRCULATION
HR: Normal (N), Bradycardia, relative bradycardia, tachycardia
Perfusion: N, shock, cardiogenic shock, vasodilatory ±
SBP: N, ↑,↓; DBP: N,↑↓; PP: N, wide; MAP: N,↑,↓

INTERVENTION Bradycardia + shock + ↓SBP: Chest compression, epinephrine bolus REASSESS

Shock + ↓SBP: NS or RL bolus (pull-push), epinephrine infusion
Shock + N SBP: Bolus by gravity
Post bolus wide PP shock + ↓MAP: Dopamine
Post bolus & Dopamine, wide PP shock +↓MAP: Nor-Epinephrine

AIRWAY Vocalize
BREATHING RR: N for age
DISABILITY
Grunt, stridor: No
LOC: Alert (baseline)
Retractions: No
T&P: Normal
Respiration: Thoracic
Eyes: EOM Normal
Air-entry: bilateral
Pupils: PERL
Added sounds: Nil
SpO2: 100%

CIRCULATION
HR: N for age; HS: no muffle, no gallop; P&C: warm, pink; Pulses: +++/++; CRT <2 secs
Liver span: N for age, soft; SBP: N for age; DBP: >50% of SBP; Pulse Pressure: 30–40 mmHg
MAP: N for age; Urine output >1 mL/kg/hour

PREM Process: After every intervention (bronchodilator, fluid bolus, intubation, anti-convulsant etc.), perform the 1-minute modified rapid
cardio-pulmonary-cerebral assessment, document, interpret vital signs and derive physiological status to decide the next step. Even if 1 sign
of deterioration is noted, interrupt current intervention and reconsider. If all variables show improvement, continue till therapeutic goals
are achieved (green triangle).

National Health Mission-Strengthening of Pediatric Emergency Care System in Tamil Nadu-Establishment of Pediatric Resuscitation and
emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 PREM Triangle: Recognition of Relative Bradypnea, Relative Bradycardia & Relative Hypotension

Normal
DISABILITY AIRWAY Vocalize
LOC: Alert BREATHING RR: N
T&P: Normal Grunt, stridor: No
Eyes: EOM Retractions: No
Pupils: PERL Respiration: Thoracic
Bilateral air-entry: Yes
Added sounds: No
SpO2: >94%

CIRCULATION
HR: N; HS: No muffling, no gallop; P&C: Warm, pink
Pulses: +++/++; CRT: <2 seconds; Liver span: N
SBP: N; DBP: >50% of SBP; PP: 30–40 mmHg; MAP: N

NORMAL VITAL SIGNS NORMAL LIVER SPAN

Age Weight Respiratory rate Heart rate SBP MAP Age Liver span
(kg) (BPM) (BPM) (mm Hg) (mm Hg) (cm)
Neonate 3.5 30–60 90–180 50–70 45 2 months 5
6 months 7 24–40 85–170 65–106 1 year 6
1 year 10 20–40 80–140 72–110 2 years 6.5
3 years 14 20–30 80–130 78–114 50 3 year 7
6 years 20 18–25 70–120 80–115 4 years 7.5
8 years 25 18–25 70–110 84–122 60 5 years 8
10 years 30 16–20 65–110 90–130 12 year 9
12 years 30–40 14–20 60–110 94–136 65

Progressive Hypoxia/Shock

Compensatory mechanisms: ↑Respiratory rate (RR), ↑Heart rate (HR) and ↑Systolic blood pressure (SBP).

Compensation fails: RR↓, HR↓ and SBP↓ fall to “normal range for age.”

VITAL SIGNS (NORMAL RANGE) ARE FAILING (RELATIVE BRADYPNEA, BRADYCARDIA, HYPOTENSION)
IF OTHER PARTS OF TRIANGLE ARE ABNORMAL

DISABILITY AIRWAY Unstable ±, obstructed ±

LOC: Pain or unresponsive BREATHING RR: “Normal” for age
T&P: Posturing ±, floppy ±, GTCs ± Grunt ±; stridor ±
Eyes: Conjugate deviation ± Retractions ±
lid twitch ±, nystagmus ± Respiration: Abdominal ±
Pupils: sluggish Air-entry: Bilateral
Added sounds ±
SpO2: ≤94% ±
CIRCULATION
HR: “Normal” for age; HS: muffling ±, gallop ±; P&C: cool, dusky
Pulses: ++/0, +++/0; CRT: >2 seconds; Hepatomegaly
SBP: “Normal” for age; MAP: Low

™ Being reassured by “normal” vital signs on the monitor can be misleading and dangerous.
™ PREM Process: Repeated cardiopulmonary cerebral assessment, documentation, interpretation of vital signs, and derivation of
physiological status (PREM triangle) are crucial to determine whether vital signs are “normal” or not. It also provides information on the
trend & change in hemodynamic status.
™ Although, SBP may be normal or high, if diastolic BP is <50% of SBP and MAP (for age) has fallen, consider HYPOTENSION.

National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
Emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 Triage & Resuscitate Using PREM Triangles

NORMAL PHYSIOLOGICAL STATUS PREM Terminology & Definitions:

™ Breathing normal = Normal RR + normal work of breathing
DISABILITY AIRWAY Stable (vocalizes)
™ Respiratory distress = Increased RR + retractions
LOC: Alert BREATHING RR: N
Grunt, stridor: No ™ Impending respiratory failure = Grunt + respiratory distress
T&P: N
Eyes: EOM Retractions: No ™ Relative bradycardia = Heart rate within normal range for age - whilst other sides of the triangle
PERL Respiration: Thoracic are abnormal
Air-entry: +
™ Wide pulse pressure = SBP-DBP >40 mm Hg
Added sounds: No
SpO2: >94% ™ Vasodilatory shock = DBP <50% SBP + wide PP with or without low MAP
CIRCULATION ™ Mean arterial pressure = DBP + one-third pulse pressure
HR: N (for age); HS: No muffling or gallop; P&C: Warm, pink sole of foot ™ Liver span = Mark lower border along right costal margin, percuss & mark upper border for liver
*Pulses +++/++; CRT: <2 seconds; Liver span: N; Blood Pressure: SBP N dullness. Measure span (cm) in the mid-clavicular line. Check lower border & remeasure span
Diastolic BP: <50% SBP; Pulse Pressure: 30-40 mm Hg, MAP: N after every intervention.
*Pulses: Femoral (F) & Dorsalis Pedis (DP) +++/++ means both normal volume ™ Non-convulsive status epilepticus = LOC: Responsive to pain or unresponsive + 1 or more
Note: +++/+++ F = DP; ++/0 or +/0 = weak FP but no DP abnormal EOM: Conjugate deviation, nystagmus, lid twitch

RESPIRATORY DISTRESS CARDIAC FAILURE VASODILATORY CARDIOGENIC SHOCK (MAP N)

DISABILITY AIRWAY Stable
DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable
LOC: BREATHING RR: N
LOC: Alert BREATHING RR: ↑ LOC: Alert BREATHING RR:↑
Incessant cry ± Grunt, stridor: ±
T&P: N Grunt, stridor: ± T&P: N Grunt, stridor ±
Not usual self ± Retractions: +
Eyes: EOM Retractions: + Eyes: EOM Retractions: +
Lethargic ± Respiration: Abdomnal ±
PERL Respiration: Thoracic PERL Respiration: Thoracic
Sleepy ± Air-entry: +
Air-entry: + Air-entry: +
T&P: N Added sounds: ±
Added sounds: ± Added sounds: ±
Eyes: EOM SpO2: ≤94% ±
SpO2: >94% SpO2: >94%
(Exception: CCHD) PERL
CIRCULATION CIRCULATION CIRCULATION
HR: ↑±; HS: N; P&C: Warm, pink; Pulses: +++/++ HR: Tachycardia; HS: N; P&C: Warm, pink or dusky HR: Tachycardia; HS: muffling ±, gallop ±
CRT: <2 seconds; No shock; Liver span: N Pulses: +++/++; CRT: <2 seconds; No shock; P&C: Warm, pink; Pulses: +++/+++; CRT: instant; Shock
SBP: N; DBP: N; PP: N; MAP: N Hepatomegaly; SBP: N; DBP: low; PP: Wide (shunt Hepatomegaly ±; SBP:↑; DBP:↓; PP: Wide; MAP: N
lesion); MAP: N
 RESPIRATORY FAILURE VASODILATORY CARDIOGENIC
LOW SBP SHOCK
(RESPIRATORY EMERGENCIES) LOW MAP SHOCK

DISABILITY LOC: AIRWAY: Unstable

DISABILITY AIRWAY DISABILITY LOC: AIRWAY: Unstable±
Responds to pain BREATHING RR: ↑↓
LOC: Responds to Unstable Responds to pain BREATHING RR:↑↓
Thirsty, agitated Grunt, stridor: ±
pain Agitated BREATHING RR: ↑↓ Thirsty, agitated Grunt, stridor: ±
Combative Retractions: +
Combative Grunt, stridor: ± Combative Retractions: +
Fighting mask Respiration: Abdominal
Fighting mask Retractions: + Fighting mask Respiration: Abdominal
T&P: Floppy Air-entry: +
T& P: Floppy Respiration: abdom ± T&P: Floppy ± Air-entry +
Posturing ± Added sounds: ±
Posturing ± Air-entry: ± Posturing ± Added sounds: ±
Eyes: NCSE ± SpO2: ≤94% ±
Eyes: NCSE ± Added sound: ± Eyes: NCSE ± SpO2: ≤94% ±
SpO2: ≤94% ± PERL PERL
PERL

CIRCULATION CIRCULATION CIRCULATION

HR: Tachycardia; HS: N; P&C: Warm, pink HR: Tachycardia/relative bradycardia HR: ↑↓; HS: muffling ±, gallop ±
Pulses: +++/+++; CRT: <2 seconds; Shock + HS: muffling ±, gallop ±; P&C: Warm, pink P&C: Cool, dusky; Pulses: ++/+, ++/0 or +/0
Liver span: N; SBP: N; DBP: ↓; PP: Wide; MAP: N Pulses: +++/+++; CRT: instant; Shock; Hepatomegaly ± CRT: >2 seconds; Shock; Hepatomegaly ±
SBP: N; DBP: ↓; PP: Wide; MAP: N SBP: ↓; MAP:↓

IMMINENT ARREST RR: Respiratory Rate

HR: Heart Rate
DISABILITY AIRWAY Unstable HS: Heart Sounds
LOC: Unresponsive BREATHING P&C: Peripheries (warmth) & Colour (foot-sole)
T&P: Floppy Bradypnea or apnea
LOC: Level of Consciousness
Posturing; GTCS ± Little/no respiratory
T&P: Tone & Posture
Eyes: NCSE ± effort
Note: Pupils: Sluggish Reduced or absent EOM: Extra Ocular Movements
All Normal (N), Increased (↑) or breath sounds PERL: Pupils Equal, Reacting to Light
Decreased (↓) values are interpreted SpO2: ≤94% ± SBP: Systolic Blood Pressure
CIRCULATION
with respect to normal ranges for age DBP: Diastolic Blood Pressure
HR: ↓; HS: muffled ±, gallop ±; P&C: Cool, dusky
Pulses: ++/0 or +/0; CRT: >>2 seconds; Shock PP: Pulse Pressure
Hepatomegaly; SBP: ↓; MAP:↓ MAP: Mean Arterial Pressure
NCSE: Non-Convulsive Status Epilepticus
GTCS: Generalised Tonic Clonic Seizures
CCHD: Cyanotic Congenital Heart Disease

National Health Mission-Strengthening of Pediatric Emergency Care System in Tamil Nadu-Establishment of Pediatric Resuscitation and emergency Units under Tamil Nadu Accidents and
Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health and Family Welfare, dated 30.11.19.
 Management of Acute Stridor Based on Severity and Etiology

1. History of noisy breathing, Stridor + Respiratory distress Stridor + Respiratory distress Stridor + Respiratory failure Neurogenic stridor: Collapse of airway +
anticipate structural (No hypoxia) (Early hypoxia) (hypoxia + vasodilatory shock) falling back of tongue in unresponsive child
obstruction.
DISABILITY AIRWAY
2. Assess child in mum’s lap. AIRWAY DISABILITY AIRWAY DISABILITY AIRWAY DISABILITY
LOC: Alert Unstable
3. Mum holds O2 mask. Stridor LOC: Incessant Stridor LOC: Agitated Stridor LOC:
T& P: N obstructed
4. Avoid laryngoscopic evaluation BREATHING cry, sleepy BREATHING Fight mask BREATHING Unresponsive
Eyes: EOM BREATHING
of alert child with stridor in RR: N not as usual RR: ↑ T&P: Floppy RR: ↑/↓ T&P:
PERL Apnea
the ED (can precipitate cardiac Grunt: No hyperalert Grunt: No Eyes: Grunt: ± Posturing ±
Retractions: + T&P: N Retractions: + Deviation ± Retractions: + Eyes: SpO2: ≤94% ±
arrest).
5. Stridor with ALOC: Call for help Resp: Thoracic Eyes: EOM Respiration: Nystagmus ± Respiration: Conjugate deviation ±
(airway expert). Air-entry + PERL Abdominal lid twitch ± Abdominal Nystagmus ±, lid twitch ±
SpO2: >94% SpO2: >94% PERL SpO2: ≤94% ± Unequal pupil ±
1. History of unresponsiveness, CIRCULATION CIRCULATION CIRCULATION CIRCULATION
anticipate falling back of HR: N; HS: No gallop, no muffling HR:↑; HS: No gallop, No muffling HR: ↑/↓; HS: muffled ±, gallop ± HR: “N”, HS: muffled ±, gallop ±
tongue. no shock; Liver span: N no shock; Liver span: N Vasodilatory shock +; Hepatomegaly ± Vasodilatory shock +; Hepatomegaly ±
2. Assess child on resus trolley. BP: N; PP: N; MAP: N BP: N; PP: N; MAP: N SBP: N; DP: low; PP: Wide; MAP ↓ SBP: ↑; DP: low ±; PP: Wide; MAP↑
3. Head tilt-chin lift, suction, NG
decompression, pre-oxygenate,
plan early intubation.
CPR alert

AETIOLOGY AGE FEVER CLINICAL FEATURES

ALTB (croup) 3 months + Cough: Brassy Oral Prednisolone Epinephrine nebulization 0.5 mg/ Start O2 via JR Head tilt, chin lift
Reconsider – 5 years Hoarse voice 2 mg/kg stat or kg up to maximum 5 mg (1:1000) Dexamethasone (if ALTB) Suction oropharynx
diagnosis if Harsh stridor Nebulized budesonide 2-4mg/4mL NS via oxygen NS bolus, NG decompression,
poor response Dexamethasone Inotrope if pulmonary edema/Cardiac Oxygen via Jackson Rees/Bag
to Epi Neb 0.6 mg/kg IV/IM/oral stat dysfunction are identified. valve mask ventilation
Early intubation using ICP
Epiglottitis 2–7 years +++ Cough: Ineffective Rapid shift to OT accompanied by Rapid shift to OT accompanied by BVM if needed precautions.
Hot potato voice airway expert. airway expert. Call for ENT / Anesthetic help Correct hypoxia,
Soft stridor Avoid placing supine for CXR Avoid placing child supine for CXR. Intubation in ED if unable to safely Correct shock, cardiovascular
Drooling of saliva shift to OT dysfunction,
Retro <5 years +++ Cough: Ineffective Maintain position of airway comfort. Maintain position of airway comfort. Avoid paralytic agents Correct GTCS/NCSE/ICP
Pharyngeal Soft stridor, Muffled voice Antibiotics Antibiotics Plan to use ETT tube half (0.5) size less Evaluate for cause
Abscess Dysphagia, Drooling of saliva,
neck stiffness, torticollis
FB Aspiration 6 months _ Sudden choking, Normal voice Plan shift to OT Plan shift to OT Back blows
– 2 years Stridor varies based on the site Chest/abdominal thrust
of obstruction, Dysphagia +/-
Angioedema Any _ Cough: Dry, staccato Inj. Epinephrine 0.1 mg/kg DEEP IM (1:1000). Repeat every 5 minutes BVM ventilation
Allergen + Hoarse voice Plan intubation
If worsening airway obstruction then
Stridor varies Call for airway expert help.
Epinephrine / Salbutamol nebulization
Dysphagia +/- Correct shock (large volume)
100% O2 through JR
Swelling of lips, tongue, Epinephrine IV if cardiac arrest, continue as infusion.
Early intubation by airway expert
mucosa, face Inj Hydrocortisone 5 mg/kg
Correct shock (large volume shock)
Inj. Ranitidine 1 mg/kg up to 50 mgIV
Inj. Hydrocortisone 5 mg/kg IV
Inj. Diphenhydramine 1-2 mg/kg (maximum 50mg) over 5-10 minutes IV
Inj. Ranitidine 1 mg/kg up to 50 mg IV

National Health Mission-Strengthening of Pediatric Emergency Care System in Tamil Nadu-Establishment of Pediatric Resuscitation and emergency Units under Tamil Nadu Accidents and
Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 FAST BREATHING
Recognizing Aetiology and Severity of Hypoxia and Shock for Children Presenting with Fever and
AGE RESPIRATORY RATE
Acute Respiratory Distress
0–2 months >60/minute
2–11 months >50/minute
1–5 years >40/minute

Respiratory failure (severe hypoxia, Respiratory arrest (severe hypoxia and

Respiratory distress
Respiratory distress (no hypoxia) vasodilatory shock, hypoxic non-convulsive low SBP shock with, hypoxic NCSE
(some hypoxia with no shock)
status epilepticus) or CSE)

DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY
LOC: Alert BREATHING RR:↑ LOC: Lethargy ± BREATHING RR:↑ LOC: Agitation ± Unstable LOC: Unresponsive Unstable
T&P: N Grunt: No Incessant cry ± Grunt: No Thirst ±, combative ± BREATHING T&P: Posturing; GTCS ±
Eyes: EOM N Retractions: Yes Not as usual ± Respiration: Fight mask ± RR:↑, N, ↓ Eyes: Deviation ± BREATHING
PERL Respiration: More sleepy ± Thoracic T&P: Posturing Grunt: yes Nystagmus ± Apnea
Thoracic T&P: N Retractions: Yes floppy Respiration: Lid twitch: ± SpO2: ≤94% ±
Added sounds: + Eyes: EOM; PERL Added sounds: + Eyes: Deviation ± Abdominal Pupils: sluggish
Retraction: +
SpO2: >94% SpO2: >94% Nystagmus ±
Added sounds: +
Lid twitch: ±; PERL
SpO2: ≤94% ±
CIRCULATION CIRCULATION CIRCULATION CIRCULATION
HR: N; HS: No muffle, gallop; P&C: Warm, pink HR: ↑; HS: No muffle, gallop; P&C: Warm, HR: ↑; HS: muffled ±, gallop ±; P&C: Warm, HR: ↓; HS: muffled ±, gallop ±; P&C: Cool,
Pulses: +++/++; CRT: <2 seconds; Liver span: N pink; Pulses: +++/++; CRT: <2 seconds flushed; Pulse: +++/+++, CRT: <2 seconds dusky; Pulse: +++/0; CRT: >2 seconds
SBP: N; DBP: >50% of SBP; PP: 30–40 mmHg Liver span: N; SBP: N; DBP: >50% of SBP Hepatomegaly ±; SBP:↑; DBP: <50% SBP Hepatomegaly; SBP: ↓; MAP ↓
MAP: N PP: 30–40 mmHg; MAP: N PP: >40 mm Hg; MAP: N /↓

AETIOLOGY CLINICAL CHEST X-RAY

FEATURES
Pneumonia Cough Patchy, segmental lobar infiltrates Oral feeds • Bed rest • O2 through Jackson Rees circuit (JR) • Head tilt-chin lift
(Any age) Focal lung signs Consolidation Oral • Oxygen via JR circuit • NS bolus 10 mL/kg • Suction oro-pharynx
Effusion Pleural effusion antibiotics • Oral fluids ad lib • Inotrope as needed • NG decompression
Empyema Paracetamol • Oral antibiotics • IV Antibiotics • Initiate BVM ventilation
Pneumothorax • Paracetamol • IV maintenance fluids at 2/3 rate • Plan early intubation
• Paracetamol • Initiate chest compressions
@15:2 (absolute
Bronchiolitis Viral prodrome Hyperinflated lungs with patchy Oral feeds • Oxygen via JR (CPAP) • O2 via JR
bradycardia)
(6 months – 2 years) Crackles / wheeze atelectasis Paracetamol • Hydration: Bolus or • NS bolus 10 mL/kg
• NS bolus 5-10 mL/kg
continuous NG feeds at • Inotrope as needed
• Call for epinephrine bolus
2/3 maintenance • IV maintenance fluids at 2/3 rate
and infusion
Pulmonary oedema Respiratory Peribronchial and perialvolar cuffing • Oxygen via CPAP or JR • Follow PALS CPR guidelines
due to cytokine or non-respiratory Bilateral interstitial and alveolar • NS bolus 10mL/kg • Avoid anti-convulsants
storm induced organ focus of infection infiltrates • Inotrope as needed until correction of hypoxia
dysfunction Pneumonia +/- • IV Antibiotic and shock
(Any age) • IV maintenance fluids at 2/3 rate • Consider Levetiracetam
If child presents with signs and symptoms across categories always treat according to the most severe triangle.
National Health Mission-Strengthening of Pediatric Emergency Care System in Tamil Nadu-Establishment of Pediatric Resuscitation and emergency Units under Tamil Nadu Accidents and
Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health and Family Welfare, dated 30.11.19.
 Triage Questions to Establish Aetiology of Respiratory Distress

™ If age >6 months with patent airway & AVPU scale is “responsive to voice or pain”, seat in mother’s lap throughout assessment and
resuscitation.
™ Mother holds O2 mask; Ensure that the resuscitation trolley with a BVM device is close at hand. If the child deteriorates, rapid shift to the
trolley becomes possible.
™ Crying can aggravate hypoxia.

Episodic: No
Days (Acute) with 1st episode, non- Acute on chronic: Mild respiratory
Hours (Hyperacute) respiratory distress
fever fever aetiologies distress persists between episodes
between episodes

Consider Drowning,
Feed, Bath: Aspiration Envenomation,
Allergen: Anaphylaxis Prolonged status Hepatomegaly No Hepatomegaly
Healthy >2
epilepticus, Cardiac
years: Asthma
Tamponade,
Cardiogenic or Non-
Cardiogenic PE

™ History of cough: ™ Arrythmias ™ Failure to thrive ™ Congestive ™ Chronic lung

Pneumonia hepatomegaly: <2 years*, recurrent heart failure disease (CLD)
™ Prodrome, 6 months to Myocarditis aspiration: GERD ™ Chronic lung ™ Cystic Fibrosis /
2 years: Bronchiolitis ™ Developmental delay disease with Bronchiectasis
™ Non-Lung focus of with palatopharyngeal right heart
sepsis: Acute lung incompetence: failure
injury due to sepsis Recurrent aspiration

“All that wheezes is not asthma!” • Suprasternal and sternal retractions: Suspect upper airway
obstruction
Probe history to avoid potentially lethal complications of
• Intercostal retractions: Consider lung pathology.
salbutamol nebulization in hypoxic children with respiratory
• Effortless tachypnea: Lung is normal. Respiratory rate increases
distress.
in metabolic acidosis.
• Bronchospasm: Asthma (episodic), Anaphylaxis
• Bronchiolar edema: Bronchiolitis (1st episode)
• Mucus plugs: Cystic Fibrosis (acute on chronic)
• Interstitial/alveolar oedema compressing bronchioles:
Pulmonary oedema.

1. Chronic respiratory distress: Structural heart disease with congestive heart failure or chronic lung disease.
2. Acute 1st episode respiratory distress with non-lung foci of sepsis: Septic cardiogenic shock
3. Pulmonary capillary leak: Acute lung injury can occur in serious illness of any aetiology.
4. *Respiratory distress in infants <2 months: First episode, hyperacute/acute respiratory distress: consider congestive heart failure due
congenital heart disease.
5. *Recurrent episodes of respiratory distress in <2 years with failure to thrive, consider gastro-esophageal reflux disease, aspiration
syndromes and recurrent pneumonia in immunocompromised infants.

National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
Emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health and
Family Welfare, dated 30.11.19.
 Management of Acute Exacerbation of Asthma

Moderate Asthma Severe Asthma Life threatening Asthma Near Fatal Asthma
Respiratory Distress. No hypoxia Respiratory Distress. Some hypoxia. Respiratory distress + Severe hypoxia Respiratory failure with severe hypoxia
No shock No shock Vasodilatory shock (normal/low MAP) Shock, low Systolic BP +/-

DISABILITY Alert AIRWAY Stable DISABILITY Alert AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable ±
T&P: N BREATHING T&P: N BREATHING Hyperalert BREATHING Combative ± BREATHING
EOM: N RR: ↑ EOM: N RR: ↑; Grunt: No T&P: N RR: ↑; Grunt: ± Fight O2 mask ± RR: >80/minute ±
PERL Retractions: + PERL Retraction: + EOM: N Retraction: + T&P: Hypotonia ± Relative bradypnea ±
Resp: Thoracic Resp: Thoracic PERL Resp: Abdominal Unable to walk Head bob ±; Grunt +
Wheeze + Wheeze Wheeze+ without support Resp: Abdominal
SpO2: >94% SpO2: >94% SpO2: ≤94% ± Diaphoresis ± Wheeze ±
Eyes: HNCSE ±; PERL SpO2: ≤94% ±
CIRCULATION CIRCULATION CIRCULATION CIRCULATION
HR: ↑; No shock; Liver span: N HR: ↑; No shock; Liver span: N HR: ↑; P&C: Warm, pink; Pulses: +++/+++ HR: ↑±, relative bradycardia ±; P&C: Cool ±, dusky ±
SBP: N; MAP: N SBP: N; MAP: N CRT: <2 seconds; Liver span: N; SBP:↑ Pulses: +++/+; CRT: >2 seconds; Hepatomegaly ±
DBP: <50% of SBP; PP: Wide; MAP: ↓± SBP: Relative hypotension ±; MAP:↓±

Oral steroids; Salbutamol via MDI 100% O2 via non rebreathing mask O2 via Non-Invasive Ventilation
Improvement
+ spacer every 2 minutes up to 10 2.5 mg Salbutamol nebulized via Nebulised (via O2) salbutamol + Deterioration Nebulise via O2: Salbutamol 2.5 mg +
puffs depending on response oxygen1. Ipratropium bromide 500 ug Ipratropium 500 ug
1
Inj Hydrocortisone Inj. Adrenaline 0.1 mL/kg 1:1,000
If child has signs and symptoms across Improvement <2 years: 4 mg/kg Improvement Sub-cutaneous (max 3 doses, based on
categories, always treat according to their 2-5 years: 50 mg repeat mRCPCA)
Oral prednisolone 1
most severe triangle. >5 years: 100 mg Treat Shock: 10 mL/kg NS2
10 mg < 2 years
(Max 30 mL/kg)
20 mg 2–5 years
Anticipate worsening of hypoxia in hypoxic If MAP is low: Plan inotrope infusion
30–40 mg >5 years
asthmatics during salbutamol nebulization. Inj. Hydrocortisone
Correct vasodilatory shock with
If agitation / posturing / unresponsiveness 10 mL/kg boluses, max 30 mL/kg Improvement
develops during salbutamol nebulization, 2
Respiratory Respiratory (up to 60 mL/kg if sepsis coexists). Reassess, document, derive PREM
consider non-asthmatic aetiology. Inotrope if MAP falls or pulmonary triangle to find out need for repeat
distress + no distress + some
Physician and pulse-Ox monitoring during hypoxia hypoxia oedema+ nebs until resolution of hypoxia (more
nebulization is mandatory. than 3 nebs may be needed). Correct
Improvement shock with fluid bolus and inotrope
1
PREM Process: 1-minute mRCPCA,
as needed.
documentation, interpretation of vitals, Repeat MDI + Continue nebulized treatment
derivation of physiological status is Repeat Salbutamol 1-3 hourly Status quo/deterioration
spacer every 2
necessary after each bronchodilator to salbutamol Ipratropium 4-6 hourly
minutes up to 10 Inj. MgSO4 (0.1 mL/kg 50%) IV bolus
decide the next step in the protocol. nebulization Continue steroids.
puffs depending over ½ hour (max. 2g). Only one dose.
1–3 hourly1
on response1
AVOID INTUBATION if possible. Status quo/deterioration
Absolute indications:
Inj. Aminophylline 5 mg/kg loading
• Respiratory arrest
dose (omit if already on Theophylline)
• Cardiac arrest
followed by infusion @ 1 mg/kg/hour.
• Severe exhaustion
• Rapid deterioration of mental status
National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and emergency Units under Tamil Nadu Accidents and
Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health & Family Welfare, dated 30.11.19.
 Management of Shock with Respiratory Distress and Cardiac Dysfunction (CD)

AIRWAY AND BREATHING: *Inotrope/Intubation Triggers

™ Respiratory distress/ impending failure: O2 via Jackson Rees Circuit or non-invasive
ventilator to provide CPAP. ™ A: Froth, new cough, neurogenic stridor
™ Apnoea: Head tilt-chin lift, suction oro-pharynx, NGT decompression, initiate BVM, plan to ™ B: Bradypnea, RR >80 BPM, grunt
intubate after correcting hypoxia and shock New retractions, abdominal respiration
™ Intubate using ketamine, atropine and muscle relaxant if intubation triggers are noted* New rales, SpO2 <94%
™ C: Relative bradycardia, bradycardia,
CIRCULATION: Establish 2 venous access (if not available → intra-osseous access) gallop, muffling, hepatomegaly, low SBP
™ SBP(N)/MAP N: NS/RL 10 mL/kg over 10 minutes* (Reduce to 2.5–5 mL/kg if chronic ™ D: Agitation, combative, demanding
respiratory distress due to structural heart disease with CCF) water, fighting the mask, worsening LOC,
™ Low SBP on arrival or any step of protocol: Pull push 5–10 mL/kg boluses of NS/RL until responsive to pain, GTCS not responding
SBP normalizes*. Call for Epinephrine infusion and plan urgent intubation* to 2nd-line anticonvulsant, raised intra-
DISABILITY: Do not give anticonvulsant drugs to hypoxic and/or hypotensive patients with cranial pressure
extensor/flexor posturing or Non-Convulsive Status Epilepticus (HNCSE). *PREM Process:
Always correct shock & hypoxia before giving anticonvulsants to any seizing child. 1. Perform 1-minute modified rapid
™ Primary GTCS with normal MAP: Benzodiazepine 1st line. Avoid Phenytoin. Consider cardiopulmonary-cerebral assessment
Levetiracetam. (mRCPCA) after every fluid bolus & every
™ Correct documented hypoglycaemia / hypocalcaemia. Follow this with maintenance fluids emergency care intervention.
containing glucose and electrolytes. 2. Document, interpret vitals & derive
™ Manage aetiology concurrently**** physiological status to guide
management.
3. mRCPCA aids in identifying early signs
After 1st bolus* look for improvement in shock goals** of pulmonary oedema and cardiac
Watch out for signs of respiratory distress, cardiac dysfunction, hepatomegaly** dysfunction thereby averting cardiac
arrest during shock resuscitation.

**Shock goals: HR Normal for age, heart sounds

well heard, no gallop, no hepatomegaly
MAP normal for age, urine output >1 mL/kg/hour
Shock goals achieved No hypoxic NCSE.
Shock goals not achieved
No RD/No CD Shock goals not achieved
No RD/No CD ***Large volume shock (>40 mL/kg):
No Hepatomegaly RD+/ CD+/hepatomegaly+
No hepatomegaly Sepsis, anaphylaxis, hypovolemia due to
No hypoxic NCSE
gastroenteritis etc.
***Small volume shock (<10–30 mL/kg):
Asthma, status epilepticus, envenomation,
submersion injury, DKA, CHD, myocarditis,
head trauma, cardiac tamponade, tension
Differentiate large v small pneumothorax etc.
Monitor for recurrence > Interrupt fluids
volume shock: Fever? Focus? ****Treat aetiology:
of RD / CD / Shock / > Initiate inotrope
Diarrhoea? Vomiting? Bleed? Sepsis: Antibiotics, source control
Hepatomegaly > Intubate
Polyuria? Anaphylaxis?
Asthma: Bronchodilators/steroid
Primary Seizures: Anticonvulsant drugs
Yes No RD/hepatomegaly Toxin: Elimination/Antidote
resolve, shock +
Trauma: Control bleed
Pneumothorax: Thoracocentesis
Envenomation: Anti-venom/Prazosin
***Treat as large volume shock. ***Treat as small volume shock.
RD/hepatomegaly SVT: Adenosine/Cardioversion
→ Continue fluid bolus → Smaller fluid boluses
persists/ Shock +
If needed → inotrope/intubate* If needed → inotrope/intubate*

Stop bolus.

These are broad guidelines for the management of shock. Repeated mRCPCA and derivation
of PREM Triangle at every step helps to individualize resuscitation of shock.

National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health and
Family Welfare, dated 30.11.19.
 Recognition of Sepsis Induced Organ Dysfunction in Children Presenting
with Febrile Illness

Consider shock if history of lethargy, excessive sleepiness, incessant cry, not as usual, combativeness, agitation,
talking unintelligibly, inability to sit or stand, being carried (in a normally ambulant child).
If acute breathlessness has developed (not episodic/not chronic), consider cardiogenic or non-cardiogenic pulmonary oedema.

VASODILATORY CARDIOGENIC (WARM) SHOCK (SBP N) VASOCONSTRICTIVE CARDIOGENIC (COOL) SHOCK (SBP N)
DISABILITY AIRWAY DISABILITY AIRWAY
LOC: Incessant cry ± Stable (cry) LOC: Sleepy ±; lethargy ± Unstable ±
lethargy ±; sleepier ± BREATHING pain responsive ± BREATHING
not usual self ±; combative ± RR: ↑ combative ±; fight mask ± RR:↑ ±, “N” ±
fighting mask ±; thirst ± Grunt: ±; stridor: ± agitated ±; thirst ±; GTCS ± Grunt: ±; stridor: ±
T&P: Floppy ±; posturing ± Retractions: + T&P: Hypotonia ± Retractions: +
Eyes: Lid twitch ± Respiration: Thoracic posturing ± Respiration: Abdominal ±
Conjugate deviation ± Added sounds: ± Eyes: Lid twitch ± Added sounds: ±
Nystagmus ± SpO2: ≤94% ± conjugate deviation ± SpO2: ≤94% ±
Pupils: Sluggish nystagmus ±
Pupils: Sluggish
CIRCULATION CIRCULATION
HR:↑; HS: muffled ±; no gallop; P&C: warm, flushed HR:↑ ±, ”N” ±; HS: muffled ±; gallop ±; P&C: cool; dusky
Pulses: +++/+++; CRT: <2 sec; Hepatomegaly ± Pulses: +++/0; CRT: >2 secs; Hepatomegaly ±
SBP:↑; DBP: <50% of SBP; PP: >40 mmHg; MAP: N /↓ SBP:↑ ±, ”N” ±; DBP: >50% of SBP; PP: <40 mmHg; MAP: N /↓

HYPOTENSIVE CARDIOGENIC SHOCK (LOW SBP)

“N” – abnormally normal vitals!
Supposedly “normal” vital signs in critically ill children with DISABILITY AIRWAY
[ALC + respiratory distress + shock] must be interpreted LOC: Combative ± Unstable ±; No cry ±; stridor ±
with a high index of suspicion. In this situation, normal vitals agitated ±; thirst ± BREATHING
are likely to be misleading: representing impending P or U on AVPU RR:↑ ±; ”normal” ±; apnea ±
organ system failure, rather than normality. T&P: Hypotonia ± Grunt: ±; stridor: ±
posturing ±; GTCS ± Retractions: ±
Eyes: Deviation ± Respiration: Abdominal ±
“Normal” nystagmus ±; lid twitch ± Added sounds: ±
Could this be:
“N” Pupils: Sluggish SpO2: not recordable ±
RR Relative bradypnea?
HR Relative bradycardia? CIRCULATION
HR:↑ ±, ”N” ±, ↓ ±; HS: muffled ±; gallop ±; P&C: cool, dusky
SBP Relative hypotension? Pulses: +++/0, ++/0; CRT: >2 secs; hepatomegaly
SBP:↓; PP: > or < 40 mmHg; MAP:↓

Normal vital signs for age Normal liver span

Age Respiratory Heart rate SBP MAP Age Liver span
rate (BPM) (BPM) mmHg (cm) Interpreting breathing
Neonate 30–60 90–180 50–70 45 2 months 5 difficulty in a shocked child
6 months 24–40 85–170 65–106 1 year 6
If there is [respiratory distress + shock + (temp <36.5°C
1 year 20–40 80–140 72–110 2 year 6.5 or >38°C)] with or without focus of infection consider:
3 year 20–30 80–130 78–114 50 3 year 7 1. Pneumonia or Bronchiolitis with shock.
6 year 18–25 70–120 80–115 2. Pulmonary oedema with shock
4 year 7.5
8 year 18–25 70–110 84–122 60 5 year 8 If respiratory distress / failure occurs (or worsens)
10 year 16–20 65–110 90–130 12 year 9 during fluid resuscitation consider
pulmonary oedema / cardiac dysfunction
12 year 14–20 65–110 94–136 65
due to sepsis.
 Management of Vasodilatory Septic Shock with Cardiac Dysfunction and
Pulmonary Oedema

Airway and Breathing:

™ First acute episode of respiratory distress / failure: Give O2 via Jackson-Rees Circuit (manual CPAP) or NIV device (Avoid salbutamol)
™ Apnea: head tilt-chin lift, suction oro-pharynx, NGT decompression, initiate Bag Valve Mask ventilation, plan intubation after pre-
oxygenation and starting inotrope. Use ketamine + atropine + muscle relaxant.
Circulation: Establish 2x IV access (If not possible → secure IO access)
™ 1SBP N, MAP N: NS / RL 5-10 mL/kg @5-10 minutes** 1
CPR ALERT: Children with septic shock have coexisting acute
™ 1Low SBP (on arrival or any step of protocol): pull-push 5-10 mL/kg bolus** lung injury + myocardial dysfunction. When signs of PO or
inotrope/intubation triggers are identified, continuing fluid
Order epinephrine infusion and plan intubation (CPR alert)1
bolus therapy without initiation of CPAP, inotrope and/or
™ Catheterize & monitor urine output. intubation, could be dangerous and lead to cardiac arrest.
Disability
y Extensor or flexor posturing, NCSE or GTCS are due to severe hypoxia ± low MAP shock. Avoid anticonvulsants (may cause CVS collapse).
y Primary GTCS with normal MAP: Benzodiazepines, consider Levetiracetam. Avoid Phenytoin (potentially lethal due to co-existing CD).
y Correct documented hypoglycemia / hypocalcemia. Follow up with glucose containing electrolyte maintenance.
y Collect blood & body fluid for biochemistry and culture. Administer anti-microbials as needed.

**PREM Process: After each fluid bolus, intubation, anti-convulsant, etc., perform 1-minute rapid cardio-pulmonary-cerebral assessment
Document findings & interpret vital signs → Derive physiological status → Decide whether to continue fluid bolus or initiate inotrope/intubate

Therapeutic goals: Respiratory distress + Froth ± Grunt + Respiratory distress ↑

¾ No respiratory distress vasodilatory shock (N MAP) Low MAP vasodilatory shock with
¾ Normal HR, pulse pressure & MAP persists; hepatomegaly ±; hepatomegaly & ALOC***
¾ No hepatomegaly, Alert or ALOC +
unresponsive (ventilated), No HNCSE

Continue CPAP# Respiratory distress ↑ Initiate dopamine or if already on

Inotropes are indicated only when Start dopamine with wide pulse pressure dopamine add norepinephrine & intubate
pulmonary oedema or cardiovascular Continue boluses of shock (N MAP) &
dysfunction are unmasked (or persist) NS 10 mL/kg until hepatomegaly ± ALOC +
after a fluid bolus. (Exception epinephrine) goals achieved No Respiratory
1. Normal SBP & wide pulse pressure Respiratory distress +;
distress; no
→ Dopamine @ 10 µg/kg/min. Continue CPAP #
hepatomegaly +;
hepatomegaly;
2. Low SBP or bradycardia → Add norepinephrine shock +, ↓ SBP,
vasodilatory shock +
Epinephrine 0.1-1.0 µg/kg/min Continue boluses of ↓ MAP
(N MAP)
3. N SBP & wide pulse pressure NS 10 mL/kg until
& low MAP refractory to fluid goals achieved
– already on dopamine → add Continue 5-10 mL/kg Epinephrine infusion;
Norepinephrine 0.3-1 µg /kg/min NS bolus until goals STOP bolus; IV
are achieved. hydrocortisone

*** Triggers for inotrope & CPAP# / intubation - in presence of cardiovascular dysfunction and or pulmonary oedema:
™ A: New cough, froth, new stridor: (due to dLOC)
™ B: RR >70-80/minute, bradypnea, new grunt, retractions, abdominal respiration, new rales or wheeze
™ C: Relative bradycardia, muffling, gallop, fall in MAP, hepatomegaly, shock not responding to 60 mL/kg fluid boluses
™ D: Agitation, combative, fighting the mask, thirst, responsive to pain, eye signs of NCSE

When to consider adding norepinephrine or epinephrine infusion – if fluid bolus therapy & dopamine already initiated:
™ Normal or high SBP, wide pulse pressure, falling MAP, froth, grunt, crepitations, SpO 2 <94%, hepatomegaly → initiate norepinephrine or
step-up norepinephrine 0.3- 1µg/kg/min. Intubate if not done already. If cardiovascular dysfunction & pulmonary oedema resolve continue
fluid bolus until shock resolves.
™ Low SBP, gallop, muffling, bradycardia, froth, grunt, crepitations, SpO 2 <94%, hepatomegaly → start epinephrine infusion 0.1 - 1µg/kg/min.
Intubate if not done already; IV hydrocortisone 2 mg/kg
™ STOP further fluid boluses (pre-load unresponsive shock).

#Santhanam I: A PRCT study of two fluid regimens in the initial management of septic shock in the ED. Pediatr Emerg Care. 2008; 24: 647-655.
National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 Recognition and Fluid Resuscitation of Diarrhoea Based on the Severity
of Dehydration and Shock

MILD DEHYDRATION (3–5%) 10% DEHYDRATION-NO SHOCK 25% DEHYDRATION WITH SHOCK

DISABILITY AIRWAY
DISABILITY AIRWAY DISABILITY AIRWAY
LOC: Incessant Unstable ±
LOC: Alert Stable (cry/vocalize) LOC: Alert Stable (cry/vocalize)
cry ±, sleepy ± BREATHING
T&P: Normal BREATHING RR: N T&P: Normal BREATHING RR: N
lethargy ± RR:↑or↓
Eyes: EOM Grunt: No Eyes: EOM Grunt: No
not as usual Grunt: No
PERL Stridor: No PERL Stridor: No
T&P: Floppy ± Stridor: ±
Retractions: No Retractions: No
posturing ± Retractions: No
Air-entry: + Air entry: +
Eyes: Conjugate Air entry: +
Respiration: Thoracic Respiration: Thoracic
deviation ± Respiration: Thoracic
Added sounds: No Added sounds: No
Nystagmus ± Added sounds: No
SpO2: >94% SpO2: >94%
lid twitch ±; PERL SpO2: ≤94% ±
CIRCULATION CIRCULATION CIRCULATION
HR: N; H&S: No muffling, no gallop; P&C: Warm HR: ↑; H&S: No muffling, no gallop; P&C: Warm HR:↑/↓; H&S: muffling ±, no gallop; P&C: Cool
pink; Pulses +++/++; CRT: <2 seconds pink; Pulses +++/++; CRT: <2 seconds dusky; Pulses: +++/+ or +++/0; CRT: >2 seconds
Liver span: N; SBP: N; DBP: >50% of SBP Liver span: N; SBP: N; DBP: >50% of SBP Liver span: N ±, soft; SBP: ↑±, N ±, ↓±
PP: 30-40 mm Hg; MAP: N PP: Narrow <30 mm Hg; MAP: N DBP: >50% of SBP; PP: Narrow <30 mm Hg
MAP:↑±,↓±
OTHERS1: Thirsty, drinks eagerly, sunken eyes, OTHERS1: Drinks poorly, very sunken eyes, OTHERS1: Drinks poorly, very sunken eyes,
absent tears, dry mucosa, skin pinch goes back absent tears, very dry mucosa, skin pinch goes absent tears, very dry mucosa, skin pinch goes
slowly back very slowly back very slowly

ORS Ringer’s Lactate Resuscitate*

75 mL/kg over 4 hours1 >1 year: 30 mL/kg over ½ hour -O2 via NRM or BVM
then 70 mL/kg over 2.5 hours -Ringer’s Lactate 10 mL/kg:
* Normal SBP: RL bolus over
<1 year: 30 mL/kg over 1 hour 10 minutes
Reassess then 70 mL/kg over 5 hours SHOCK * Low SBP: Pull-push until
IMPROVES RESOLVES hypotension resolves

PREM Process: Repeat modified rapid cardio-pulmonary cerebral assessment, document, interpret vital signs and derive PREM Triangle after ORS/bolus to
decide next step in protocol.

*Consider septic shock with cardiovascular dysfunction and pulmonary oedema if on arrival or during fluid resuscitation any of the signs are
noted. (See triangle below). If these signs develop, administer O2 via Jackson Rees circuit, inotrope and continue RL bolus until signs of PE and
CD resolve. Correct metabolic derangements. Administer anti-microbials as indicated.

DISABILITY AIRWAY
LOC: Incessant cry ±, sleepy ± Unstable ±
Lethargy ±, fight O2 mask ± BREATHING RR:↑/↓
agitated ±, combative ± Grunt: ±
pain responsive ±; GTCS ± Stridor: ±
T&P: Floppy ±, posturing ± Retractions: ±
Eyes: Conjugate deviation ± Air entry: +
Nystagmus ±, lid twitch ± Respiration: Abdominal ±
Pupils: Sluggish SpO2: ≤94% ±
CIRCULATION
HR:↑; H&S: muffling ±; gallop ±; P&C: Warm, flushed
Pulses: +++/+++; CRT: <2 seconds; Liver span:↑±
SBP: N ±,↑±,↓±; DBP: <50% of SBP; PP: >40 mmHg; MAP: ↓±

1
WHO Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Illness with Limited Resources. Geneva: World
Health Organization; 2005
National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
Emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 Dengue—Recognition of Severity

1
PROBABLE DENGUE 1
DENGUE WITH WARNING SIGNS (LEAKING/NO SHOCK)

DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable

LOC: Alert, mum denies BREATHING RR: N LOC: Looks alert ± BREATHING RR: N
lethargy, sleepy Grunt, stridor: No mum reports lethargy ± Grunt, stridor: No
not as usual Retractions: No sleepy ±, not as usual ± Retractions: +
incessant cry Respiration: Thoracic incessant cry ± Respiration: Thoracic
T&P: N Air-entry: + T&P: N Air-entry: ±
Eyes: EOM N Sounds: No Eyes: EOM N Added sounds: ±
PERL SpO2: >94% PERL SpO2: >94%
CIRCULATION CIRCULATION
HR: N; HS: N; No shock; Liver span: N HR: N; HS: N; No shock; Hepatomegaly ±
SBP: N; DBP: N; PP: N; MAP: N SBP: N; DBP: N; PP: N; MAP: N
Abdominal pain, tenderness; persistent vomiting; mucosal bleed
Live in/Travel endemic region: Fever + 2 of the following:
Fluid accumulation: (puffy eyelids, slightly distended abdomen,
Nausea, vomiting; erythematous rash; aches & pains
minimal fluid in pleura); lethargy, restlessness; hepatomegaly
Tourniquet test +; Leucopenia; Any 1 warning sign
HCT:↑, Platelets: ↓

1
SEVERE DENGUE: CAPILLARY LEAK WITH (N BP) SHOCK 1
SEVERE DENGUE: LEAK WITH LOW BP SHOCK

DISABILITY AIRWAY Stable DISABILITY AIRWAY

LOC: Looks alert BREATHING RR:↑ LOC: Looks “alert” ± Stable ±, unstable ±
mum reports lethargy ± Grunt, Stridor: No fight mask ±, Agitated ± BREATHING RR:↑/↓
incessant cry ± Retractions: + Combative ±, Thirst ± Grunt ±, stridor ±
not as usual ±, sleepy ± Air entry: ↓due to Pain responsive ± Respiration: Abdominal ±
T&P: N pleural effusion ± T&P: Normal ± Retractions: +
Eyes: EOM N Sounds: ± Eyes: Conj deviation ± Air-entry: ↓ due to
PERL SpO2: >94% Lid twitch ± pleural effusion ±
Nystagmus ± SpO2: ≤94% ±
CIRCULATION PERL CIRCULATION
HR: “N”(relative bradycardia); HS: N; Shock; Hepatomegaly HR: Relative bradycardia; HS: muffled ± gallop ±; shock
SBP: N; DBP: >50% of SBP; PP <20 mmHg; MAP: N; oliguria hepatomegaly; SBP: ↓; MAP: ↓; oliguria

Hematocrit↑; Thrombocytopenia Hematocrit↑; Thrombocytopenia

1
World Health Organization, Special Program for Research, Training in Tropical Diseases, Epidemic, Pandemic Alert. Dengue: Guidelines for Diagnosis,
Treatment, Prevention, and Control. 2009.

DIFFERENCE BETWEEN DENGUE SHOCK AND EARLY SEPTIC SHOCK (DS + SS NOT UNCOMMON)

DENGUE SHOCK (DS) AIRWAY SEPTIC SHOCK (SS) AIRWAY

Stable Stable: Cry
DISABILITY BREATHING DISABILITY BREATHING RR:↑↑
LOC: “Alert”; mum RR: ”N” (Relative bradypnea) LOC: Impaired alertness ± Grunt ±; stridor
reports lethargy ± Grunt ±, stridor incessant cry ± Retractions: Yes
sleepy ± Retractions: ± not as usual ±, Sleepier ± Respiration: Thoracic ±
not as usual ± Respiration: Thoracic T&P: Floppy ±, posturing ± Air-entry: ±
incessant cry Air-entry: ↓(pleural effusion) ± Eyes: Conjugate deviation ± Sounds: yes ±
T& P: N Added sounds: ± Nystagmus ±, Lid twitch ± SpO2: ≤94% ±
Eyes: EOM SpO2: >94% ± PERL
PERL CIRCULATION CIRCULATION
HR: “Normal” (relative bradycardia); HS: N; Shock; Hepatomegaly HR: ↑↑↑; HS: muffle ±, gallop ±; vasodilatory shock
SBP: N or ↓; DBP: >50% SBP (often difficult to determine) Hepatomegaly ±; SBP: ↑; DBP: <50% of SBP
PP: <20 mm Hg; MAP: N/↓ PP: >40 mmHg (wide); MAP: N /↓

• Temperature: N; No obvious foci of infection • Temperature: 36.5°C–38°C; Focus of infection present

• Bleeding ± (petechiae, melena, hematemesis) • No obvious bleed in early sepsis
• Pleural effusion, Ascites, HCT↑, Thrombocytopenia • Leukocytosis, HCT N, Platelet count N in early sepsis

2
National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
Emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 Dengue—Management Based on Severity

1 1
PROBABLE DENGUE DENGUE WITH WARNING SIGNS (LEAKY/NO SHOCK)

™ ORS @ 3 mL/kg/hour if child tolerates oral. If not, NS 3 mL/kg/hour

™ Bed rest ™ Hemodynamically stable with↑ Hematocrit (HCT), ↓ urine output: NS @ 5–7 mL/kg/hour for 1–2
™ Adequate fluid intake: ORS, fruit juices hours 3–5 mL/kg/hour for next 2–4 hours then 3 mL/kg/hour
™ Paracetamol 10 mg/kg 6th hourly (no NSAIDs) ™ PREM Process: Repeat mRCPCA every hour/document/interpret vitals/derive PREM Triangle
™ Ask mom to note input/output chart (urine measured using measuring cup) during the critical phase (48–72 hours)
™ Watch for warning signs. ™ Check HCT & Urine output every hour (ensure >0.5 mL/kg/hour)
™ If signs of pulmonary edema/cardiac dysfunction+, start O2 via JR & inotrope
1
DENGUE (LEAKY) RESPIRATORY DISTRESS + COMPENSATED SHOCK
1
DENGUE RESPIRATORY DISTRESS/FAILURE WITH DECOMPENSATED SHOCK

2
O2 via Jackson Rees circuit, 10–20 mL/kg/hour over 1 hour 2
O2 via JR or Non-invasive ventilator, Colloid 20 mL/kg over 15 minutes, order Epinephrine infusion

Yes No
IMPROVEMENT Yes No
IMPROVEMENT

5–7 mL/kg/hr @ 2–4 hours HCT↑ CHECK HCT↓

IV Crystalloid or colloid HCT↑ CHECK HCT↓
3–5 mL/kg/hr @ 2–4 hours HCT
10 mL/kg/hour for 1 hour HCT
2–3 mL/kg/2–4 hours
SEVERE SEVERE
OVERT BLEED IV Crystalloid reduce gradually: OVERT BLEED
If clinical improvement Crystalloid 2nd bolus
5–7 mL/kg/hour for 1–2 hours Crystalloid 2nd bolus
is noted reduce fluid or colloid 10–20 mL/ Yes No 3–5 mL/kg/hour for 2–4 hours or colloid 10–20 mL/ No
accordingly kg/hour for 1 hour Yes
2–3mL/kg/hour for 2–4 hours kg/hour for 1 hour

Urgent Colloid 10–20 10–20 mL/kg Fresh

Fluid therapy may be No fresh blood mL/kg/hour whole blood Colloid 10–20
needed for the next IMPROVEMENT As clinical improvement is No
transfusion evaluate IMPROVEMENT (<72 hours old)/ mL/kg/hour
24–48 hours noted reduce fluid accordingly
to consider 5–10 mL/kg consider
Yes blood PRBC fresh blood
transfusion, Yes
Stop IV fluid at //10–20 mL/kg Fresh transfusion,
Reduce IV crystalloids if no clinical
48 hours Stop IV fluid @ 48 hours Reduce IV crystalloids whole blood if no clinical
7–10 mL/kg/hour @ improvement 7–10 mL/kg/hour for (<72 hours old)/ improvement
1–2 hours.
1–2 hours. 5–10 mL/kg PRBC//
2
Provide O2 throughout shock resus via JR/NIV since leak into lungs is anticipated. After every fluid bolus, (1) Repeat 1-minute rapid cardiopulmonary cerebral assessment (mRCPCA),
document, interpret vital signs using reference for age, derive PREM Triangle. (2) Check urine output. (3) Check HCT. (4) Plan next intervention. Order appropriate Inotrope if signs of
pulmonary oedema or hepatomegaly noted. Order Epinephrine infusion if low SBP. Avoid intubation by using NIV. Intubate ONLY if intubation triggers are noted. Avoid platelet transfusions.
If signs of septic shock co-exist treat based on physiological status.
1 2
WHO, Special Program for Research, Training in Tropical Diseases, Epidemic, Pandemic NHM–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of
Alert. Dengue: Guidelines-2009. PREM Units under TAEI G.O(D)No. 539.
 Management of Status Epilepticus with Hypoxia & Vasodilatory Cardiogenic Shock

PREM Process: After each intervention (e.g., fluid bolus,

AIRWAY: Open airway: Head-tilt chin-lift manoeuvre. If trauma
intubation, anti-convulsant, etc.) perform 1-minute modified rapid
is suspected → jaw thrust & cervical spine stabilization
cardio-pulmonary-cerebral assessment → Document findings→
Oro-pharyngeal suction; NGT decompression
interpret vital signs → Derive PREM triangle (physiological status)
BREATHING: Spontaneous breathing: O2 through Jackson-Rees circuit
→ Decide next action (e.g., whether to continue or stop fluid
Apnea: BVM with O2 @ 10–15 L/minute
bolus, initiate inotrope/intubate or add anti-convulsant.)
CIRCULATION: IV access, correct shock with 1st bolus 10 mL/kg NS/RL*
Correct documented hypoglycaemia/hypocalcaemia. Start glucose & electrolyte maintenance solution. 1st dose antibiotic
if sepsis is suspected.
Posturing + hypoxic NCSE (HNCSE2)
Idiopathic or febrile SE Secondary SE Fever, diarrhoea, vomiting, breathlessness,
toxin, trauma→↓↓LOC & eye signs due to
severe hypoxia, shock & cardiac dysfunction
No precipitating event or fever only → No LOC Fever, acute watery diarrhoea, vomiting,
→sudden unresponsiveness→ GTCs breathlessness, toxin, trauma etc.→ LOC→GTC Avoid rushing to give anti-convulsant

DISABILITY AIRWAY DISABILITY AIRWAY & BREATHING DISABILITY AIRWAY & BREATHING
LOC: Unresponsive A: Unstable LOC: Unresponsive A: Unstable ± LOC: U or P A: Unstable
Tone: Abn B: Apnea (Jerky T&P: Posturing ± B: RR↑↓, apnea T&P: Posturing B: RR↑↓
Posture: Abn abdominal floppy; GTCs ± Grunt, stridor: ± Eyes: Deviation ± Grunt, stridor: ±
GTCS + respiration does Eyes: Lid twitch ± Retractions: ± nystagmus ± Retractions: +
Eyelid twitch + not indicate nystagmus ± Respiration: lid twitch ± Respiration:
Nystagmus + effective deviation ± Abdominal ± Pupils: Sluggish Abdominal
Conjugate ventilation) Pupils: Sluggish SpO2: ≤94% ± SpO2: ≤94% ±
deviation + SpO2: ≤94% ±
CIRCULATION CIRCULATION CIRCULATION
Small volume shock Shock volume depends on etiology Shock volume based on etiology
HR ↑; HS: N; vasodilatory shock HR ↑; HS: N; vasodilatory shock HR ↑↓; HS: muffling ±, gallop ±; shock +
Hepatomegaly ±; SBP: ↑, DPB: Low; MAP:↓± Hepatomegaly ±; SPB: ↑, DPB: Low; MAP: ↓± Hepatomegaly
SBP: ↓ or “N”; (Relative hypotension)
Non-convulsive seizures or "subtle seizures," i.e., no
DPB:↓; MAP: ↓±
jerking of limbs, only eye signs & ↓LOC) can have
1 & 2 have
different aetiologies:
different
1. NCSE (non-convulsive status epilepticus) is due to
treatment
neuronal excitation: Classical GTCS without overt CPR alert
& 1. Resolve hypoxia & shock
jerking
prognosis. 2. Avoid anti-convulsant until hypoxia & MAP
2. Hypoxix NCSE occurs due to severe cerebral
normalizes/cardiogenic shock has resolved
hypoxia or hypoperfusion (unstable CVS)
3. Treat precipitating cause
IV Lorazepam (0.1 mg/kg; Max 4mg) over 1 minute OR
IV Midazolam (0.15 mg/kg) over 1 minute OR 0 minute
IV Diazepam (0.2 mg/kg; Max 10 mg)
Therapeutic goals: Stable airway; Normal breathing
IV access not available: Midazolam IM (0.15 mg/kg) or buccal (0.3 mg/kg)
(If low SBP/MAP for age, correct hypotension PRIOR to benzodiazepine) Normal HR; No shock; Alert (baseline)

A&B: JR/BVM; C: NS 2nd 10 mL/kg**; If pulmonary

oedema or cardiac dysfunction → inotrope & intubate; 10 minutes
If still fitting: Give 2nd benzodiazepine dose (as above)
™ *Idiopathic SE or SE secondary to “small volume”
aetiology: NS 10-20 mL/kg
A&B: JR/BVM; C: NS 3rd bolus*; If signs of pulmonary
20 minutes ™ Sepsis or hypovolemia: NS 60–80 mL/kg
oedema or cardiac dysfunction → inotrope & intubate.
Duration of SE >30 minutes or cardiac dysfunction, low SBP, ™ **During bolus: mRCPCA for pink froth, grunt, retractions,
low MAP → initiate IV Levetiracetam 60 mg/kg over 5–10 minutes. SpO2 <94%, muffling of heart sounds, gallop, bradycardia,
No signs cardiac dysfunction, N SBP, N MAP: IV Fosphenytoin 20 mg/kg IV hepatomegaly, ↓ MAP <65 mmHg.
™ If ≥1 sign: Inotrope***& intubate.
A&B: JR/BVM; C: NS 4th bolus**( If sepsis or hypovolemia);
Inotrope & intubate if needed. 40 minutes
Sodium valproate 40 mg/kg over 5 minutes
***Inotrope choice is based on shock, pulse pressure & MAP
1) Dopamine: N SBP + wide PP (>40 mm Hg)
IV Pyridoxine 100 mg IV stat < 2years 60 minutes
Start Midazolam infusion @ 1 µg/kg/minute; every 15 minutes 2) Dobutamine: High SBP + narrow PP
3) Epinephrine: Low SBP with narrow PP
Plan intubation after pre-oxygenation, bolus & inotrope 4) Norepinephrine: Wide PP + ↓MAP (not responding to fluids
Midazolam 0.2 mg/kg bolus (Max. 10 mg) over 2 minutes >60 minutes & dopamine)
IV Phenobarbitone 20 mg/kg over 10–20 minutes up to a
maximum of 40 mg/kg

National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
Emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 Approach to Abnormal Movements with Decreased Level of Consciousness

Sudden unresponsiveness (No significant Sudden unresponsiveness (No significant Significant precipitating events* followed by
precipitating event) + GTCS + not regained precipitating event) + not regained basal incessant cry/sleepy/lethargy/not as usual →
basal LOC. LOC→ GTCS ± followed by unresponsiveness

DISABILITY AIRWAY DISABILITY AIRWAY DISABILITY AIRWAY

LOC: Unresponsive Unstable LOC: Unresponsive Unstable, LOC: Unresponsive Unstable
T&P: Floppy ± BREATHING T&P: Floppy ± obstructed T&P: Floppy ± obstructed
Posturing ± Apnea posturing ± BREATHING Posturing ± BREATHING
GTCS SpO2: ≤94% ± Eyes: NCSE Apnea ± GTCS Apnea ±
Eyes: NCSE PERL Respiratory Eyes: Hypoxic Respiratory
PERL distress ± NCSE distress ±
SpO2: ≤94% ± Pupils: Sluggish SpO2: ≤94% ±
CIRCULATION CIRCULATION CIRCULATION
HR:↑; HS: N HR:↑; HS: N HR: ↓; HS: muffle ±; gallop ±
Vasodilatory shock; Hepatomegaly ± Vasodilatory shock; Hepatomegaly ± Shock; Hepatomegaly
SBP ↑; DBP↓; PP: wide; MAP: N SBP↑; DBP↓; PP: Wide; MAP: N SBP: ↓; MAP: ↓

Convulsive Status Epilepticus (CSE) Non-Convulsive Status Epilepticus (NCSE) Imminent Arrest

BVM/ET; Epinephrine
BVM, bolus, inotrope, correct metabolic BVM/JR, bolus, inotrope, correct metabolic Correct metabolic derangement
derangements; IV anticonvulsant drugs derangements; IV anticonvulsant drugs Delay anti-epileptics until hypoxia/
cardiovascular dysfunction normalizes.

*Fever, breathlessness, diarrhea, allergen, toxin, trauma,

*Fever, Headache, Vomiting, Prolonged Fits, Head Trauma
submersion, foreign body obstruction etc. followed by dLOC
DISABILITY LOC: Pain AIRWAY DISABILITY AIRWAY
responsive Unstable, obstructed LOC: Pain responsive Unstable, obstructed
T&P: Posturing BREATHING Apnea ± T&P: Posturing BREATHING Apnea ±
Eyes: Hypoxic NCSE Relative bradypnea ± Eyes: NCSE ± Relative bradypnea
Pupils: Sluggish Respiratory distress ± Pupils: Unequal Respiratory distress ±
SpO2: ≤94% ± SpO2: ≤94% ±
CIRCULATION CIRCULATION
HR: ↓ or ↑; HS: muffle ±, gallop ± HR: ”N”(relative Bradycardia), HS: N
Shock; Hepatomegaly Vasodilatory shock ±; Hepatomegaly ±
SBP: ↑ or ↓; MAP: ↓ SBP↑; DBP↑↓; PP: Wide; MAP↑

Hypoxic/Shock with Posturing Raised Intra-Cranial-Pressure

BVM/ET: Correct hypoxia BVM→ET: Secure airway; Bolus, Inotrope: Correct shock & cardiac
Bolus/inotrope: Correct shock/cardiac dysfunction dysfunction; Treat metabolic derangement; Treat fever
Treat metabolic derangement Avoid noxious stimuli
Specific treatment of underlying cause where possible Measures to reduce raised ICP (Head up 30 degrees, hypertonic
Avoid anti-epileptics until hypoxia/cardiovascular dysfunction saline, ensure eucapnia); Mannitol (if no shock)
normalizes IV Anticonvulsants if NCSE/CSE is noted

Focal seizures Intake of medication Behavioural problems Developmental delay

DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable
LOC: Alert BREATHING LOC: Alert BREATHING LOC: Alert BREATHING LOC: Chronic BREATHING
T&P: Normal Normal T&P: Extensor Normal Tonic-clonic Normal impaired Normal
Lip smack posturing movements alertness
Facial twitch Eyes: T&P: Normal T&P:
Involuntary Oculogyric Eyes: EOM Intermittent
contractions crisis PERL posturing
Eyes: EOM; PERL PERL Eyes: EOM; PERL
CIRCULATION CIRCULATION CIRCULATION CIRCULATION
HR: Normal; No shock HR: Normal; No shock HR: Normal; No shock HR: Normal; No shock
Simple Partial Seizure Extrapyramidal symptoms Conversion Reaction Dystonia

National Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and
Emergency Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 Approach to Snake Bite

Bite: No hypoxia or Shock Haemotoxic: No-hypoxia or shock Neurotoxic: No hypoxia or shock

DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable DISABILITY AIRWAY Stable

LOC: Alert BREATHING RR: N LOC: Alert BREATHING RR: N LOC: Alert BREATHING RR: N
T&P: Normal Grunt: No T&P: Normal Grunt: No T&P: Descending Grunt: No
Eyes: EOM Stridor: No Eyes: EOM Stridor: No paralysis Stridor: No
PERL Retractions: No PERL Retractions: No Eyes: Diplopia Retractions: No
Air entry: + Air entry: + Ptosis Air entry: +
Respiration: Thoracic Respiration: Thoracic dysarthria Respiration: Thoracic
Sounds: No Sounds: No Dysphagia Sounds: No
SpO2: >94% SpO2: >94% PERL SpO2: >94%
CIRCULATION CIRCULATION CIRCULATION
HR: N /↑; H&S: No muffling, no gallop HR: N/↑; H&S: No muffling, no gallop HR: N/↑; H&S: No muffling, no gallop
P&C: Warm, pink; Pulses: +++/++ P&C: Warm, pink; Pulses: +++/++ P&C: Warm, pink; Pulses: +++/++
CRT: <2 seconds; Liver span: N, soft; SBP: N CRT: <2 seconds; Liver span: N, soft; SBP: N CRT: <2 secs; Liver span: N, soft; SBP: N
DBP: >50% of SBP; PP: 30–40 mmHg; MAP: N DBP: >50% of SBP; PP: 30–40 mmHg; MAP: N DBP: >50% of SBP; PP: 30–40 mmHg; MAP: N

OTHERS: Cellulitis (severe, painful ™ ASV 8-10 vials over 1 hour. Repeat 10 vials
OTHERS: WBCT >20 minutes bleed from
progressive swelling, rapidly crossing the if no improvement
bite site
joint); Bite mark; Tender lymphadenitis ™ Atropine 0.02–0.05 mg/kg, ½ hourly
Other bleeding manifestations
WBCT: N/>20 minutes; Confirmed snake bite ™ Neostigmine 40 µg/kg ½ hourly until
neurological recovery. Subsequent doses
™ ASV 8-10 vials
given (10-40 µg/kg) at 1, 2, 6 and 12 hours.
™ Repeat WBCT 6 hourly after ASV
™ Reassure, immobilize the affected limb (Improvement is noted only in cobra bite)
™ If WBCT >20 minutes repeat 8–10 vials
™ Tetanus prophylaxis, antibiotics for ™ If no improvement after 3 doses of
(Max 30 vials)
cellulitis (not bite mark) Neostigmine + atropine give Inj. Calcium
™ If patient continues to bleed briskly, give
™ ASV 8-10 vials in Normal Saline over Gluconate 1-2 mL/kg (1:1 dilution over
ASV within 1 to 2 hours
1–2 hours 5–10 minutes). (Max dose: 10 mL). Repeat
™ Consider FFP or cryoprecipitate or fresh
6 hourly. (useful for Krait bite)
blood after neutralizing dose of ASV

UNKNOWN BITE: Hemotoxic: Neurotoxic:

• If 20-minute Whole Blood Clotting Time Hypoxia; Cardiovascular Dysfunction ± Hypoxia; Cardiovascular Dysfunction ±
is normal: No ASV. Non-Convulsive Status Epilepticus ± Non-Convulsive Status Epilepticus ±
• Repeat WBCT ½ hourly for 3 hours, then
DISABILITY AIRWAY: DISABILITY AIRWAY
hourly for 24 hours.
LOC: Responsive to pain ± Stable or Unstable LOC: Unresponsive Unstable
• If WBCT is >20 minutes: Start Anti-Snake
Unresponsive ± BREATHING RR: ↑ T&P: Floppy BREATHING
Venom (ASV)
T&P: Abnormal Grunt: ± Eyes: Conjugate Apnoea
Eyes: Conjugate Stridor: + deviation ± SpO2: ≤94% ±
PRIOR to ASV administration, prepare: deviation ± Retractions: + Nystagmus ±
• IM Adrenaline: 0.01 mL/kg of 1:1000 Nystagmus ± Air entry: + lid twitch ±
(max 0.5 mL) or 0.1 mL/kg of 1: 10,000 IV lid twitch ± Respiration: PERL
• IV Chlorpheniramine maleate: 0.2 mg/kg PERL Thoracic
• IV Hydrocortisone: 2–6 mg/kg Sounds: +
• When allergic symptoms resolve/ PREM SpO2: ≤94% ±
CIRCULATION CIRCULATION
triangle becomes normal, continue
HR: HR:↓/↓; H&S: muffling ± HR:↓/↓; H&S: muffling ±
ASV infusion at a slower rate for
gallop ±; P&C: Cool, dusky; Pulses: +++/+ gallop ±; P&C: Cool, dusky; Pulses: +++/+
10–15 minutes. If child remains stable,
CRT: >2 seconds; Hepatomegaly ±; SBP: N/↓ CRT: >2 seconds; Hepatomegaly ±
continue infusion at normal rate.
DBP: <50% of SBP; PP: N/↓; MAP:↓ SBP: N/↓; DBP: <50% of SBP; PP: N/↓; MAP:↓

™ Oxygen via BVM ventilation, Plan early

SURGICAL ISSUES
™ Oxygen via Jackson Rees circuit intubation. Cardiac massage & epinephrine
• Compartment syndrome is rare in
™ NS 10 mL/kg boluses (small volume) if cardiac arrest or low BP
children.
™ Inotropic support if needed. ™ NS 10 mL/kg (small volume shock)
• Early and adequate antivenom is the best
™ ASV maximum 30 vials ™ ASV 8-10 vials maximum 20 vials
strategy to prevent irreversible muscle
™ Blood & blood components ™ Inj. Atropine, Neostigmine ½ hourly
damage and gangrene
(see above)

Standard Treatment Guidelines. Management of Snake Bite. Ministry of Health and Family Welfare, Government of India. August 2017. National
Health Mission–Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and Emergency
Units under Tamil Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539, Department of Health and Family
Welfare, dated 30.11.19.
 Management of Scorpion Sting

Scorpion Sting

LOCAL EFFECTS SYSTEMIC EFFECTS (AUTONOMIC STORM)

Oral paracetamol 15 mg/kg/dose Profuse sweating, vomiting, cold peripheries,
Ice compression at the site of bite hyper-salivation, priapism, bradycardia

NO SHOCK COMPENSATED CARDIOGENIC SHOCK HYPOTENSIVE CARDIOGENIC SHOCK

DISABILITY AIRWAY DISABILITY AIRWAY DISABILITY AIRWAY

LOC: Alert Stable (cry/vocalize) LOC: Impaired Stable (cry/vocalize) LOC: Pain Unstable ±
T&P: Normal BREATHING RR: N alert ± BREATHING RR:↑ responsive ± BREATHING
Eyes: EOM Grunt: No Hyper-alert ± Grunt: No Unresponsive ± RR:↑/↓
PERL Stridor: No Lethargy ± Stridor: No T&P: Floppy ± Grunt: ±
Retractions: No T&P: Normal Retractions: + posturing ± Stridor: ±
Air entry: + Eyes: EOM Air entry: + Eyes: Nystagmus ± Retractions: +
Respiration: Thoracic Pupils: Sluggish ± Respiration: Thoracic Conjugate Air entry: +
Sounds: No Added sounds: + deviation ± Respiration: Abdominal ±
SpO2: >94% SpO2: >94% Lid twitch ± Added sounds: +
Pupils: Sluggish SpO2: ≤94% ±

CIRCULATION CIRCULATION CIRCULATION

HR: N; H&S: No muffling, no gallop; P&C: Cool HR:↑; H&S: No muffling, no gallop HR:↑±; N (Relative Bradycardia) ±
dusky; Pulses: +++/++; CRT: <2 seconds P&C: Cool, dusky; Pulses: +++/+ or +++/0 H&S: muffling ±; gallop ±; P&C: Cool, dusky
Liver span: N, soft; SBP:↑± CRT: >2 seconds; Liver span:↑± Pulses: +++/0 or ++/0; CRT: <<2 seconds
DBP: >50% of SBP; PP: 30–40; MAP:↑± SBP:↑; DBP: >50% of SBP Liver span:↑±; SBP:↓; DBP:↓±
PP: Narrow (<30 mmHg); MAP:↑ PP: Narrow; MAP: ↓

™ Prazosin 30 µg/kg/dose (oral/NGT) ™ O2 through Jackson-Rees Circuit 1. O2 via JR circuit CPR alert
™ Maintain supine position to prevent ™ 1
NS/RL boluses @5–10 mL/kg 2. 1NS/RL bolus @5 mL/kg
hypotension. ™ Prazosin 30 µg/kg/dose (oral/NGT) 3. Epinephrine infusion
Prazosin can be repeated after 3 hours ™ *Scorpion anti-venom: @ 0.3–0.5 µg/kg/minute
and then 6-hourly until extremities are 30 mL + 100 mL NS over 30 minutes 4. Intubate to provide PEEP
warm + dry (rarely need >4 doses) 5. Withhold Prazosin until BP normalizes
™ *Scorpion anti-venom: 6. *Scorpion anti-venom:
30 mL + 100 mL NS over 30 minutes 30 mL + 100 mL NS over 30–60 minutes
(1 more dose if needed after 4–6 hours)

™ Shock + no PE ™ 1
Shock + PE or hepatomegaly +
™ Continue O2 through JR circuit ™ Stop fluid bolus
™ If evidence of hypovolemia due to ™ Initiate dobutamine
vomiting + or severe perspiration +, ™ Intubate to provide PEEP
continue 5–10 mL/kg until shock
resolves (usually needs <30 mL/kg)

1
Risk of cardiogenic or non-cardiogenic pulmonary edema complicates shock management due to scorpion envenomation. During fluid
therapy (small volume shock), monitor for airway instability, pink froth, increase or decrease in respiratory rates, grunt, retractions,
abdominal respiration, fresh rales, gallop, increasing liver span, agitation, fighting the mask and drop in oxygen saturation (i.e., signs of
pulmonary oedema). If any one or a cluster of these signs develop, stop further fluid bolus, initiate inotrope, and prepare to intubate.

*Use with caution in infants less than 13 kg.

Strengthening of Pediatric Emergency Care System in Tamil Nadu–Establishment of Pediatric Resuscitation and Emergency Units under Tamil
Nadu Accidents and Emergency Care Initiative under the name of PREM G.O(D)No. 539.
 READY RECKONER
AIRWAY & BREATHING

Presume apnea in unresponsive children Initiate Bag valve mask ventilation

• Reservoir is mandatory to provide 100% oxygen Prior to mask ventilation

• 1-1.5 liters bag necessary to effectively ventilate all
• Head tilt chin lift
ages
• Suction oro-pharynx using Yankauer suction
• Use age-appropriate mask
• Decompress stomach with age appropriate
NGT
• Ensure air-tight EC Clamp

Impending respiratory failure Use Jackson Rees circuit

• Set oxygen at 10-15 liters • Provide airtight seal (reservoir should be

• Ensure partially open valve to prevent rebreathing distended during respiration)
• Insert NGT to avoid stomach distension

Early shock is often vasodilatory and associated with cardiac dysfunction/pulmonary oedema

Fluid bolus therapy • Start 10 ml/ kg by gravity

• Subsequent boluses based on modified rapid
• Glucose free Normal saline or Ringers Lactate
cardiopulmonary cerebral assessment &
etiology of shock
• During fluid bolus therapy if signs of cardiac
dysfunction/ pulmonary oedema are noted
initiate appropriate inotrope.
• Hypotensive shock: 5-10 ml/kg (pull-push
technique)

INOTROPE PREPARATION

Drug Add in mg to 50 ml of 1ml/hour will deliver Dose

NS

Dopamine 3 x Body weight 1 microgram/ kg/min 10 micrograms /kg/min

Dobutamine 3 x Body weight 1 microgram/kg/min 10 micrograms /kg/min

Epinephrine 0.3 x Body weight 0.1 microgram/kg/min 0.1 -1 microgram /kg/min

Nor-epinephrine 0.3 x Body weight 0.1 microgram/kg/min 0.1- 1 microgram/kg/min

 CARDIOPULMONARY RESUSCITATION

Technique HIGH QUALITY CPR (15:2)

• Extend the elbow and wrist • Push hard 1/3 of anterior posterior
• Shoulder and wrist in same straight plane diameter of chest)
• Use one hand to lift the heel of the other hand • Push fast (at least 100/min)
• Count loudly • Allow for complete chest recoil but don’t take
your hand completely off the chest
• Minimize interruptions (next compressor
should be standing right behind the 1st )
• Change person who is compressing every 2
minutes where possible to avoid fatigue
• Avoid excessive ventilation

Epinephrine dosage ( 1ml = 1mg)

• Cardiac arrest =0.1 ml/kg of 1:10000 dilution given IV/ IO q 3-5 mins bolus
• Anaphylaxis = 0.1 ml/ kg of 1:10000 or 0.01 ml/ kg of 1:1000 dilution as IM every 15 mins PRN
• ALTB = 0.4 ml /kg of 1:1000 dilution nebulization ( maximum 5ml)
• Asthma = 0.1 ml/ kg of 1:10000 dilution SC q 15 mins
• Hypotensive shock = 0.1 -1 ug / kg/ min infusion IV/IO

Hypoglycemia: If CBG < 54 mg/ dl administer 5 ml/kg of 10% Dextrose

Hypocalcemia: If ionized calcium < 1 mmol/dl give 2 ml / kg of 10% calcium gluconate with equal amount of 10%
Dextrose over 20 mins under cardiac monitoring

Age (Weight) Laryngoscope ET tube size ET-tube Suction NG tube Foley’s Chest tube

blade size distance from catheter catheter

lip

Newborn 1 3-3.5 8-9.5 6 8 5 8-10

(3.5)

6 months 1 3.5-4 9.5 -11 8 8 5 12-16

( 7)

1 year ( 10) 2 4-4.5 11-12.5 8 10 8 14-20

3 year ( 15) 2 4.5-5 12.5-14 8 10 10 18-22

6 year ( 20) 2 5-5.5 14-15.5 10 12 10 20-28

8 year (25) 2 6-6.5(cuff) 17-18.5 10 12 10 28-32

10 year( 30) 3 6.5-7(cuff) 18.5-20 12 14 12 28-32

12 year (40) 3 7(cuff) 20 12 14 12 28-32