Chapter 36: Emergency Care – Unstable Child: Infection, Seizure, Coma, Metabolic, Cardiac, Respiratory, Surgical, Poisoning

Approach to the acutely deteriorating child · Recognition of underlying pathology · Targeted stabilization · Poisoning: toxidromes, antidotes, decontamination
⚕️ Core principles: ABCD + history guides differential. Infection (sepsis → antibiotics, fluids). Seizure (status epilepticus → benzodiazepines). Coma (glucose, naloxone, imaging). Metabolic (DKA, inborn errors). Cardiac (arrhythmia, myocarditis). Respiratory (asthma, foreign body). Surgical (intussusception, appendicitis). Poisoning (toxidrome, activated charcoal, antidote).

🚨 Summary: management of unstable child – underlying pathologies & poisoning

🦠 Infection (sepsis)
Fever, hemodynamic instability. Early broad‑spectrum antibiotics (within 1h), fluid resuscitation, vasoactive support. Consider source control.
🧠 Seizure disorder
Status epilepticus: benzodiazepine (IV lorazepam, buccal midazolam). Second‑line phenytoin/levetiracetam. Treat underlying cause (hypoglycemia, infection).
😞 Coma
ABC, bedside glucose, naloxone (opioid), thiamine. Evaluate for trauma, meningitis, toxins. Imaging (CT/MRI) after stabilization.
⚖️ Metabolic abnormalities
DKA, hypoglycemia, electrolyte disorders (Na, K, Ca). Correct hypoglycemia (D10W), DKA: fluids, insulin infusion, monitor cerebral edema.
❤️ Cardiac lesions
Unstable arrhythmia (cardioversion), myocarditis (support), congenital heart disease with shunt (balance pulmonary/systemic flow). Prostaglandin E1 for duct‑dependent lesions.
🫁 Respiratory disorders
Status asthmaticus (continuous bronchodilators, steroids, Mg, consider non‑invasive ventilation). Foreign body (Heimlich, bronchoscopy). Tension pneumothorax (decompress).
🔪 Surgical causes
Intussusception (air enema), appendicitis, malrotation with volvulus, testicular torsion. Abdominal exam, imaging (ultrasound, CT).
☠️ Poisoning
Toxidrome recognition (cholinergic, anticholinergic, opioid, sympathomimetic). Activated charcoal (if safe). Antidotes: naloxone, flumazenil (caution), N‑acetylcysteine, atropine/pralidoxime.
📊 Conclusion: Systematic ABCDE + targeted history/exam identifies underlying emergency. Time‑sensitive interventions improve outcome. Poisoning requires toxidrome approach and specific antidote when available.

🔍 Approach to the unstable child: identify underlying pathology

1
Rapid primary survey (ABCDE) – Stabilize airway, breathing, circulation. Simultaneously obtain history (fever, seizure, ingestion, past medical).
2
Infection / sepsis screen – Fever, hypothermia, rash. Blood cultures, lactate, start broad‑spectrum antibiotics (ceftriaxone + vancomycin).
3
Seizure / coma evaluation – Bedside glucose, electrolytes, calcium. EEG for non‑convulsive status. CT head if focal deficit or trauma.
4
Metabolic / cardiac / respiratory – ECG, chest X‑ray, VBG. Ductal‑dependent lesion: PGE1 infusion. Status asthmaticus: continuous albuterol, ipratropium, magnesium.
5
Surgical abdomen / poisoning – Abdominal exam (rigidity, distension), ultrasound for intussusception/testicular torsion. Toxidrome recognition, decontamination, antidote.

📋 Stepwise management – unstable child by underlying cause

1
Sepsis / septic shock – 20 mL/kg crystalloid bolus, reassess, repeat up to 60 mL/kg. Vasopressors (dopamine/epinephrine) if fluid refractory. Antibiotics within 1 hour.
2
Status epilepticus – 0-5 min: airway, O2, glucose check. 5-20 min: IV lorazepam (0.1 mg/kg) or buccal midazolam. 20-40 min: IV phenytoin (20 mg/kg) or levetiracetam (60 mg/kg).
3
Coma of unknown cause – Dextrose (D10W 2 mL/kg), naloxone (0.1 mg/kg), thiamine. CT head if trauma/focal signs. Lumbar puncture if no contraindication.
4
Duct‑dependent cardiac lesion (cyanotic newborn) – PGE1 infusion (0.05-0.1 mcg/kg/min). Avoid hyperoxia, maintain ductus arteriosus patency.
5
Poisoning (general) – Airway protection. Activated charcoal 1 g/kg if within 1h of ingestion and no risk of aspiration. Specific antidotes: naloxone (opioid), flumazenil (benzodiazepine – caution in seizure risk), N‑acetylcysteine (acetaminophen).
⚡ Conclusion: Structured approach (ABCDE) + focused diagnostics saves lives. Poisoning: toxidrome recognition directs therapy. Always reassess after interventions.

🧠 Reflex prompts – unstable child & poisoning

🦠 First antibiotic for suspected septic shock (child)?
Ceftriaxone + vancomycin (cover MRSA, pseudomonas if risk).
🧠 Second‑line anticonvulsant after benzodiazepine?
IV phenytoin 20 mg/kg or levetiracetam 60 mg/kg.
💉 Bedside test to perform immediately in coma?
Blood glucose (hypoglycemia common reversible cause).
❤️ Ductal‑dependent lesion – drug to keep PDA open?
Prostaglandin E1 (alprostadil) 0.05-0.1 mcg/kg/min.
☠️ Antidote for opioid overdose?
Naloxone 0.1 mg/kg IV/IM (may repeat).
🧪 Toxidrome: miosis, respiratory depression, coma?
Opioid – naloxone.