Practical skills in pediatrics: common pediatric emergencies

Acute heart failure (AHF) – a clinical syndrome, which is characterized by a decrease in cardiac output, tissue hypoperfusion, increased pressure in pulmonary capillaries and stagnant phenomena in tissues. AHF is determined by intracardiac or extracardiac mechanisms that can pass or cause the development of clinical syndrome or irreversible lesions with the development of chronic heart failure (Video).

• to provide free permeability of respiratory tract, tracheobronchial sanation;
• to maintain oxygen therapy (supplemental oxygen) with 30-40% oxygen (if possible in combination with a 10% antifomsilanum or a 30% ethanol solution) through a mask or nasal cannula, mechanical ventilation if necessary;
• loop diuretics (furosemide (lasix) 1-2 mg/kg to 4 times a day IV);
• glucocorticosteroids (prednisolone from 2-3 mg/kg to 5-7 mg/kg IV) with reduced blood pressure;
• with pronounced psychoemotional excitation of the child, sedatives (diazepam (seduxen) 0,1-0,3 mg/kg iv) are prescribed;
• with progressive pulmonary edema - 1% solution of trimeperidine (promedol) 0.05-0.1 ml/year of life or morphine (provided the absence of oppressed breathing).

In the case of reduced BP and the hypokinetic variant of myocardial insufficiency, cardiotonic agents are prescribed:

• sympathomimetic amines: infusion of dopamine in an average dose of 5-10 mg/kg/min or dobutamine - 5-15 mg/kg/min by using an infusion pump in order to increase heart emission in violation of blood circulation;
• adrenaline (epinephrine) at very low doses (0.03-0.1 mg/kg/min) should be used for children with cardiac insufficiency provided ineffectiveness of other drugs;
• infusion therapy using a 10% glucose solution with a 4% potassium chloride solution (panangin).  Daily flow of liquid is limited to 2/3 of age consumption, high-quality food;
• cardiometabolites (potassium preparations, cocarboxylase, riboxin, L-carnitine, mildronate, etc.) to improve metabolic processes in myocardium and correction of acid-base homeostasis;
• antimicrobial therapy (antibiotics of a wide spectrum of action iv) if necessary;
• mucolytics (acetylcysteine, etc.) according to indications;
• special treatment (correction of severe degrees of mitral stenosis, antiarrhythmic measures with arrhythmogenic form of heart failure, etc.);
• treatment of the main disease, which led to the development of acute left ventricular failure.

Acute Right Ventricular Failure

Acute Right Ventricular Failure is a pathological condition due to a sharp decrease in the operating capacity of the right parts of heart, which leads to a redistribution of circulating blood volume in a systemic circulation.  It is the result of a sudden reduction of blood flow in the lungs against the background of various diseases and pathological conditions (congenital heart failures, bronchial asthma attacks, pulmonary artery thromboembolism, lung atelectasis, foreign body of bronchi, hydrotorax, etc.).

Emergency assistance in acute right ventricular failure:

• to clarify and quick eliminate the reason that caused the development of a violent AHF (pneumothorax,  obstructive lung disease, a foreign body in the respiratory tract);
• to come down the child, let her/him lie down in bed with a slightly raised position of a head and dangling legs;
• to provide fresh air access, to carry out inhalation of 40-50% oxygen, mechanical ventilation if necessary;
• to control HR, BP, ECG, diuresis;
• loop    diuretics – furosemide  (lasix) 1% solution iv slowly by a dose 1-2 mg/kg;
• aminophylline (lat. euphyllinum) 2-3 mg/kg IV drip or inject slowly;
• with pulmonary embolism - heparin at a dose of 100-400 U/kg/day IV divided into 4-6 doses or fraxiparin 225 U/kg under the control of coagulogram and fibrinolytic agents (streptokinase in older children IV drip at a dose of 100 000 U dissolved in 50 ml of isotonic solution of NaCl), embolectomy;
• with arterial hypotension - dextran (rheopolyglucin) or its analogues at a dose of 5-10 ml/kg, IV inject slowly or drip; cardiotropic drugs (dopamine or dobutamine in the above doses);
• correction of acid-base balance and water-electrolyte balance;
• extremely careful use of peripheral vasodilators (nitroglycerin or sodium nitroprusside IV drip) in the intensive care unit;
• in case of pain and significant psychomotor excitation/agitation, inject 1% solution of promedol at a dose of 0.1-0.2 mg/kg (children over 2 years);
• with congenital cardiac malformations with reduced pulmonary circulation - myotropic antispasmodics (drotaverine, atropine) and beta-blockers propranolol (anaprilin);
• specific treatment aimed at treating the main disease complicated by the development of acute right ventricular heart failure: immediate hospitalization of the patient to the intensive care unit.

Breath-cyanotic attack (hypoxemic crisis)

Shortness of breath-cyanotic attack (hypoxemic crisis) is an attack of paroxysmal shortness of breath with severe cyanosis, which can be observed in children with congenital heart defects of the blue type, especially with tetralogy of Fallot (TOF). The onset of attacks is due to spasm of the outflow tract of the right ventricle and a decrease in pulmonary circulation, as a result of which a significant portion of venous blood due to a ventricular septal defect enters the aorta and progresses to hypoxemia of the systemic circulation.