DÄ internationalArchive17/2010Pay Attention to the Target Group
LNSLNS The paper discussed (3) was addressed to emergency physicians. The rate of severely ill children is low (less than 1% of all emergency cases). Because of the low incidence we suggest hands-on training possibilities for emergency physicians in pediatric and pediatric surgery departments. As a prerequisite in caring for paediatric emergency patients the equipment (drugs, material etc.) available plays a key role. The regular equipment in the German EMS is according to DIN.

The authors should address the following points:

Non-invasive oscillometric blood pressure measurement only assesses the mean arterial pressure. Values like 98/64 mm Hg give a fiction of accuracy.

Do the authors only use cuffed endotracheal tubes (sometimes inflated, sometimes not), or do they mean cuffed and uncuffed tubes?

Intravenous piritramide can produce respiratory arrest in a neonate even at a dose of 50 µg/kg. A dose of 30 µg/kg would be safer and could be repeated in 10 minutes if necessary. Morphine is more potent than piritramide (1:0.75), not only for its primary effect, but for its side effects as well, and should NOT be given at the same doses. Our experience suggests that opioids are underused in pediatrics despite their immense clinical value. There are no nebulizers in first aid materials, although families often have them.

Although EMS vehicles generally do not carry nebulizers, the families of the affected patients often already have one at home.

In general, emergency physicians have more experience with midazolam than with diazepam. Midazolam has nearly only inactive metabolites. If a seizure continues until the emergency physician arrives (12–15 min), it is a mistake to administer a rectal drug. Intravenous midazolam and propofol are to be preferred.

According to the ERC guidelines after the third attempt to place an IV catheter line or after 120 sec an intraosseous needle should be placed. What are the relevant prehospital risks of IO-access seen by the authors? Furthermore, the 22 G peripheral venous catheter is the smallest catheter in the EMS; this could be used to deliver 7 mL/kg/min of fluid to a child weighing 5 kg. Fluid resuscitation using a 26 G peripheral venous catheter is impossible. The recommendations of the association of German pediatric anesthesiologists for fluid management (1) represent the evidence, as does the work of Murat and Dubois. Fluid replacement should be done with a balanced, acetate-based full electrolyte solution, in children <3 years with the addition 1% glucose.

The authors propose a treatment of diabetic ketoacidosis with 0.9% NaCl solution or 0.45% NaCl solution with glucose, but at the same time they warn of a cerebral edema of unknown etiology. Under conditions of hyperglycemia and hyponatremia a cerebral edema is anticipated. The free water infused follows the concentration gradient of sodium ions into the cells (2). A balanced, acetate-based full electrolyte solution would be better.
DOI: 10.3238/arztebl.2010.0303b

Dr. med. Thomas Mader DEAA
Rosenstr. 16
06114 Halle (Saale), Germany
maderth@gmx.de
1.
Sümpelmann R, et al.: Empfehlungen zur perioperativen Infusionstherapie bei Neugeborenen, Säuglingen und Kleinkindern. Anästh Intensivmed 2007; 48: 73–7.
2.
Arieff A: Postoperativ hyponatriaemic encephalopathy following electiv surgery in children. Paediatric Anaesthesia 1998; (8): 1–4. MEDLINE
3.
Meyburg J, Bernhard M, Hoffmann GF, Motsch J: Principles of pedi-atric emergency care. [Grundlagen für die Behandlung von Notfällen im Kindesalter]. Dtsch Arztebl Int 2009; 106: 739–48. VOLLTEXT
1. Sümpelmann R, et al.: Empfehlungen zur perioperativen Infusionstherapie bei Neugeborenen, Säuglingen und Kleinkindern. Anästh Intensivmed 2007; 48: 73–7.
2. Arieff A: Postoperativ hyponatriaemic encephalopathy following electiv surgery in children. Paediatric Anaesthesia 1998; (8): 1–4. MEDLINE
3. Meyburg J, Bernhard M, Hoffmann GF, Motsch J: Principles of pedi-atric emergency care. [Grundlagen für die Behandlung von Notfällen im Kindesalter]. Dtsch Arztebl Int 2009; 106: 739–48. VOLLTEXT