348 Paediatric Emergencies
BREATHLESS CHILD(iv) Tachycardia ≥130 beats/min if aged 2–5 years, or >120/min if
>5 years.
(v) Peak expiratory flow rate (PEFR) ≤50% or less of predicted or best
(a) PEFR has a minimal role in the diagnosis and monitoring of
progress in children with asthma
(b) spirometry can be used in children >6 years, but is also of
limited use in the acute setting.
7 Markers of a critical, life-threatening attack include any one of:
(i) Silent chest with absent wheeze on auscultation.
(ii) Exhaustion.
(iii) Altered level of consciousness.
8 Send blood for full blood count (FBC), urea and electrolytes (U&Es) and
blood sugar levels only if the attack is severe.
(i) Hypokalaemia and hyperglycaemia are side effects of treatment.
9 Perform a chest radiograph (CXR) only if the diagnosis is in doubt, infection
is suspected, or there is sudden deterioration to exclude a pneumothorax.
Mucus plugging or collapse is sometimes mistaken for pneumonia.MANAGEMENT1 Sit the child up and give oxygen, ideally with the parent in attendance to
reassure the child. Attach a pulse oximeter, aiming for an oxygen saturation
above 92%.
2 Give a bronchodilator such as salbutamol:
(i) Use a metered-dose inhaler with spacer device (MDI spacer).
Administer 6 puffs if the child is <6 years of age and 12 puffs if
>6 years, as a ‘single dose’.
(ii) Review the response after 10 min in a mild case.
(iii) Administer a burst of three doses over an hour in moderate to
severe attacks and review.
(iv) The severity of the attack will determine the frequency of
administration thereafter.
3 Add ipratropium bromide (four puffs if <6 years and eight puffs if >6 years) to
the MDI spacer every 20 min for the first hour of treatment in moderate
to severe ast hma, and or if t he response to sa lbutamol is inef fective.
4 Give prednisolone 1–2 mg/kg orally to a maximum of 40 mg, or hydrocorti-
sone 4 mg/kg i.v. if the child is vomiting.
5 Commence i.v. f luid administration if dehydration is present, but limit to
75% of maintenance requirements.
6 Refer all severe cases to the paediatric team.
7 Indications for ICU admission and possible ventilatory support include:
(i) Progressive clinical deterioration.
(ii) Increasing exhaustion.