Paediatric STGs and EML 2023 Edition PDF

Standard Treatment Guidelines and Essential Medicines List for South Africa PAEDIATRIC HOSPITAL LEVEL 2023 EDITION First printed 1998 Second edition 2006 Third edition 2013 Fourth edition 2017 Fifth edition 2023 Electronic copies can be downloaded from the Knowledge Hub Website:  https://kn...

Standard Treatment Guidelines and Essential Medicines List for South Africa PAEDIATRIC HOSPITAL LEVEL 2023 EDITION First printed 1998 Second edition 2006 Third edition 2013 Fourth edition 2017 Fifth edition 2023 Electronic copies can be downloaded from the Knowledge Hub Website:  https://knowledgehub.health.gov.za/content/standard-treatment- guidelines-and-essential-medicines-list Additionally, the updated Paediatric Standard Treatment Guidelines and Essential Medicines List can be access from the “EMGuidance mobile application. This mobile application can be downloaded on android, IOS and windows operating systems, from the relevant app stores. Note: The information presented in these guidelines conforms to the current medical, nursing and pharmaceutical practice. Contributors and editors cannot be held responsible for errors, individual responses to drugs and other consequences. © Copyright 2023, the National Department of Health. Any part of this material may be reproduced, copied or adapted to meet local needs, without permission from the Committee or Department of Health, provided that the parts reproduced are distributed free of charge/not for profit. Produced by: The National Department of Health, Pretoria, South Africa  FOREWORD “Investing in children is one of the most important things a society can do to build a better future” – World Health Organization The children of South Africa are our future, they will be driving the success of the country as they become adults. Good healthcare in childhood is the foundation on which a healthy life is developed, fundamental for the mental, social, emotional and physical development of children as they grow into functional adults. Children form a distinctive population, with unique treatment and patient care requirements. This vulnerable population group should be considered differently to adults in order to appropriately meet needs. The National Department of Health has brought together the country’s leading experts in paediatric healthcare to develop treatment guidelines reflective of the ever-changing needs of our children. The Paediatric Hospital Level Standard Treatment Guidelines (STGs) and Essential Medicines List (EML) aim to provide equitable access to good quality healthcare for all children, a vital element of universal healthcare that South Africa is striving for through the implementation of National Health Insurance. I am proud to present the 5th version of the Paediatric Hospital Level STGs. This latest edition of the Paediatric Hospital Level STGs and EML is a culmination of many efforts from a broad range of experts, and we are thankful to all those who participated in the review process. The review of the STGs and EML is a dynamic process. We thus encourage the continued engagement, feedback, and collaboration from all healthcare stakeholders to ensure continued quality care for our children. It is our hope that healthcare workers will continue to make use of the STGs and EML in their endeavors in providing quality care to the children of South Africa. DR MJ PHAAHLA, MP MINISTER OF HEALTH DATE: 20 July 2023 i  INTRODUCTION The COVID-19 pandemic had a profound impact on health systems across the world. Access and availability of health services were limited and care to children, one of the most vulnerable populations, was negatively impacted. The latest emerging evidence on the treatment and care of children with COVID-19 was evaluated and a section dedicated to management of COVID- 19 was added to the Infectious Diseases Chapter of the Paediatric Standard Treatment Guidelines. The National Department of Health would like to thank the wide range of experts that provided inputs into these guidelines as part of the Paediatric Hospital Level Expert Review Committee. The dedication of these individuals through the COVID-19 pandemic, when virtual meetings between increased clinical responsibilities became the norm, is highly appreciated. In addition, we would like to thank the members of the National Essential Medicines List Committee and all external stakeholders who provided feedback. The fifth version of the Paediatric Hospital Level Standard Treatment Guidelines and Essential Medicines List has been enhanced through the improvement in methodology and rigor of decision-making. Expansion of chapters such as those addressing Palliative Care and Intensive Care was enabled through consultation with key experts in these areas. It is my pleasure to present to you the fifth edition of the Paediatric Hospital Level Standard Treatment Guidelines and Essential Medicines List. DR SSS BUTHELEZI DIRECTOR-GENERAL: HEALTH DATE: 12 July 2023 ii  ACKNOWLEDGEMENTS Without the continued dedication of the members of the Paediatric Expert Review Committee for the Hospital Level Essential Medicines List, this edition of the Standard Treatment Guidelines and Essential Medicines List would not have been possible. The quality of this edition was further enhanced by the contribution of many doctors, pharmacists, professional societies and other health care professionals. We are humbled by the willingness to participate in the consultative peer review process. We hope that, with renewed enthusiasm, future editions will benefit from your contributions. PAEDIATRIC HOSPITAL LEVEL EXPERT REVIEW COMMITTEE Mr A Gray (Chairperson) Dr L Doedens (resigned) Dr G Reubenson (Vice Chairperson) Dr M Makiwane (resigned) Dr M Archary Dr N Moshesh (resigned) Dr A Bhettay Mrs S Hassan (resigned) Prof P Jeena Ms K MacQuilkan (resigned) Dr N Lala Dr T Ruder CONSULTANTS Dr P Ambaram Prof R Mathivha Dr K Balme Dr M Meiring Dr C Hlela Dr H Naidoo Mr A Hohlfeld Dr K Naidoo Dr D Kloeck Dr S Paruk Dr S Kubheka Mr H Sablay Dr J Lawrenson Dr C Stephens NATIONAL ESSENTIAL MEDICINES LIST COMMITTEE (2017– 2021) Prof A Parrish (Chairperson) Mrs N Makalima Dr G Reubenson (Vice Chairperson) Dr M Makua Prof L Bamford Ms E Maramba Dr A Black Ms T Matsitse Prof S Boschmans Ms N Mazibuko Dr RC Chundu Prof M Mendelson Dr K Cohen Ms N Mokoape Dr R de Waal Ms N Mpanza Dr H Dawood Dr C Mugero Mr M Dheda Dr E Mulutsi Dr N Dlamini Dr L Mvusi Ms D du Plessis Mr R Naidoo Ms S Dube Dr N Ndjeka Prof M Freeman Dr N Ndwamato Ms S Govender Dr L Padayachee iii Mr A Gray Dr Z Pinini Dr G Grobler Mr W Ramkrishna Ms N Gumede Ms R Reddy Prof B Hoek Prof G Richards Ms K Jamaloodien Dr A Robinson Ms Y Johnson Ms Z Rhemtula Dr T Kredo Prof P Ruff Ms T Links Mr G Steel Ms F Loonat Prof M Tshifularo Dr J Lotter Mr G Tshitaudzi Prof G Maartens Dr K Vilakazi-Nhlapo Mr K Mahlako Mr R Wiseman NATIONAL ESSENTIAL MEDICINES LIST COMMITTEE (2021– current) Dr R de Waal (Co-Chairperson) Dr M Matlala Prof A Parrish (Co-Chairperson) Dr J Miot Ms Z Adams Mrs B Molongoana Ms A Jacobs Dr K Motse Dr L Bamford Dr L Mvusi Prof M Blockman Ms N Naicker Dr T Chidarikire Dr N Ndjeka Prof K Cohen Mrs T Njapha Dr H Dawood Col JH Nortjie Dr M Dheda Prof E Osuch Mr A Gray Dr G Reubenson Ms A Hargreaves Ms Z Rhemtula Mrs Y Johnson Prof L Robertson Dr T Kredo Dr R Romero Mr K Mahlako Prof P Ruff Mrs L Mahlangu Dr GW Seaketso Ms N Makalima Dr B Semete Dr K Makgamathe Ms S Singh Dr M Makua Dr K Vilakazi-Nhlapo Dr H Mamorobela Mr R Wiseman Dr M Matandela COMMENTS AND CONTRIBUTIONS Dr J Ambler Dr N Makubalo Dr P Appalsamy Dr J McGuire Dr A Asghar Dr C Mnyani Dr K Balme Dr E Moshokoa Ms J Coetzee Prof S Mutambirwa Prof E Decloedt Dr M Necibi Dr J Furin Dr J Nuttall Dr B Harley Prof K Petersen Dr K Harper Dr V Pillay-Fuentes Lorente Dr J Howlett Dr A Reuter iv Prof G Lamacraft Dr B Rossouw Dr H Lochan Prof R Seedat Sr R Lodewyk Dr S Singh Dr L Mabaso Dr C Stephens Dr S Maharaj Dr H Tootla Dr B Makongwana Prof E Zöllner Medscheme: Health Policy Unit Occupational Therapy Association of South Africa South African Medical Association (SAMA) CLINICAL EDITING Dr K Harper SECRETARIATE Dr J Riddin Ms K MacQuilkan Dr J Jugathpal CHIEF DIRECTOR: SECTOR WIDE PROCUREMENT Ms K Jamaloodien v  TABLE OF CONTENTS Foreword i Introduction ii Acknowledgements iii Table of Contents vi The Essential Medicines Concept xxii How to use this book xxiii A guide to patient adherence in chronic disease xxviii CHAPTER 1: EMERGENCIES AND TRAUMA 1.1 Paediatric emergencies 1.1 1.1.1 Triage 1.1 1.1.2 Resuscitation of the child 1.3 1.1.3 Anaphylaxis/Anaphylactic Reactions 1.5 1.1.4 Cardiorespiratory arrest 1.8 1.1.5 Post resuscitation care 1.11 1.1.5.1 Termination of resuscitation 1.12 1.1.6 Convulsions, Not Febrile Convulsions 1.13 1.1.7 Inhalation, foreign body 1.14 1.1.8 Shock 1.15 1.1.9 Massive haemorrhage with massive transfusion of blood 1.19 1.1.10 Intra-osseous infusion in emergencies 1.20 1.1.11 Exposure to poisonous substances 1.22 1.1.12 Insect bites and stings 1.22 1.2 Trauma 1.22 1.2.1 Burns 1.22 1.2.2 Traumatic brain injury 1.30 CHAPTER 2: ALIMENTARY TRACT 2.1 Dental and oral disorders 2.1 2.1.1 Gingivitis, uncomplicated 2.1 2.1.2 Periodontitis 2.1 vi  2.1.3 Necrotising Periodontitis 2.2 2.1.4 Candidiasis, oral 2.2 2.1.5 Aphthous ulcers 2.3 2.1.6 Herpes gingivostomatitis 2.3 2.2 Gastrointestinal disorders 2.4 2.2.1 Cholera 2.4 2.2.2 Constipation/faecal loading 2.6 2.2.3 Cystic fibrosis 2.7 2.2.4 Diarrhoea, acute 2.8 2.2.5 Persistent diarrhoea 2.19 2.2.6 Diarrhoea, chronic other than post-infectious 2.22 2.2.7 Dysentery 2.23 2.2.8 Gastro-oesophageal reflux disease (GORD) 2.24 2.2.9 Peptic ulcer disease 2.25 2.3 Hepatic disorders 2.26 2.3.1 Cirrhosis 2.26 2.3.2 Chronic cholestasis 2.28 2.3.3 Portal hypertension 2.28 2.3.3.1 Bleeding oesophageal varices 2.29 2.3.3.2 Ascites, due to portal hypertension 2.30 2.3.4 Hepatitis, viral, acute 2.30 2.3.5 Hepatitis B, chronic 2.31 2.3.6 Hepatitis C, chronic 2.32 2.3.7 Hepatitis, toxin induced, acute 2.33 2.3.8 Hepatitis, chronic, autoimmune 2.33 2.3.9 Liver failure, acute 2.34 2.4 Malnutrition 2.37 2.4.1 Malnutrition, severe acute 2.37 2.5 Rickets 2.48 2.6 Worm bolus 2.49 2.7 Recurrent abdominal pain 2.50 CHAPTER 3: BLOOD AND BLOOD-FORMING ORGANS Approach to a child with a haemotological problem 3.1 vii  3.1 Anaemia, aplastic 3.2 3.2 Anaemia, haemolytic 3.3 3.2.1 Thalassaemia 3.6 3.2.2 Anaemia, sickle cell 3.6 3.3 Anaemia, megaloblastic 3.8 3.4 Anaemia, iron deficiency 3.9 3.5 Anaemia of chronic disorders (infection or disease) 3.11 3.6 Haemophilia A and B 3.12 3.7 Von Willebrand disease 3.15 3.8 Haemorrhagic disease of the newborn 3.16 3.9 Immune thrombocytopaenic purpura (ITP) 3.16 Thrombotic thrombocytopaenic purpura/haemolytic 3.10 uraemic syndrome 3.19 3.11 Disseminated intravascular coagulation 3.19 3.12 Venous thrombo-embolic disease 3.20 3.13 Special considerations in HIV infected children 3.22 3.13.1 Thrombocytopaenia 3.23 CHAPTER 4: CARDIOVASCULAR SYSTEM 4.1 Cardiac dysrhythmias 4.1 4.2 Congenital heart disease (CHD) 4.5 Cyanotic congenital heart disease with hypoxaemia 4.2.1 attacks/spells (hypercyanotic spells) 4.6 4.2.2 Tetrology of Fallot 4.7 4.2.3 Congenital heart disease with left to right shunt 4.8 4.3 Endocarditis, infective 4.9 4.4 Rheumatic fever, acute 4.13 4.5 Myocarditis 4.15 4.6 Dilated cardiomyopathy 4.16 4.7 Pericardial Effusion 4.17 4.8 Pericarditis 4.19 4.9 Heart failure 4.20 4.9.1 Heart failure, acute with pulmonary oedema 4.21 4.9.2 Heart failure, maintenance therapy 4.22 4.10 Dyslipidaemia 4.23 viii  4.11 Hypertension in children 4.24 4.11.1 Hypertension, acute severe 4.35 4.11.2 Hypertension, chronic 4.36 4.12 Children with prosthetic heart valves 4.38 CHAPTER 5: DERMATOLOGY 5.1 Bullae 5.1 5.1.1 Epidermolysis Bullosa 5.1 5.1.2 Staphylococcal scalded skin syndrome 5.1 5.1.3 Chronic bullous disease of childhood 5.2 5.2 Erythema and desquamation 5.2 5.2.1 Erythema multiforme 5.2 Stevens-Johnson Syndrome (SJS)/Toxic Epidermal 5.2.2 Necrosis (TEN) 5.5 5.3 Macules and papules 5.7 5.3.1 Drug reactions 5.7 5.3.2 Acne 5.8 5.3.3 Cellulitis and erysipelas 5.9 5.3.4 Eczema 5.10 5.3.5 Candidiasis 5.12 5.3.6 Psoriasis 5.13 5.3.7 Urticaria 5.14 5.3.8 Tinea capitis 5.14 5.4 Purpura 5.15 5.4.1 Meningococcaemia 5.15 5.4.2 Henoch-Schönlein purpura 5.15 5.4.3 Immune thrombocytopaenic purpura (ITP) 5.15 5.5 Vesicles and pustules 5.15 5.5.1 Infections - vesicles and pustules 5.15 5.5.2 Skin and mucosal disorders in HIV 5.15 5.5.2.1 HIV papular pruritic eruption 5.16 5.5.2.2 Kaposi sarcoma 5.17 5.5.2.3 Warts 5.17 5.5.3 Impetigo 5.18 ix  5.5.4 Cutaneous haemangiomas 5.18 CHAPTER 6: NEPHROLOGICAL/UROLOGICAL DISORDERS 6.1 Post streptococcal glomerulonephritis 6.1 6.2 Urinary tract infection (UTI) 6.4 6.3 Nephrotic syndrome 6.8 6.4 Acute kidney injury (renal failure, acute) 6.15 6.5 Chronic kidney disease (renal failure, chronic) 6.20 6.6 Enuresis 6.26 6.7 Dysfunctional bladder 6.27 CHAPTER 7: ENDOCRINE SYSTEM 7.1 Disorders of sex development (DSD) 7.1 7.2 Adrenal hyperplasia, congenital 7.2 7.3 Adrenal insufficiency, acute 7.3 7.4 Diabetes insipidus 7.4 7.5 Diabetes mellitus 7.6 7.5.1 Type 1 diabetes mellitus 7.6 7.5.1.1 Guidelines for management of diabetics on sick days 7.16 7.5.2 Diabetes mellitus, insulin dependent: acute complications 7.18 7.5.2.1 Cerebral oedema in diabetic ketoacidosis (DKA) 7.18 7.5.2.2 Diabetic ketoacidosis 7.19 7.5.2.3 Hypoglycaemia in diabetics 7.24 7.5.2.4 Diabetic nephropathy 7.26 7.5.2.5 Dyslipidaemia 7.26 7.5.3 Diabetes mellitus in adolescents 7.29 7.5.4 Diabetes mellitus, type 2 7.30 7.6 Hypoglycaemia in children 7.31 7.7 Growth disorders 7.32 7.8 Hypocalcaemia in children 7.34 7.9 Hyperkalaemia 7.35 7.10 Hypokalaemia 7.35 7.11 Hypopituitarism 7.36 7.12 Hypothyroidism, congenital 7.37 x  7.13 Hypothyroidism in older children and adolescents 7.38 7.14 Hyperthyroidism, Graves disease 7.39 7.15 Obesity 7.40 7.16 Disorders of puberty 7.41 7.17 Polycystic ovary syndrome 7.42 CHAPTER 8: INFECTIVE/INFECTIOUS DISEASES 8.1 Helminthiasis, intestinal 8.1 8.2 Amoebiasis (entamoeba histolytica) 8.2 Cutaneous larva migrans/ancylostoma braziliense (dog 8.3 hookworm) 8.3 8.4 Hydatid disease 8.3 8.5 Schistosomiasis (Bilharzia) 8.4 8.6 Candidiasis, systemic and other 8.5 8.7 Cytomegalovirus (CMV) infection 8.8 8.8 Diphtheria 8.9 8.9 Malaria 8.12 Plasmodium Falciparum malaria, non-severe, 8.9.1 uncomplicated 8.13 8.9.2 Plasmodium Falciparum malaria, severe, complicated 8.14 Plasmodium Ovale, Plasmodium Vivax and Plasmodium 8.9.3 Malariae 8.16 8.9.4 Malaria prophylaxis 8.16 8.10 Measles 8.17 8.11 Meningitis, acute bacterial 8.20 8.12 Meningitis, cryptococcal 8.23 8.13 Meningo-encephalitis/encephalitis, acute viral 8.26 8.14 Mumps 8.28 8.15 Mycobacterium avium complex (MAC) infection 8.28 8.16 Pertussis 8.29 8.17 Pneumocystis Jiroveci Pneumonia (PJP) 8.30 8.18 Poliomyelitis (acute flaccid paralysis) 8.30 8.19 Rabies 8.31 8.20 Tetanus 8.34 8.21 Tick bite fever 8.36 xi  8.22 Toxoplasmosis 8.37 8.23 Typhoid 8.37 8.24 Non-typhoid salmonella (NTS) 8.38 8.25 Varicella (chicken pox) 8.40 8.26 Zoster 8.42 8.27 Sepsis 8.43 8.28 Staphylococcal septicaemia 8.44 8.29 Arthritis, septic (pyogenic) 8.46 8.30 Arthritis, juvenile idiopathic 8.48 8.31 Osteitis/osteomyelitis, acute 8.49 8.32 COVID-19 in children 8.51 8.32.1 Multisystem inflammatory syndrome in children (MIS-C) 8.54 8.32.2 Neonatal issues related to COVID-19 8.55 CHAPTER 9: HUMAN IMMUNODEFICIENCY VIRUS INFECTION 9.1 Human immunodeficiency virus infections 9.1 9.1.1 The HIV exposed infant 9.3 9.1.2 The HIV infected neonate (< 1 month of age) 9.10 9.1.3 The HIV infected infant/child 9.13 9.2 Tuberculosis and HIV 9.35 9.3 Immune reconstitution inflammatory syndrome (IRIS) 9.37 Post exposure prophylaxis following alleged penetrative 9.4 sexual abuse 9.38 9.5 HIV in adolescence 9.38 CHAPTER 10: TUBERCULOSIS 10.1 Tuberculosis. perinatal 10.1 10.2 Tuberculosis, pulmonary in children 10.3 10.2.1 Non-severe tuberculosis disease 10.6 10.2.2 Severe tuberculosis disease 10.8 10.3 Miliary tuberculosis in children 10.11 10.4 Meningitis, tuberculous (TBM) in children 10.13 10.5 TB Preventive therapy (TPT) for TB exposure/infection 10.18 Treatment of children who were previously successfully 10.6 treated for TB (retreatment) 10.19 xii  10.7 Drug Resistant TB (DR-TB) 10.19 CHAPTER 11: SURGICAL PROPHYLAXIS 11.1 CHAPTER 12: RHEUMATOLOGY AND VASCULITIDES 12.1 Henoch-Schönlein purpura (HSP) 12.1 12.2 Juvenile idiopathic arthritis (JIA) 12.2 12.3 Kawasaki disease/mucocutaneous lymph node syndrome 12.7 12.4 Systemic lupus erythematosus 12.9 12.5 Takayasu arteritis 12.11 CHAPTER 13: THE NERVOUS SYSTEM 13.1 Seizures 13.1 13.2 Seizures, febrile 13.4 13.3 Status epilepticus (convulsive) 13.6 13.4 Epilepsy 13.9 13.5 Antiretroviral therapy and antiepileptic drugs 13.14 13.6 Headaches 13.15 13.7 Neurocysticercosis 13.17 13.8 Neuromuscular disorders 13.19 13.8.1 Inflammatory Polyneuropathy (Guillain-Barré Syndrome) 13.19 13.8.2 Myasthenia gravis 13.22 13.8.2.1 Myasthenic crisis (MC) 13.23 13.8.3 Duchenne muscular dystrophy (DMD) 13.23 13.9 Acute disseminated encephalomyelitis (ADEM) 13.25 13.10 Sydenham chorea 13.26 13.11 Cerebrovascular disease/stoke 13.27 13.12 Lumbar puncture 13.28 13.13 Raised intracranial pressure 13.30 13.14 Cerebral palsy (CP) 13.33 CHAPTER 14: CHILD AND ADOLESCENT PSYCHIATRY Principles for the safe and effective prescribing of psychotropic medication 14.1 Common medications used in psychiatry and their side effects 14.2 xiii  14.1 Sedation of an acutely disturbed child or adolescent 14.5 14.2 Elimination disorders 14.6 14.2.1 Enuresis 14.6 14.2.2 Encopresis 14.8 14.3 Attention deficit hyperactivity disorder (ADHD) 14.8 14.4 Mood disorders 14.12 14.4.1 Depression in childhood and adolescence 14.12 14.4.2 Bipolar disorder 14.15 14.4.3 Disruptive mood dysregulation disorder (DMDD) 14.17 14.5 Anxiety disorders 14.19 14.5.1 Generalised anxiety disorder (GAD) 14.19 14.6 Obsessive compulsive disorder (OCD) 14.20 14.7 Post traumatic stress disorder (PTSD) 14.22 14.8 Feeding and eating disorders 14.23 14.8.1 Pica 14.23 14.8.2 Avoidant/restrictive food intake disorder 14.24 14.8.3 Anorexia nervosa 14.24 14.8.4 Bulimia nervosa 14.25 14.9 Childhood psychosis 14.25 14.9.1 Schizophrenia 14.26 14.10 Tic disorders 14.28 Psychiatric presentations in HIV infected children and 14.11 adolescents 14.29 14.12 Autism spectrum disorder (ASD) 14.30 14.13 Substance use disorder 14.30 14.13.1 Substance -induced psychotic disorder 14.31 14.13.2 Substance-induced mood disorder 14.32 14.13.3 Substance withdrawal 14.32 14.13.3.1 Alcohol withdrawal 14.33 14.13.3.2 Alcohol withdrawal delerium 14.33 14.13.3.3 Opioid withdrawal 14.37 14.13.3.4 Stimulant/methaqualone (mandrax)/cannabis withdrawal) 14.38 14.13.3.5 Benzodiazepine withdrawal 14.38 14.14 Behavioural problems associated with intellectual disability 14.40 xiv CHAPTER 15: RESPIRATORY SYSTEM Acute lower respiratory tract infections in young children 15.1 15.1 Cough with predominant fever and tachypnoea 15.1 15.1.1 Pneumonia 15.1 15.1.1.1 Pneumonia, viral infection 15.5 15.1.1.2 Pneumonia due to anaerobic infection 15.6 15.1.1.3 Pneumonia in HIV exposed or infected children 15.6 15.1.1.4 Pneumonia, nosocomial 15.9 15.1.1.5 Recurrent pneumonia 15.10 15.1.2 Bronchiolitis 15.11 15.2 Pleural disease 15.13 15.2.1 Effusion and empyema 15.13 15.3 Chronic lung infections 15.14 15.3.1 Bronchiectasis 15.14 15.3.2 Lung abscess 15.16 15.4 Conditions with predominant wheeze 15.18 15.4.1 Asthma attack, acute 15.18 15.4.2 Asthma, chronic 15.23 15.4.2.1 Infrequent asthma 15.25 15.4.2.2 Persistent asthma 15.26 15.5 Upper airway diseases 15.29 15.5.1 Epiglottitis 15.29 15.5.2 Laryngotracheobronchitis, acute viral (Croup) 15.30 15.6 Obstructive sleep apnoea 15.33 CHAPTER 16: EYE CONDITIONS 16.1 Eye infection, complicated (severe eye infection) 16.1 16.2 Conjunctivitis 16.2 16.3 Herpes keratitis and conjunctivitis 16.2 16.4 Cytomegalovirus (CMV) retinitis 16.3 16.5 Chemical burn to the eye 16.4 16.6 Penetrating eye injury with/without a foreign body 16.5 16.7 Non-penetrating eye injury 16.6 xv  16.8 Retinopathy of prematurity (ROP) 16.7 16.9 Congenital Glaucoma 16.8 16.10 Leukocoria 16.9 16.11 Strabismus 16.9 16.12 Loss of vision 16.10 16.13 Preseptal and orbital cellulitis 16.10 CHAPTER 17: EAR, NOSE AND THROAT 17.1 Abscess, retropharyngeal 17.1 17.2 Tonsillitis and pharyngitis 17.2 Tonsillitis, complicated (peritonsillar cellulitis, peritonsillar 17.3 abscess) 17.2 17.3.1 Acute bacterial tracheitis 17.4 17.4 Epistaxis (nose bleed) 17.5 17.5 Acute mastoiditis 17.6 17.6 Otitis externa 17.7 17.7 Otitis media, acute (AOM) 17.7 17.8 Otitis media, with effusion (OME) 17.8 17.9 Otitis media, chronic, suppurative 17.9 17.10 Rhinitis, allergic/allergic rhinosinusitis 17.10 17.11 Rhinosinusitis, acute bacterial (ABRS) 17.11 17.12 Sinusitis, complicated 17.11 CHAPTER 18: POISONING 18.1 Poisoning 18.1 18.1.1 Anticholinergic poisoning 18.5 18.1.2 Anticoagulant poisoning 18.6 18.1.3 Tricyclic antidepressant poisoning 18.7 18.1.4 Ingestion of caustic or corrosive agents 18.9 18.1.5 Volatile solvents 18.10 18.1.6 Ethanol poisoning 18.11 18.1.7 Iron poisoning 18.11 18.1.8 Neuroleptic poisoning 18.13 18.1.9 Organophosphate poisoning 18.14 18.1.10 Opioid poisoning 18.16 xvi  18.1.11 Paracetamol poisoning 18.17 18.1.12 Petrochemical poisoning 18.20 18.1.13 Salicylate poisoning 18.20 18.1.14 Benzodiazepine poisoning 18.22 18.1.15 Sulfonylurea poisoning 18.22 18.1.16 Sympathomimetic agent poisoning 18.23 18.1.17 Isoniazid poisoining 18.25 18.1.18 Theophylline poisoning 18.26 18.1.19 Amitraz poisoning 18.27 18.1.20 Antiretroviral agents poisoning 18.28 18.1.21 Carbon monoxide poisoning 18.28 18.2 Envenomation 18.29 18.2.1 Insect bites and stings 18.29 18.2.2 Scorpion stings 18.30 18.2.3 Snakebite 18.31 18.2.4 Snake venom in the eye 18.35 18.2.5 Spider bites 18.36 18.2.5.1 Spider bites, neurotoxic (button/widow spiders) 18.36 18.2.5.2 Spider bites, necrotic arachnidism 18.37 CHAPTER 19: PREMATURITY AND NEONATAL CONDITIONS 19.1 Resuscitation of the newborn 19.2 19.2 Newborn 19.5 19.2.1 Jaundice, neonatal 19.5 19.2.1.1 Hyperbilirubinaemia, unconjugated 19.6 19.2.1.2 Hyperbilirubinaemia, conjugated 19.11 19.2.1.3 Jaundice, neonatal, prolonged 19.11 19.2.2 Respiratory distress in the newborn 19.13 19.3 Prematurity/preterm neonate 19.18 19.3.1 Enterocolitis, necrotizing (NEC) 19.20 19.3.2 Patent ductus arteriosus (PDA) in the newborn 19.24 19.3.3 Retinopathy of prematurity 19.26 19.3.4 Apnoea, neonatal 19.26 xvii  19.4 Cardiovascular 19.28 19.4.1 Heart failure in neonates 19.28 19.4.2 Cyanotic heart disease in the newborn 19.30 19.5 Infections 19.33 19.5.1 Meningitis bacterial, neonatal 19.33 19.5.2 Septicaemia of the newborn 19.35 19.5.3 Group B Streptococcus 19.38 19.5.4 Syphilis, early congenital 19.39 19.5.5 Tetanus, neonatal 19.41 19.5.6 Prevention of mother to child transmission (PMTCT) 19.41 19.5.7 Neonates with exposure to chronic hepatitis B infection 19.42 19.6 Neurological 19.42 Hypoxia/ischaemia of the newborn (perinatal 19.6.1 hypoxia/hypoxic-ischaemic encephalopathy) 19.42 19.6.2 Seizures, neonatal 19.48 19.7 Metabolic 19.51 19.7.1 Hypocalcaemia, neonatal 19.51 19.7.2 Hypoglycaemia, neonatal 19.53 19.7.3 The infant of a diabetic mother (DM) 19.54 19.8 Haemotology 19.55 19.8.1 Haemorrhagic disease of the newborn 19.55 19.9 Underweight for gestational age (UGA) 19.57 19.10 Neonatal abstinence syndrome (NAS) 19.58 CHAPTER 20: PAIN CONTROL 20.1 Pain control 20.1 20.1.1 Management of pain 20.7 20.1.1.1 Acute pain 20.7 20.1.1.2 Persistent/chronic pain (non-cancer pain) 20.14 20.1.1.3 Cancer Pain 20.15 20.1.2 Procedural sedation and analgesia 20.16 CHAPTER 21: PALLIATIVE CARE 21.1 Symptom Control 21.1 21.1.1 Gastro-intestinal symptom 21.2 xviii  21.1.1.1. Odynophagia 21.2 21.1.1.2 Nausea and vomiting 21.4 21.1.1.3 Intractable diarrhoea 21.6 21.1.1.4 Constipation 21.7 21.1.2 Respiratory Symptoms 21.8 21.1.2.1 Dyspnoea 21.8 21.1.2.2 Chronic cough 21.11 21.1.3 Neuropsychiatric symptoms 21.11 21.1.3.1 Anxiety 21.11 21.1.3.2 Depression 21.12 21.1.3.3 Dystonia/muscle spasm/spasticity 21.13 21.1.3.4 Intractable seizures 21.15 21.1.4 Dermatological symptoms 21.16 21.1.4.1 Pruritus 21.16 21.1.4.2 Malodorous fungating wounds/tumors 21.17 21.2 Paediatric palliative care emergencies 21.18 21.2.1 Mucosal bleeds 21.18 21.2.2 Spinal cord compression 21.19 21.2.3 Respiratory panic 21.19 21.3 End of life and terminal care 21.20 21.3.1 Terminal care 21.21 CHAPTER 22: ANAESTHETICS 22.1 Anaesthetic and post-anaesthetic care of children 22.1 22.1.1 Local and regional anaesthesia 22.1 22.1.2 General anaesthesia 22.4 22.1.2.1 Preparation 22.4 22.1.2.2 Induction of anaesthesia 22.6 22.1.2.3 Maintenance of anaesthesia 22.9 22.1.3 Post operative care 22.12 Management of anaesthetic and post-anaesthetic 22.1.4 complications 22.14 CHAPTER 23: PAEDIATRIC INTENSIVE CARE 23.1 Rapid sequence intubation (RSI) 23.1 xix  23.2 Analgosedation 23.4 23.3 Nutritional care in ICU 23.6 23.3.1 Parenteral nutrition 23.7 23.4 Post cardiac-arrest syndrome 23.8 23.5 Fluids in ICU 23.9 23.6 Electrolyte abnormalities 23.10 23.6.1 Dysnatraemias in ICU 23.10 23.6.2 Potassium abnormalities in ICU 23.15 23.6.3 Magnesium abnormalities in ICU 23.17 23.6.4 Calcium abnormalities in ICU 23.18 23.6.5 Phosphate abnormalities in ICU 23.20 23.6.6 Hyperglycaemia 23.21 23.6.7 Hypoglycaemia 23.22 23.6.8 Diabetic ketoacidosis 23.22 23.7 Traumatic brain injury (TBI) and neuroprotection in ICU 23.22 23.8 Inotropes and vasopressors 23.26 23.9 Venous thrombo-embolism (VTE) 23.29 23.9.1 Thromboprophylaxis in ICU 23.29 23.9.2 Treatment of VTE 23.29 23.10 ICU medications 23.30 CHAPTER 24: ADOLESCENCE Child Rights 24.1 24.1 Adolescent chronic disease: transition of care 24.3 24.2 Contraception, teenage pregnancy and teratogenicity risks 24.4 CHAPTER 25: DRUG ALLERGIES 25.1 Drug allergies 25.1 25.2 Immediate hypersensitivity reactions 25.2 25.2.1 Drug related anaphylaxis 25.2 25.2.2 Drug related urticaria 25.2 25.2.3 Drug related angioedema 25.2 25.3 Delayed hypersensitivity reactions 25.3 25.4 Specific allergies 25.4 xx  25.4.1 Allergies to penicillins 25.4 25.4.2 Allergies to sulphonamides 25.5 Annexure 1: Amoxicilin/clavulanic acid – Weight Band Dosing Table xxxv Guideline for the motivation of a new medicine on the National Essential Medicines List xxxvi Guidelines for adverse drug reaction reporting xl Disease notification procedure xliii Using the road to health booklet xlvi Boy’s weight-for-age chart xlviii Girl’s weight-for-age chart xlix Boy’s weight-for-length chart l Girl’s weight-for-length chart li Ballard score assessment lii Index of conditions liii Index of medicines lxv Abbreviations lxxx xxi  THE ESSENTIAL MEDICINES CONCEPT The World Health Organization (WHO) describes essential medicines as those that satisfy the priority health care needs of the population. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate quantities, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. The concept of essential medicines is forward-looking. It incorporates the need to regularly update medicines selections to: » reflect new therapeutic options and changing therapeutic needs; » the need to ensure medicine quality; and » the need for continued development of better medicines, medicines for emerging diseases, and meet changing resistance patterns. Effective health care requires a judicious balance between preventive and curative services. A crucial and often deficient element in curative services is an adequate supply of appropriate medicines. In the health objectives of the National Drug Policy, the government of South Africa clearly outlines its commitment to ensuring availability and accessibility of medicines for all people. These are as follows: » To ensure the availability and accessibility of essential medicines to all citizens. » To ensure the safety, efficacy and quality of drugs. » To ensure good prescribing and dispensing practices. » To promote the rational use of drugs by prescribers, dispensers and patients through provision of the necessary training, education and information. » To promote the concept of individual responsibility for health, preventive care and informed decision-making. Achieving these objectives requires a comprehensive strategy that not only includes improved supply and distribution, but also appropriate and extensive human resource development. The Essential Drugs Programme (EDP) forms an integral part of this strategy. Essential medicines are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost. The implementation of the concept of essential medicines is intended to be flexible and adaptable to different and changing situations. xxii  HOW TO USE THIS BOOK Principles The National Drug Policy makes provision for an Essential Drugs Programme (EDP), which is a key component in promoting rational medicines use. Each treatment guideline in the Paediatric Hospital Level Standard Treatment Guidelines (STGs) and Essential Medicines List (EML) has been designed as a progression in care from the current Primary Health Care (PHC) STGs and EML. In addition, where a referral is recommended, the relevant medicines have either been reviewed and included in the tertiary level EML, or are in the process of being reviewed. The STGs serve as a standard for practice, but do not replace sound clinical judgment. It is important to remember that the recommended treatments provided in this book are guidelines only, and are based on the assumption that prescribers are competent to handle patients with the relevant conditions presenting to their facilities. All reasonable steps have been taken to align the STGs with Department of Health guidelines that were available at the time of review. A medicine is included or removed from the list using an evidence based medicine review of safety and effectiveness, followed by consideration of cost and other relevant practice factors. The EML has been developed down to generic or International Non-propriety Name (INN) level. It is anticipated that each Province will review the EML and prevailing tenders to compile a formulary which: » lists formulations and pack sizes that will facilitate care in alignment with the STG; » selects the preferred member of the therapeutic class based on cost; » Implements formulary restrictions consistent with the local environment; and » provides information regarding the prices of medicines. xxiii Therapeutic classes are designated in the "Medicine treatment” section of the STGs which provides a class of medicines followed by example such as, topical retinoid e.g. tretinoin. These therapeutic classes have been designated where none of the members of the class offers a significant benefit over the other registered members of the class. It is anticipated that by limiting the listing to a class there is increased competition and hence an improved chance of obtaining the best possible price in the tender process. In circumstances where you encounter such a class always, consult the local formulary to identify the example that has been approved for use in your facility. The perspective adopted is that of a competent medical officer practicing in a public sector hospital. As such, the STGs serve as a standard for practice but do not replace sound clinical judgment. Navigating the book It is important that you become familiar with the contents and layout of the book in order to use the STGs effectively. Where relevant this book is consistent with the Standard Treatment Guidelines for Primary Health Care, Integrated Management of Childhood Illness Strategy (IMCI) guidelines and other National Programme Guidelines. The ICD-10 number, included with the conditions, refers to an international classification method used when describing certain diseases and conditions. A brief description and diagnostic criteria are included to assist the medical officer to make a diagnosis. These guidelines also make provision for referral of patients with more complex and uncommon conditions to facilities with the resources for further investigation and management. The dosing regimens provide the recommended doses used in usual circumstances however, the final dose should take into consideration capacity to eliminate the medicine, interactions and comorbid states. It is important to remember that the recommended treatments provided in this book are guidelines only and are based on the assumption that prescribers are competent to handle patients' health conditions presented at their facilities. The STGs are arranged into chapters according to the organ systems of the body. Conditions and medicines are cross-referenced in two separate indexes of the book. In some therapeutic areas that are not easily amenable to the xxiv development of a STG, the section is limited to a list of medicines. The Paediatric Hospital Level STGs and EML provides additional information regarding Patient Adherence in Chronic Conditions, Measuring Medication Level and Prescription Writing. The section on Patient Education in Chronic Conditions aims to assist health workers to improve patient adherence and health, generally. Furthermore, to promote transparency, in this fourth edition, revisions are accompanied by the level of evidence that is cited and hyperlinked accordingly. All evidence is graded according to the Strength of Recommendation Taxonomy (SORT) (a patient-centered approach to grading evidence in the medical literature). Finally, the guidelines make provision for referral of patients with more complex and uncommon conditions to facilities with the resources for further investigation and management. Medicines Safety Provincial and local Pharmaceutical and Therapeutics Committees (PTCs) should develop medicines safety systems to obtain information regarding medication errors, prevalence and importance of adverse medicine events, interactions and medicines quality. These systems should not only support the regulatory pharmacovigilance plan but should also provide pharmacoepidemiology data that will be required to inform future essential medicines decisions as well as local interventions that may be required to improve safety. In accordance with the South African Health Products Regulatory Authority’s (SAHPRA) guidance on reporting adverse drug reactions in South Africa, all healthcare professionals, including doctors, dentists, pharmacists, nurses and other healthcare professionals, patients, caregivers and representatives of the patient (e.g., lawyer) are encouraged to report all suspected adverse reactions to medicines. (see page xl: Guidelines for adverse drug reaction reporting. Feedback Comments that aim to improve these treatment guidelines will be appreciated. The submission form and guidelines for completing the form are included in the book. Motivations will only be accepted from the Provincial PTC. xxv MEASURING MEDICATION LEVELS Potentially toxic medicines, medicines with narrow therapeutic indices and those with variable pharmacokinetics should be monitored to optimise dosing, obtain maximum therapeutic effect, limit toxicity and assess compliance. Routine measurement is rarely warranted, but rather should be tailored to answering a specific clinical question, and is of most value in medicines with a narrow therapeutic index or where there is considerable individual variation in pharmacokinetics. Aminoglycosides Peak levels will be adequate if dosing is adequate. Trough levels taken immediately before the next dose are valuable in identifying potential toxicity before it manifests as deafness or renal impairment. Aminoglycosides are contraindicated in renal impairment. Anti-epileptics Levels may be helpful to confirm poor adherence or to confirm a clinical suspicion of toxicity. Routine measurement in patients with well controlled seizures and no clinical evidence of toxicity is not appropriate. Individual levels may be difficult to interpret - if in doubt, seek assistance from a clinical pharmacokineticist. Therapeutic Drug Level Monitoring Guidance on therapeutic drug level monitoring has been added to this edition of the Paediatric Hospital Level STGs and EML in certain indications requiring vancomycin and gentamycin. PRESCRIPTION WRITING Medicines should be prescribed only when they are necessary for treatments following clear diagnosis. Not all patients or conditions need prescriptions for medicine. In certain conditions simple advice and general and supportive measures may be more suitable. In all cases, carefully consider the expected benefit of a prescribed medication against potential risks. All prescriptions should: » be written legibly in ink by the prescriber with the full name and » address of the patient, and signed with the date on the prescription form; » specify the age and, in the case of children, weight of the patient; » signature of prescriber and practice/prescriber number; xxvi » have contact details of the prescriber e.g.name and telephone number. In all prescription writing the following should be noted: » The name of the medicine or preparation should be written in full using the generic name. » No abbreviations should be used, due to the risk of misinterpretation. » Avoid the Greek mu (µ): write mcg as an abbreviation for micrograms. » Avoid unnecessary use of decimal points and only use where decimal points are unavoidable. A zero should be written in front of the decimal point where there is no other figure, e.g. 2 mg not 2.0 mg or 0.5 mL and not.5 mL. » Frequency: Avoid Greek and Roman frequency abbreviations that cause considerable confusion (qid, qod, tds, tid, etc.). Instead, either state the frequency in terms of hours (e.g. 8 hourly) or times per day in numerals (e.g. 3 times daily). » State the treatment regimen in full: o medicine name and strength, o route, o dose or dosage, o dose frequency, o duration of treatment, e.g., amoxicillin, oral, 250 mg 8 hourly for 5 days. » In the case of ‘as required’, a minimum dose interval should be specified, e.g. every 4 hours as required. » Most monthly outpatient scripts for chronic medication are for 28 days; check that the patient will be able to access a repeat before the 28 days are completed. » After writing a script, check that the dose, dose units, route, frequency, and duration for each item is stated. Consider whether the number of items is too great to be practical for the patient, and check that there are no redundant items or potentially important drug interactions. Check that the script is dated and that the patient's name and folder number are on the prescription form. Only then sign the script, and provide some other way for the pharmacy staff to identify you if there are problems (print your name, use a stamp, or use your institution issued prescriber number). xxvii  A GUIDE TO PATIENT ADHERENCE IN CHRONIC CONDITIONS Achieving health goals for chronic conditions such as asthma, diabetes, HIV and AIDS, epilepsy, hypertension, mental health disorders and TB requires attention to: » Adherence to long term pharmacotherapy-incomplete or non-adherence can lead to failure of an otherwise sound pharmacotherapeutic regimen. » Organisation of health care services, which includes consideration of access to medicines and continuity of care. Patient Adherence Adherence is the extent to which a person's behavior-taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider. Poor adherence results in less than optimal management and control of the illness and is often the primary reason for suboptimal clinical benefit. It can result in medical and psychosocial complications of disease, reduced quality of life of patients, and wasted health care resources. Poor adherence can fall into one of the following patterns where the patient: » takes the medication very rarely (once a week or once a month); » alternates between long periods of taking and not taking their medication e.g. after a seizure or BP reading: » skips entire days of medication; » skips doses of the medication; » skips one type of medication: » takes the medication several hours late: » does not stick to the eating or drinking requirements of the medication: » adheres to a purposely modified regimen; and » adheres to an unknowingly incorrect regimen. Adherence should be assessed on a regular basis. Although there is no gold standard, the current consensus is that a multi method approach that includes self-report be adopted such as that below. xxviii Barriers that contribute toward poor adherence. BARRIER RECOMMENDED SUPPORT Life style » It is often difficult to take » Create a treatment plan with multiple medications. information on how and when to take the medications. » A busy schedule makes it » Use reminders such as cues that difficult to remember to take the form part of the daily routine. medication. Attitudes and beliefs » Remind patients that they have a » The condition is misunderstood long-term illness that requires or denied. their involvement. » Use change techniques such as » Treatment may not seem to be motivational interviewing. necessary. » Identify goals to demonstrate » May have low expectations improvement/stabilisation. about treatment. Social and economic » May lack support at home or in » Encourage participation in the community treatment support programs. » May not have the economic » Consider down referral or resources to attend reschedule appointment to fit in appointments. with other commitments. Healthcare team related » Little or no time during the visit » Encourage patient to ask to provide information. questions. » Information may be provided in » Use patient literacy materials in a way that is not understood. the patient's language of choice. » Relationship with the patient » Engage active listening. may not promote understanding and self- management. Treatment related » Complex medication regimens » If possible, reduce treatment (multiple medications and complexity. doses) can be hard to follow. » Help the patient understand the » May be discouraged if they do condition and the role of their not feel better right away. medication. » May be concerned about » Discus treatment goals in adverse effects. relation to potential adverse effects. xxix Although many of these recommendations require longer consultation time, this investment is rewarded many times over during the subsequent years of management. For a patient to consistently adhere to long term pharmacotherapy requires integration of the regimen into his or her daily life style. The successful integration of the regimen is informed by the extent to which the regimen differs from his or her established daily routine. Where the pharmacological proprieties of the medication permits it, the pharmacotherapy dosing regimen should be adapted to the patient's daily routine. For example, a shift worker may need to take a sedating medicine in the morning when working night shifts, and at night, when working day shifts. If the intrusion into life style is too great, alternative agents should be considered if they are available. This would include situations such as a lunchtime dose in a school-going child who remains at school for extramural activity and is unlikely to adhere to a three times a regimen but may very well succeed with a twice-daily regimen. Towards concordance when prescribing Establish the patient's: » occupation, » daily routine, » recreational activities, » past experiences with other medicines, and » expectations of therapeutic outcome. Balance these against the therapeutic alternatives identified based on clinical findings. Any clashes between the established routine and life style with the chosen therapy should be discussed with the patient in such a manner that the patient will be motivated to a change their lifestyle. Note: Education that focuses on these identified problems is more likely to be successful than a generic approach toward the condition/medicine. Education points to consider » Focus on the positive aspects of therapy whilst being encouraging regarding the impact of the negative aspects and offer support to deal with them if they occur. » Provide realistic expectations regarding:  normal progression of the Illness - especially important in those diseases where therapy merely controls the progression and those that are asymptomatic; xxx   the improvement that therapy and non-drug treatment can add to the quality of life. » Establish therapeutic goals and discuss them openly with the patient. » Any action to be taken with loss of control or when side effects develop. » In conditions that are asymptomatic or where symptoms have been controlled, reassure the patient that this reflects therapeutic success, and not that the condition has resolved. » Where a patient raises concern regarding anticipated side effects, attempt to place this in the correct context with respect to incidence, the risks vs. the benefits, and whether or not the side effects will disappear after continued use. Note: Some patient's lifestyles make certain adverse responses acceptable which others may find intolerable. Sedation is unlikely to be acceptable to a student but an older patient with insomnia may welcome this side effect. This is where concordance plays a vital role. Notes on prescribing in chronic conditions. » Do not change doses without good reason. » Never blame anyone or anything for non-adherence before fully investigating the cause. » If the clinical outcome is unsatisfactory- investigate adherence (remember side effects may be a problem here). » Always think about side effects and screen for them from time to time. » When prescribing a new medicine for an additional health related problem ask yourself whether this medicine is being used to manage a side effect. » Adherence with a once daily dose is best. Twice daily regimens show agreeable adherence. However once the intervals decreased to 3 times a day there is a sharp drop in adherence with poor adherence to 4 times a day regimens. » Keep the total number of tablets to an absolute minimum as too many may lead to medication dosing errors and may influence adherence Improving Continuity of Therapy » Make clear and concise records. » Involvement the patient in the care plan. » Every patient on chronic therapy should know:  his/her diagnosis,  the name of every medicine,  the dose and interval of the regimen,  his/her BP or other readings. xxxi Note: The prescriber should reinforce this only once management of the condition has been established. » When the patient seeks medical attention for any other complaints such as a cold or headache, he/she must inform that person about any other condition/disease and its management. » If a patient indicates that he/she is unable to comply with a prescribed regimen, consider an alternative - not to treat might be one option, but be aware of the consequences e.g. ethical. xxxii xxxiii xxxiv  CHAPTER 1 EMERGENCIES AND TRAUMA 1.1 PAEDIATRIC EMERGENCIES Certain emergencies are dealt with in the chapters on respiratory, cardiac and nervous system. This section deals only with the approach to the severely ill child and selected conditions (cardiorespiratory arrest, anaphylaxis, shock, foreign body inhalation and burns). All doctors should ensure that they can provide basic (and preferably advanced) life support to children. The most experienced clinician present should take control of the resuscitation. 1.1.1 TRIAGE Early recognition of life-threatening emergencies and rapid provision of appropriate care can prevent childhood deaths and reduce associated morbidity. Triage aims to identify those children most in need of resuscitation and emergency care. It involves the rapid examination of all sick children when they first arrive in hospital to prioritise their care. They should be reassessed regularly while awaiting definitive care. Categories 1. Emergencies: Conditions that cannot wait and require immediate treatment. 2. Priority signs (place ahead of the normal queue). 3. Non-urgent (join the queue). Emergencies: Conditions that cannot wait and require immediate treatment. If any emergency sign is present: give emergency treatment, call for help, and perform relevant emergency laboratory investigations. (A&B) Airway and Breathing » Not breathing or » Airway obstructed or 1.1 CHAPTER 1 EMERGENCIES AND TRAUMA » Central cyanosis or » Severe respiratory distress (C) Circulation » Cold hands and » Capillary refill  3 seconds and » Weak and fast pulse (C) Coma/Convulsing » Coma or » Convulsing (at the time of evaluation) (D) Severe dehydration Fluid loss plus any two of the following: » Lethargy » Sunken eyes » Very slow skin pinch (the fold is visible for more than 2 seconds) Priority signs (place ahead of the normal queue): These children need prompt assessment and treatment: » young infant (< 3 months), » temperature very high (> 38 ºC) or very low (< 36.4 ºC), » trauma or other urgent surgical condition, » severe pallor, » history of poisoning, » severe pain, » respiratory distress, » restless, continuously irritable, or lethargic, » urgent referral from another health professional, » malnutrition: visible severe wasting, » oedema of both feet, » burns (major). Non-urgent (queue): Proceed with assessment and further treatment according to the child’s priority. A number of different triage processes exist and the above is based on the South African Emergency Triage Assessment and Treatment (ETAT). In addition, the use of clinical markers such as respiratory rate, blood pressure and pulse rate add precision to triage. 1.2 CHAPTER 1 EMERGENCIES AND TRAUMA Other important conditions may be added to the ETAT guidelines based on local circumstances, such as identifying infectious diseases that need immediate isolation, dehydration (not severe), facial or inhalational burns, evidence of meningococcal septicaemia, and inconsolable crying. The ETAT triage presented above should be a minimum standard of triage in community health centres, district or regional hospitals in South Africa. 1.1.2 RESUSCITATION OF THE CHILD A structured approach to the seriously ill or injured child can rapidly optimise their outcome. Estimation of weight in children is inaccurate and they should be weighed as soon as stabilised. The PAWPER tape allows for consideration of body habitus when estimating weight and can be used as an alternative to the formulae provided (in the diagram below). The following is a diagrammatic overview derived from an approach to advanced paediatric life support. 1.3 CHAPTER 1 EMERGENCIES AND TRAUMA 1.4 CHAPTER 1 EMERGENCIES AND TRAUMA To optimise oxygen delivery:  Oxygen, high flow, 15 L/minute via facemask with reservoir bag or 6– 10 L/minute. o If oxygen saturation < 92% or PaO2 < 80 mmHg despite maximal oxygen supply, consider providing additional respiratory support. 1.1.3 ANAPHYLAXIS/ANAPHYLACTIC REACTIONS T78.2 DESCRIPTION An acute, potentially life-threatening hypersensitivity reaction starting within seconds to minutes after administration of, or exposure to, a substance to which the individual is sensitised. Clinical manifestations include at least one of the following: upper airway obstruction, bronchospasm, hypotension, or shock. The reaction can be short-lived, protracted or biphasic, i.e. acute with recurrence several hours later. Immediate reactions are usually the most severe. DIAGNOSTIC CRITERIA Clinical » Acute onset of signs and symptoms. » Dizziness, paraesthesia, syncope, sweating, flushing, dysrhythmias. » Swelling of eyes, lips and tongue (angioedema). » Upper airway obstruction with stridor. » Hypotension and shock. » Bronchospasm, wheezing, dyspnoea, chest tightness. » Gastrointestinal symptoms such as nausea, vomiting, diarrhoea. A life-threatening anaphylactic reaction requires immediate treatment. Facilities to initiate treatment must be available at all health centres. GENERAL AND SUPPORTIVE MEASURES » Place hypotensive or shocked patient in the horizontal position. Do not place in a sitting position. » Assess and secure airway. If necessary, bag via mask or intubate. MEDICINE TREATMENT  Adrenaline (epinephrine) 1:1000 (undiluted), IM, 0.01 mL/kg. (i.e. 10 mcg/kg). o Can be repeated every 5 minutes, if necessary. o Maximum per dose: 0.5 mL. 1.5  CHAPTER 1 EMERGENCIES AND TRAUMA Do not administer IV unless there is failure to respond to several doses of IM. If no response, use IV:  Adrenaline (epinephrine) 1:1000 (undiluted), IV infusion at 0.02 mcg/kg/minute (mix 0.06 mg/kg adrenaline in 50 mL 5% dextrose, 1 mL/hour = 0.02 mcg/kg/minute). To maintain arterial oxygen saturation  95%:  Oxygen, at least 1–2 L/minute by nasal prong. In severe anaphylaxis, nasal oxygen is unlikely to be adequate:  Oxygen, 15 L/minute by face mask with a reservoir bag. Crystalloid solutions, e.g.:  Sodium chloride 0.9% OR Modified Ringers Lactate, IV, 20 mL/kg rapidly. o Repeat if necessary until circulation, tissue perfusion and blood pressure improves (up to 60 mL/kg). LoE I1  Hydrocortisone, IV, 5 mg/kg, 4–6 hourly for 12–24 hours. o Note: Steroids are adjunctive therapy, are not part of first line treatment, and should never be the sole treatment of anaphylaxis.  Promethazine, IV/IM, 0.25–0.5 mg/kg/dose. Contra-indicated in children < 2 years old. Continue with:  Chlorphenamine, oral, 0.1 mg/kg/dose 6 hourly for 24–48 hours, if necessary. If associated bronchospasm:  Salbutamol, nebulised, 1 mL salbutamol respirator solution in 3 mL sodium chloride 0.9%. o Nebulise at 20-minute intervals. If associated stridor:  Adrenaline (epinephrine), 1:1000, nebulise with oxygen, every 15–30 minutes until expiratory obstruction is abolished. o 1 mL adrenaline (epinephrine) 1:1000 diluted in 1 mL sodium chloride 0.9%. Observe for 24 hours, in particular for recurrent symptoms as part of a ‘biphasic’ reaction. PREVENTATIVE MEASURES AND HOME BASED TREATMENT » Obtain a history of allergies/anaphylaxis on all patients before administering medication/immunisation. » Identify offending agent and avoid further exposure. 1.6 CHAPTER 1 EMERGENCIES AND TRAUMA » Ensure patient wears allergy identification disc/bracelet. » Train patients to self-administer adrenaline (epinephrine) pre-filled auto injecting device. Specialist initiated for patients who have anaphylactic reactions. » Educate patient and parent/caregiver on allergy and anaphylaxis. REFERRAL Caution » Do not refer the patient during the acute phase. » Transfer can only be done once the patient is stable. » Patients supplied with self-administered adrenaline (epinephrine) must be informed of the shelf life of adrenaline (epinephrine) and when they must come in to get a replacement. » Bee sting anaphylaxis for desensitisation. 1.7 CHAPTER 1 EMERGENCIES AND TRAUMA 1.1.4 CARDIORESPIRATORY ARREST I46.9 1.8 CHAPTER 1 EMERGENCIES AND TRAUMA DESCRIPTION Cardiorespiratory arrest in children usually follows a period of circulatory or respiratory insufficiency and less commonly is precipitated by a sudden cardiac event. It is, therefore, important to pre-empt cardiorespiratory arrest in children by recognising and urgently treating respiratory or circulatory compromise. Cardiorespiratory arrest is diagnosed clinically in the unresponsive child who has no respiratory effort and/or in whom there is no palpable pulse and no signs of life, i.e. cough or spontaneous movement. GENERAL AND SUPPORTIVE MEASURES Always call for help immediately. Ensure an open airway (position head in a neutral position for toddlers or sniffing position for older children with head-tilt, chin-lift manoeuvre or jaw-thrust in trauma cases). If there is still no respiration, then commence with artificial breathing using a self- inflating bag, with a reservoir and an appropriate mask. Connect the bag to a high flow oxygen source (15 L/minute). Squeeze the bag with enough air to cause the chest to rise, do not overinflate the child’s lungs with too much tidal volume. If there is inadequate chest movement with bag-valve-mask ventilation, re-assess airway patency and adjust, re-positioning the airway with a naso or oropharyngeal tube/airway. If necessary, place an appropriately sized endotracheal tube. In the event of an unexpected arrest or an arrest where there are no witnesses, consider foreign body obstruction. See section 1.1.7: Inhalation, foreign body. Checklist: 1. Reassess head position to keep airway open. 2. Reassess for an adequate seal when performing bag-mask ventilation. 3. Ensure an adequate size bag is used according to the size of the patient. 4. Ensure no leaks in bag. 5. Exclude a pneumothorax. Once effective breathing has been established, provide chest compressions at a rate of 100–120/minute for all children excluding neonates. Provide artificial breaths at a ratio of 30 compressions to 2 breaths (30:2) if alone and 15 compressions to 2 breaths (15:2) if two rescuers are present. Attach a cardiac monitor to the child and secure vascular access. If unable to insert an IV line, obtain intra-osseous access. See section 1.1.10: Intra-osseous infusion in emergencies. MEDICINE TREATMENT Asystole or pulseless electrical activity (i.e. no palpable pulse even if normal electrical pattern (PEA)):  Adrenaline (epinephrine) 1:10 000 (diluted), IV/intra-osseous, 0.1 mL/kg. (Follow each dose with a small bolus of sodium chloride 0.9%) 1.9 CHAPTER 1 EMERGENCIES AND TRAUMA o 0.1 mL of 1:10 000 solution = 10 mcg. o Dilute a 1 mL ampoule of adrenaline (epinephrine) 1:1000 in 9 mL of sodium chloride 0.9% or sterile water to make a 1:10 000 solution. ETT adrenaline is no longer recommended as absorption is unpredictable. It is faster to get an IO line than intubating the child – rather go for IO adrenaline. Repeat the dose of adrenaline (epinephrine) every 4 minutes if asystole/PEA persists while CPR continues. When an ECG sinus rhythm trace is present, continue CPR until an effective pulse and circulation is present. If the arrest was preceded by circulatory shock:  Sodium chloride 0.9% OR Modified Ringers Lactate, IV, 20 mL/kg as a bolus. LoE I1 During the resuscitation consider if any of the following correctable conditions are present (and if present correct them): » Hypoxia » Hypovolaemia » Hyperkalaemia, hypokalaemia, hypocalcaemia. » Hypothermia » Tension pneumothorax. » Tamponade (cardiac). » Toxins (e.g. tricyclic antidepressants). » Thrombo-embolic event. Note: There is no evidence to support the routine use of any of the following in cardiac arrest: » sodium bicarbonate, » calcium, » high dose IV adrenaline (epinephrine) (100 mcg/kg/dose). Ventricular fibrillation or pulseless ventricular tachycardia Consider the following and if present, correct: » Hypoxia » Hypovolaemia » Hyperkalaemia, hypokalaemia, hypocalcaemia. » Hypothermia » Tension pneumothorax. » Tamponade (cardiac). » Toxins (e.g. tricyclic antidepressants). » Thrombo-embolic event. 1.10 CHAPTER 1 EMERGENCIES AND TRAUMA Proceed to immediate defibrillation, but during this process cardiorespiratory resuscitation (compressions and ventilation) must continue, except during the actual administration of each shock. Continue until adequate circulation can be demonstrated. For pulseless ventricular tachycardia and ventricular fibrillation, the defibrillator should be set to asynchronous mode and 4 J/kg shocks administered. Do not increase voltage; give 4 J/kg repeatedly, if needed. After each shock continue CPR immediately for 2 minutes and only re-assess the ECG rhythm thereafter. If ventricular tachycardia/fibrillation has reverted to sinus rhythm, stop shock cycle, but continue CPR until good stable circulation and adequate spontaneous breathing is evident. If fibrillation/ventricular tachycardia is still present, give further shocks for 3 x 2-minute cycles of shocks every 4 minutes. Thereafter, if necessary, the 2-minute shock cycles should continue but, in addition, give the following after the 3rd shock:  Adrenaline (epinephrine) 1:10 000 (diluted), IV, 0.1 mL/kg and then repeat after every 2nd shock, i.e. every 4 minutes. (Follow each dose with a small bolus of sodium chloride 0.9%.) o 0.1 mL of 1:10 000 solution = 10 mcg. o Dilute a 1 mL ampoule of adrenaline (epinephrine) 1:1000 in 9 mL of sodium chloride 0.9% or sterile water to make a 1:10 000 solution. Allow one minute of cardiopulmonary resuscitation between the administration of any medicine and a repeat cycle of shocks. REFERRAL » To an intensive care unit after recovery from an arrest. 1.1.5 POST RESUSCITATION CARE Once children have been successfully resuscitated and emergency treatment provided, they remain at high risk for death or disability. In order to optimise outcomes, the following principles of care apply: 1. Admit or refer to a ward with appropriate monitoring facilities, e.g. a high care or intensive care unit as soon as possible. 2. Identify and manage underlying pathology. 3. Maintain normoxia (avoid both hyperoxia and hypoxia). 4. Avoid hypo- and hypercapnia. 1.11 CHAPTER 1 EMERGENCIES AND TRAUMA 5. Maintain systolic BP ≥ 5thpercentile for age (refer to Chapter 4: Cardiovascular System, section 4.11: Hypertension); this may require intravascular fluids and/or inotropes. 6. Avoid hyperthermia and treat fever aggressively. 7. Provide adequate nutrition. 8. Monitor and correct glucose and electrolyte abnormalities. 9. Provide appropriate analgesia. 10. Consider rehabilitation requirements. 1.1.5.1 TERMINATION OF RESUSCITATION » The decision to stop CPR attempts depends on the specifics of the individual patient and should be based on clinical judgement. » Consider stopping resuscitation attempts and pronouncing death if there is incurable underlying disease, or if asystole > 20 minutes. Consider carrying on for longer especially with: » hypothermia and drowning, » poisoning or medicine overdose, » neurotoxic envenomation (e.g. black and green mamba or Cape cobra snakebite) – see section 18.2.3: Snakebite. This decision should take into consideration the potential risk that CPR poses to the rescuer, e.g. infectious diseases. 1.12 CHAPTER 1 EMERGENCIES AND TRAUMA 1.1.6 CONVULSIONS, NOT FEBRILE CONVULSIONS See section 13.1: Seizures. 1.13 CHAPTER 1 EMERGENCIES AND TRAUMA 1.1.7 INHALATION, FOREIGN BODY T17.9 DESCRIPTION Accidental inhalation of a solid object that may obstruct the airway at any level. DIAGNOSTIC CRITERIA Ask specifically about a possible choking episode if there is any suspicion of a foreign body aspiration. » Initial symptom is frequently sudden onset of choking followed by persistent unilateral wheeze (may be bilateral), chronic cough, or stridor. » Segmental or lobar pneumonia failing to respond to standard therapy. » Mediastinal shift. » Chest X-ray on full expiration and full inspiration may show hyperinflation and/or collapse or sometimes, a radio-opaque foreign body. GENERAL AND SUPPORTIVE MEASURES ACUTE EPISODE » If coughing effectively and breathing adequately, provide oxygen and refer urgently for airway visualisation. Carry out transfer with a person who is able to manage the foreign body process accompanying the child. » If the child is still breathing but unable to cough or breathe adequately, attempt to dislodge the foreign body by cycles of 5 back slaps followed by 5 chest compressions (infants), or 5 Heimlich manoeuvres (child) repeatedly. » If the child is unresponsive, carry out standard cardiorespiratory resuscitation, i.e. cardiac compressions and ventilation (provide artificial breaths at a ratio of 30 compressions to 2 breaths (30:2) if alone and 15 compressions to 2 breaths (15:2) if two rescuers are present). Caution Blind finger sweeps are dangerous and contra-indicated. Foreign bodies may be removed under direct vision. All cases should have airway visualisation or be referred for airway visualisation. REFERRAL » All cases for the removal of retained foreign bodies. » Unresolved respiratory complications. 1.14 CHAPTER 1 EMERGENCIES AND TRAUMA 1.1.8 SHOCK R57.9 DESCRIPTION An acute syndrome that reflects the inability of the pulmonary and circulatory system to provide adequate perfusion, oxygen and nutrients to meet physiological and metabolic demands. Compensation is achieved by increased pulse rate, and peripheral vascular constriction. The blood pressure may be relatively well maintained but the patient still requires urgent resuscitation. Hypotension is a late and ominous sign. Shock can be further characterised: » Hypovolaemic shock: e.g. dehydration, haemorrhage or fluid shifts. » Distributive shock: e.g. septicaemia and anaphylaxis. » Cardiogenic shock: e.g. cardiac dysfunction. » Dissociative shock: e.g. profound anaemia and carbon monoxide poisoning. » Obstructive shock: e.g. pneumothorax and cardiac tamponade. » Septic shock: many mechanisms are operative in septic shock. » Neurogenic shock: e.g. spinal cord trauma. Complications of shock include multi-organ dysfunction and/or failure. A patient may have more than one type of shock present, e.g. a trauma patient with spinal cord injury, pneumothorax and haemorrhagic shock. DIAGNOSTIC CRITERIA Evidence of compensated shock includes: » cold peripheries, » weak pulse pressure especially peripheral pulse weaker than central pulses, » prolonged capillary filling, i.e. ≥ 3 seconds, » agitation/confusion/decreased level of consciousness, » skin pallor, » increased heart rate, » signs and symptoms of underlying conditions. In uncompensated shock, falling BP and failure to act urgently will result in irreversible shock and death. Facilities to start treatment of shock must be available at all health centres. GENERAL AND SUPPORTIVE MEASURES » Follow the ABCDE algorithm. See section 1.1.1: Triage. » Identify and treat the underlying cause. » Ensure good intravenous or intra-osseous access. In trauma, two large bore lines for access are important. See section 1.1.10: Intra-osseous infusion in emergencies. 1.15 CHAPTER 1 EMERGENCIES AND TRAUMA » Perform relevant investigations. » Monitor: > Vital signs and maintain within normal limits. > Metabolic parameters and correct as needed. > Urinary output – aim for at least 1 mL/kg/hour. MEDICINE TREATMENT To optimise oxygen delivery to the tissue, administer:  Oxygen, high flow, 15 L/minute via facemask with reservoir bag or 6–10 L/minute. If oxygen saturation < 92% or PaO2 < 80 mmHg, consider the need to intubate and continue respiratory support. 1. Hypovolaemic shock Response to each step of management must be reviewed every 15 minutes. If after administration of a total of 40 mL/kg of sodium chloride 0.9% fluid, shock has not resolved, consider other causes and the need for inotropes. For fluid deficit (vs. blood loss): IV fluids to correct the intravascular fluid deficit and improve circulation:  Sodium chloride 0.9% OR Modified Ringers Lactate, IV, 20 mL/kg rapidly. o Review after each bolus to see if shock has resolved. LoE I1 In children with severe malnutrition:  Sodium chloride 0.9%, IV, 10 mL/kg administered over 20 minutes. o Review after each bolus to see if shock has resolved. With each re-assessment, if: » Shock has resolved (capillary filling time < 3 seconds, good pulse, normal blood pressure, urine output, skin perfusion and level of consciousness improved), do not repeat the fluid bolus. » Shock is better but still present, repeat bolus (up to 40 mL/kg). After this further care should be in an ICU setting. Consider initiation of inotropes/vasopressors. » Monitor for persistence of shock, i.e.: > Non-responding or decreasing BP. > Non-responding or increasing pulse rate/decreasing volume. > Non-responding or increasing capillary filling time. » Monitor for fluid or circulatory overload, i.e.: > Increasing respiratory rate. > Increasing basal crepitations. > Increasing pulse rate. > Increasing liver size/tenderness. > Increasing JVP. > Increasing oxygen requirement. After circulatory stabilisation, continue with appropriate maintenance fluid. 1.16 CHAPTER 1 EMERGENCIES AND TRAUMA For blood loss:  Packed red cells or whole blood, 10–20 mL/kg, repeat if required. o Stop once haemodynamic stability reached. While awaiting blood products to arrive, proceed with volume resuscitation. See section 1.1.9: Massive blood loss. 2. Cardiogenic shock Ideally, children receiving treatment for cardiogenic shock should be in a high care or ICU. Inotropic support: When perfusion is poor and blood pressure response is unsatisfactory, despite adequate fluid replacement.  Dobutamine, IV, 5–15 mcg/kg/minute. o Initiate slowly and with caution as dobutamine can potentially drop BP due to unopposed β-2 adrenergic vasodilation properties. Chronotropic/inotropic plus vascular tone support: If tissue perfusion and blood pressure do not improve satisfactorily on adequate fluid volume replacement and inotropic support, consider:  Adrenaline (epinephrine), IV infusion, 0.05–1 mcg/kg/minute. If poor ventricular contractility and increased afterload are considered as the primary problem, do not give adrenaline (epinephrine) but consider adding an afterload reducing agent to the dobutamine infusion but only with specialist advice. 3. Septic shock Treatment for septic shock should be initiated urgently and then patients should preferably be transferred to an ICU. Response to each step of management must be reviewed every 15 minutes. IV fluids:  Sodium chloride 0.9% OR Modified Ringers Lactate, IV, 10 mL/kg rapidly. o Review after each bolus to see if shock has resolved. LoE I1 In children with severe malnutrition:  Sodium chloride 0.9%, IV, 10 mL/kg administered over 20 minutes. o Review after each bolus to see if shock has resolved. With each reassessment, if: » Shock has not resolved after 40 mL/kg of sodium chloride 0.9% fluid, consider inotropes. 1.17 CHAPTER 1 EMERGENCIES AND TRAUMA » Shock has resolved (capillary filling time < 3 seconds, good pulse, normal blood pressure), do not repeat bolus. Proceed to other care. » Shock is better but still present, repeat bolus (up to 40 mL/kg). After this, further care should be in an ICU setting. » Monitor for persistence of shock, i.e.: > Non-responding or decreasing BP. > Non-responding or increasing pulse rate/decreasing volume. > Non-responding or increasing capillary filling time. » Monitor for fluid or circulatory overload, i.e.: > Increasing respiratory rate. > Increasing basal crepitations. > Increasing pulse rate. > Increasing liver size/tenderness. > Increasing JVP. Chronotropic/Inotropic plus vascular tone support: If tissue perfusion and blood pressure do not improve satisfactorily on adequate fluid volume replacement: titrate inotropes against the response and add an additional agent if poor response.  Adrenaline (epinephrine), IV infusion, 0.05–1 mcg/kg/minute. If inadequate response: ADD  Dobutamine, IV, 5–15 mcg/kg/minute. Septicaemic shock unresponsive to inotropes:  Hydrocortisone, IV, 1–2 mg/kg/dose, 6 hourly until shock has resolved. Antibiotic therapy » Start empiric antibiotics early. » Aim to get source control: all pus should be drained; all necrotic tissue should be removed/debrided. Before initiating antibiotic therapy, take blood and urine specimens, if appropriate, for culture and sensitivity testing. Consider whether community or hospital acquired and treat based on anticipated susceptibility. Ensure immediate administration. Reconsider antibiotic and/or antifungal therapy when culture and sensitivity results become available. Caution Patients must be resuscitated and stabilised before referral. 1.18 CHAPTER 1 EMERGENCIES AND TRAUMA 1.1.9 MASSIVE HAEMORRHAGE WITH MASSIVE TRANSFUSION OF BLOOD DEFINITION Massive blood loss in children is recognised when a child re