"Purchase shallaki us, spasms and cramps".

T. Rendell, MD

Medical Instructor, Icahn School of Medicine at Mount Sinai

Dehydration also can be caused by a lot of vomiting, which often accompanies diarrhea. Treating Diarrhea: the most important measures in treating diarrhea are to: Prevent dehydration from occurring if possible Treat dehydration quickly and well if it does occur Feed the child 121 Pediatric Nursing and child health care 9. Mix well with a clean spoon until the powder is dissolved - Taste the solution so that you would know its taste like salt - Then give the child frequent small sips out of a cup or spoon. Chart for assessing dehydration in patients with diarrhea Two of the following signs: -Lethargic or unconscious - Sunken eyes -Not able to drink or drinking poorly -Skin pinch goes back very slowly. When water is offered to drink, is it taken normally, eagerly or is the patient unable to drink? Ask for other problems than dehydration: Ask about blood in the stool If blood is present, treat for 5 days with an oral antibiotic recommended for shigella in your area. See the child again after 2 days if: Under 1 year of age Initially dehydrated There is still blood in stool Not getting better If the stool is bloody after 2 days, change to a second oral antibiotic recommended for shigella in your area. If there is Falciparum malaria in the area and the child has any fever (38 or above) or history of fever in the past 5 days give anti-malarial treatment according to malaria program recommendation in your area 128 Pediatric Nursing and child health care 9. Treatment of Diarrhea Decide on appropriate treatment: After the examination, decide how to treat the child if the child has any of the signs in the column labeled "for other problems" specific treatment is needed in addition to treatment given for dehydration if there is blood in the stool and diarrhea for less than 14 days, the child has dysentry and appropriate antibiotics should be given if there is diarrhea for longer than 14 days with or without blood in the stool and/or if there is severe under nutrition, continue feeding the child and refer for treatment. Determine the degree of dehydration Look at the upper row, the assessing and classifying chart. Repeat once if radial pulse is still very weak or not detectable Reassess the patient every 1-2 hours. If the signs of dehydration are worse or remain unchanged rehydration therapy with treatment plan C should be continued. What important measures should be taken to prevent dehydration in children with diarrhea? What important pieces of advice would you give to the mother for home treatment of diarrhea? Older children are more likely to have acquired heart diseases such as rheumatic fever, endomyocardial fibrosis. Cyanosis can best be detected under the fingernails or on the mucus membranes of the mouth (lips, under side of the tongue). One of the main causes of this is chronic under saturation of the blood with oxygen. Signs of Cardiac Failure: Tachycardia-rapid pulse Tachyponea-rapid respiration Dyspnea-shortness of breath Edema and other signs of raised venous pressure Fatigue and failure to thrive Arrhythmia-irregular heart beat Systolic and more frequently diastolic murmurs Cough Orthophea Management: Any child with congestive heart failure should be referred to hospital whenever possible. Digitalization is most important In order to achieve effective blood levels quickly a digitizing dose is calculated and given over 24 hours. Abnormal communication in the heart or between big vessels Atrial septal defect Ventricular septal defect Patent ductus arteriosus In these due to the highest pressure in the left heart, there is a shunt from left to right heart with an increased blood load in lesser circulation. Congenital obstruction of the blood flow pulmonary stenosis aortic stenosis coarctation of the aorta) c. Any child with congestive heart failure should be referred to hospital whenever possible. In all cases where you have to start treatment: check weight of the child,record the pulse and respiration carefully at 2 hours intervals and indicate the exact time of any drugs given. Give prophylaxis against subacute bacterial endocarditis a well-timed comprehensive vaccination Prognosis: Many children with congenital heart disease die in early childhood. Rheumatic Heart Disease: Rheumatic fever is an inflammatory disease related to streptococcal infection affecting mostly the heart and joints, but also other tissues including the brain and skin. This is due to a specific reaction of tissues, mainly the heart and the joints, to the streptococcal toxins. Clinical Features: Painful swelling of one or more big joints (knee, ankle, elbow, shoulder) may last for one day or longer, subside and another joint may then be affected (rheumatic polyarthritis) Fever malaise rheumatic carditis (heart become enlarged murmur develops and sign Of congestive heart failure may occur. Etiology: a) Congenital heart disease (in the first 3 years of life) b) Acquired heart disease (rheumatic heart disease) c) Non cardiovascular causes (anemia, pulmonary disease.

After initial fluid resuscitation, and in the absence of a head injury, do not withhold analgesia. A recommended regime is: 50 microgm/kg intravenous bolus of morphine, followed by 10­20 microgm/kg increments at 10 minute intervals until an adequate response is achieved. If tracheal intubation is required, avoid cuffed tubes in children less than 10 years old so as to minimize subglottic swelling and ulceration. Shock in the paediatric patient the femoral artery in the groin and the brachial artery in the antecubital fossa are the best sites to palpate pulses in the child. Good sites are the long saphenous vein at the ankle and the femoral vein in the groin. Exposure of the child is necessary for assessment, but consider covering as soon as possible. Respiratory parameters and endotracheal tube size and placement Age Weight (kg) 1. Anatomical and physiological changes occur in pregnancy which are extremely important in the assessment of the pregnant trauma patient. Anatomical changes the size of the uterus gradually increases and becomes more vulnerable to damage both by blunt and penetrating injury ­ At 12 weeks of gestation the fundus is at the symphysis pubis ­ At 20 weeks it is at the umbilicus ­ At 36 weeks it is at the xiphoid the fetus at first is well protected by the thick walled uterus and large amounts of amniotic fluid. Physiological changes Increased tidal volume and respiratory alkalosis Increased heart rate 30% increased cardiac output Blood pressure is usually 15 mmHg lower Aortocaval compression in the third trimester with hypotension. Special issues in the traumatized pregnant female Blunt trauma may lead to: Uterine irritability and premature labour Partial or complete rupture of the uterus Partial or complete placental separation (up to 48 hours after trauma) With pelvic fracture, be aware of severe blood loss potential. Aortocaval compression must be prevented in resuscitation of the traumatized pregnant woman. Assess: Airway Breathing: beware of inhalation and rapid airway compromise Circulation: fluid replacement Disability: compartment syndrome Exposure: percentage area of burn. The severity of the burn is determined by: Burned surface area Depth of burn Other considerations. The burned surface area Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people. Burns greater than 15% in an adult, greater than 10% in a child, or any burn occurring in the very young or elderly are considered serious. The body is divided into anatomical regions that represent 9% (or multiples of 9%) of the total body surface (Figure 7). Clinical manifestations of inhalation injury may not appear for the first 24 hours. Depth of burn First degree burn Characteristics Erythema Pain Absence of blisters Second degree (partial thickness) Third degree (full thickness) Red or mottled Flash burns Dark and leathery Dry Fire Electricity or lightning Prolonged exposure to hot liquids/objects Contact with hot liquids Cause Sunburn It is common to find all three types within the same burn wound and the depth may change with time, especially if infection occurs. Burns to the face, neck, hands, feet, perineum and circumferential burns (those encircling a limb, neck, etc. Serious burn requiring hospitalization Greater than 15% burns in an adult Greater than 10% burns in a child Any burn in the very young, the elderly or the infirm Any full thickness burn Burns of special regions: face, hands, feet, perineum Circumferential burns Inhalation injury Associated trauma or significant pre-burn illness. Specific issues for burns patients the following principles can be used as a guide to detect and manage respiratory injury in the burn patient: Burns around the mouth Facial burns or singed facial or nasal hair Hoarseness, rasping cough Evidence of glottic oedema Circumferential, full-thickness burns of chest or neck. Nasotracheal or endotracheal intubation is indicated especially if patient has severe increasing hoarseness, difficulty swallowing secretions, or increased respiratory rate with history of inhalation injury. The burn patient requires at least 2­4 ml of crystalloid solution per kg body weight per percent body surface burn in the first 24 hours, starting from the time of the burn, to maintain an adequate circulating blood volume and provide adequate renal output. The estimated fluid volume is then proportioned in the following manner: One half of the total estimated fluid is provided in the first 8 hours post-burn the remaining one half is administered in the next 24 hours, to maintain an average urinary output of 0. This formula is only a rough guide and it is essential to reassess the fluid state of the patient regularly. Undertake the following, if possible: Pain relief Bladder catheterization if burn > 20% Nasogastric drainage Tetanus prophylaxis. Any patient who requires transportation must be effectively stabilized before departure. As a general principle, patients should be transported only if they are going to a facility that can provide a higher level of care.

Syndromes

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• Pregnancy
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