She is describing egg anaphylaxis, a potentially fatal condition. The treatment of choice is intramuscular adrenaline, and effectively, without wasting too much time. The first thing is INTRAMUSCULAR adrenaline NOW! The venous route, corticosteroids, antihistamines, etc. will come later.

A 15-month-old boy, who during dinner, after eating a bite of tortilla, suddenly presented with facial reddening predominantly perioral, habonous lesions on the trunk and extremities and cough. On arrival at the center, the patient was conscious and, in addition to what was described above, the following were observed: suprasternal twitching, abundant watery rhinorrhea, bilateral hypoventilation without wheezing and capillary refill of less than 2 seconds. Of the following statements, indicate the CORRECT answer:

The priority is to cannulate a venous line.

Intramuscular methylprednisolone is the treatment of choice.

It is a picture of urticaria associated with asthma, and should be treated with antihistamines and inhaled bronchodilators.

Parents should be advised to transfer to a hospital emergency department.

Intramuscular adrenaline should be administered without further delay.

[Emergency due to allergy: the therapy--adrenaline for physicians and patients].

Emergency due to allergy may proceed within minutes to life-threatening respiratory and circulatory problems. Therefore, after diagnosis prompt and correct therapy might be vital. Because of its effect on alpha-, beta1-, and beta2-receptors, adrenaline is the treatment of choice in emergency due to allergy. For fear of cardiovascular side effects, often adrenaline is withheld even in case of anaphylaxis. If given properly such as an intramuscular injection the danger of undesirable side effects, however, is small. After a systemic, allergic reaction each patient needs to be equipped with rescue medications. If an adrenaline-containing device is prescribed--nowadays with EpiPen and the metered-dose inhaler Primatene Mist 2 systems are available--, the patient must get a correct instruction in its use. In case of a severe allergic reaction, antihistamines and corticosteroids are given in second line. Following any systemic allergy, an allergological work-up should be required. Only through exact diagnosis and profound patient's education, recurrences can be avoided, and in some cases, specific immunotherapy is indicated.

Randomized, double-blind, placebo-controlled trial of intravenous salbutamol and nebulized ipratropium bromide in early management of severe acute asthma in children presenting to an emergency department.

In acute severe asthma, treatment must be initiated early to reverse the pathophysiology that may render airways less responsive to bronchodilation. The addition of nebulized ipratropium bromide to initial emergency department therapy improves pulmonary function, but it is unclear whether this approach results in earlier hospital discharge. The early use of bolus intravenous salbutamol has also been shown to improve outcome, including earlier discharge. We therefore assessed the relative benefits of intravenous salbutamol and nebulized ipratropium bromide in the early management of acute severe asthma in children by a double-blind, randomized, controlled trial. This study was undertaken at a tertiary children's hospital, The Children's Hospital at Westmead, The Royal Alexandra Hospital for Children, Westmead, Sydney, Australia. Only children with severe acute asthma as determined by the National Asthma Campaign guidelines criteria and pulmonary index were included. All children received initial nebulized salbutamol therapy (2.5-5 mg salbutamol in 4 mL of normal saline depending on age) at initial emergency department presentation. If asthma remained severe 20 mins later, an intravenous cannula was inserted and intravenous methylprednisolone (1 mg/kg) was administered to all children receiving nebulized salbutamol every 20 mins. Children were then randomized to one of three groups: intravenous salbutamol (15 microg/kg as a single bolus over 10 mins), ipratropium bromide (250 microg), or intravenous salbutamol plus ipratropium bromide. All observers were blinded to treatment groups. Children were randomly assigned to receive a single-dose intravenous bolus of either saline or salbutamol and either nebulized saline or ipratropium bromide determined by a number generated randomly in the hospital pharmacy. The primary outcomes were recovery time and discharge time of each group. Respiratory and hemodynamic monitoring were continuous during the first 2 hrs of the study and then children were monitored clinically for 24 hrs. A total of 55 children with acute severe asthma were entered into the study over an 18-month period. The three groups were similar demographically, with a mean age of 5.9 yrs, and mean duration of attack of 19.6 hrs. No side effects or treatment intolerance were reported. Children in the groups that received intravenous salbutamol had a significant reduction in recovery time to achieving second hourly inhaled salbutamol (p =.008) compared with those administered inhaled bronchodilator alone. The addition of ipratropium bromide to intravenous salbutamol provided no significant further benefit in terms of nebulizer therapy (intravenous salbutamol compared with intravenous salbutamol plus ipratropium bromide). Children administered intravenous salbutamol ceased supplemental oxygen therapy earlier than those administered ipratropium alone at 12 hrs post-randomization (p =.0003). Children administered intravenous salbutamol could be discharged from the hospital 28 hrs earlier than those administered ipratropium bromide (p =.013). Children administered intravenous salbutamol for severe acute asthma showed a more rapid recovery time, which resulted in earlier discharge from the hospital than those administered inhaled ipratropium bromide. There was no additional benefit obtained by combining ipratropium bromide and intravenous salbutamol administration.

[Medical treatment of respiratory emergencies].

Of the four treatments that can be used to treat respiratory insufficiency due to laryngitis, two, nebulized adrenaline and O2 therapy, are undoubtedly effective. The inhalation of water vapour appears to be increasingly useless and may be also harmful. The use of steroids is still under debate. In recent literature, however, the utility of steroids seems to be confirmed, especially if administered per Os, and even at a relatively low single oral dose (1-2 mg/kg of prednisone). According to the official organs (see Red Book) and according to the Evidence Based Medicine (see Cochrane Library) the treatment of bronchiolitis should be limited to an eventual support therapy, i.e. O2 therapy and rehydration. However, the approach adopted by North American Hospitals and European specialists in infectious diseases is in contrast and consists in the use of beta 2 agonists and steroids in 90-100% and 40-80% of patients, respectively. This contrast could be due to a deficiency in the researches of the Evidenced Based Medicine which is obliged to retrieve studies done over 10-15 years in order to obtain a sufficient number of data for a statistically valid investigation. These studies unfortunately are not updated with regard to the dose of individual drugs and the immediate association of drugs. In particular, with regard to nebulized beta 2 agonists, the absence of a positive effect could be due to an excessively low dose in relation to the age of the patient. According to the most recent knowledge, in fact, reduced doses are no longer required for babies in consideration of age and weight. In reality an equal and even higher dose than that used in adults would be best. The other reason for a lack of response could be the absence of the association of a steroid with a beta 2 agonists at the right moment. The lack of timing in associating these two drugs could also account for the absent response to the steroid. On the basis of these considerations it would be a mistake to give up the use of beta 2 agonists and steroids. Considering also the severity and frequency of a disease as bronchiolitis. To follow the "fashion" of the Evidence Based Medicine. Recently, magnesium sulphate, ketamine and the association elium-O2 have been suggested as marginal and not revolutionary medical interventions for the treatment of asthma. Among bronchodilators, the subordinate role of anticholinergics (for ex. ipratropium bromide), and of adrenaline has been defined with respect to beta 2 agonists, in particular salbutamol. The optimisation of the administration by nebulizers of the latter has been fundamental as it has a key role in the treatment of acute severe asthma. In detail, traditional nebulizers tend to be substituted by Metered Dose Inhaler + spacer with a ratio in the dose of 5/1. The venous route is used only in very severe cases and is used late and in intensive care although a single initial intravenous administration could determine a more rapid reduction of bronchoconstriction and reduce the number of nebulized bronchodilatators that can become extremely frequent in most severe cases. For steroids, instead, the only safe therapeutic route is by PO, i.v., i.m.: nebulized steroids although used with a definitely higher dose than that used for chronic asthma, can be used only in the milder forms.

[Round Table: Severe asthma in pediatrics: treatment of acute crises].

Morbidity and mortality derived from asthma continue to be a main public health problem in many countries, in spite of the advances in the knowledge on the disease and its treatment. There are several risk factors for asthma attack which have to be considered in the management of patients in order to prevent exacerbations and mortality. Smooth bronchial muscle constriction and inflammation with oedema of the bronchial wall are the facts that cause airway flow and resistance disturbances, with hyperinflation, leading to a bigger respiratory work. On the other hand, the bronchial obstruction leads to a ventilation-perfusion disequilibrium and hypoxia. At the beginning of the process there is hypocarbia, but when the attack progresses muscle fatigue happens, and retention of CO2, being a sing of alarm (predictive of respiratory failure) a normal and rising PaCO2. The evaluation of an acute asthmatic patient should accomplish a clinical and objective assessment (peak flow rate and saturation of O2), in order to classify the crisis in: mild, moderate or severe. Managing acute asthmatic patient includes: oxygen, bronchodilator ss2 agonists at high and even continuous doses and systemic corticosteroids to prevent the progression and to control inflammation. These procedures should be promptly instituted. Although there is less evidence on their beneficial effects other measures as intravenous aminophylline, nebulized anticholynergics, magnesium sulphate and intravenous ss2 agonists may be used when the conventional therapy is not quickly successful and the patient is in a critical situation, at a real risk of respiratory failure, and in order to avoid mechanical ventilation. If this is finally instituted, controlled hypoventilation with permissive hypercarbia is now recommended, to avoid barotrauma, which used to be a frequent complication when more aggressive attitude was the rule. Interaction between paralytic agents and corticosteroids may produce a miopathy, so the recommendation now is to try not to use paralytic agents, even with profound sedation of needed. Sixty four patients were treated on 77 occasions in the Pediatric Intensive Care Unit of our hospital. They were 0,5 to 13,9 years old, being 50% less than 5 years old. It was the first attack in 9 (14%) patients. The standard management consisted of oxygen, frequently or continuously nebulized salbutamol and intravenous methylprednisolone (1 to 6 mg/kg/day). Furthermore nebulized ipratropium bromide was administered 58 times (75%), as well as intravenous aminophylline 69 (89%), intravenous salbutamol 23 (30%), magnesium sulphate 16 (21%) and ketamine 10 (13%). Antibiotics were given 22 times (29%). Two 15 month old infants received mechanical ventilation in three occasions, and relevant complications happened (pneumothorax and myopathy, and pneumomediastinum and bronchiolitis obliterans respectively). Fifty six patients have been followed for a period of 3 to 110 months (median 48 months), and 16 (29%) have needed high doses (equal to or move than 800 mcg of budesonide or equivalent). There are data on lung function in 36 of them, FEV1 is normal (> 85% of predicted, between 86 and 127) in 26 (78%) and < 85% (65 to 84%) of predicted in 8 (22%) FEV1 rises more than 15% (16 to 23%) in four patients after the inhalation of a ss2 agonist. Inhaled anesthetic agents and heliox have been used in some pediatric cases. After a severe asthma attack the strategy of management should be reviewed, as well as the possible risk factors.

Shortness of breath

Asthma Asthma is the most common reason for presenting to the emergency room with shortness of breath. It is the most common lung disease in both developing and developed countries affecting about 5% of the population. Other symptoms include wheezing, tightness in the chest, and a non productive cough. Inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate. Acute symptoms are treated with short-acting bronchodilators. Pneumothorax Pneumothorax presents typically with pleuritic chest pain of acute onset and shortness of breath not improved with oxygen. Physical findings may include absent breath sounds on one side of the chest, jugular venous distension, and tracheal deviation.

Pediatrics_Nelson

Anaphylaxis is a medical emergency; prompt recognition and immediate treatment are crucial (Fig. 81-2). Early administration of intramuscular epinephrine is the mainstay of therapy and should be given at the same time that basic measures of cardiopulmonary resuscitation are being performed. If the child is not in a medical setting, emergency medical services should be called. Supplemental oxygen and intravenous fluid should be administered with the child lying in supine position. An airway must be secured; intubation or tracheotomy may be required. Additional pharmacologic therapies, such as corticosteroids, antihistamines, H2-receptor antagonists, and bronchodilators, may be given to improve symptoms. Up to 20% of people with anaphylaxis have biphasic or protracted anaphylaxis.

Methylprednisolone

In 2001–2002, 11.4% of patients diagnosed with asthma and seen at an outpatient visit were prescribed oral corticosteroids as a long-term control therapy. The National Asthma Education and Prevention Program (NAEPP) indicates systemic methylprednisolone in both short and long term therapies to quickly control and to suppress persistent asthma, respectively. For exacerbations that result in a visit to the Emergency Department (ED), oral methylprednisolone is preferred over intravenous administration, unless there are issues with adherence or vomiting. Oral methylprednisolone is less invasive and studies have shown that equivalent efficacy compared to intravenous methylprednisolone. Dosage above 60–80 mg/day or 2 mg/kg/day is not recommended as it has not been shown to alter pulmonary function, rate of admission, or length of stay in the hospital compared to lower doses. Following ED discharge, it is advised to prescribed a five-day course of methylprednisolone to decrease the

Pediatrics_Nelson

First-line management of asthma exacerbations includes supplemental oxygen, repetitive, or continuous administration of short-acting bronchodilators. Early administration of oral or intravenous corticosteroids (Fig. 78-4) is important in treating the underlying inflammation. Administration of anticholinergic agents (ipratropium) with bronchodilators decreases rates of hospitalization and duration of time in the emergency department. Intravenous magnesium sulfate is given in the emergency department if there is clinical deterioration, despite treatment with β2-agonists, ipratropium, and systemic glucocorticoids. The typical dose is 25 to 75 mg/kg (maximum 2.0 g) intravenously administered over 20 minutes. Epinephrine (intramuscular) or terbutaline (subcutaneous) is rarely used except when severe asthma is associated with anaphylaxis or unresponsive to continuous administration of short-acting bronchodilators.

Anaphylaxis

Epinephrine Epinephrine (adrenaline) (1 in 1,000) is the primary treatment for anaphylaxis with no absolute contraindication to its use. It is recommended that an epinephrine solution be given intramuscularly into the mid anterolateral thigh as soon as the diagnosis is suspected. The injection may be repeated every 5 to 15 minutes if there is insufficient response. A second dose is needed in 16–35% of episodes with more than two doses rarely required. The intramuscular route is preferred over subcutaneous administration because the latter may have delayed absorption. It is recommended that after diagnosis and treatment of anaphylaxis, the patient should be kept under observation in an appropriate clinical setting until symptoms have fully resolved. Minor adverse effects from epinephrine include tremors, anxiety, headaches, and palpitations.

Pediatric Bronchospasm -- Treatment / Management -- Anaphylaxis

First assess the airway, breathing, and circulation of the patient. Place the child on a cardiorespiratory monitor, provide supplemental oxygen, and acquire intravenous or intraosseous access for aggressive volume resuscitation. Epinephrine is the most important treatment. As readily as possible, administer intramuscular epinephrine to the anterolateral surface of the child’s mid-thigh. [16] Intramuscular epinephrine is preferred over intravenous because it is typically faster to administer, has fewer cardiovascular complications (arrhythmias, myocardial ischemia, hypertension), and has less dosing errors. [17] Avoid subcutaneous epinephrine administration, as it is slower to absorb than intramuscular, has inconsistent pharmacodynamics, and the response is unreliable. [16] Epinephrine dosing is repeatable every five to 15 minutes. If the patient is hemodynamically unstable and not responding to repeated doses of intramuscular epinephrine and fluid resuscitation, then an intravenous epinephrine infusion can be initiated. If stridor, other signs of airway involvement, or severe respiratory compromise are present, the child should undergo immediate intubation. If the healthcare provider is unable to secure an airway, an emergent cricothyroidotomy or tracheostomy should be performed. Additional therapies used in conjunction with epinephrine are H1 antihistamines (i.e., diphenhydramine), H2 antihistamines (i.e., ranitidine), bronchodilators, and glucocorticoids. If bronchospasm is present and unresponsive to epinephrine, inhaled bronchodilators use is necessary.

Meningococcal disease

Treatment When meningococcal disease is suspected, treatment must be started immediately and should not be delayed while waiting for investigations. Treatment in primary care usually involves prompt intramuscular administration of benzylpenicillin, and then an urgent transfer to hospital (hopefully, an academic level I medical center, or at least a hospital with round the clock neurological care, ideally with neurological intensive and critical care units) for further care. Once in the hospital, the antibiotics of choice are usually IV broad spectrum 3rd generation cephalosporins, e.g., cefotaxime or ceftriaxone. Benzylpenicillin and chloramphenicol are also effective. Supportive measures include IV fluids, oxygen, inotropic support, e.g., dopamine or dobutamine and management of raised intracranial pressure. Steroid therapy may help in some adult patients, but is unlikely to affect long term outcomes.

Early use of inhaled nedocromil sodium in children following an acute episode of asthma.

Current guidelines on the treatment of childhood asthma recommend the introduction of an anti-inflammatory drug in children who have persistent symptoms and require regular treatment with a bronchodilator. The efficacy and safety of inhaled nedocromil sodium (Tilade Mint aerosol) administered using a Fisonair spacer at a dose of 4 mg three times daily was compared with placebo in the treatment of asthmatic children aged 6-12 years who are symptomatic and recovering from an acute exacerbation of asthma. A group comparative, double blind, placebo controlled trial was performed in children who were recovering from an acute episode of asthma following treatment in the emergency department of the hospital or in children referred from their general practitioner following a wheezing episode and documented evidence of at least two previous episodes of wheezing. A two week baseline period on existing bronchodilator treatment was followed by a 12 week treatment period on either nedocromil sodium (2 mg/puff) or placebo. Both treatments were administered using a Fisonair spacer at a dose of two puffs three times daily. Changes from baseline values in daytime asthma and night time asthma symptom scores, usage of rescue bronchodilators, mean peak expiratory flow (PEF) recorded twice daily on diary cards, patients' opinion of treatment, and withdrawals due to treatment failure were measured during the primary treatment period (last six weeks of treatment). One hundred and forty two children aged 6-12 years entered the baseline period. Sixty three were withdrawn due to failure to meet the entry criteria (18) or the criteria for asthma symptom severity (15) or reversibility (9), because they developed uncontrolled asthma (2), because they took disallowed treatment (2), or for other non-trial related reasons (17). Seventy nine patients (46 boys) of mean age 8. 8 years entered the treatment period. There were significant differences in the changes from baseline values during the last six weeks of treatment in favour of nedocromil sodium compared with placebo in the primary variables of daytime asthma and night time asthma, morning and evening PEF, and the usage of rescue inhaled bronchodilators; 53% of patients reported nedocromil sodium to be very or moderately effective compared with 44% placebo. Improvement in asthma symptoms, PEF, and reduction in use of rescue bronchodilators did not reach statistical significance until after six weeks of treatment. Twenty two patients were withdrawn or dropped out during the treatment phase, 12 due to uncontrolled asthma or persistence of asthma symptoms, four due to suspected adverse drug reactions (nedocromil sodium 3 (headaches 2, angio-oedema/urticaria 1), placebo 1(persistent cough)), and six due to non-treatment related reasons. Seventy one adverse events were reported by 27 patients in the nedocromil group and 75 by 30 patients in the placebo group. Asthma symptoms, use of bronchodilators, and lung function can be improved significantly in children recovering from an acute exacerbation of asthma or wheeze and currently receiving treatment with bronchodilators alone by the addition of inhaled nedocromil sodium at a dose of 4 mg three times daily administered using a Fisonair holding chamber.

[A notice for use for patients who benifit from an adrenaline pen. "Having an emergency kit is a good thing but knowing how to use it is better"].

We realized that it is essential that the patient who has an auto injector also has the direction sheet in its emergency bag. Patients, families but also young medical doctors' remarks and reflexions led us to create an explanatory didactic, precise, illustrated and practical direction sheet. The goals are to gather succinct information about the patient (personal contact information, medical history); remind emergency numbers (15 or 112) and the emergency treatment (antihistamine, broncholitor if necessary, epinephrine shots). It also indicates step by step how to use the auto injector (Anapen) and emphasizes the need for a medical supervision if the shot has been used. We present this direction sheet and the way to use it.

Diffuse capillary malformation with overgrowth

Small CMs are typically benign and require no treatment. Large CMs should be treated due to aesthetic reasons and societal exclusion, as they have a higher tendency to hypertrophy. Pulse-dye laser photocoagulation should be used for large CM. Therapy should be initiated before the age of 6 months. Laser treatments typically have greater efficacy for CMs on face than non-facial areas such as distal extremities. Potential explanations for reduced efficacy in extremities include greater lesion size and deeper location of vessels due to thicker epidermis. Patients may be less inclined to pursue treatments for non-facial lesions due to lesser visibility and financial burden of multiple laser treatment sessions necessary for visible improvement. As DCMO frequently involves trunk and lower extremities, more studies are needed to improve laser treatment in non-facial areas and identify barriers to treatment.

Cough

Asthma is a common cause of chronic cough in adults and children. Coughing may be the only symptom the person has from their asthma, or asthma symptoms may also include wheezing, shortness of breath, and a tight feeling in their chest. Depending on how severe the asthma is, it can be treated with bronchodilators (medicine which causes the airways to open up) or inhaled steroids. Treatment of the asthma should make the cough go away. Chronic bronchitis is defined clinically as a persistent cough that produces sputum (phlegm) and mucus, for at least three months in two consecutive years. Chronic bronchitis is often the cause of "smoker's cough". The tobacco smoke causes inflammation, secretion of mucus into the airway, and difficulty clearing that mucus out of the airways. Coughing helps clear those secretions out. May be treated by quitting smoking. May also be caused by pneumoconiosis and long-term fume inhalation.

Acute upper airway obstruction.

Upper airway obstruction is defined as blockage of any portion of the airway above the thoracic inlet. Stridor, suprasternal retractions, and change of voice are the sentinel signs of upper airway obstruction. Most of the common causes among children presenting to emergency department are of acute infectious etiology. Among these, croup is the commonest while diphteria remains the most serious life-threatening cause. Recent reports indicate that bacterial tracheitis has become increasingly common. In ER evaluation the key clinical data in determining the cause and the site of obstruction are the onset, presence of fever, character of the stridor, retractions, the voice and the ability to handle secretions. After assessment of the severity of respiratory distress and resuscitative or supportive therapy including oxygen and emergent airway, specific treatment is directed at underlying etiology. All patients with audible stridor require early endotracheal intubation/tracheostomy. In croup the mainstay of treatment are cold humidified oxygen, budesonide nebulization ( in mild cases), Dexamethasone 0.6 mg/kg iv or im (in moderate and severe cases), and Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization ( in severe cases). In diphtheria, early tracheostomy, anti-diphtheric serum and injectable penicillin are critical. Bacterial Tracheitis and Retropharyngeal abscess need early administration of injectable Cloxacillin, Amikacin and Clindamycin. ENT consultation should be obtained for early surgical drainage of retropharyngeal abscess. Angioneurotic edema is treated with subcutaneous adrenaline (1:1000, 0.01 ml/kg); hydrocortisone 10 mg/kg IV and antihistamines. Patients with severe obstruction and those with endotracheal tube/ trachesotomy should be transferred to PICU.

Atypical antipsychotic medication poisoning: an evidence-based consensus guideline for out-of-hospital management.

The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and out-of-hospital management of patients with suspected acute ingestions of atypical antipsychotic medications by 1) describing the process by which an ingestion of an atypical antipsychotic medication might be evaluated, 2) identifying the key decision elements in managing cases of atypical antipsychotic medication ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of atypical antipsychotic medications alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or the recipient of a potentially malicious administration of an atypical antipsychotic medication should be referred to an emergency department immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) Patients without evidence of self-harm should have further evaluation, including determination of the precise dose ingested, presence of signs or symptoms of toxicity, history of other medical conditions, and the presence of co-ingestants (Grade C). 3) Asymptomatic patients without evidence of attempted self-harm are unlikely to develop symptoms if the interval between the ingestion and the call is greater than 6 hours. These patients do not need referral and should receive follow-up based on local poison center protocols (Grade C). 4) All patients less than 12 years of age who are naïve to atypical antipsychotic medications and are experiencing no more than mild drowsiness (lightly sedated and can be aroused with speaking voice or light touch) can be observed at home unless they have ingested more than four times the initial adult dose for the implicated antipsychotic medication or a dose that is equal to or more than the lowest reported acute dose that resulted in at least moderate toxicity, whichever dose is smaller (i.e., aripiprazole 15 mg, clozapine 50 mg, olanzapine 10 mg, quetiapine 100 mg, risperidone 1 mg, ziprasidone 80 mg) (Grade D). 5) All patients 12 years of age or older who are naïve to atypical antipsychotic medications and are experiencing no more than mild drowsiness can be observed at home unless they have ingested more than five times the initial adult dose for the implicated antipsychotic medication (i.e., aripiprazole 50 mg, clozapine 62.5 mg, olanzapine 25 mg, quetiapine 125 mg, risperidone 5 mg, ziprasidone 100 mg) (Grade D). 6) Patients who use atypical antipsychotic medications on a chronic basis can be observed at home unless they have acutely ingested more than 5 times their current single dose (not daily dose) of the implicated antipsychotic medication (Grade C). 7) Patients who have ingested less than a threshold dose (see Recommendations 4-6) and are exhibiting no more than mild drowsiness can be observed at home with instructions to call the poison center if symptoms develop or worsen. If mild drowsiness is present at the time of the initial call, the poison center should make follow-up calls until at least 6 hours after ingestion. Consideration should be given to the time of day that home observation will take place. Observation during normal sleep hours might not be reliable. Depending on local poison center policy, patients could be referred to an emergency department if the observation would take place during normal sleeping hours of the patient or caretaker (Grade D). 8) Any patient already experiencing any signs or symptoms, other than mild drowsiness, thought to be related to atypical antipsychotic medication toxicity should be transported to an emergency department. Transportation via ambulance should be considered based on the condition of the patient and the length of time it will take the patient to arrive at the emergency department (Grade D). 9) Do not induce emesis (Grade D). 10) There are no specific data to suggest benefit from out-of-hospital administration of activated charcoal in patients exposed to atypical antipsychotic medications. Poison centers should follow local protocols and experience with the out-of-hospital use of activated charcoal in this context. Do not delay transportation in order to administer charcoal (Grade D). 11) For patients who merit evaluation in an emergency department, transportation via ambulance should be considered based on the condition of the patient and the length of time it will take the patient to arrive at the emergency department. Continuous cardiac monitoring should be implemented given reports of conduction disturbances associated with this class of medications. Provide usual supportive care en route to the hospital, including airway management and intravenous fluids for hypotension (Grade D). 12) Depending on the specific circumstances, follow-up calls should be made to determine outcome at appropriate intervals based on the clinical judgment of the poison center staff (Grade D).

[Childhood croup].

Hoarseness, whooping cough and stridor are elements of a syndrome of upper airway obstruction. In childhood, acute laryngotracheobronchitis is by far the commonest cause of this syndrome. Yet, the differential diagnosis includes a number of rare and severe entities. In many cases, the traditional distinction between viral and spasmodic types is not possible. The value of humidifying therapy has not been established. In severe cases, nebulized adrenaline is of benefit but should be reserved for hospital. The effect lasts only two hours and at times a rebound effect is observed. It is now realized that some patients treated with adrenaline can safely be discharged after a two to three hours observation. There is a large body of evidence that all children arriving at the emergency department with croup should receive steroids without delay. This policy results in a much better outcome, with important reduction in hospitalizations, intensive care unit admissions and incubations. Oral dexamethasone is the drug of choice: it is as effective, easier to administer and cheaper than nebulised budesonide. In most studies, dexamethasone has been used at a dose of 0.6 mg/kg but there is some evidence that 0.15 mg/kg may be just as effective.

Hypoglycemia

If the person is unconscious, a glucagon kit may be used to treat severe hypoglycemia, which delivers glucagon either by injection into a muscle or through nasal inhalation. In the United States, glucacon kits are available by prescription for diabetic patients to carry in case of an episode of severe hypoglycemia. Emergency services should be called for further assitance. Treatment by medical professionals In a healthcare setting, treatment depends on the severity of symptoms and intravenous access. If a patient is conscious and able to swallow safely, food or drink may be administered, as well as glucose tabs or gel. In those with intravenous access, 25 grams of 50% dextrose is commonly administered. When there is no intravenous access, intramuscular or intra-nasal glucagon may be administered.

Early administration of hydrocortisone in the emergency room treatment of acute asthma: a controlled clinical trial.

To determine whether early administration of a single dose of intravenous hydrocortisone (500 mg) modified the need for hospitalization and duration of treatment, and improve pulmonary function assessed by subjective and objective criteria of acute asthma patients. Randomized, double-blind, placebo-controlled trial. The emergency room (ER) of a large, urban hospital with primary and referral care responsibilities. Ninety-eight patients from 18 to 50 years of age with acute bronchial asthma, with a PEFR and FEV1 in the first second below 50% of predicted value (FEV1 mean % of predicted = 27.8 +/- 10.0) and without history of chronic cough or other medical disease. The corticosteroid group received 500 mg of intravenous hydrocortisone whereas the control group received intravenous normal saline immediately after arrival to the ER. Additional treatment included salbutamol delivered with metered-dose inhaler into a spacer device (Volumatic), in four puffs actuated in rapid succession (100 micrograms per actuation), at 10-min intervals. The final mean dose was 5.7 mg for the steroid group and 5.6 mg for the control one (P = 0.86). Hospitalization was mandatory if total treatment time was greater than 6 h. Age, sex, PEFR, FEV1, FVC, symptom index, and corticosteroids use were similar in both groups. FEV1 expressed as mean % of predicted was 54.6 +/- 17.3% in the control group and 54.6 +/- 17.4% in the steroid group (P = 0.75). Duration of ER treatment was 2.22 +/- 1.75 h in the corticosteroid group and 2.24 +/- 1.70 h in the control group (P = 0.81). The hospital admission rate was 10.2% for the corticosteroid group and 8.16% for the control group. There were no differences between the groups when patients admitted or discharged were examined separately. Early administration of corticosteroids does not modify outcome of ER treatment of asthma, and does not improve pulmonary function in the first 6 h of treatment. In accord with this, administration of corticosteroids to these patients could be delayed by several hours without modifying clinical outcome. When an aggressive beta-agonist bronchodilator regimen is used, it obviates the need for steroids in this early stage of treatment.

Single Intramuscular Methylprednisolone dose in Asthma and Chronic Obstructive Pulmonary Disease Patients on Discharge.

In this pilot study we aimed to evaluate the safety of a single intramuscular methylprednisolone (IM) injection at the time of discharge as a replacement for oral steroid therapy for patients in our population with asthma or chronic obstructive pulmonary disease (COPD). This proof-of-concept, open label clinical trial without randomisation was conducted at the Pulmonary Department of Ziauddin Hospital and University, Karachi from January 2018 to March 2018. Patients discharged after in-hospital treatment for exacerbations of either asthma or COPD were recruited for this study. Intramuscular injection of methylprednisolone was administered to these patients who were then followed-up after one week and one month. During that period, information was collected of the patients' self-report of any unscheduled emergency room visit, blood sugar and blood pressure control, symptoms suggestive of thrush, increase gastric acidity and weight gain. For the data analysis, frequency and percentages were calculated with SPSS version 21. A total of 30 patients aged 52.83 ± 14.27 years were recruited for this pilot study. At one month follow-up, no unscheduled emergency room visits were observed in all of the study patients. Symptoms suggestive of oral thrush were recorded in only 2 (6.7%) patients and weight gain was reported by only 5 (16.7%). Controlled blood sugar and blood pressure was reported by all the patients. No incidence of nocturnal symptoms, awakening and dyspepsia were reported. A single dose of methylprednisolone injection without any obvious side effects over one month among patients with asthma and COPD demonstrated a safe strategy for them.

First_Aid_Step2

Mild cases: Outpatient management with cool mist therapy and ﬂ uids. Moderate cases: May require supplemental O2, oral and IM corticosteroids, and nebulized racemic epinephrine. Severe cases (e.g., respiratory distress at rest, inspiratory stridor): Hospitalize and give nebulized racemic epinephrine. A serious and rapidly progressive infection of supraglottic structures (e.g., the epiglottis and aryepiglottic folds). Prior to immunization, H. inﬂ uenzae type b was the 1° pathogen. Common causes now include Streptococcus species, Epiglottitis can lead to nontypable H. inﬂ uenzae, and viral agents. obstruction. Presents with acute-onset high fever (39–40°C), dysphagia, drooling, a mufﬂed voice, inspiratory retractions, cyanosis, and soft stridor. Patients sit with the neck hyperextended and the chin protruding (“sniffing dog” position) and lean forward in a “tripod” position to maximize air entry.

[Serious systemic adverse events associated with allergen-specific immunotherapy in children with asthma].

To retrospectively assess serious systemic adverse effects of standardized dust-mite vaccine in children with asthma. Medical records of 704 children (5-17 years in age) with asthma between January, 2005 and December, 2011 were reviewed. Serious systemic adverse events following treatment with a standardized dust-mite vaccine in these children were analyzed. A total of 336 systemic adverse reactions were observed in 17.0% (120/704) of the patients analyzed of these adverse reactions, 18 (5.4%) were serious (level 3), 318 (94.6%) were not serious (below level 3), and no single case of anaphylactic shock (level 4) was recorded. Systemic adverse events occurred most frequently in the 5 to 11-year age group and in the summer season (from June to August). In the 18 severe cases, the peak expiratory flow (PEF) dropped by 20% immediately after the vaccine injection, and other major clinical symptoms included cough, wheezing and urticaria. All children with serious systemic adverse effects were given inhaled hormone and atomized short-acting beta agonists, oral antihistamines, intravenous dexamethasone and/or intramuscular adrenaline. After these treatments, the clinical symptoms were significantly relieved. The rate of serious systemic adverse events following allergen-specific immunotherapy is relatively low in children with allergic asthma. Conventional medications are effective in managing these immunotherapy-associated adverse events.

[Drug administration via the endobronchial route. Possibilities of drug administration in emergency medicine].

For cardiopulmonary resuscitation, the endobronchial route represents a good means of administering drugs with a systemic effect, such as adrenaline and atropine, even without a venous line. Via this route, however, higher doses are needed (2.5 times as much as those normally given intravenously). In order to produce a larger surface area within the bronchio-alveolar space and thus speed up absorption, the drugs are diluted in 5-10 ml solvent (isotonic saline solution or distilled water). For endobronchial administration of a drug, various techniques are employed, for example, simply injecting it into the upper end of the (endotracheal) tube, puncture of the tube the use of an application probe introduced into the endobronchial tube, aspiration or venacaval catheter, or the EDGAR tube with an injection needle incorporated within the tube wall. After injection, the diluted medication is distributed into the tiny branches of the bronchial tree by repeated hyperventilation. Despite the need for an adequate alternative to the venous route in the field of cardiopulmonary resuscitation, we still have very few reliable facts about the endobronchial application technique.

THE CASE OF A 14-YEAR-OLD BOY WHO EXPERIENCED ANAPHYLAXIS DUE TO JELLYFISH (MASTIGIAS PAPUA) INGESTION.

We report a case of jellyfish allergy diagnosed via an oral food challenge. A 14-year-old boy had no history of jellyfish stings and had been eating commercially available jellyfish products twice yearly for the past 5-6 years. Five minutes after eating a commercially available boiled jellyfish product (100g), he experienced nausea, wheezing, and erythema and had visited our hospital. We suspected an anaphylactic reaction and treated him with intramuscular adrenaline injection, corticosteroid and antihistamine infusions, volume resuscitation, and salbutamol sulfate inhalation, which resulted in an improvement of the symptoms. One-month later in our hospital, we administered an oral food challenge of the same boiled jellyfish product bought at the same grocery store to the patient. After ingesting 14g of boiled jellyfish, he experienced erythema, wheezing, nausea, and abdominal pain. Several reports have described anaphylaxis caused by the ingestion of jellyfish, but the allergens in jellyfish have not been analyzed. A skin prick test for poly-gamma-glutamic acid (PGA) which is a component of jellyfish stings was negative. This suggests that he was sensitized to some allergen other than PGA via a route different from that of jellyfish sting. Our skin prick test for several kinds of edible jellyfish suggests that allergenicity may be different for different jellyfish.

[Suffocation attack].

An acute attack of suffocation is a life threatening event which may be fatal within minutes. Since the oxygen stores of the body are small, any interruption of oxygen uptake by the lungs results in immediate anoxia of tissue and in particular in perilous cerebral anoxia. The primary aims in the management of this emergency situation are: (1.) opening of the airways, clearing any obstruction, and keeping airways open; (2.) administration of oxygen and, if possible, assisted ventilation. This "reflex management" will gain time for diagnostic evaluation, for the decision about further management and, in most cases, for safe transport to the nearest emergency hospital. Further emergency measures are required in the case of upper airway obstruction due either to a foreign body or to laryngeal edema caused by local insect stings or anaphylaxis. Occasionally a foreign body obstructing the upper airways can be cleared using the Heimlich maneuver, i.e. rapid inward and upward pressure on the victim's epigastrium. Mild forms of laryngeal edema can be relieved by inhalation of epinephrine. If these methods fail, cricothyroidotomy or transtracheal ventilation must be performed. Patients with acute severe asthma must be immediately treated with inhalations of a beta-agonist, parenteral prednisolone and administration of oxygen, while emergency transport to the nearest hospital must be organized. To ensure first aid the emergency physician must be equipped with the necessary instruments such as a small oxygen cylinder, appropriate cannula with connectors and tubings for transtracheal ventilation, and a suitable bag-valve-mask device.

[It is all about the form - adrenaline in anaphylaxis: intravenous or intramuscular administration?]

Medication errors are a frequent problem in the accident and emergency (A&E) department. A 17-year-old boy was referred to our A&E department with an anaphylactic reaction to peanuts. Because of various shortcomings in the care process in A&E, adrenaline was administered intravenously instead of intramuscularly, resulting in a broad complex tachycardia. We analysed these shortcomings using the 'Prevention and recovery information system for monitoring and analysis' (PRISMA) method. Medication errors are usually a result of shortcomings in non-technical skills, such as communication and situational awareness. Training these skills by applying the concept 'Crew resource management' may reduce medication errors and improve patient safety.

Special problems in the management of chronic asthma in children.

Children with asthma may be misdiagnosed when they present with chronic cough or wheezing following an upper respiratory infection. Such children are more appropriately treated with bronchodilators than with antibiotics and cough medicine. Failure to recognise these presentations of childhood asthma often lead to its increased morbidity. Inappropriate bronchodilator therapy and the failure to consider prophylactic drugs are common causes of poor control of childhood asthma. Wherever possible, the beta 2-sympathomimetics should be prescribed in the inhaled form. The inhalation methods and devices employed should be appropriate for the age of the child. Steroids are often necessary for good control in children with chronic asthma. Fear of their systemic side-effects may delay their use. These side-effects can be avoided if the inhaled beclomethasone dipropionate is used. The majority of chronic asthmatic children will improve with beclomethasone dipropionate without the need for additional oral steroids. It is important to note that successful management of childhood asthma does not only depend on the appropriate use of drugs but also the education of the child and parents on asthma.

[Clinical management of upper airway obstruction: epiglottitis and laryngotracheobronchitis]

OBJECTIVE: To present current concepts on diagnosis and treatment of upper airway obstruction, mainly related to differential diagnosis between acute viral laryngotracheobronchitis and epiglottitis.METHODS: Bibliographic review covering the last ten years, using both Medline system and direct research. The most relevant articles published about the subject were selected.RESULTS: Viral laryngotracheobronchitis is an acute self-limited disease of the upper airway in a child, clinically characterized by barking cough, stridor, hoarse voice, and upper respiratory symptoms. The disease is diagnosed by clinical signs and symptoms. Rarely, if no immediate airway management is needed, radiography of the neck may help to exclude other entities that cause laryngeal obstruction. In contrast to viral laryngotracheobronchitis, epiglottitis is characterized by inflammation of the supraglottic tissues and is caused mainly by Haemophilus influenzae type b. A previously healthy child suddenly develops a sore throat and fever. Within hours after the onset of symptoms the patient looks toxic, swallowing is painful and breathing is difficult. Drooling and cervical hyperextension are frequently present. Lateral neck radiograph is rarely required to the diagnosis and may delay appropriate management of the airway. Moderate viral laryngotracheobronchitis with stridor at rest and retractions should be treated with steroids (systemic or nebulized) and nebulized epinephrine. Severe viral laryngotracheobronchitis should be treated aggressively while arregements are made for endotracheal intubation. The diagnosis of epiglottitis requires immediate endotracheal intubation in the appropriate unit (emergency department, intensive care unit or surgical unit) and antimicrobial therapy. Alternatively at some medical centers children with severe upper airway obstruction have been treated with a mixture of helium and oxygen (70 to 80% concentration of helium) instead of room air or pure oxygen to avoid intubation.CONCLUSIONS: There are different levels of care for patients with upper airway obstruction, depending on their clinical presentation. The clinical manifestations of viral laryngotracheobronchitis may be confused with the presentation of epiglottitis. Despite this observation we believe that differential diagnosis between viral laryngotracheobronchitis and epiglottitis rests on clinical grounds.

Kounis syndrome

Management The management of these patients may be challenging for clinicians. Although beta blockers can be beneficial in ACS, they are contraindicated in Kounis syndrome. In allergic ACS, blocking beta receptors while giving epinephrine (which is the basis of treatment of anaphylaxis) can lead to an unopposed activity of α-adrenergic receptors which would aggravate the coronary spasm. Also opioids, indicated to relieve chest pain, may induce massive mast cell degranulation which in turn will worsen the anaphylaxis. They should hence be given carefully in such patients Type I variant Type I variant is treated based on its clinical presentation and how severe the allergic reaction is. If it is a mild reaction, then antihistamines and corticosteroids can help control the symptoms. If the patient’s presentation involves anaphylaxis, intramuscular adrenaline should be given.

[Allergic emergencies].

Both anaphylactic reactions and angioedema in the head and neck area can be life-threatening and require emergency treatment. Therapy needed is primarily directed by the patient's symptoms. The first measures taken should consist of immediate disruption of the allergen contact, adequate positioning of the patient, the insertion of an intravenous catheter and an emergency call. In case of cardiovascular or respiratory involvement, intramuscular ± inhalative adrenalin is the treatment of choice. In case of cardiovascular involvement, volume substitution by intravenous catheter and oxygen administration are crucial and in lower airway obstruction, additionally short-acting beta mimetics should be inhaled. Intravenous H1-antihistamines and glucocorticoids are added. Allergic reaction confined to the skin and mucosal surfaces without respiratory involvement or to the gastrointestinal tract should also be treated with intravenous H1-antihistamines and glucocorticoids. Angioedema in the head and neck area can, however, also be associated with a life-threatening upper airway obstruction. Histamine-induced angioedema should be treated as anaphylaxis involving the upper respiratory tract. In hereditary angioedema, or in unclassified angioedema unresponsive to therapy, early airway maintenance and subcutaneous injection of bradykinin-receptor antagonist icatibant, intravenous injection of C1-inhibitor concentrate or fresh frozen plasma is recommended. The same approach should be taken for severe angiotensin converting enzyme inhibitor-induced angioedema with dyspnea. Intubation by skilled personal is indicated in inspiratory stridor and dyspnea at rest. In all cases of anaphylaxis or angioemdema, patients should be surveyed until a safe remission is achieved.

Symptomatic improvement following emergency department management of asthma: a pilot study of intramuscular dexamethasone versus oral prednisone.

Systemic corticosteroid therapy is an established adjunct to beta-adrenergic medications in acute exacerbations of asthma. To date, no study has defined the role of long-acting intramuscular preparations of corticosteroids in pediatric patients with asthma. A pilot study was conducted to prospectively compare symptomatic improvement following a single injection of intramuscular dexamethasone (IMD) to a 3-day regimen of oral prednisone (OP) for children with mild to moderate wheezing episodes that are responsive to nebulized medications in the Pediatric Emergency Department (PED). The following children presenting with acute exacerbations of asthma to the PED were eligible for enrollment: age 3-16 years; more than two prior wheezing episodes; mild to moderate wheezing; and oxygen saturation 95% or more in room air. The study patients were randomly assigned to receive either IMD (n = 21) or OP (n = 21) in addition to a standardized treatment regimen of nebulized albuterol. All of the children were clinically rated for wheezing severity by the Pulmonary Index (PI) score at regular intervals during the study. Discharge home was based on clinical improvement during treatment in the PED; patients who were admitted to the hospital were removed from the study. Follow-up was conducted the fifth day after discharge from the ED either by clinic visit or by telephone. Patients were assessed for symptomatic improvement and relapse or clinical deterioration during the study period by a clinician blinded to group assignment. Forty-two children participated in this pilot study. There were no significant differences between the IMD and OP groups for gender or age. Mean ages were: 82 months (SD 46 months), IMD group; 63 months (SD 36 months), OP group. Clinical progress (based on PI) with treatment in the PED was the same in both groups: pretreatment median, PI = 6; PED discharge median, PI = 2. None of the study patients were hospitalized during the follow-up period, and all reported symptomatic improvement since initial treatment. The data of this pilot study suggest that IMD may be a feasible alternative to OP for treatment of acute wheezing episodes in children with asthma. IMD provides sufficient treatment to prevent clinical deterioration within 5 days after initial therapy for mild to moderate pediatric exacerbations of asthma that are responsive to nebulized medications.