A child came to casualty after seizures. On examination, respiratory rate is 5 per min. pulse 54 per min and cyanosis is present. What should be the next step of management?
Ans-BRef: I.AP's Principles of Pediatric Neonatal Emergencies. HPS Saclulev ct ai. 2nd edition, Page 171 and Nelson Textbook of Pediatrics. 19th edition, Pages 287-8. Kleinnum ME, Chameides L. Schexnayder SM, et al: 2010; American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 14, Circulation 122 :S876-S908, 2010. Fig. 1. Page S885Explanation:"A heart rate less than 60 beats/min with poor perfusion is an indication to begin chest compressions." Ref: NelsonThe child has acute respiratory failure hypopnea (RR-5/min and cyanosis). So the first step would be to secure an airway by intubation followed by ventilation with CL.The child does not have active seizures at presentation. So diazepam or IV midazolam may not be required immediately but should be given after the child is stabilized.BRADYCARDIASymptomatic bradycardia occurs most often in the setting of hypoxia but can also be caused by hypoglycemia, hypocalcemia, other electrolyte abnormalities, and intracranial hypertension.Initial management of symptomatic bradycardia includes support or opening of the airway and confirming or establishing adequate oxygenation and ventilation.After the child's breathing has been secured, the child should be reassessed for continued bradycardia and poor perfusion--if a cardiac compromise was solely the result of respiratory insufficiency, support of the child's airway and breathing may have been sufficient to restore normal hemodynamics.If respiratory support does not correct the perfusion abnormalities, then further care is based on the quality of perfusion and the degree of bradycardia.A heart rate less than 60 beats/min w ith poor perfusion is an indication to begin chest compressions.In Our Case:Child has presented after seizures and is not havingactive seizures at present.Problems are:Hypoapnea (RR - 6 min).Bradycardia (HR - 66 min).Cyanosiso All these features are indicative of acute respiratory failure.o Bradycardia is secondary to hypoxia due to respiratory insufficiencyo At this stage the next step would be to ventilate the child (either by hag and mask followed by endotracheal intubation or directly intubating the child).Chest compressions are indicated when HR < 60 beats/min.
Give diazepam (seizures) and then give adrenaline and chest compression
Intubation followed by ventilation with O2 and give chest compression
O2 chest compression and adrenaline. LMA
IV Midazolam stat followed by LMA