Intensive Care Chapter
Indian Academy of Pediatrics
P-ISSN : 2349-6592 and E-ISSN : 2455-7099
Website : www.journalofpediatriccriticalcare.com
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CONTENTS
Editorial Board
Original Article
Pediatric Residents Perception of Pediatric Intensive Care Training During Post Graduation
Shruti TK; et al, Chennai
Special Article
Management of Poisonings in Children Puneet Aulakh Pooni, Vikas Bansal, Ludhiana
Review Article
Envenomation -1: Snake Bite Suchita Khadse, Nagpur
Envenomation -2: Scorpion Sting Suchita Khadse, Nagpur
Clinical Pearls
Guidelines on Bronchiolitis: Clinical AAP Guidelines summary: Bronchiolitis
Case Report
Migratory Foreign Body in the Airway Manifesting as Recurrent Cardio-respiratory Arrest:
A rare case report Goyal VK; et al, Jodhpur
Waterhouse Friderichsen Syndrome in a Case of Staphylococcal Toxic Shock Syndrome
Devdeep Mukherjee; et al, Kolkotta
Bradyarrythmia in Acute Phase of Viral Hemorrhagic Fever Maniya N; et al, Delhi
Acute Intermittent Porphyria in Childhood Presenting with Hypertensive Emergency and Posterior
Reversible Encephalopathy Syndrome Rishab Bharadwaj; et al, Ahmedabad
A Case of Landau-Kleffner Syndrome Manjunath S Pandit; et al, Jaipur
Journal Scan Sharma R; et al, New Delhi
Vol.3 No.2
April-June 2016
Critical Thinking
PICU Quiz Praveen Khilnani, New Delhi
Vol. 3 - No.2 April - June 2016
a
JOURNAL OF PEDIATRIC CRITICAL CARE
Manual of Basic Pediatric Intensive Care Course
(BPICC Manual)
N
ew
3 rd E
ditio
n,
BPIC
C Ma 2015
nu
Publ
ishe al
d
Some upcoming
Basic Pediatric Intensive Care Course (BPICC)
Courses:
NCPCC 2016, Mumbai
Pedicon 2017, Bengaluru
Criticare 2017, Kochi
BPICC 2016
April 2016 Kanpur, Amritsar, lucknow, Ahmedabad
and more
To Organize a BPICC in your area, please contact:
Dr Rajiv Uttam
National Co Convener, BPICC
M: 9810055670 • Email: [email protected]
Dr Vishram Buche
Chairperson, IAP Intensive Care Chapter
M: 9823017254 • Email: [email protected]
Dr Anil Sachdev
Chairperson, IAP Intensive Care Chapter
M: 9810098360 • Email: [email protected]
Regional Conveners:
Dr Vikas Taneja (Gurgaon)
Dr Anjul Dayal (Hyderabad)
Dr Gnanam (Bengaluru)
Dr Parthsarathi Bhattacharya (Kolkotta)
Dr Vinay Joshi (Mumbai)
Founder Conveners:
Dr Praveen Khilnani
Vol. 3 - No.2 April - June 2016
Dr Rajiv Uttam
b
Dr Krishan Chugh
JOURNAL OF PEDIATRIC CRITICAL CARE
Contents
Editorial Board
2
IAP IC Chapter Executive Committee 2016
3
Basic Pediatric Intensive Care Nursing Course (BPICNC)
4
From the Editors Desk
5
JPCC Copyright Form
6
Author Instructions
9
Original Article
Pediatric Residents Perception of Pediatric Intensive Care Training During Post
Graduation
16
Shruti TK, Rajakumar PS, Shubha S
Sri Ram Chandra Medical College and Research Centre, Chennai, India
Special Article
Management of Poisonings in Children
20
Puneet Aulakh Pooni, Vikas Bansal
Dayanand Medical College and Hospital, Ludhiana; SPS Apollo Hospitals Ludhiana, Punjab
Review Article
Suchita Khadse
Pediatric Intensivist, CHILD Hospital, Nagpur
Envenomation -1: Snake Bite
Envenomation -2: Scorpion Sting
33
42
Clinical Pearls
Guidelines on Bronchiolitis: Clinical AAP Guidelines summary: Bronchiolitis
Case Report
Migratory Foreign Body in the Airway Manifesting as Recurrent Cardio-respiratory
Arrest: A rare case report
49
50
Goyal VK, Singh A, Nagar R, Singh S
Dr S N Medical College, Jodhpur
Waterhouse Friderichsen Syndrome in a Case of Staphylococcal Toxic Shock
Syndrome
52
Devdeep Mukherjee, Prabhas Prasun Giri, Suman Poddar
Institute of Child Health, Kolkata
Bradyarrythmia in Acute Phase of Viral Hemorrhagic Fever
55
Maniya N, Ohri A, Sharma R, Lal N, Khilnani P
BLK Superspeciality Hospital, New Delhi
Acute Intermittent Porphyria in Childhood Presenting with Hypertensive
Emergency and Posterior Reversible Encephalopathy Syndrome
58
Rishab Bharadwaj, Pallavi P Dagli, Aasheeta S Shah
Smt. NHL Municipal Medical College and V.S. General Hospital, Ellis Bridge, Ahmedabad
A Case of Landau-Kleffner Syndrome
61
Manjunath S Pandit, Ashok Gupta, Priyanshu Mathur, Manish Sharma, Manisha Garg
SMS Medical College, Jaipur
Journal Scan
64
Sharma R, Lal N, Maniya N, Vasudevan V, Ohri A, Khilnani P
Pediatric Intensive Care Unit (PICU), BLK Superspeciality Hospital, New Delhi
Critical Thinking
PICU Quiz
74
Praveen Khilnani
BLK Superspeciality Hospital, New Delhi & Mediclinic City Hospital, Dubai
Vol. 3 - No.2 April - June 2016
1
JOURNAL OF PEDIATRIC CRITICAL CARE
Journal of Pediatric Critical Care (JPCC)
Editorial Board
Editor-In-Chief:
Dr Praveen Khilnani
Senior Editors and Reviewers:
Dr (Prof) Sunit Singhi (PGIMER, Chandigarh)
Dr K Chugh (Fortis Hospital, Gurgaon)
Dr S Udani (Hinduja Hospital, Mumbai)
Dr S Ranjit (Appollo Hospital, Chennai)
Dr Rajiv Uttam (Max Hospital, New Delhi)
Dr Anil Sachdev (Sir GangaRam Hospital, New Delhi)
Dr Madhu Otiv (KEM Hospital, Pune)
Dr S Deopujari (Child Hospital, Nagpur)
Dr Bala Ramachandran (Child Trust Hospital, Chennai)
Dr S Soans (AJIMS, Mangalore)
Executive Members:
Dr Arun Bansal (Chandigadh)
Associate Editors:
Dr Dhiren Gupta (Sir GangaRam Hospital, New Delhi)
Dr Nameet Jarath (Apollo Hospital, Delhi)
Dr Kundan Mittal (PGIMS, Rohtak)
Dr Rakshay Shetty (Rainbow Hospital, Banglore)
Dr Basavaraj (Banglore)
Dr Gnanam (Manipal Hospital, Banglore)
Dr Sandeep Kanwal (New Delhi)
Executive Editor:
Dr V S V Prasad (Lotus Hospital, Hyderabad)
Managing Editor:
Dr Vinayak Patki (Wanless Hospital, Miraj)
Biostatistics:
Dr M Jayshree (Chandigarh)
Dr Banani Poddar (Vellore)
Dr Jhuma Sankar (New Delhi)
Dr Ebor Jacob (Vellore)
Dr Arun Baranwal (Patana)
Dr Lokesh Tiwari (Patana)
Dr Partha Bhattacharya (Kolkatta)
Dr Prabhat Maheshwari (Gurgaon)
Dr Dinesh Chirla (Hyderabad)
Dr Deveraj Raichur (Hubali)
Dr Karunakara (Bangalore)
Dr Mritunjay Pao (Assam)
Ethics:
Dr Urmila Jhamb (New delhi)
Dr Rakesh Lodha (New Delhi)
Dr Meera Ramakrishnan (Banglore)
Dr Vinay Joshi (Mumbai)
Website:
Dr Deepika Gandhi (Chennai)
Dr Maninder Dhaliwal (Gurgaon)
Dr Bhaskar Saikia (New Delhi)
Dr Anjul Dayal (Hyderabad)
Dr Shipra Gulati (New Delhi)
Dr Vikas Taneja (Gurgaon)
Dr Indira Jayakumar (Chennai)
Dr Sanjay Bafna (Pune)
Dr Sanjay Ghorpade (Satara)
Publication:
Dr Rachna Sharma (New Delhi)
Dr Pradeep Sharma (New Delhi)
Dr Sanjeev Kumar (Gurgaon)
Dr Sagar Lad (Pune)
Vol. 3 - No.2 April - June 2016
2
International Advisory Board:
Dr Niranjan Kissoon (Canada)
Dr Jerry Zimmerman (USA)
Dr Joseph Carcillo (USA)
Dr Ashok Sarnaik (USA)
Dr Peter Cox (Canada)
Dr Shekhar Venkataraman (USA)
Dr Vinay Nadkarni (USA)
Dr Mohan Mysore (USA)
Dr Utpal Bhalala (USA)
Dr Suneel Pooboni (UK)
Dr Rahul Bhatia (USA)
Dr Ravi Samraj (USA)
Dr Dipankar Gupta (USA)
National Advisors:
Dr Y Amdekar (Mumbai)
Dr S C Arya (New Delhi)
Dr R N Srivastava (New Delhi)
Dr Anupam Sachdeva (New Delhi)
Dr C P Bansal (Gwalior)
Dr V Yewale (Mumbai)
Dr M P Jain (Gurgaon)
JOURNAL OF PEDIATRIC CRITICAL CARE
IAP Intensive Care Chapter
Executive Committee 2016
Dr Vishram Buche
Dr B P Karunakara
Dr Kundan Mittal
Dr Anil Sachdev
Chairman
Nagpur
Chairman Elect
Bangaluru
Vice-Chairman
Rohtak
Imm. Past Chairman
Delhi
Dr Sanjay Ghorpade
Dr D P Nakate
Dr Praveen Khilnani
Dr Bakul Parekh
Secretary
Maharashtra
Joint Secretary
Maharashtra
Editor
Delhi
Treasurer
Mumbai
Dr Manish Sharma
Dr Arun Bansal
Dr Devaraj Raichur
Dr G V Basavraj
Dr J Ebor Jacob
North Zone
Jaipur
North Zone
Chandigarh
South Zone
Karnataka
South Zone
Karnataka
South Zone
Vellore
Dr Hiren Patel
Dr Sunil Vaidya
Dr Sachin Shah
Dr Agni Shekar
Dr Arun Baranwal
West Zone
Gujarat
West Zone
Solapur
West Zone
Pune
East Zone
Kolkotta
East Zone
Bihar
Vol. 3 - No.2 April - June 2016
Executive Members
3
JOURNAL OF PEDIATRIC CRITICAL CARE
Basic Pediatric Intensive Care Nursing Course (BPICNC)
One day training course has been initiated by the College of Pediatric Critical Care and
IAP Intensive Care Chapter for the critical care providers especially nurses working in the
PICU, Pediatric emergency and pediatric cardiac care units. This is a comprehensive course
that includes lectures on basic intensive care and workstations with hand on sessions in the
afternoon. A manual of pediatric critical care nursing has been prepared for the participating
candidates.
For organizing this course, you may contact:
Dr Soonu Udani
Chancellor (EX Officio),
College of Pediatric Critical Care
Mob: +919820999310
Email: [email protected]
Dr Krishan Chugh
Chancellor
College of Pediatric Critical Care
Mob: +919810608580
Email: [email protected]
Dr Anil Sachdev
Course Co-ordinator
Mob: 9810098360
Email: [email protected]
Vol. 3 - No.2 April - June 2016
4
JOURNAL OF PEDIATRIC CRITICAL CARE
From the Editors Desk
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Vol. 3 - No.2 April - June 2016
5
JOURNAL OF PEDIATRIC CRITICAL CARE
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Journal of Pediatric Critical care (JPCC) – Authorship Responsibility, Disclosure and
Copyright Transfer
Manuscript
Title
Author name
Are you the
corresponding Author?
Yes
Corresponding Author's Name
No
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Instructions
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Conditions of Submission
RETAINED RIGHTS:
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ORIGINALITY:
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PREPRINTS:
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Vol. 3 - No.2 April - June 2016
6
JOURNAL OF PEDIATRIC CRITICAL CARE
DISCLAIMER:
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Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
Transfer of Copyright
AUTHOR's OWN WORK:
,- B'-+0@"$#.0'- '1 2'*$-#(%'1%3"@0#.$0B%&$0.0B#(%&#$"%423&&<N ,53%0-."-+0>"%B#$"%B/#6."$%6*?(0B#.0'- '1%./" ]'$GN ./"
#*./'$%/"$"?A%.$#-+1"$+N #++0)-+N%#-@%'./"$=0+" B'->"A+ #(( /0+^/"$ B'6A$0)/. '=-"$+/06 ='$(@=0@"N 0- #(( (#-)*#)"+N #-@ 0#(( 1'$C+ '1 C"@0# -'= '$ /"$"#1."$ G-'=-N 0-B(*@0-) "("B.$'-0B C"@0# +*B/ #+ &!7 MSUN ,-."$-".N #-@ ,-.$#-".N .' 23&&D
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GOVERNMENT EMPLOYEESa
,1%./"%]'$G%'$%#%6'$.0'-%'1%0.%/#+%?""-%B$"#."@%0-%./"%B'*$+"%'1%#-A%#*./'$`+% "C6('AC"-.%?A%./"%b'>"$-C"-. '1%,-@0#N
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INSTITUTIONAL REVIEW BOARD/ANIMAL CARE COMMITTEE APPROVAL:
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Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
Author Instructions
Journal of Pediatric Critical Care (JPCC)
2'*$-#(% '1% 3"@0#.$0B% &$0.0B#(% &#$"% 423&&<% 0+% #-% 0-."$-#.0'-#(N% '-(0-"% #-@% 6$0-.% J'*$-#(% 6*?(0+/"@% P*#$."$(A%
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Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
Duplicate Submission and Plagiarism
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Embargo Policy
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Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
"@0.'$0#(%P*"$0"+%'$%$"P*"+.+D%&'$$"B."@%6$''1+%C*+.%?"%$".*$-"@%=0./0-%Lf%/'*$+%'1%$"B"06.N%6$"1"$#?(A%?A%"%
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-'%"$$'$+%.'%B'$$"B.N%#-@%./"%#$.0B("%=0((%?"%6*?(0+/"@%#1."$%0-7/'*+"%B'$$"B.0'-D%H/"%$"6$0-.%'$@"$%1'$C%4=0./%
-*C?"$% '1% $"6$0-.+% $"P*"+."@N% 0->'0B"% #-@% @"(0>"$A% #@@$"++<% +/'*(@% ?"% $".*$-"@% =0./% ./"% B'$$"B."@% 6$''1D%
M"6$0-.+%C#A%?"%'$@"$"@%6$0'$%.'%6*?(0B#.0'-%'-%./"%1'$C%6$'>0@"@D%H/"%@"+0)-#."@%$">0"=0-)%#*./'$%=0((%
?"%$"+6'-+0?("%1'$%'$@"$0-)%$"6$0-.+%1'$%#((%#*./'$+D%M"6$0-.+%'$@"$"@%#1."$%6*?(0B#.0'-%'1%./"%J'*$-#(%B#-%?"%
'$@"$"@%#.%0-B$"#+"@%B'+.%?A%+6"B0#(%#$$#-)"C"-.D%H/"%6*?(0+/"$%4,SE%6$"++<%=0((%6$'>0@"%.'%#*./'$+%=0./%#%1$""%
=#."$C#$G"@%3!Q%!%("%'1%./"0$%#$.0B("D
Authorship Criteria
5((%./"%#*./'$+%+/'*(@%/#>"%+*?+.#-.0#(%B'-.$0?*.0'-+%.'%"#B/%'1%./"%1'(('=0-)%./$""%B'C6'-"-.+a%:D%&'-B"6.%
#-@%@"+0)-%'1%+.*@A%'$%#BP*0+0.0'-%'1%@#.#%'$%#-#(A+0+%#-@%0-."$6$".#.0'-%'1%@#.#Z%8D%!$#1.0-)%./"%#$.0B("%'$%
$">0+0-)%0.%B$0.0B#((A%1'$%0C6'$.#-.%0-."(("B.*#(%B'-."-.Z%#-@%hD%Q0-#(%#66$'>#(%'1%./"%>"$+0'-%.'%?"%6*?(0+/"@D%
3#$.0B06#.0'-%+'("(A%0-%./"%#BP*0+0.0'-%'1%1*-@0-)%'$%./"%B'(("B.0'-%'1%@#.#%@'"+%-'.%J*+.01A%#*./'$+/06%#+%./"%
)"-"$#(%+*6"$>0+0'-%'1%./"%$"+"#$B/%)$'*6D
Contribution Details
5*./'$+%+/'*(@%6$'>0@"%#%@"+B$06.0'-%'1%B'-.$0?*.0'-+%C#@"%?A%"#B/%'1%./"C%.'=#$@+%./"%C#-*+B$06.D%5.%("#+.%
'-"%#*./'$%+/'*(@%.#G"%./"%$"+6'-+0?0(0.A%1'$%./"%0-.")$0.A%'1%./"%='$G%#-@%+/'*(@%?"%@"+0)-#."@%#+%i)*#$#-.'$dD%
5*./'$+d%B'-.$0?*.0'-+%=0((%?"%6*?(0+/"@%#('-)%=0./%./"%#$.0B("D
Con icts of Interest/ Competing Interests
5((%#*./'$+%C*+.%@0+B('+"%#-A%B'-"%0B.+%'1%0-."$"+.%./"A%C#A%/#>"%=0./%6*?(0B#.0'-%'1%./"%C#-*+B$06.%'$%#-%
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6$"+"-."@D
Copies of any Permission (S)
,.%0+%./"%$"+6'-+0?0(0.A%'1%#*./'$+^B'-.$0?*.'$+%.'%'?.#0-%6"$C0++0'-+%1'$%$"6$'@*B0-)%#-A%B'6A$0)/."@%C#."$0#(D%
5%B'6A%'1%./"%6"$C0++0'-%'?.#0-"@%C*+.%#BB'C6#-A%./"%C#-*+B$06.D
Clinical Trial Registry
23&&%$"B'CC"-@+%$")0+.$#.0'-%'1%B(0-0B#(%.$0#(+%#-@%6$"1"$"-B"%='*(@%?"%)0>"-%.'%$")0+."$"@%B(0-0B#(%.$0#(+D%
H$0#(+% B#-% ?"% $")0+."$"@% 0-% #-A% '1% ./"% 1'(('=0-)% .$0#(% $")0+."$+a/..6a^^===DB.$0D0-^Z% /..6a^^===D#B.$D'$)D#*^Z%
/..6a^^===DB(0-0B#(.$0#(+D)'>^Z%/..6a^^0+$B.-D'$)^D
Preparation of Manuscript
U#-*+B$06.+% C*+.% ?"% 6$"6#$"@% 0-% #BB'$@#-B"% =0./% j[-01'$C% $"P*0$"C"-.+% 1'$% U#-*+B$06.+% +*?C0.."@% .'%
I0'C"@0B#(%2'*$-#(+k%@">"('6"@%?A%./"%,-."$-#.0'-#(%&'CC0..""%'1%U"@0B#(%2'*$-#(%V@0.'$+%4SB.'?"$%899;<D%
U#-*+B$06.% +/'*(@% ?"% .A6"=$0.."-% 0-% :8% 1'-.% +0O"% *+0-)%H0C"+% Y"=% M'C#-% 1'-.N% =0./% C#$)0-+% '1% #.% ("#+.%
'-"%0-B/%'-%#((%+0@"+D%3#)"+%+/'*(@%?"%-*C?"$"@%B'-+"B*.0>"(A%'-%./"%.'6%$0)/.%B'$-"$%'1%./"%6#)"+N%+.#$.0-)%
=0./%./"%.0.("%6#)"D%H/"%C#.."$%+/'*(@%?"%#$$#-)"@%0-%./"%1'(('=0-)%'$@"$a%H0.("%6#)"N%5?+.$#B.N%,-.$'@*B.0'-N%
U#."$0#(+% #-@% U"./'@+N% M"+*(.+N% !0+B*++0'-% #-@% &'-B(*+0'-+N%5BG-'=("@)"C"-.N% M"1"$"-B"+N% H#?("+% #-@%
Q0)*$"+%#('-)%=0./%B#6.0'-%#-@%(")"-@+D%H/"%C#-*+B$06.%+/'*(@%?"%+*?C0.."@%0-%.='%+"6#$#."%!%("+a%:D%H0.("%
6#)"N%#-@%8D%I(0-@"@%#$.0B("%!%("
Vol. 3 - No.2 April - June 2016
11
JOURNAL OF PEDIATRIC CRITICAL CARE
Title Page
H/0+%!%("%+/'*(@%6$'>0@"%7%:D%HA6"%'1%./"%C#-*+B$06.%4'$0)0-#(%#$.0B("N%$">0"=%#$.0B("N%+/'$.%B'CC*-0B#.0'-N%
B#+"%$"6'$.N%(".."$%.'%"@0.'$N%".BD<%8D%H0.("%'1%./"%C#-*+B$06.%hD%E/'$.%$*--0-)%.0.("%4*6.'%g9%B/#$#B."$+<%LD%Y#C"+%
'1%#((%./"%#*./'$+^%B'-.$0?*.'$+%4=0./%./"0$%/0)/"+.%#B#@"C0B%@")$""+N%@"+0)-#.0'-%#-@%#1!%(0#.0'-+<%gD%Y#C"4+<%
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0-B(*@0-)%1*((%#@@$"++N%"7C#0(%#@@$"++%#-@%6/'-"%-*C?"$%'$%C'?0("%-*C?"$%lD%H/"%.'.#(%-*C?"$%'1%6#)"+N%
!%)*$"+% #-@% .#?("+% fD% ]'$@% B'*-.+% 4+"6#$#."(A% 1'$% #?+.$#B.% #-@% ./"% ."T.% "TB(*@0-)% ./"% #?+.$#B.N% $"1"$"-B"+N%
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&'-.$0?*.0'-%@".#0(+
Blinded Article File
H/"%C#-*+B$06.%C*+.%-'.%B'-.#0-%#-A%C"-.0'-%'1%./"%#*./'$+d%-#C"+N%0-0.0#(+%'$%./"%0-+.0.*.0'-D%H/"%C#0-%."T.%
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5?+.$#B.a%5-% #?+.$#B.% 4-'.% "TB""@0-)% 8g9% ='$@+<% +/'*(@% ?"% 6$'>0@"@% .A6"@% '-% #% +"6#$#."% +/"".D%5?+.$#B.%
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C"./'@+%C#A%?"%@"+B$0?"@%0-%+*1!%B0"-.%@".#0(D%H/"%+.#.0+.0B#(%C"./'@+%#-@%./"%(">"(%'1%+0)-0!%B#-B"%B/'+"-%
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M"+*(.+a%H/"%0C6'$.#-.%$"+*(.+%'1%./"%='$G%+/'*(@%?"%B("#$(A%+.#."@%#-@%0((*+.$#."@%=/"$"%-"B"++#$A%?A%.#?("+%
#-@%!%)*$"+D%H/"%+.#.0+.0B#(%.$"#.C"-.%'1%@#.#%#-@%+0)-0!%B#-B"%(">"(%'1%./"%1#B.'$+%+/'*(@%?"%+.#."@%=/"$">"$%
-"B"++#$AD%!#.#%./#.%0+%-'.%+.#.0+.0B#((A%+0)-0!%B#-.%-""@%'-(A%.'%?"%C"-.0'-"@%0-%./"%."T.%#-@%-'%0((*+.$#.0'-%0+%
-"B"++#$AD
!0+B*++0'-a% H/0+% +"B.0'-% +/'*(@% @"#(% =0./% ./"% 0-."$6$".#.0'-% '1% $"+*(.+N% C#G0-)% $"#@"$+% .'% *-@"$+.#-@% ./"%
6$'?("C%.#G"-%#-@%+/'*(@%?"%(')0B#(D%H/"%@0+B*++0'-%+/'*(@%+.#."%./"%+B'6"%'1%./"%$"+*(.+N%=/0B/%-""@%.'%?"%
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Types of Manuscripts
Original articles:%M#-@'C0O"@%B'-.$'(("@%.$0#(+N%0-."$>"-.0'-%+.*@0"@N%+.*@0"+%'1%+B$""-0-)%#-@%@0#)-'+.0B%."+.N%
'*.B'C"%+.*@0"+N%B'+.%"11"B.0>"-"++%#-#(A+"+N%B#+"7B'-.$'(%+"$0"+N%#-@%+*$>"A+%?#+"@%+.*@0"+%B#-%?"%+"-.%*-@"$%
./0+%/"#@0-)D%M"6'$.+%'1%$#-@'C0O"@%B(0-0B#(%.$0#(+%+/'*(@%6$"+"-.%0-1'$C#.0'-%'-%#((%C#J'$%+.*@A%"("C"-.+N%
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M"1"$"-B"+N%H#?("+% #-@% Q0)*$"% (")"-@+D% M"B'CC"-@"@% ='$@% (0C0.% 0+% *6.'% h999% ='$@+% "TB(*@0-)% #?+.$#B.N%
.#?("+N%!%)*$"+%#-@%#?'*.%L9%$"1"$"-B"+D
Vol. 3 - No.2 April - June 2016
12
JOURNAL OF PEDIATRIC CRITICAL CARE
Review Articles:%M">0"=%#$.0B("+%#$"%+A+."C0B%B$0.0B#(%">#(*#.0'-%'1%#($"#@A%6*?(0+/"@%C#."$0#(D%,.%0+%"T6"B."@%
./#.%./"+"%#$.0B("+%='*(@%?"%=$0.."-%?A%"T6"$.+%'$%0-@0>0@*#(+%=/'%/#>"%@'-"%+*?+.#-.0#(%='$G%'-%./"%+*?J"B.D%5%
$">0"=%#$.0B("%+/'*(@%?"%=$0.."-%0-%1'(('=0-)%+."6+%7%@"!%-"%./"%6$'?("CN%+*CC#$0O"%6$">0'*+%0->"+.0)#.0'-+%.'%
@"!%-"%./"%+.#."%'1%B*$$"-.%$"+"#$B/N%0@"-.01A%$"(#.0'-+N%B'-.$#@0B.0'-+N%)#6+%#-@%0-B'-+0+."-B0"+%0-%./"%(0."$#.*$"%
$">0"="@N% +*))"+.% B(0-0B#(% 6$#B.0B"% ?#+"@% '-% ./"% B*$$"-.% ">0@"-B"% #-@% +*))"+.% 1*$./"$% #$"#+% '1% $"+"#$B/D%
M"B'CC"-@"@%='$@%(0C0.%0+%*6.'%L999%='$@+%"TB(*@0-)%#?'*.%#?+.$#B.N%.#?("+N%!%)*$"+%#-@%*6.'%g9%$"1"$"-B"+D
Systematic Reviews & Meta-analysis:%23&&%#(+'%"-B'*$#)"+%6*?(0B#.0'-%'1%+A+."C#.0B%$">0"=+%#-@%C".#7
#-#(A+0+%'-%>#$0'*+%.'60B+%'1%B(0-0B#(%+0)-0!%B#-B"D%H/"+"%+/'*(@%6$'>0@"%0-1'$C#.0'-%'-%+"#$B/%+.$#.")0"+%.'%
$".$0">"%$"(">#-.%+.*@0"+N%C"./'@+%*+"@%.'%#++"++%./"%+B0"-.0!%B%>#([email protected]%'1%$".$0">"@%+.*@0"+N%#-@%./"%6$'B"++%
'1%)"-"$#.0-)%#%?0#+71$""%(0+.%'1%B0.#.0'-+%.'%#-+="$%./"%.'60B%*-@"$%$">0"=D%M"B'CC"-@"@%='$@%(0C0.%0+%*6.'%
L999%='$@+%"TB(*@0-)%#?'*.%#?+.$#B.N%.#?("+N%!%)*$"+%#-@%*6.'%lg%$"1"$"-B"+D
Short Communications:%E/'$.%B'$$"+6'-@"-B"%6"$.#0-0-)%.'%$"+"#$B/%B#-%?"%+"-.%*-@"$%./0+%/"#@0-)D%]'$@%
B'*-.%+/'*(@%-'.%"TB""@%8999%='$@+%=0./%#-%#?+.$#B.%'1%*6.'%899%='$@+%#-@%*6.'%8g%$"1"$"-B"+D%K".."$+%C*+.%
-'.% @*6(0B#."% './"$% C#."$0#(% 6*?(0+/"@N% +*?C0.."@% '$% 6(#--"@% .'% ?"% +*?C0.."@% 1'$% 6*?(0B#.0'-D% H/"% C#.."$%
+/'*(@%?"%@0>0@"@%0-.'%0-.$'@*B.0'-N%C"./'@+N%$"+*(.+%#-@%@0+B*++0'-%#-@%+/'*(@%1'(('=%#((%'./"$%)*0@"(0-"+%0-%
i3$"6#$0-)%./"%U#-*+B$06.d
Case reports:%Y"=N%0-."$"+.0-)%'$%$#$"%B#+"+%'1%B(0-0B#(%+0)-0!%B#-B"%B#-%?"%$"6'$."@D%X'=">"$N%C"$"%$"6'$.0-)%
'1%#%$#$"%B#+"%C#A%-'.%?"%B'-+0@"$"@D%3$"+B$0?"@%='$@%(0C0.%0+%*6.'%:g99%='$@+%"TB(*@0-)%*6.'%:g%$"1"$"-B"+%
#-@% #?+.$#B.D% &#+"% $"6'$.+% +/'*(@% ?"% =$0.."-% *-@"$% ./"% 1'(('=0-)% /"#@0-)+a%5?+.$#B.% 4*-+.$*B.*$"@<N% F"A7
='$@+N%,-.$'@*B.0'-N%&#+"%$"6'$.N%!0+B*++0'-N%M"1"$"-B"+N%H#?("+%#-@%K")"-@+%0-%./#.%'$@"$D
Letter to the Editor:% H/"+"% +/'*(@% ?"% +/'$.% #-@% @"B0+0>"% '?+"$>#.0'-N% 6$"1"$#?(A% ?"% $"(#."@% .'% #$.0B("+%
6$">0'*+(A%6*?(0+/"@%0-%./"%J'*$-#(D%]'$@%(0C0.%0+%*6.'%:999%='$@+%#-@%*6.'%:9%$"1"$"-B"+D
Reporting Guidelines for Speci c Study Designs
:D M#-@'C0O"@%B'-.$'(("@%.$0#(+%7%&SY+'(0@#."@%E.#-@#$@+%S1%M"6'$.0-)%H$0#(+%4&SYESMH<%7%/..6a^^===D
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+.#$@7+.#."C"-.D'$)^
hD U".#7#-#(A+"+% '1% '?+"$>#.0'-#(% +.*@0"+% 7% U".#7#-#(A+0+% S1% S?+"$>#.0'-#(% E.*@0"+% 0-% V60@"C0'(')A
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5-#(A+"+%43M,EU5<%7%/..6a^^===D6$0+C#7+.#."C"-.D'$)
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References
M"1"$"-B"+% +/'*(@% ?"% -*C?"$"@% B'-+"B*.0>"(A% 0-% ./"% '$@"$% 0-% =/0B/% ./"A% #$"% !%$+.% C"-.0'-"@% 0-% ./"% ."T.%
4-'.%0-%#(6/#?".0B%'$@"$<D%,@"-.01A%$"1"$"-B"+%0-%./"%."T.N%.#?("+N%#-@%(")"-@+%?A%5$#?0B%-*C"$#(+%0-%+P*#$"%
?$#BG".%#1."$%./"%6*-B.*#.0'-%C#$G+D%M"1"$"-B"+%B0."@%'-(A%0-%.#?("+%'$%!%)*$"%(")"-@+%+/'*(@%?"%-*C?"$"@%0-%
#BB'$@#-B"%=0./%./"%+"P*"-B"%"+.#?(0+/"@%?A%./"%!%$+.%0@"-.0!%B#.0'-%0-%./"%."T.%'1%./"%6#$.0B*(#$%.#?("%'$%!%)*$"D%
H/"%.0.("+%'1%J'*$-#(+%+/'*(@%?"%#??$">0#."@%#BB'$@0-)%.'%./"%+.A("%*+"@%0-%,-@"T%U"@0B*+D%[+"%B'C6("."%-#C"%
'1%./"%J'*$-#(%1'$%-'-70-@"T"@%J'*$-#(+D%5>'0@%*+0-)%#?+.$#B.+%#+%$"1"$"-B"+D
Standard Journal Articles
#D Q'$%*6%.'%+0T%#*./'$+a%5)$#=#(%5N%E0-)/%WFN%W#$C#%5N%E/#$C#%MD%,-.$#>"-'*+%#$)0-0-"%>#+'6$"++0-%0-1*+0'-
Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
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Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
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Publisher details: Journal of pediatric critical care
ISSN:2349-6592; E-ISSN 2455-7099
Journal of pedicatric critical care is a peer reviewed quarterly journal published by IAP intensive care chapter
Editor in Chief
Dr Praveen Khilnani MD FAAP FCCM
Managing Editor
Dr Vinayak Patki MD, DNB, FCCP
B-42, Panchsheel Enclave, New Delhi - 110 017
Email: [email protected]
[email protected]
Indraprastha, 5th Lane, Jaysingpur - 416 101
Email: [email protected]
Website: www.journalofpediatriccriticalcare.com
Webmaster: Dreamzconference pvt limited
Chairman 2016 IAP IC Chapter:
Dr Vishram Bushe MD
Printed at: Process & Spot
C-179, GF (Backside), Naraina Industrial Area
Phase-1, New Delhi - 110 028
Child Hospital, Nagpur
Email: [email protected]
Vol. 3 - No.2 April - June 2016
15
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::f
Original Article
Pediatric Residents Perception of Pediatric Intensive Care Training
During Post Graduation
Shruti TK, Rajakumar PS, Shubha S
Faculty, Sri Ram Chandra Medical College and Research Centre, Chennai, India
Received:18-Mar-2016 /Accepted:17-May-2016/Published online:20-May-2016
ABSTRACT
Introduction:% 3"@0#.$0B% ,-."-+0>"% &#$"% .$#0-0-)% 0+% #-% 0-.")$#(% 6#$.% '1% 3"@0#.$0B% 3'+.)$#@*#."% 3$')$#C%
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$")#$@0-)%./"%B*$$"-.%+.#.*+%'1%3,&[%.$#0-0-)%0-%+'*./"$-%,-@0#D
Methods: :99%3"@0#.$0B%$"+0@"-.+%'1%>#$0'*+%0-+.0.*.0'-+%'1%E'*./%,-@0#%=0./%•%h%C'-./+%'1%3,&[%.$#0-0-)%
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Conclusion:%5((%Lg%$"+0@"-.+%1"(.%./#.%3,&[%.$#0-0-)N%./'*)/%+.$"++1*(N%=#+%0-."$"+.0-)N%0-B$"#+"@%./"%'>"$#((%
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Vol. 3 - No.2 April - June 2016
16
JOURNAL OF PEDIATRIC CRITICAL CARE
ORIGINAL ARTICLE
Pediatric Residents Perception of Pediatric Intensive Care Training During Post Graduation
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Vol. 3 - No.2 April - June 2016
17
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Discussion
H'%'*$%G-'=("@)"%./"$"%#$"%-'%+.*@0"+%@'-"%='$(@=0@"%
$")#$@0-)% 6"@0#.$0B% $"+0@"-.+% 6"$B"6.0'-% #?'*.% ./"0$%
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6"$0'@D% 3#$.0B06#-.+% B'-+0@"$"@% 0-."$#B.0>"% $'*-@+N%
+G0((+% .$#0-0-)% *-@"$% )*0@#-B"% '1% 1#B*(.AN% C'$-0-)%
$"6'$.0-)N%35KE%.$#0-0-)%#+%C#0-%+.$"-)./%'1%6"@0#.$0B%
B$0.0B#(%B#$"%.$#0-0-)D%H/0+%B'C"+%#+%-'%+*$6$0+"D%K#BG%
'1%+.#-@#$@0O"@%6$'.'B'(+N%(#BG%'1%.$#0-"@%6"$+'--"(%
0-%6"@0#.$0B%B$0.0B#(%B#$"N%0-#@"P*#."%"P*06C"-.N%"#$(A%
$"1"$$#(N%-'.%#(('=0-)%3b%.'%#BB"++%B"-.$#(%>"-'*+%(0-"%
="$"% C'+.% B'CC'-(A% '?+"$>"@% ="#G-"++% '1% 3,&[%
.$#0-0-)D% ]"#G-"++"+% '1% +*B/% .$#0-0-)% 6$')$#C+% #+%
JOURNAL OF PEDIATRIC CRITICAL CARE
ORIGINAL ARTICLE
Pediatric Residents Perception of Pediatric Intensive Care Training During Post Graduation
@"+B$0?"@%#?'>"%-""@%('.%'1%='$G%#-@%*-@"$+.#-@0-)%
'-%./"%6#$.%'1%."#B/0-)%1#B*(.A%0-%+*B/%6'+.%)$#@*#."%
6$')$#C+D%E0C*(#.0'-%#+%#%."#B/0-)%.''(%/#+%$"B"-.(A%
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?"%6#$.%'1%./"0$%.$#0-0-)D%E0C*(#.0'-%/#+%C#@"%)$"#.%
6$')$"++% 0-% $">'(*.0'-0+0-)% ./"% C"@0B#(% .$#0-0-)%
='$G+/'6+N%?*.%0.%0+%B*$$"-.(A%-'.%0-B(*@"@%#+%6#$.%'1%
C#-@#.'$A%)$#@*#."%'$%6'+.%)$#@*#."%B*$$0B*(*CD
5+%"T6"B."@N%X#-@+%'-%+G0((+%1'$%6$'B"@*$"+N%.'%1'(('=%
*-0.% 6$'.'B'(+% ?#+"@% '-% -#.0'-#(% #-@% 0-."$-#.0'-#(%
Table 1:% K">"(% '1% 3b% .$#0-0-)% '1% 6#$.0B06#.0-)% $"+0@"-.+% #.% ./"%
.0C"%'1%+.*@AD
Current level of
PG training
:+.%A"#$
8-@%A"#$
h$@%A"#$
2*+.%B'C6("."@%3b
Number of PGs (45)
Percentage
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!%$+.% A"#$N% $")*(#$% +0C*(#.0'-% ?#+"@% .$#0-0-)% #-@%
B'CC*-0B#.0'-% +G0((% .$#0-0-)% ="$"% C'+.% B'CC'-%
+*))"+.0'-+%C#@"%?A%$"+0@"-.+%.'%0C6$'>"%6"@0#.$0B%
B$0.0B#(% B#$"% .$#0-0-)D% K0C0.#.0'-+% '1% ./0+% +.*@A% #$"%
C#0-(A%$"(#."@%.'%#%+C#((%+#C6("%+0O"%#-@%+"("B.0'-%
?0#+%D,-#BB*$#."%#-@%>#)*"%$"+6'-+"+%/#>"%#(+'%)'.%.'%
?"%B'-+0@"$"@%#+%0-/"$"-.%"%#=+%0-%#((%+.*@0"+%$"(#."@%
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$"#+'-#?(A%)''@%?A%#*./'$+D
Conclusion
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6$0'$%.'%3,&[%.$#0-0-)D%U#-A%'1%./"C%1""(%./#.%3,&[%
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#-@%-""@%1'$%C'$"%@'B*C"-.#.0'-D%5((%Lg%$"+0@"-.+%1"(.%
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0-B$"#+"@%./"%'>"$#((%B'-!%@"-B"%#-@%=#+%>"$A%C*B/%
-""@"@%#+%6#$.%'1%./"0$%6'+.%)$#@*#."%.$#0-0-)D%
Q*$./"$%+.*@0"+%#$"%-""@"@%=0./%(#$)"$%6'6*(#.0'-%.'%
G-'=%01%$"+0@"-.+%6"$B"6.0'-%#-@%+6"B0!%B%+*))"+.0'-+%
='*(@% /"(6% .'% C'@01A% #-@% 0C6$'>"% B*$$"-.% .$#0-0-)%
C"./'@+%$"(#."@%.'%6"@0#.$0B%B$0.0B#(%B#$"D
Table 2: M"+6'-+"%'1%6'+.)$#@*#."+%1'$%./"%P*"+.0'--#0$"
Questionnaire
:D !'%A'*%./0-G%./#.%'-"%='*(@%?"%B'-!%@"-.%0-%$"B')-0+0-)%#-@%C#-#)0-)%B$0.0B#(%B#$"%0((-"++
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LD !'%A'*%./0-G%./#.%1'$C#(%B'CC*-0B#.0'-%+G0((+%.$#0-0-)%0+%$"P*0$"@%@*$0-)%6'+.)$#@*#.0'0-B(*@0-)%/'=%.'%?$"#G%?#@-"=+_
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:9D !'%A'*%./0-G%./#.%+0C*(#.0'-%?#+"@%("#$-0-)%@*$0-)%./"%B'*$+"%=0((%0-B$"#+"%./"%B'-!%@"-B"
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Vol. 3 - No.2 April - June 2016
18
Yes (n) (%)
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No (n) (%)
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JOURNAL OF PEDIATRIC CRITICAL CARE
ORIGINAL ARTICLE
Pediatric Residents Perception of Pediatric Intensive Care Training During Post Graduation
]/#.%./0+%+.*@A%#@@+_
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ConIOict of Interesta%Y'-"
Source of Fundinga%Y'-"
References
:D MDYDE$0>#+.#>#N% EDFDU0..#(N% W0-'@% F% 3#*(N% ,53% )*0@"(0-"+
1'$% 3'+.)$#@*#."% U"@0B#(% V@*B#.0'-% 0-% 3"@0#.$0B+N% ,-@0#-%
3"@0#.$0B+Z%899:ahfafLl7f;8D
8D U"@0B#(% B'*-B0(% '1% ,-@0#% 7% W0+0'-% 89:gN% 3'+.% b$#@*#."
U"@0B#(%V@*B#.0'hD Ub%b"".#N%3%F$0+/-#G*C#$N%5%M0A#ON%3"@0#.$0B%3'+.)$#@*#."
H$#0-0-)%0-%,-@0#%7%M"+0@"-.+%3"$+6"B.0>"N%,-@0#-%2'*$-#(%'1%
3"@0#.$0B+a%2*(A%89:La%lLg7lL;
X'=%.'%B0."%./0+%#$.0B("a%E/$*.0%HFN%M#J#G*C#$%3EN%E/*?/#%ED%3"@0#.$0B%$"+0@"-.+%6"$B"6.0'-%'1%3"@0#.$0B%0-."-+0>"%B#$"%.$#0-0-)%
@*$0-)%6'+.%)$#@*#.0'-D%2%3"@0#.$%&$0.%&#$"%89:;Z8a:;7:m
X'=%.'%B0."%./0+%[MKa%E/$*.0%HFN%M#J#G*C#$%3EN%E/*?/#%ED%3"@0#.$0B%$"+0@"-.+%6"$B"6.0'-%'1%3"@0#.$0B%0-."-+0>"%B#$"%.$#0-0-)%
@*$0-)%6'+.%)$#@*#.0'-D%2%3"@0#.$%&$0.%&#$"%89:;Z%8a:;7:mD
5>#0(#?("%1$'Ca%%/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h9899;D/.C(
Vol. 3 - No.2 April - June 2016
19
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::m
Special Article
Management of Poisonings in Children
Puneet Aulakh Pooni* Vikas Bansal**
*Professor of pediatrics, Dayanand Medical College and Hospital, Ludhiana
**Consultant Pediatrics & Pediatric Intensive Care,SPS Apollo Hospitals Ludhiana, Punjab.
Received:1-Apr-2016/Accepted:15-May-2016/Publishedonline:20-May-2016
ABSTRACT
5B*."% 6'0+'-0-)% 0-% B/0(@$"-% 0+% B'CC'-% 6$'?("C% ='$(@=0@"N% 6$">#("-.% 0-% $*$#(% #+% ="((% #+% *$?#-% #$"#+D
VT6'+*$"%'1%#%B/0(@%.'%+*B/%#%+*?+.#-B"%0+%*+*#((A%#BB0@"-.#(%#-@%%B#-%B#*+"%+AC6.'C+%#-@%+0)-+%'1%'$)#-%
@A+1*-B.0'-%("#@0-)%.'%0-J*$A%'$%@"#./D
H/0+% $">0"=% 0+% 0-."-@"@% .'% @0+B*++% )"-"$#(% #66$'#B/% .'% >#$0'*+% .A6"+% '1% #BB0@"-.#(% 6'0+'-0-)% ?#+"@%
'-% #(."$"@% 6/A+0'(')A% 0-% )"-"$#(% #-@% /0+.'$A% #-@% #% 6/A+0B#(% "T#C0-#.0'-% =0./% 0-."-.% .'% !%.% ./"% B(0-0B#(%
B/#$#B."$0+.0B+%0-.'%#%)$'*6%'1%+0)-+%#-@%+AC6.'C+%#++'B0#."@%=0./%#%6#$.0B*(#$%+*?+.#-B"D%4#(+'%G-'=-%#+%
HSu,!MSUVE<
Q'$.*-#."(AN% >"$A% 1"=% 6#.0"-.+% $"P*0$"% /'+60.#(% #@C0++0'-% #-@% ">"-% 1"="$% 6#.0"-.+% -""@% .$"#.C"-.% 0-% #%
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('B#."@%0-%./"%"C"$)"-BA%=#$@%'$%0-%#%+."6%@'=-%(">"(%'1%6"@0#.$0B%0-."-+0>"%B#$"%*-0.
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Key words: 3'0+'-0-)N%0-)"+.0'-N%B/0(@$"-N%.'T0B
Introduction
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"C"$)"-BA% #-@% 0+% #% ='$(@% =0@"% 6$'?("CD% IA%
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@A+1*-B.0'-%("#@0-)%.'%0-J*$A%'$%@"#./D%H/"%B#*+"%#-@%
.A6"+%'1%6'0+'-0-)%>#$A%0-%@011"$"-.%6#$.+%'1%./"%='$(@%
@"6"-@0-)% *6'-% ./"% 1#B.'$+% +*B/% #+% @"C')$#6/AN%
+'B0'"B'-'C0B% +.#.*+N% "@*B#.0'-N% #>#0(#?0(0.A% '1%
6'0+'-'*+% +*?+.#-B"N% 'BB*6#.0'-% 6$">#("-.% 0-% ./"%
+'B0".A%".BD%H/'*)/%6'0+'-0-)%0+%#%B'CC'-%'BB*$$"-B"%
@*$0-)% B/0(@/''@N% 1'$.*-#."(AN% >"$A% 1"=% 6#.0"-.+%
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Correspondence
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5@@Z%m^8g%3D5D[D%&#C6*+N%K*@/0#-#
VC#0(a%6''-06#\A#/''DB'CN%U'?0("a%mg9::9L:h:
Vol. 3 - No.2 April - June 2016
20
-""@%.$"#.C"-.%0-%#%3#"@0#.$0B%,-."-+0>"%&#$"%[-0.D%H/"%
B/#(("-)"%.'%./"%6"@0#.$0B%0-."-+0>0+.%B#-%?"%@#*-.0-)%
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6#$"-.+%#+%="((%#+%+.'$#)"%'1%6'0+'-'*+%+*?+.#-B"+%0-%
"#+0(A%#BB"++0?("%6(#B"+D
Epidemiology
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JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
#BB0@"-.#(N%#-@%./0+%#)"%#BB'*-.+%1'$%#66$'T%fgeq
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Patient history
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Anion Gap:% V("B.$'(A."+% #-@% ?(''@% *$"#% -0.$')"-%
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Vol. 3 - No.2 April - June 2016
21
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
'1% #-% #-0'-% )#6% #B0@'+0+N% ?#+0B% "("B.$'(A."+N% #-@%
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"T.$"C"(A%/"(61*(%0-%('B#.0-)%#%-*C?"$%'1%$#@0'6#P*"%
60((+% '$% .#?(".+% #-@% 0-% "(*B0@#.0-)% #+60$#.0'-% '$%
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Vol. 3 - No.2 April - June 2016
22
N"*$'("6.0B+N%#-@
S*+.#0-"@q$"("#+"%'$%"-."$0B%B'#."@%.#?(".+D
Management:
H/"%)"-"$#(%#66$'#B/%.'%./"%6'0+'-"@%6#.0"-.%B#-%?"%
+*CC#$0O"@%#+a
t% +.#?0(0O#.0'-N
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t% H/"%1#C0(0#$%#@#)"%jHMV5H%HXV%35H,VYHN%YSH%
HXV%3S,ESYk%0+%#66$'6$0#."(A%+.#."@
Initial steps in treating the poisoned patient.
STABILIZATION:%E.#?0(0O#.0'-%0+%./"%!%$+.%6$0'$0.A%
0-% C#-#)0-)% .'T0B% 0-)"+.0'-D%H/"% 6#.0"-.% +/'*(@% ?"%
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t% 0C6#0$"@% >0.#(% 6#$#C"."$+7.#B/A^% ?$#@AB#$@0#N%
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Speci c poisonings - most commonly seen in
Indian children
ALUMINIUM PHOSPHIDE%45K3<N%#%=0@"(A%*+"@%
+'(0@% 1*C0)#-.N% =#+% @"B(#$"@% #+% #-% 0@"#(% 1*C0)#-.%
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('=%B'+.%6$'6"$.0"+D%5>#0(#?("%#+%.#?(".+%'1%i&"(6/'+dN%
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./"% +.'$"@% )$#0-+N% ("#>0-)% -'-7.'T0B% $"+0@*"+% 0-% ./"%
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
1'$C%'1%6/'+6/0."%#-@%/A6'6/'+6/0."%'1%#(*C0-0*C%
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Vol. 3 - No.2 April - June 2016
23
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
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Vol. 3 - No.2 April - June 2016
24
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
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/0)/%*+"%#+%B''G0-)%1*"(%#-@%(0)/."-0-)%0-%./"%/'*+"D%
"-#?("+%0CC"@0#."%0-0.0#.0'-%'1%./"$#6AN%#+%="((%#+%
H/0+% +*?+.#-B"% =#+% *+*#((A% +.'$"@% 0-% ./"% +'1.% @$0-G%
./"%#?0(0.A%.'%@"!%-0.0>"(A%0@"-.01A%B"$.#0-%.'T0-+D
'$% C0-"$#(% =#."$% ?'..("% #-@% 0+% "#+0(A% 0-)"+."@% ?A%
t%
3$">"-.0'-%
+.$#.")0"+% #$"% G"A% 0-% @"B$"#+0-)%
B/0(@$"-D% F"$'+"-"% '0(% 0-)"+.0'-% $"+*(.+% 0-% .'T0B0.A%
C'[email protected]%#-@%C'$.#(0.AD
Management of Poisonings in children
Tables and Figures
Table 1:%H'T0B0.A%(">"(+%'1%+"("B."@%C"@0B#.0'-+%#-@%C"@0B#.0'-%B(#++"+
Agents
Minimum potential lethal dose Maximum dose available
Antimalarials
&/('$'P*0-"
89%C)^G)
g99%C)
XA@$'TAB/('$'P*0-"
89%C)^G)
899%C)
Camphor
:99%C)^G)
899%C)^CK
Vol. 3 - No.2 April - June 2016
25
Potentially fatal units in a 10-kg child
:
:
g%CK
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
Imidazolines
&('-0@0-"
9D9:%C)^G)
9Dh%C)Z%lDg%C)^6#.B/
:
H".$#/A@$'O'(0-"
8Dg%.'%g%CK
9D:e
8Dg%.'%g%CK
Methyl Salicylates
:g9%.'%899%C)^G)
:L99%C)^CK
:D:%.'%:DL%CK
Sulfonylureas
b(060O0@"
9D:%C)^G)
g%C)
:
b(A?*$0@"
9D:%C)^G)
:9%C)
:
Q$'C%U#.."*BB0%U2D%S-"%60((%B#-%G0((a%5++"++0-)%./"%6'."-.0#(%1'$%1#.#(%6'0+'-0-)+%0-%B/0(@$"-D%Pediatr Ann%899gZhLam;L7m;fD
Table 2:%5)"-.+%#-@%.'T0@$'C"+
Anticholinergic toxidrome*
5)0.#.0'-N%!"(0$0*CN%&'C#N%UA@$0#+0+
!$A%C'*./
]#$CN%@$AN%"%*+/"@%+G0-N%Q">"$%
H#B/AB#$@0#N%XA6"$."-+0'[$0-#$A%$"."-.0'-N%!"B$"#+"@%?'="(%+'*-@+
5++'B0#."@%"T6$"++0'-+
jU#@%#+%#%X#.."$k
jI(0-@%#+%#%I#.k
jM"@%#+%#%I"".k
jX'.%#+%#%X#$"k
j!$A%#+%#%I'-"k
Cholinergic toxidrome
U*+B#$0-0B%"11"B.+%46#$#+AC6#./".0B<%![UIIVKEa%%!0#$$/"#N%
[$0-#$A%0-B'-.0-"-B"N%U0'+0+N%I$#@AB#$@0#
I$'-B/'$$/"#N%VC"+0+N%K#B$0C#.0'%%%E#(0>#.0'EK[!bVa%E#(0>#.0'-N%K#B$0C#.0'-N%[$0-#$A%0-B'-.0-"-B"N%
!0#$$/"#^%!0#6/'$"+0+N%b,%*6+".^/A6"$#B.0>"%?'="(N%VC"+0+
Y0B'.0-0B%"11"B.+
4EAC6#./".0B%#-@%6#$#+AC6#./".0B%#*.'-'C0B%)#-)(0#<
UA@$0#+0+N%Q#+B0B*(#.0'-+N%]"#G-"++
%%%3#$#(A+0+N%H#B/AB#$@0#N%XA6"$."-+0'%%%5)0.#.0'-N%!0#6/$#)C#.0B%1#0(*$"
&"-.$#(%"11"B.+
K"./#$)AN%&'C#N%5)0.#.0'-N%E"0O*$"+N%X"#@#B/"N%&'-1*+0'-N%
5.#T0#N%M"+60$#.'$A%@"6$"++0'Opioid Toxidrome
&"-.$#(%-"$>'*+%+A+."C%@"6$"++0'-N%/A6'./"$C0#N%/A6'."-+0'-N%
/A6'>"-.0(#.0'-N%C0'+0+%?$#@AB#$@0#%@"B$"#+"@%b,%C'.0(0.A
4H$0#@%'17%%$"+60$#.'$A%@"6$"++0'-N%B'C#N%C0'+0+N%"TB"6.0'-%
C"6"$0@0-"7CA@$0#+0+%#-@%+"0O*$"+<D
Sympathomimetic toxidrome*
5)0.#.0'-N%E"0O*$"+
UA@$0#+0+
H#B/AB#$@0#N%XA6"$."-+0'!0#6/'$"+0+N%&''(%EG03#(('$
Q">"$N%+="#.0-)
Agents
5-.0/0+.#C0-"+x@06/"-/A@$#C0-"N%/A@$'TAO0-"N%
5-.06#$G0-+'-0#-%@$*)+N%5-.0+6#+C'@0B+N%5.$'60-"N%5(G#('0@+
I"((#@'--#N%I"-O.$'60-"%C"+A(#."
&#$?#C#O"60-"N%&AB('?"-O#6$0-"N%&AB('6"-.'(#."%"A"@$'6+
XA'+BA#C0-"
20C+'-=""@
STA?*.A-03/"-'./0#O0-"+
EB'6'(#C0-"N%+'C"%C*+/$''C+
H$0&AB(0B%#-.0@"6$"++#-.+N%H$0/"TA6/"-0@A(
Agents
S$)#-'6/'+6/#."%0-+"B.0B0@"+
!$*)+%1'$%CA#+./"-0#%)$#>0+%4"D)DN%6A$0@'+.0)C0-"<
Y0B'.0-"
&#$?#C#."%0-+"B.0B0@"+
Agents
'60*C%#-@%'60'0@+%4+*?+.#-B"+%@"$0>"@%1$'C%'60*C%#-@%
+A-./".0B#((A%@"$0>"@%#)"-.+%=0./%+0C0(#$%6$'6"$.0"+<D%
&'@"0-"N%/A@$'B'@'-"N%'TAB'@'-"N%
!06/"-'TA(#."
Q"-.#-A(%6#.B/"+%
X"$'0U"./#@'-"%6$'6'TA6/"-"
4B('-0@0-"7B"-.$#((A%#B.0-)%0-B(*@"@%#+%@0C0-0+/"+%+AC6#./".0B%
.'-"N%B#*+0-)%.$0#@<
Agents
5(?*."$'(N%5C6/".#C0-"+
&#11"0-"N%&#."B/'(#C0-"+N%&'B#0-"
V6/"@$0-"
F".#C0-"
KA+"$)0B%#B0@%@0"./A(#C0@"%4KE!<
U"./#C6/".#C0-"
3/"-BAB(0@0-"%43&3<N%3/"-A("6/$0-"%4@">B'-)"+.#-.+<N%
3/"-A(6$'6#-'(#C0-"N%3+"*@'"6/"@$0-"
H"$?*.#(0-"N%H/"'6/A((0-"
wI'./% #(C'+.% +0C0(#$% B(0-0B#(% 1"#.*$"+% "TB"6.% +G0-% @$AN% =#$CN% #-@% ?'="(% +'*-@+% @"B$"#+"@% 0-% Anticholinergic toxidrome. EG0-% B''(N
@0#6/'$".0BN%#-@%/A6"$#B.0>"%?'="(%+'*-@+%%0-%Sympathomimetic toxidrome.
Vol. 3 - No.2 April - June 2016
26
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
Management of Poisonings in Children
Table 3:%W#$0'*+%+0)-+%#-@%6'0+'-%0->'(>"@D
OCULAR SIGNS
U0'+0+
?#$?0.*$#."+%4(#."<N%B/('$#(%/A@$#."N%B('-0@0-"N%@0#O"6#CN%C*+B#$0-0B%C*+/$''C+N%Y#$B'.0B+%4"TB"6.%C"6"$0@0-"<N%
Y#$B'.0B+%4"TB"6.%!"C"$'(%#-@%K'C'.0(<N%'$)#-'6/'+6/#."+N%6/"-'./0#O0-"+N%3&3%6/"-'./0#O0-"+N%
UA@$0#+0+
5-.0B/'(0-"$)0B+N%5.$'60-"N%#(B'/'(N%#C6/".#C0-"+N%#-.0/0+.#C0-"+N%B'B#0-"N%BA#-0@"N%B#$?'-%C'-'T0@"N%
)(*."./0C0@"N%KE!N%C"./#-'(N%+AC6#./'C0C".0B+N%.$0BAB(0B%#-.0@"6$"++#-.+%
YA+.#)C*+
?#$?0.*$#."+N%B#$?#C#O"60-"N%B#$?'-%C'-'T0@"N%"./#-'(N%)(*."./0C0@"N%%3/"-A.'0-N%3&3N%
K#B$0C#.0'S$)#-'6/'+6/#."+N%0$$0.#-.%)#+%'$%>#6'$+
M".0-#(%/A6"$"C0#
U"./#-'(
3''$%>0+0'U"./#-'(N%?'.*(0+CN%B#$?'-%C'-'T0@"
SKIN
&A#-'+0+%4*-$"+6'-+0>"% Y0.$#."+N%-0.$0."+N%6/"-#B".0-N%?"-O'B#0-"
.'%'TA)"-<
M"@%"%*+/N%V$A./"C#
#-.0B/'(0-"$)0B+N%?'$0B%#B0@N%&#$?'-%C'-'T0@"N%BA#-0@"N%C"$B*$A
E="#.0-)N%!0#6/'$"+0+ 5C6/".#C0-"+N%?#$?0.*$#."+%B'B#0-"%KE!N%C*+B#$0-0B%C*+/$''C+N%-0.$#."+N%'$)#-'6/'+6/#."+N%+#(0BA(#."+%
I*((#"
I#$?0.*$#."+N%B#$?'-%C'-'T0@"
2#*-@0B"
5B".#C0-'6/"-N%C*+/$''C+N%B#$?'-%.".$#B/('$0@"N%0$'-N%6/'+6/'$*+
3*$6*$#
5+60$0-N%=#$1#$0-N%+-#G"?0."
Y""@("%.$#BG+
X"$'0-N%3&3N%#C6/".#C0-"+
!$AN%/'.%+G05-.0B/'(0-"$)0B%#)"-.+N%?'.*(0+C
5('6"B0#
H/#((0*CN%#$+"-0BN%("#@N%C"$B*$A
TEMPERATURE
XA6'./"$C0#
B#$?'-%C'-'T0@"N%B('-0@0-"N%"./#-'(N%E"@#.0>"%/A6-'.0B+N%6/"-'./0#O0-"+N%H&5+N%
XA6"$./"$C0#
5-.0B/'(0-"$)0B+N%#C6/".#C0-"+N%B'B#0-"N%6/"-'./0#O0-"+N%+#(0BA(#."+N%H&5+N%./"'6/A((0-"
ORAL SIGNS
E#(0>#.0'B#$?#C#."+N%B'$$'+0>"+N%S$)#-'6/'+6/#."+N%+#(0BA(#."+N%+.$AB/-0-"N%
!$A%C'*./
5C6/".#C0-"+N%#-.0B/'(0-"$)0B+N%#-.0/0+.#C0-"
I*$-+
&'$$'+0>"+N%'T#(#."7B'-.#0-0-)%6(#-.+
b*C%(0-"+
K"#@N%C"$B*$AN%#$+"-0B
!A+6/#)0#
&'$$'+0>"+N%?'.*(0+C
CARDIAC SIGNS
H#B/AB#$@0#
5.$'60-"%45-.0B/'(0-"$)0B+<N%#(B'/'(N%#-.0@"6$"++#-.+N%#C6/".#C0-"+N%B'B#0-"N%+#(0BA(#."+N%+AC6#./'C0C".0B+N%
./"'6/A((0-"
I$#@AB#$@0#
ȕ%?('BG"$+N%B#(B0*C%B/#--"(%?('BG"$+N%B('-0@0-"N%!0)0.#(0+N%/A6-'.0B+N%C*+/$''C+N%-#$B'.0B+N%
'$)#-'6/'+6/#."+N%+"@#.0>"%
XA6"$."-+0'5C6/".#C0-"+N%B'B#0-"N%KE!N%3&3
XA6'."-+0'3/"-'./0#O0-"+N%?#$?0.*$#."+N%BAB(0B%#-.0@"6$"++#-.+N%0$'-N%ȕ%?('BG"$+N%B#(B0*C%B/#--"(%?('BG"$+
5$$/A./C0#+
5C6/".#C0-"%5-.0#$$/A./C0B+%%5-.0B/'(0-"$)0B+N%5-.0/0+.#C0-"+%5$+"-0B%#-.0@"6$"++#-.+N%ȕ7?('BG"$+N%%
B#$?'-%C'-'T0@"N%&/('$#(%/A@$#."%%&'B#0-"%BA#-0@"N%&AB(0B%#-.0@"6$"++#-.+%@0)'T0-N%'$)#-'6/'+6/#."+N%
6/"-'./0#O0-"+N%./"'6/A((0-"%p*0-0-"N%P*0-0@0-"
RESPIRATORY SIGNS
!"6$"++"@%$"+60$#.0'- 5(B'/'(N%?#$?0.*$#."+N%-#$B'.0B+N%+"@#.0>"^/A6-'.0B+
,-B$"#+"@%$"+60$#.0'5C6/".#C0-"+N%B#$?'-%C'-'T0@"N%BA#-0@"N%"./A("-"%)(AB'(N%+#(0BA(#."+
3*(C'-#$A%"@"C#N%
5+60$#.0'-N%XA@$'B#$?'-+N%/"$'0-N%-#$B'.0B+%'$)#-'6/'+6/#."+N%+#(0BA(#."+N%+AC6#./'C0C".0B+N%
3-"*C'-0#
F*++C#*(
"./A("-"%)(AB'(N%U"./#-'(N%+#(0BA(#."+
]/""O0-)
S$)#-'6/'+6/#."+
GASTROINTESTINAL SYSTEM
W'C0.0-)N%@0#$$/"#N%
,$'-N%6/'+6/'$*+N%/"#>A%C".#(+N%(0./0*CN%C*+/$''C+N%5-.0C0B$'?0#(+N%#$+"-0BN%?'$0B%#B0@N%"%*'$0@"N%0$'-N%
#?@%6#0-N%&$#C6+
("#@%'$)#-'6/'+6/#."+
&'-+.06#.0'K"#@N%-#$B'.0B+N%?'.*(0+C
X"C#."C"+0+
5C0-'6/A((0-"N%B'$$'+0>"+N%0$'-N%K"#@N%+#(0BA(#."+
Vol. 3 - No.2 April - June 2016
27
JOURNAL OF PEDIATRIC CRITICAL CARE
SPECIAL ARTICLE
CNS SIGNS
5.#T0#%'$%-A+.#)C*+
&'C#
XA6"$6A$"T0#
U*+B("%1#+B0B*(#.0'U*+B("%$0)[email protected]%
UA'B('-*+
3#$"+./"+0#
3"$06/"$#(%-"*$'6#./A
5(."$"@%?"/#>0'$
E"0O*$"+%
(MNEMONIC%y%
CAPS)
!"(0$0*C^6+AB/'+0+
]"#G-"++N%6#$#(A+0+
XA6"$.'-*+
YA+.#)C*+
VT.$#6A$#C0@#(
Management of Poisonings in Children
5(B'/'(N%5-.0/0+.#C0-"+N%#-.0@"6$"++#-.+N%#-.0B/'(0-"$)0B+N%I$'C0@"+N%?#$?0.*$#."+N%5-.0B'->*(+#-.+%%4"+6"B0#((A%
6/"-A.'0-N%B#$?#C#O"60-"N%I#$?0.*$#."+<N%&#$?'-%C'-'T0@"%-#$B'.0B+N%S$)#-0B%+'(>"-.+%306"$#O0-"
5(B'/'(+N% #-.0B/'(0-"$)0B+N% 5-.0/0+.#C0-"+% ?#$?0.*$#."+N% BA#-0@"N% &('-0@0-"% B#$?'-% C'-'T0@"N% BAB(0B%
#-.0@"6$"++#-.+N% E"@#.0>"+N% K"#@% -#$B'.0B+N% U"./A(@'6#% Y#$B'.0B+% 3/"-BAB(0@0-"% 3/"-'./0#O0-"+% 3&3N%
'$)#-'6/'+6/#."+N% +#(0BA(#."+N% ("#@N% +"@#.0>"% /A6-'.0B+N% XA6')(AB"C0B% #)"-.+% -#$B'.0B+N% .$0BAB(0B%
#-.0@"6$"++#-.+N%+#(0BA(#."+N%'$)#-'6/'+6/#."+N%?#$?0.*$#."+
5-.0B/'(0-"$)0B+N%P*0-0-"N%+#(0BA(#."+N%KE!N%6/"-'./0#O0-"+N%#C6/".#C0-"+N%B'B#0-"
S$)#-'6/'+6/#."+N%./"'6/A((0-"
&AB(0B%#-.0@"6$"++#-.+N%3&3N%6/"-'./0#O0-"+N%/#('6"$0@'(N%5-.0B/'(0-"$)0B+
&'B#0-"N%B#C6/'$N%3&3N%UEb
K"#@N%#$+"-0BN%C"$B*$AN%'$)#-'6/'+6/#."+
KE!N%3&3N%#C6/".#C0-"+N%B'B#0-"N%#(B'/'(N%#-.0B/'(0-"$)0B+N%B#C6/'$
C#C6/'$N%&#$?#C#O"60-"N%&#$?'-%C'-'T0@"N%&'B#0-"N%&A#-0@"N
AC0-'6/A((0-"N%#C6/".#C0-"+N%5-.0B/'(0-"$)0B+N%#-.0/0+.#C0-"+N%5-.0@"6$"++#-.+%4BAB(0B<%
P?%4("#@<N%6/"-'./0#O0-"+N%6$'6'TA6/"-"%3"+.0B0@"%4'$)#-'6/'+6/#."<N%3/"-BAB(0@0-"N%3/"-'(
S#(0BA(#."+N%+.$AB/-0-"%
5-.0B/'(0-"$)0B+N% +AC6#./'C0C".0B+N% #(B'/'(N% 6/"-'./0#O0-"+N% 3&3N% KE!N% C#$0J*#-#N% B'B#0-"N% /"$'0-N%
C"./#P*#('-"N%/"#>A%C".#(+
S$)#-'6/'+6/#."+N%B#$?#C#."+N%/"#>A%C".#(+
5-.0B/'(0-"$)0B+N%+.$AB/-0-"N%6/"-'./0#O0-"+
!06/"-A(/A@#-.'0-N%?#$?0.*$#."+N%B#$?#C#O"60-"N%3&3N%B#$?'-%C'-'T0@"N%)(*."./0C0@"N%"./#-'(
3/"-'./0#O0-"+N%/#('6"$0@'(N%C".'B('6$#C0@"
Table 4:%&'CC'-%H'T0@$'C"%Q0-@0-)+
Physical Findings Adrenergic
Anti-cholinergic
MM
,-B$"#+"@
Y'%B/#-)"
XM
,-B$"#+"@
,-B$"#+"@
H"C6
,-B$"#+"@
,-B$"#+"@
I3
,-B$"#+"@
Y'&/#-)"^0-B$"#+"@
U"-.#(%+.#.*+
5("$.^%#)0.#."@ !"6$"++"@^%&'-1*+"@^%
/#((*B0-#."
6*60(+
!0(#."@
!0(#."@
U*B*+%C"C?$#-" ]".
!$A
+G0!0#6/'$".0B
!$A
Anti-cholinesterase
Y'%B/#-)"
!"B$"#+"@
Y'%B/#-)"
Y'%B/#-)"
!"6$"++"@^%&'-1*+"@^
OPIOID
!"B$"#+"@
Y'$C#(^%@"B$"#+"@
Y'$C#(^%@"B$"#+"@
Y'$C#(^%@"B$"#+"@
!"6$"++"@
Sedative-hypnotic
!"B$"#+"@
Y'$C#(^%@"B$"#+"@
Y'$C#(^%@"B$"#+"@
Y'$C#(^%@"B$"#+"@
!"6$"++"@
&'-+.$0B.
]".
!0#6/'$".0B
&'-+.$0B.
Y'$C#(
Y'$C#(
Y'$C#(
Y'$C#(
Y'$C#(
Table 5:%5)"-.+%[+"@%1'$%b#+.$'0-."+.0-#(%!"B'-.#C0-#.0'-%0-%&/0(@$"-%
Agent
Dose
Risks
indications
t% 5-.0@"6$"++#-.+
t% 5+60$#.0'5B.0>#."@%
:%.'%8%)%6"$%G)%
t% &#$?#C#O"60-"
t% &'-+.06#.0'B/#$B'#(wz
4C#T0C*C%'1%g9%
t% !#6+'-"
t% W'C0.0-)
.'%;9%)<%@0(*."@%
t% !"T.$'6$'6'TA6/"-"
t% ,("*+
=0./%1$*0.%J*0B"%
t% !0)'T0t% +"0O*$"+D
'$%?'..("@%@$0-G+%
t% !00+'6A$#C0-@"
'$#((A%'$%./$'*)/%
,1%#+60$#."@
t% Y#@'('(
'$')#+.$0B%.*?"%0-%
t% 6-"'C'-0.0+
t% '60'0@+
#-%*-B''6"$#.0>"%
t% "C6A"C#
t% 3/"-'?#$?0.'(
B/0(@D%!*"%.'%0.+%
t% 6-"*C'./'$#T%
t% 3/"-A(?*.#O'-"
B'-+.06#.'$A%"11"B.N%
t% 6/"-'./0#O0-"+%3/"-A.'0#%@'+"%'1%B#./#$.0B%0+%
t% 6/"-BAB(0@0-"
#@@"@%=0./%./"%!%$+.%
t% 30$'T0B#C
@'+"D
t% p*0-0-"
5(+'%9D8gq9Dg9%)^G)%
t% +#(0BA(#."+
">"$A%8qL%/$%
t% E'.#('(
t% H/"'6/A((0-"
Vol. 3 - No.2 April - June 2016
28
Contraindications
H'T0-+%,-"11"B.0>"(A%I'*-@%
?A%5B.0>#."@%&/#$B'#(%B#-%?"%
$"C"C?"$"@%?A%C-"C'-0B
3X5,KE
3%q%3"+.0B0@"+N%6".$'("*C%
@0+.0((#."+N%*-6$'."B."@%#0$=#A
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UD% X*C% VT6% H'T0B'(D% 899g%56$Z% 8L4L<a% 8:g7fD% E*BB"++1*(
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V@+%X3E%E#B/@">N%3#--#%&/'*@/*$AN%5$>0-@%I#))#N%F$0+/#-%
&/*)/N% E0@@#$./% M#CJ0N% M#C"+/% F% 3*$0D% 5% 6*?(0B#.0'-% '1%
,-@0#-%3"@0#.$0B+D%2#A6""%?$'./"$+N%Y"=%!"(/0%899LD
;D S+."$/'*@.% F&N% E/#--'-% UN% X"-$".0)% QUD% H'T0B'(')0B#(
"C"$)"-B0"+D% ,-a% Q("0+/"$% bMN% K*@=0)% EN% 4"@0<D% H"T.?''G%
'1% 6"@0#.$0B% "C"$)"-BA% C"@0B0-"D% L./% "@D% 3/0(#@"(6/0#a%
K0660-B'..%]0((0#C+%r%]0(G0-+N%8999D
X'=%.'%B0."%./0+%#$.0B("a%3''-0%35N%I#-+#(%WD%U#-#)"C"-.%'1%3'0+'-0-)+%0-%B/0(@$"-D%2%3"@0#.$%&$0.%&#$"%89:;Z8a897h8
X'=%.'%B0."%./0+%[MKa%3''-0%35N%I#-+#(%WD%U#-#)"C"-.%'1%3'0+'-0-)+%0-%B/0(@$"-D%2%3"@0#.$%&$0.%&#$"%89:;Z8a897h8D%5>#0(#?("%
1$'Caa/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h9899lD/.C(
Vol. 3 - No.2 April - June 2016
32
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99:8:
Envenomation -1
Snake Bite
Suchita Khadse
Pediatric Intensivist, CHILD Hospital, Nagpur
Received:15-April-2016 /Accepted:15-May-2016/Published online:20-May-2016
Introduction
S6/0.'T#"C0#% 0+% ./"% $#./"$% "T'.0B% ."$C% ./#.%
B/#$#B."$0O"+% ./"% B(0-0B#(% +6"B.$*C% '1% +-#G"% ?0."%
"->"-'C#.0'-D% S1% ./"% 8g997h999% +6"B0"+% '1% +-#G"+%
@0+.$0?*."@%='$(@7=0@"N%#?'*.%g99%#$"%>"-'C'*+D%H/"%
C#J'$%1#C0(0"+%0-%./"%,-@0#-%+*?B'-.0-"-.%#$"a%V(#60@#"%
=/0B/%0-B(*@"+%B'CC'-%B'?$#N%G0-)%B'?$#%#-@%G$#0.N%
W06"$0@#"%=/0B/%0-B(*@"+%M*++"((d+%>06"$N%60.%>06"$%#-@%
+#=7+B#("@% >06"$% #-@% XA@$'6/0@#"% 4./"% +"#% +-#G"+<D%
S1% ./"% g8% 6'0+'-'*+% +6"B0"+% 0-% ,-@0#N% C#J'$0.A% '1%
?0."+% #-@% B'-+"P*"-.% C'$.#(0.A% 0+% #..$0?*.#?("% .'% g%
+6"B0"+% >0OD% S6/0'6/#)*+% /#--#/% 4G0-)% B'?$#<N% Y#J#%
Y#J#% 4B'CC'-% B'?$#<N% !#?'0#% $*+"((00% 4M*++"((d+%
>06"$<N%I*-)#$*+%B#"$*("*+%4G$#0.<%#-@%VB/0+%B#$0-#.#"%
4+#=7+B#("@% >06"$<D% ,-% ,-@0#% hgN9997g9N999% (0>"+% #$"%
('+.%6"$%A"#$%@*"%.'%>"-'C'*+%+-#G"%?0."D%U'$"%./#-%
8999%@"#./+%6"$%A"#$%#$"%$"6'$."@%1$'C%U#/#$#+/.$#D%
H/0+%0+%./"%.06%'1%./"%0B"?"$)%#+%./"%C#J'$0.A%'1%+-#G"%
?0."% @"#./+% )'% *-$"6'$."@% #+% C#-A% >0((#)"$+% )'% .'%
.$#@0.0'-#(%/"#("$+%(0G"%C#-.$0G+%#-@%.#-.$0G+D
Venom composition
U'$"% ./#-% m9e% '1% +-#G"% >"-'C% 4@$A% ="0)/.<% 0+%
6$'."0-D%V#B/%>"-'C%B'-.#0-+%C'$"%./#-%#%/*-@$"@%
@011"$"-.% 6$'."0-+a% "-OAC"+% 4B'-+.0.*.0-)% f97m9e%
'1% >06"$0@% #-@% 8g7l9e% '1% "(#60@% >"-'C+<N% -'-7
"-OAC#.0B%6'(A6"6.0@"%.'T0-+N%#-@%-'-7.'T0B%6$'."0-+D
Venom enzymes
E-#G"% >"-'CN% ./"% C'+.% B'C6("T% '1% #((% 6'0+'-+% 0+% #%
C0T.*$"%'1%"-OAC#.0B%#-@%-'-7"-OAC#.0B%B'C6'*-@+%#+%
="((%#+%'./"$%-'-7.'T0B%6$'."0-+%0-B(*@0-)%B#$?'/A@$#."+%
#-@% C".#(+D% H/"$"% #$"% '>"$% 89% @011"$"-.% "-OAC"+%
0-B(*@0-)% 6/'+6/'(06#+"+% 58N% IN% &N% !% /A@$'(#+"+N%
6/'+6/#.#+"+% 4#B0@% #+% ="((% #+% #(G#(0-"<N% 6$'."#+"+N%
"+."$#+"+N%
#B".A(B/'(0-"+."$#+"N%
.$#-+#C0-#+"N%
Correspondence
!$%E*B/0.#%F/#@+"
&'-+*(.#-.%3"@0#.$0B%,-."-+0>0+.N%&X,K!%X'+60.#(N%Y#)6*$%
VC#0(a%@$+*B/0.#\)C#0(DB'CN%U'?0("a%vm:mf8h9h8m9f
Vol. 3 - No.2 April - June 2016
33
/A#(*$'-0@#+"N% 6/'+6/'@0"+."$#+"N% -*B("'.0@#+"% #-@%
5H3#+"%#-@%-*B("'+0@#+"+%4!Y5%r%MY5<D%H/"%-'-7
"-OAC#.0B% B'C6'-"-.+% #$"% (''+"(A% B#.")'$0O"@% #+%
-"*$'.'T0-+% #-@% /#"C'$$/#)"-+D% !011"$"-.% +6"B0"+%
/#>"% @011"$0-)% 6$'6'$.0'-+% '1% C'+.N% 01% -'.% #((% '1%
./"% #?'>"% C0T.*$"+7% ./0+% 0+% =/A% 6'0+'-'*+% +6"B0"+%
="$"% 1'$C"$(A% B(#++0!%"@% "TB(*+0>"(A% #+% -"*$'.'T0BN%
/#"C'.'T0B% '$% CA'.'T0BD%H/"% 6#./'6/A+0'(')0B% ?#+0+%
1'$%C'[email protected]%#-@%C'$.#(0.A%0+%./"%@0+$*6.0'-%'1%-'$C#(%
B"((*(#$%1*-B.0'-+%?A%./"+"%"-OAC"+%#-@%.'T0-+D%E'C"%
"-OAC"+% +*B/% #+% /A#(*$'-0@#+"% @0++"C0-#."% >"-'C%
?A% ?$"#G0-)% @'=-% .0++*"% ?#$$0"$+D% H/"% >#$0#.0'-% '1%
>"-'C% B'C6'+0.0'-% 1$'C% +6"B0"+% .'% +6"B0"+% "T6(#0-+%
./"% B(0-0B#(% @0>"$+0.A% '1% '6/0.'T#"C0#D% H/"$"% 0+% #(+'%
B'-+0@"$#?("% >#$0#.0'-% 0-% ./"% $"(#.0>"% 6$'6'$.0'-+% '1%
@011"$"-.% >"-'C% B'-+.0.*"-.+% =0./0-% #% +0-)("% +6"B0"+%
./$'*)/'*.% 0.+% )"')$#6/0B#(% @0+.$0?*.0'-N% #.% @011"$"-.%
+"#+'-+%'1%./"%A"#$%#-@%#+%#%$"+*(.%'1%#)"0-)D
Table 1: E-#G"+% =0./% >"-'C% A0"(@N% ("./#(% @'+"N% #-.0>"-0-%
-"*.$#(0O0-)%@'+"D
Snakes
Venom yeild Lethal dose
per bite
for man
&'?$#
F$#0.
M*++"((d+%>06"$
VB/0+%B#$-#.*+
9D8%)$#C
9D988%)$#C
9D:g%)$#C
9D99L;%)$#C
9D:8%)$#C+
9D9;%)$#C+
9D:g%)$#C+
9D9f%)$#C+
1ml of
antivenom
neutralised
9D;C)
9DLg%C)
9D;%C)
9DLg%C)
Quantity of venom injected at a bite, “dry bites”
H/0+%0+%>"$A%>#$0#?("N%@"6"-@0-)%'-%./"%+6"B0"+%#-@%
+0O"% '1% ./"% +-#G"N% ./"% C"B/#-0B#(% "1!%B0"-BA% '1% ./"%
?0."N%=/"./"$%'-"%'$%.='%1#-)+%6"-".$#."@%./"%+G0-%#-@%
=/"./"$%./"$"%="$"%$"6"#."@%+.$0G"+D%V0./"$%?"B#*+"%
'1%C"B/#-0B#(%0-"1!%B0"-BA%'$%./"%+-#G"d+%B'-.$'(%'1%
>"-'C%@0+B/#$)"N%#%6$'6'$.0'-%'1%?0."+%?A%>"-'C'*+%
+-#G"+% @'"+% -'.% $"+*(.% 0-% ./"% 0-J"B.0'-% '1% +*1!%B0"-.%
>"-'C%.'%B#*+"%B(0-0B#(%"11"B.+D%5?'*.%g9e%'1%?0."+%
?A%M*++"((d+%>06"$+N%h9e%'1%?0."+%?A%B'?$#+%#-@%ge7
:9e% '1% ?0."+% ?A% +#=7+B#("@% >06"$+% @'% -'.% $"+*(.% 0-%
#-A%+AC6.'C+%'$%+0)-+%'1%"->"-'C0-)%
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
5(./'*)/% (#$)"% +-#G"+% ."-@% .'% 0-J"B.% C'$"% >"-'C%
./#-% +C#(("$% +6"B0C"-+% '1% ./"% +#C"% +6"B0"+N% ./"%
>"-'C% '1% +C#(("$N% A'*-)"$% >06"$+% C#A% ?"% $0B/"$% 0-%
+'C"%@#-)"$'*+%B'C6'-"-.+N%+*B/%#+%./'+"%#11"B.0-)%
/#"C'+.#+0+D
Recommendation: I0."+%?A%+C#((%+-#G"+%+/'*(@%-'.%
?"%0)-'$"@%'$%@0+C0++"@D%H/"A%+/'*(@%?"%.#G"-%J*+.%#+%
+"$0'*+(A%#+%?0."+%?A%(#$)"%+-#G"+%'1%./"%+#C"%+6"B0"+D
.#+."% #-@% +C"((N% j/"#>Ak% "A"(0@+N% 6.'+0+N% "T."$-#(%
'6/./#(C'6(")0#N% 6#$#(A+0+% '1% 1#B0#(% C*+B("+% #-@%
'./"$%C*+B("+%0--"$>#."@%?A%./"%B$#-0#(%-"$>"+N%-#+#(%
>'0B"% '$% #6/'-0#N% $")*$)0.#.0'-% ./$'*)/% ./"% -'+"N%
@01!%B*(.A% 0-% +=#(('=0-)% +"B$".0'-+N% $"+60$#.'$A% #-@%
)"-"$#(0O"@%"%#BB0@%6#$#(A+0+D
'(@% 6#$.(A7/"#("@% ='*-@+% E6'-.#-"'*+% +A+."C0B%
?(""@0-)% 7% 1$'C% )*C+N% "60+.#T0+N% ?(""@0-)% 0-.'%
./"% ."#$+N% 0-.$#B$#-0#(% /#"C'$$/#)"% 4C"-0-)0+C%
1$'C% +*?#$#B/-'0@% /#"C'$$/#)"N% (#."$#(0O0-)%
+0)-+% #-@^'$% B'C#% 1$'C% B"$"?$#(% /#"C'$$/#)"N%
/#"C'6.A+0+N% /#"C#."C"+0+N% $"B.#(% ?(""@0-)% '$%
C"(#"-#N% /#"C#.*$0#N% >#)0-#(% ?(""@0-)N% ?(""@0-)%
0-.'% ./"% C*B'+#"N% +G0-% 46"."B/0#"N% 6*$6*$#N% @0+B'0@%
/#"C'$$/#)"+%%#-@%"BB/AC'+"+<%#-@%$".0-#D
Long-term complications (sequelae) of snake-bite
5.% ./"% +0."% '1% ./"% ?0."N% ('++% '1% .0++*"% C#A% $"+*(.%
1$'C% +('*)/0-)% '$% +*$)0B#(% @}?$0@"C"-.% '1% -"B$'.0B%
#$"#+% '$% #C6*.#.0'-a% B/$'-0B% *(B"$#.0'-N% 0-1"B.0'-N%
'+."'CA"(0.0+N% B'-.$#B.*$"+N% #$./$'@"+0+% '$% #$./$0.0+%
C#A% 6"$+0+.% B#*+0-)% +">"$"% 6/A+0B#(% @0+#?0(0.AD%
U#(0)-#-.% .$#-+1'$C#.0'-% C#A% 'BB*$% 0-% +G0-% *(B"$+%
#1."$%#%-*C?"$%'1%A"#$+
Skeletal muscle breakdown (sea snakes, some
krait species)
Symptoms and signs of snake-bite
b"-"$#(0O"@% 6#0-N% +.011-"++% #-@% ."-@"$-"++% '1%
When venom has not been injected
C*+B("+N% .$0+C*+N% CA')('?0-*$0#N% /A6"$G#(#"C0#N%
E'C"%6"'6("%=/'%#$"%?0.."-%?A%+-#G"+%'$%+*+6"B.%'$% B#$@0#B%#$$"+.N%#B*."%$"-#(%1#0(*$"D
0C#)0-"%./#.%./"A%/#>"%?""-%?0.."-N%C#A%@">"('6%P*0."%
+.$0G0-)% +AC6.'C+% #-@% +0)-+% ">"-% =/"-% -'% >"-'C% Renal (Viperidae, sea snakes)
6#0-N%
/#"C#.*$0#N%
/#"C')('?0-*$0#N%
/#+%?""-%0-J"B."@D%W#+'>#)#(N%B'((#6+"%=0./%+('=0-)% K'0-%
CA')('?0-*$0#N%'(0)*$0#^#-*$0#N%+AC6.'C+%#-@%+0)-+%
'1%/"#$.%$#."N%C0)/.%'>"$%?$"#./"%#-@%@">"('6%.".#-AD%
'1%*$#"C0#D
When venom has been injected
Endocrine 4#B*."% 60.*0.#$A^#@$"-#(% 0-+*1!%B0"-BA%
Local symptoms and signs in the bitten part:
1$'C%0-1#$B.0'-%'1%./"%#-."$0'$%60.*0.#$A<%
Q#-)% C#$G+N% ('B#(% 6#0-N% ('B#(% ?(""@0-)% ?$*0+0-)% 5B*."% 6/#+"a% E/'BGN% /A6')(AB#"C0#% &/$'-0B% 6/#+"%
(AC6/#-)0.0+N%(AC6/%-'@"%"-(#$)"C"-.%0-"%#CC#.0'-N% 4C'-./+% .'% A"#$+% #1."$% ./"% ?0."<a% ]"#G-"++N% ('++% '1%
?(0+."$0-)%('B#(%0-1"B.0'-N%#?+B"++%1'$C#.0'-%-"B$'+0+D +"B'-@#$A% +"T*#(% /#0$N% ('++% '1% (0?0@'N% #C"-'$$/'"#N%
."+.0B*(#$%#.$'6/AN%/A6'./A$'0@0+C%".B%
Generalized (systemic) symptoms and signs:
General
Locked in syndrome 7% Q"=% B#+"+% @">"('6%
Y#*+"#N% >'C0.0-)N% C#(#0+"N% #?@'C0-#(% 6#0-N% P*#@$06(")0#% =0./% .'.#(% '6./#(C'6(")0#% #-@% @0(#."@%
="#G-"++N%@$'=+0-"++N%6$'+.$#.0'-D
6*60(+D% H/"% B(0-0B0#-% C#A% 1""(% ./"% 6#.0"-.% 0+% ?$#0-%
@"#@% '$% B'C#.'+"N% ?*.% +*B/% >0B.0C+% $"B'>"$% .'.#((A%
Cardiovascular (Viperidae)
=0./0-% h7L% @#A+% 01% .$"#."@% 6$'6"$(A% ?A% C#0-.#0-0-)%
W0+*#(% @0+.*$?#-B"+N% @0OO0-"++N% 1#0-.-"++N% B'((#6+"N% 'TA)"-% +#.*$#.0'-% =0./% 6$'6"$% >"-.0(#.'$% +*66'$.%
+/'BGN%/A6'."-+0'-N%B#$@0#B%#$$/A./C0#+N%6*(C'-#$A% #-@% "("B.$'(A.0B% ?#(#-B"% #-@% -*.$0.0'-% #-@% B#$"%
'"@"C#N%B'-J*-B.0>#(%'"@"C#%4B/"C'+0+<
'1% 0-1"B.0'-D% H/0+% 6/"-'C"-'-% 0+% @*"% .'% ?('BG"@%
6'+.+A-#6.0B% #B".A(% B/'(0-"% $"B"6.'$+% 0-B(*@0-)% ./"%
Bleeding and clotting disorders (Viperidae)
H$#*C#.0B% ?(""@0-)% 1$'C% $"B"-.% ='*-@+% 40-B(*@0-)% +6/0-B."$% 6*60((#$A% C*+B("% =/0B/% #$"% $0B/% 0-% #B".A(%
6$'('-)"@%?(""@0-)%1$'C%./"%1#-)%C#$G+%%#-@%1$'C% B/'(0-"%$"B"6.'$+D
Neurological (Elapidae, Russell’s viper)
!$'=+0-"++N% 6#$#"+./"+0#"N% #?-'$C#(0.0"+%
Vol. 3 - No.2 April - June 2016
Symptoms and signs of cobra-spit ophthalmia
(eye injuries from spitting cobras)
'1% ,1% ./"% j+6#.k% >"-'C% "-."$+% ./"% "A"+N% ./"$"% 0+%
34
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
0CC"@0#."% #-@% 6"$+0+."-.% 0-."-+"% ?*$-0-)N% +.0-)0-)%
6#0-N% 1'(('="@% ?A% 6$'1*+"% =#."$0-)% '1% ./"% "A"+%
=0./% 6$'@*B.0'-% '1% =/0.0+/% @0+B/#$)"N% B'-)"+."@%
B'-J*-B.0>#"N% +6#+C% #-@% +="((0-)% '1% ./"% "A"(0@+N%
6/'.'6/'?0#N% B('*@0-)% '1% >0+0'-% #-@% ."C6'$#$A%
?(0-@-"++D% &'$-"#(% *(B"$#.0'-N% 6"$C#-"-.% B'$-"#(%
+B#$$0-)% #-@% +"B'-@#$A% "-@'6/./#(C0.0+% #$"%
$"B')-0+"@% B'C6(0B#.0'-+% '1% 51$0B#-% +60..0-)% B'?$#%
>"-'C%?*.%/#>"%-'.%?""-%@"+B$0?"@%0-%5+0#D
6$"+"-.#.0'-D0D"DA0$=#A, B$"#./0-) #-@%C0$B*(#.0'-.
50$=#A% 6#."-BAN% $"+60$#.'$A% C'>"C"-.+N% #$."$0#(%
6*(+"% #-@% (">"(% '1% B'-+B0'*+-"++% C*+.% ?"% B/"BG"@%
0CC"@0#."(AD% X'=">"$N% ./"% b(#+)'=% &'C#% EB#("%
B#--'.%?"%*+"@%.'%#++"++%./"%(">"(%'1%B'-+B0'*+-"++%
'1%6#.0"-.+%6#$#(AO"@%?A%-"*$'.'T0B%>"-'C+D
,1%./"$"%0+%">0@"-B"%'1%#%?0."N%=/"$"%./"%+G0-%/#+%?""-%
?$'G"-N%)0>"%Tetanus Toxoid%
M'*.0-"%*+"%'1%anti-biotic%0+%-'.%-"B"++#$AN%#(./'*)/%
0.% +/'*(@% ?"% B'-+0@"$"@% 01% ./"$"% 0+% ">0@"-B"% '1%
B"((*(0.0+%'$%-"B$'+0+D%
First Aid Treatment Protocol
U*B/%'1%./"%!%$+.%#0@%B*$$"-.(A%B#$$0"@%'*.%0+%0-"11"B.0>"%
#-@%@#-)"$'*+D%
Diagnosis Phase: General Principles
t% ]/"$"%6'++0?("%0@"-.01A%./"%+-#G"%$"+6'-+0?("D
Recommended Method for India
H/"%!%$+.%#0@%?"0-)%B*$$"-.(A%$"B'CC"-@"@%0+%?#+"@% t% All patients will be kept under observation for a
minimum of 24 hours. &'?$#%6$'@*B"+%+AC6.'C+%
#$'*-@%./"%C-"C'-0Ba%
#+%"#$(A%#+%g%C0-*."+%'$%#+%(#."%#+%:9%/'*$+%#1."$%./"%
?0."D%W06"$+%.#G"%+(0)/.(A%('-)"$%7%./"%C"#-%@*$#.0'-%
“Do it R.I.G.H.T.”
'1% '-+".% ?"0-)% 89% C0-*."+D% X'=">"$N% +AC6.'C+%
,.%B'-+0+.+%'1%./"%1'(('=0-)a
C#A%?"%@"(#A"@%1'$%+">"$#(%/'*$+D%E"#%+-#G"%?0."+%
RD%y%M"#++*$"%./"%6#.0"-.D%l9e%'1%#((%+-#G"?0."+%#$"%
#(C'+.% #(=#A+% 6$'@*B"% CA'.'T0B% 1"#.*$"+% =0./0-%
1$'C%-'-7%>"-'C'*+%+6"B0"+D%S-(A%g9e%'1%?0."+%?A%
8% /'*$+% +'% ./#.% ./"A% #$"% $"(0#?(A% "TB(*@"@% 01% -'%
>"-'C'*+%+6"B0"+%#B.*#((A%"->"-'C#."%./"%6#.0"-.%
+AC6.'C+%#$"%">0@"-.%=0./0-%./0+%6"$0'@D%
I%y%,CC'?0(0+"%0-%./"%+#C"%=#A%#+%#%1$#B.*$"@%(0C?D%
t%
,-%,-@0#%?0."%C#$G+%#$"%'1%-'%*+"%0-%0@"-.01A0-)%01%#%
[+"%?#-@#)"+%'$%B('./%.'%/'(@%./"%+6(0-.+N%-'.%.'%?('BG%
+6"B0"+%0+%>"-'C'*+%'$%-'.D%
./"%?(''@%+*66(A%'$%#66(A%6$"++*$"D%!'%-'.%#66(A%#-A%
t%
!"."$C0-"%
01% #-A% .$#@0.0'-#(% C"@0B0-"+% /#>"%
B'C6$"++0'-%0-%./"%1'$C%'1%.0)/.%(0)#.*$"+N%./"A%@'-d.%
?""-% *+"@N% ./"A% B#-% +'C".0C"+% B#*+"% B'-1*+0-)%
='$G%#-@%B#-%?"%@#-)"$'*+~%
+AC6.'C+D%
G. HD% y% b".% .'% X'+60.#(% ,CC"@0#."(AD% H$#@0.0'-#(%
t%
!"."$C0-"%./"%"T#B.%.0C"%'1%./"%?0."D%H/0+%B#-%)0>"%
$"C"@0"+% /#>"% YS% 3MSWVY% ?"-"!%.% 0-% .$"#.0-)%
0-@0B#.0'-+%#+%.'%./"%6$')$"++0'-%'1%#-A%+AC6.'C+D%
+-#G"?0."D%
t%
5+G%P*"+.0'-+%#+%.'%=/#.%./"%>0B.0C%=#+%@'0-)%#.%
Ty%H"((%./"%@'B.'$%'1%#-A%+A+."C0B%+AC6.'C+%+*B/%#+%
./"%.0C"%'1%./"%?0."D
6.'+0+%./#.%C#-01"+.%'-%./"%=#A%.'%/'+60.#(D
Do not handle the snake with your bare hands as
even a severed head can bite!
Most Traditional First Aid Methods should be
Discouraged: They do more harm than good!
M"("#+"% '1% .0)/.% ?#-@+N% ?#-@#)"+% #-@% (0)#.*$"+a%
,@"#((AN%./"+"%+/'*(@%-'.%?"%$"("#+"@%*-.0(%./"%6#.0"-.%
0+% *-@"$% C"@0B#(% B#$"% 0-% /'+60.#(N% $"+*+B0.#.0'-%
1#B0(0.0"+%#$"%#>#0(#?("%#-@%#-.0>"-'C%.$"#.C"-.%/#+%
?""-%+.#$."@D
H0)/.%4#$."$0#(<%.'*$-0P*".+%#$"%-'.%$"B'CC"-@"@~%
3#.0"-.%5++"++C"-.%3/#+"a%S-%#$$0>#(D%
!"#(% =0./% #-A% (01"% ./$"#."-0-)% +AC6.'C+% '-%
Vol. 3 - No.2 April - June 2016
35
Pain
E-#G"?0."% B#-% '1."-% B#*+"% +">"$"% 6#0-% #.% ./"% ?0."%
+0."D% H/0+% B#-% ?"% .$"#."@% =0./% 6#0-G0(("$+% +*B/% #+%
6#$#B".#C'(D% 3"@0#.$0B% @'+"% :9C)^G)% ">"$A% L7;%
/'*$(A%'$#((AD%
5+60$0-%+/'*(@%-'.%?"%*+"@%@*"%.'%0.+%#@>"$+"%0C6#B.%
'-% B'#)*(#.0'-D% !'% -'.% *+"% -'-% +."$'0@#(% #-.07
0-"%#CC#.'$A% @$*)+% 4YE5,!+<% #+% ./"A% B#-% B#*+"%
?(""@0-)D%%
U0(@%'60#."+%+*B/%#+%H$#C#@'(N%g9%C)%B#-%?"%*+"@%
'$#((A%'$%,W%1'$%$"(0"1%'1%+">"$"%6#0-
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
Table 2:%E-#G"+N%&(0-0B#(%#+6"B.+%r%./"$#6"*.0B%$"+6'-+"
Features
K'B#(%3#0-^%H0++*"%!#C#)"
cobra
RVE
Krait
YS
Russell’s viper
RVE
Sawscaled viper
RVE
Hump nose viper
RVE
3.'+0+^%Y"*$'(')0B#(%E0)-+
X#"C'+.#.0B%#?-'$C#(0.A
M"-#(%B'C6(0B#.0'-+
M"+6'-+"%.'%-"'+.0)C0-"
RVE
YS
YS
RVE
RVE
YS
YS
YS_
RVE
RVE
RVE
YS_
YS
RVE
YS
YS
YS
RVE
RVE
YS
Clinical situations in which snake-bite victims
might require urgent resuscitation:
3$'1'*-@%/A6'."-+0'-%#-@%+/'BG%$"+*(.0-)%1$'C%@0$"B.
4#<% B#$@0'>#+B*(#$%"11"B.+%'1%./"%>"-'C%'$%+"B'-@#$A%
"11"B.+N% +*B/% #+% /A6'>'("C0#N% $"("#+"% '1%
0-"%#CC#.'$A%>#+'#B.0>"%C"@0#.'$+N%/"C'$$/#)0B%
+/'BG%'$%$#$"(A%6$0C#$A%#-#6/A(#T0+%0-@*B"@%?A%
./"%>"-'C%0.+"(1D
4?<% H"$C0-#(% $"+60$#.'$A% 1#0(*$"% 1$'C% 6$')$"++0>"%
-"*$'.'T0B%"->"-'C0-)D
4B<% E*@@"-% @"."$0'$#.0'-% '$% $#60@% @">"('6C"-.% '1%
+">"$"%+A+."C0B%"->"-'C0-)%1'(('=0-)%./"%$"("#+"%
'1%#%.0)/.%.'*$-0P*".%'$%B'C6$"++0'-%?#-@#)"D
4@<% &#$@0#B% #$$"+.% 6$"B060.#."@% ?A% /A6"$G#("C0#%
$"+*(.0-)%1$'C%+G"(".#(%C*+B("%?$"#G@'=-D
4"<% ,1%./"%6#.0"-.%#$$0>"+%(#."a%K#."%$"+*(.+%'1%+">"$"%
"->"-'C0-)%+*B/%#+%$"-#(%1#0(*$"%#-@%+"6.0B"C0#%
B'C6(0B#.0-)%('B#(%-"B$'+0+D
Early clues that a patient has severe envenoming:
t% E-#G"%0@"-.0!%"@%#+%#%>"$A%@#-)"$'*+%'-"D%%
t% M#60@% "#$(A% "T."-+0'-% '1% ('B#(% +="((0-)% 1$'C% ./"%
+0."%'1%./"%?0."D
t% V#$(A% ."-@"$% "-(#$)"C"-.% '1% ('B#(% (AC6/% -'@"+N%
0-@0B#.0-)% +6$"#@% '1% >"-'C% 0-% ./"% (AC6/#.0B%
+A+."CD%
t% V#$(A% +A+."C0B% +AC6.'C+a% B'((#6+"% 4/A6'."-+0'-N%
+/'BG<N% -#*+"#N% >'C0.0-)N% @0#$$/'"#N% +">"$"%
/"#@#B/"N%j/"#>0-"++k%'1%./"%"A"(0@+N%0-#66$'6$0#."%
46#./'(')0B#(<% @$'=+0-"++% '$% "#$(A% 6.'+0+^%
'6/./#(C'6(")0#D%
t% V#$(A%+6'-.#-"'*+%+A+."C0B%?(""@0-)D
t% 3#++#)"%'1%@#$G%?$'=-^?(#BG%*$0-"
Investigations/laboratory tests
20-minute whole blood clotting test (20WBCT)
3(#B"% 8% C(+% '1% 1$"+/(A% +#C6("@% >"-'*+% ?(''@% 0-% #%
+C#((N%-"=%'$%/"#.%B("#-"@N%@$AN%)(#++%>"++"(D%K"#>"%
*-@0+.*$?"@%1'$%89%C0-*."+%#.%#C?0"-.%."C6"$#.*$"D
Vol. 3 - No.2 April - June 2016
36
H06%./"%>"++"(%'-B"D%,1%./"%?(''@%0+%+.0((%(0P*0@%4*-B('.."@<%
#-@% $*-+% '*.N% ./"% 6#.0"-.% /#+% /A6'!%?$0-')"-#"C0#%
4j0-B'#)*(#?("%?(''@k<D
If the vessel used for the test is not made of
ordinary glass, or if it has been cleaned with
detergent, its wall may not stimulate clotting of
the blood sample (surface activation of factor XI–
Hageman factor) and test will be invalid
,1% ./"$"% 0+% #-A% @'*?.N% $"6"#.% ./"% ."+.% 0-% @*6(0B#."N%
0-B(*@0-)% #% jB'-.$'(k% 4?(''@% 1$'C% #% /"#(./A% 6"$+'-%
+*B/%#+%#%$"(#.0>"
Other tests
Hemoglobin concentration/ hematocrit:%5%.$#-+0"-.%
0-B$"#+"%0-@0B#."+%/"C'B'-B"-.$#.0'-%
Platelet count:%H/0+%C#A%?"%@"B$"#+"@%0-%>0B.0C+%'1%
"->"-'C0-)%?A%>06"$+D
White blood cell count:% 5-% "#$(A% -"*.$'6/0(%
("*B'BA.'+0+% 0+% ">0@"-B"% '1% +A+."C0B% "->"-'C0-)%
1$'C%#-A%+6"B0"+D
Blood lm:% Q$#)C"-."@% $"@% B"((+% 4j/"(C".% B"((kN%
+B/0+.'BA."+<%#$"%+""-%=/"-%./"$"%0+%C0B$'#-)0'6#./0B%
/#"C'(A+0+D
Plasma/serum: U#A%?"%60-G0+/%'$%?$'=-0+/%01%./"$"%
0+%)$'++%/"C')('?0-#"C0#%'$%CA')('?0-#"C0#D
Biochemical abnormalities: 5C0-'.$#-+1"$#+"+%
#-@% C*+B("% "-OAC"+% 4B$"#.0-"% G0-#+"N% #(@'(#+"%
".B<%=0((%?"%"(">#."@%01%./"$"%0+%+">"$"%('B#(%C*+B("%
@#C#)"D% I0(0$*?0-% 0+% "(">#."@% 1'(('=0-)% C#++0>"%
"T.$#>#+#.0'-% '1% ?(''@D% 3'.#++0*CN% B$"#.0-0-"N% *$"#%
'$%?(''@%*$"#%-0.$')"-%(">"(+%#$"%$#0+"@%0-%./"%$"-#(%
1#0(*$"%'1%M*++"((d+%>06"$N%/*C67-'+"@%>06"$%?0."+%#-@%
+"#% +-#G"?0."+D% V#$(A% /A6"$G#(#"C0#% C#A% ?"% +""-%
1'(('=0-)% "T."-+0>"% $/#?@'CA'(A+0+% 0-% +"#% +-#G"7
?0."+D%I0B#$?'-#."%=0((%?"%('=%0-%C".#?'(0B%#B0@'+0+%
4"D)D%$"-#(%1#0(*$"<D
Arterial blood gases and pH C#A%+/'=%">0@"-B"%'1%
$"+60$#.'$A%1#0(*$"
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
Warning: Arterial puncture is contraindicated in
patients with hemostatic abnormalities (Viperidae)
Desaturation:% 5$."$0#(% 'TA)"-% +#.*$#.0'-% B#-% ?"%
#++"++"@%-'-70->#+0>"(AD
Urine examination: H/"% B'('$% '1% ./"% *$0-"% 460-GN%
$"@N% ?$'=-N% ?(#BG<% +/'*(@% ?"% -'."@% #-@% ./"% *$0-"%
+/'*(@%?"%."+."@%?A%@06+.0BG+%1'$%?(''@%'$%/"C')('?0-%
'$% CA')('?0-D% M"@% B"((% B#+.+% 0-@0B#."% )('C"$*(#$%
?(""@0-)D%U#++0>"%6$'."0-*$0#%0+%#-%"#$(A%+0)-%'1%./"%
)"-"$#(0O"@%0-B$"#+"%0-%B#60((#$A%6"$C"#?0(0.AD
Antivenom treatment
Antivenom is the only speciILc antidote to snake
venom.
What is antivenom?
./"% ,-@0#-% #-.0>"-'C% C#-*1#B.*$"$+d% j6'(A>#("-.%
#-.07+-#G"% >"-'C% +"$*Ck% 0+% $#0+"@% 0-% /'$+"+% *+0-)%
./"% >"-'C+% '1% ./"% 1'*$% C'+.% 0C6'$.#-.% >"-'C'*+%
+-#G"+%0-%,-@0#%4,-@0#-%B'?$#N%Y#J#%-#J#Z%,-@0#-%G$#0.N%
I*-)#$*+%B#"$*("*+Z%M*++"((d+%>06"$N%!#?'0#%$*++"(00Z%
+#=7+B#("@%>06"$N%VB/0+%B#$0-#.*+<N
Indications for antivenom
Systemic envenoming:
X"C'+.#.0B% #?-'$C#(0.0"+a% E6'-.#-"'*+% +A+."C0B%
?(""@0-)%4B(0-0B#(<N
&'#)*('6#./A% 489]I&H% '$% './"$% (#?'$#.'$A% ."+.+%
+*B/% #+% 3$'./$'C?0-% .0C"<% '$% ./$'C?'BA.'6"-0#%
4s:99%T%:9m^(0.$"%'$%:99%999^B*%CC<%4(#?'$#.'$A<D
Y"*$'.'T0B% +0)-+a% 6.'+0+N% "T."$-#(% '6/./#(C'6(")0#N%
6#$#(A+0+%".B%4B(0-0B#(<D%
&#$@0'>#+B*(#$% #?-'$C#(0.0"+a% /A6'."-+0'-N% +/'BGN%
B#$@0#B% #$$/A./C0#% 4B(0-0B#(<N% #?-'$C#(% V&bD%
5B*."% G0@-"A% 0-J*$A% 4$"-#(% 1#0(*$"<a% '(0)*$0#^#-*$0#%
4B(0-0B#(<N%$0+0-)%?(''@%B$"#.0-0-"^%*$"#%4(#?'$#.'$A<D
4X#"C')('?0-7^CA')('?0-*$0#a<% @#$G% ?$'=-% *$0-"%
4B(0-0B#(<N%*$0-"%@06+.0BG+N%'./"$%">0@"-B"%'1%0-.$#>#+B*(#$%
/#"C'(A+0+% '$% )"-"$#(0+"@% $/#?@'CA'(A+0+% 4C*+B("%
#B/"+%#-@%6#0-+N%/A6"$G#(#"C0#<%4B(0-0B#(N%(#?'$#.'$A<D%
E*66'$.0-)% (#?'$#.'$A% ">0@"-B"% '1% +A+."C0B%
"->"-'C0-)+D
Local envenomation
K'B#(%+="((0-)%0->'(>0-)%C'$"%./#-%/#(1%'1%./"%?0.."-%
Vol. 3 - No.2 April - June 2016
37
(0C?%40-%./"%#?+"-B"%'1%#%.'*$-0P*".<%=0./0-%Lf%/'*$+%
'1% ./"% ?0."D% E="((0-)% #1."$% ?0."+% '-% ./"% @0)0.+% 4.'"+%
#-@% "+6"B0#((A% !%-)"$+<D% M#60@% "T."-+0'-% '1% +="((0-)%
41'$%"T#C6("N%?"A'-@%./"%=$0+.%'$%#-G("%=0./0-%#%1"=%
/'*$+%'1%?0."%'-%./"%/#-@+%'$%1"".<D%!">"('6C"-.%'1%#-%
"-(#$)"@%."-@"$%(AC6/%-'@"%@$#0-0-)%./"%?0.."-%(0C?
How long after the bite can antivenom be expected
to be effective?
5-.0>"-'C%.$"#.C"-.%+/'*(@%?"%)0>"-%#+%+''-%#+%0.%0+%
0-@0B#."@D%,.%C#A%$">"$+"%+A+."C0B%"->"-'C0-)%">"-%
=/"-% ./0+% /#+% 6"$+0+."@% 1'$% +">"$#(% @#A+% '$N% 0-% ./"%
B#+"% '1% /#"C'+.#.0B% #?-'$C#(0.0"+N% 1'$% .='% '$% C'$"%
=""G+D%,.%0+N%./"$"1'$"N%#66$'6$0#."%.'%)0>"%#-.0>"-'C%
1'$%#+%('-)%#+%">0@"-B"%'1%./"%B'#)*('6#./A%6"$+0+.+D
Antivenom reactions
(1) Early anaphylactic reactions:%[+*#((A%=0./0-%:97
:f9%C0-*."+%'1%+.#$.0-)%#-.0>"-'CN%./"%6#.0"-.%?")0-+%
.'%0.B/%4'1."-%'>"$%./"%+B#(6<%#-@%@">"('6+%*$.0B#$0#N%
@$A%B'*)/N%1">"$N%-#*+"#N%>'C0.0-)N%#?@'C0-#(%B'(0BN%
@0#$$/'"#%#-@%.#B/B#$@0#D
(2) Pyrogenic (endotoxin) reactions: [+*#((A%./"+"%
@">"('6%:78%/'*$+%#1."$%.$"#.C"-.D%EAC6.'C+%0-B(*@"%
+/#G0-)% B/0((+% 4$0)'$+<N% 1">"$N% >#+'@0(#.#.0'-% #-@% #%
1#((% 0-% ?(''@% 6$"++*$"D% Q"?$0("% B'->*(+0'-+% C#A% ?"%
6$"B060.#."@% 0-% B/0(@$"-D%H/"+"% $"#B.0'-+% #$"% B#*+"@%
?A%6A$')"-%B'-.#C0-#.0'-%@*$0-)%./"%C#-*1#B.*$0-)%
6$'B"++N
(3) Late (serum sickness type) reactions:
!">"('6% :7:8% 4C"#-% l<% @#A+% #1."$% .$"#.C"-.D%
&(0-0B#(% 1"#.*$"+% 0-B(*@"% 1">"$N% -#*+"#N% >'C0.0-)N%
@0#$$/'"#N% 0.B/0-)N% $"B*$$"-.% *$.0B#$0#N% #$./$#()0#N%
CA#()0#N% (AC6/#@"-'6#./AN% 6"$0#$.0B*(#$% +="((0-)+N%
C'-'-"*$0.0+% C*(.06("TN% 6$'."0-*$0#% =0./% 0CC*-"%
B'C6("T% -"6/$0.0+% #-@N% $#$"(AN% "-B"6/#('6#./AD%
3#.0"-.+% =/'% +*11"$% "#$(A% $"#B.0'-+% #-@% #$"% .$"#."@%
=0./%#-.0/0+.#C0-"+%#-@%B'$.0B'+."$'0@%#$"%("++%(0G"(A%
.'%@">"('6%(#."%$"#B.0'-+D
3$"@0B.0'-% '1% #-.0>"-'C% $"#B.0'-+D% EG0-% #-@%
B'-J*-B.0>#(% j/A6"$+"-+0.0>0.Ak% ."+.+% =0((% $">"#(%
,)V% C"@0#."@D% HA6"% ,% /A6"$+"-+0.0>0.A% .'% /'$+"% '$%
+/""6%6$'."0-+D%X'=">"$N%+0-B"%./"%C#J'$0.A%'1%"#$(A%
4#-#6/A(#B.0B<%'$%(#."%4+"$*C%+0BG-"++%.A6"<%#-.0>"-'C%
$"#B.0'-+% $"+*(.% 1$'C% @0$"B.% B'C6("C"-.% #B.0>#.0'-%
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
$#./"$% ./#-% 1$'C% ,)V% C"@0#."@% /A6"$+"-+0.0>0.AN%
./"+"%."+.+%#$"%-'.%6$"@0B.0>"D%E0-B"%./"A%C#A%@"(#A%
.$"#.C"-.%#-@%B#-%0-%./"C+"(>"+%?"%+"-+0.0+0-)N%./"+"%
."+.+%+/'*(@%-'.%?"%*+"@.
Contraindications to antivenom: Prophylaxis of
high risk patients
H/"$"% 0+% -'% #?+'(*."% B'-.$#0-@0B#.0'-% .'% #-.0>"-'C%
.$"#.C"-.N%?*.
6#.0"-.+% =/'% /#>"% $"#B."@% .'% /'$+"% 4"P*0-"<% '$%
+/""6%4'>0-"<%+"$*C%0-%./"%6#+.%
% ./'+"% =0./% #% +.$'-)% /0+.'$A% '1% #.'60B% @0+"#+"+%
4"+6"B0#((A% +">"$"% #+./C#<% #$"% #.% /0)/% $0+G% '1%
+">"$"% $"#B.0'-+% #-@% +/'*(@% ./"$"1'$"% ?"% )0>"-%
#-.0>"-'C% '-(A% 01% ./"A% /#>"% +0)-+% '1% +A+."C0B%
"->"-'C0-)D
E0-B"% -'% 6$'6/A(#B.0B% @$*)% $")0C"-% /#+% 6$'>"@%
"11"B.0>"% 0-% $"@*B0-)% ./"% 0-B0@"-B"% '$% +">"$0.A% '1%
"#$(A%#-.0>"-'C%$"#B.0'-+N%./"+"%@$*)+%+/'*(@%-'.%?"%
*+"@%"TB"6.%0-%/0)/%$0+G%6#.0"-.+D
#-.0>"-'C+%4+/"(1%(01"%87h%A"#$+<%+/'*(@%?"%+.'$"@%#.%
87f%&%#-@%-'.%1$'O"-D%,@"#((AN%#-.0>"-'C+%+/'*(@%?"%
*+"@%?"1'$"%./"%+.#."@%"T60$A%@#."+%?*.N%6$'>0@"@%./#.%
./"A%/#>"%?""-%6$'6"$(A%+.'$"@N%./"A%B#-%?"%"T6"B."@%
.'% $".#0-% *+"1*(% #B.0>0.A% 1'$% C'-./+% '$% ">"-% A"#$+%
#1."$%./"+"%@#."+%4]XSN%:mf:Z%SdK"#$A%".%#(DN%899m<D%
,-%6#.0"-.+%=0./%+">"$"%"->"-'C0-)N%$"B"-.(A%"T60$"@%
#-.0>"-'C+%C#A%?"%*+"@%01%./"$"%0+%-'%#(."$-#.0>"D
Administration of antivenom
5EW% 0+% $"B'CC"-@"@% .'% ?"% #@C0-0+."$"@% 0-% ./"%
1'(('=0-)%0-0.0#(%@'+"a
Neurotoxic/ Anti Haemostatic 8-10 Vials
H='%C"./'@+%'1%#@C0-0+.$#.0'-%#$"%$"B'CC"-@"@a
4:<% ,-.$#>"-'*+% j6*+/k% 0-J"B.0'-a% M"B'-+.0.*."@%
1$""O"7@$0"@% #-.0>"-'C% '$% -"#.% (0P*0@% #-.0>"-'C% 0+%
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Treatment of antivenom reactions. Early 8g97g99%C(%'1%0+'.'-0B%+#(0-"<%
anaphylactic and pyrogenic antivenom reactions: #-@%0+%0-1*+"@%#.%#%B'-+.#-.%$#."%'>"$%#%6"$0'@%'1%#?'*.%
V60-"6/$0-"% 4#@$"-#(0-"<% 0+% )0>"-% 0-.$#C*+B*(#$(A% '-"%/'*$D
40-.'% *66"$% (#."$#(% ./0)/<% 0-% #-% 0-0.0#(% @'+"% '1% 9D9:%
C)^G)% ?'@A% ="0)/.% 1'$% B/0(@D% H/"% @'+"% B#-% ?"% Local administration of antivenom at the site of
$"6"#."@%">"$A%g7:9%C0-*."+%01%./"%6#.0"-.d+%B'[email protected]'-% the bite is not recommended:
The only situations in which intramuscular
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Additional treatment:% #-% #-.0/0+.#C0-"% #-.07X:% administration might be considered:
?('BG"$%+*B/%#+%B/('$6/"-#C0-"%C#("#."%4B/0(@$"-%9D8% 4:<%5.%#%6"$06/"$#(%!%$+.%#0@%+.#.0'-N%?"1'$"%#%6#.0"-.%
C)^G)%?A%0-.$#>"-'*+%0-J"B.0'-%'>"$%#%1"=%C0-*."+<r% =0./%'?>0'*+%"->"-'C0-)%0+%6*.%0-%#-%#C?*(#-B"%1'$%
0-.$#>"-'*+%/A@$'B'$.0+'-"%4B/0(@$"-%8%C)^G)%?'@A% #%J'*$-"A%.'%/'+60.#(%./#.%C#A%(#+.%+">"$#(%/'*$+Z
48<%S-%#-%"T6"@0.0'-%"T6('$0-)%#%$"C'."%#$"#%>"$A%1#$%
="0)/.<N%C#A%6$">"-.%$"B*$$"-.%#-#6/A(#T0+D
Treatment of late (serum sickness) reactions: K#."% 1$'C%C"@0B#(%B#$"Z
4+"$*C% +0BG-"++<% $"#B.0'-+% C#A% $"+6'-@% .'% #% g7@#A% 4h<%]/"-%0-.$#>"-'*+%#BB"++%/#+%6$'>"@%0C6'++0?("D
B'*$+"% '1% '$#(% #-.0/0+.#C0-"D% 3#.0"-.+% =/'% 1#0(% .'%
Antivenom must never be given by the intramuscular
$"+6'-@%0-%8L7Lf%/'*$+%+/'*(@%?"%)0>"-%#%g7@#A%B'*$+"%
route if it could be given intravenously.
'1% 6$"@-0+'('-"D% !'+"+a% &/('$6/"-#C0-"a% B/0(@$"-%
9D8g% C)^G)% ^@#A% 0-% @0>0@"@% @'+"+D% 3$"@-0+'('-"a% Snakes inject the same dose of venom into children
B/0(@$"-%9Dl%C)^G)^@#A%0-%@0>0@"@%@'+"+%1'$%g7l%@#A+ and adults. Children must therefore be given
exactly the same dose of antivenom as adults.
Selection, storage and shelf life of antivenom
H'%$".#0-%./"0$%1*((%6'."-BA%=0./0-%./"%(0C0.+%'1%+.#."@% Observation of the response to antivenom: ,1% #-%
"T60$A%@#."+N%(A'6/0(0O"@%#-.0>"-'C+%4+/"(1%(01"%#?'*.% #@"P*#."% @'+"% '1% #66$'6$0#."% #-.0>"-'C% /#+% ?""-%
g% A"#$+<% +/'*(@% ?"% +.'$"@% #.% ?"('=% 8g&% #-@% (0P*0@% #@C0-0+."$"@N%./"%1'(('=0-)%$"+6'-+"+%C#A%?"%'?+"$>"@D
Vol. 3 - No.2 April - June 2016
38
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
Algorithmic approach to snake bite
Approach to Clinical aspects and treatment of Snake bite
First Aid ‘R.I.G.H.T’
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+AC6.'C+7%)'%.'
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Vol. 3 - No.2 April - June 2016
39
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
4#<%b"-"$#(a%H/"%6#.0"-.%1""(+%?".."$D%Y#*+"#N%/"#@#B/"%
#-@%)"-"$#(0O"@%#B/"+%#-@%6#0-+%C#A%@0+#66"#$%>"$A%
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"11"B.D
4?<% E6'-.#-"'*+% +A+."C0B% ?(""@0-)% 4"D)D% 1$'C% ./"%
)*C+<a%H/0+%*+*#((A%+.'6+%=0./0-%:g7h9%C0-*."+D
4B<%I(''@%B'#)*(#?0(0.A%4#+%C"#+*$"@%?A%89]I&H<a%
H/0+%0+%*+*#((A%$"+.'$"@%0-%h7m%/'*$+D%I(""@0-)%1$'C%
-"=% #-@% 6#$.(A% /"#("@% ='*-@+% *+*#((A% +.'6+% C*B/%
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4B'?$#% ?0."+<% C#A% ?")0-% .'% 0C6$'>"% #+% "#$(A% #+% h9%
C0-*."+% #1."$% #-.0>"-'CN% ?*.% *+*#((A% .#G"+% +">"$#(%
/'*$+D% V->"-'C0-)% =0./% 6$"+A-#6.0B% .'T0-+% 4G$#0.+%
#-@%+"#%+-#G"+<%=0((%-'.%$"+6'-@%0-%./0+%=#AD
41<%5B.0>"%/"C'(A+0+%#-@%$/#?@'CA'(A+0+%C#A%B"#+"%
=0./0-%#%1"=%/'*$+%#-@%./"%*$0-"%$".*$-+%.'%0.+%-'$C#(%
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Recurrence of systemic envenoming
E0)-+%'1%+A+."C0B%"->"-'C#.0'-%C#A%$"B*$%/'*$+%'$%
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6#.0"-.+%1'$%#.%("#+.%h7L%@#A+
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+*@@"-(A% $"("#+"@% 0-.'% ./"% ?(''@% +.$"#CN% "+6"B0#((A%
=/"-%./"%='*-@%0+%/#-@("@%+*$)0B#((A
Criteria for repeating the initial dose of antivenom
3"$+0+."-B"% '$% $"B*$$"-B"% '1% ?(''@% 0-B'#)*(#?0(0.A%
#1."$% ;% /'*$+% '$% '1% ?(""@0-)% #1."$:78% /'*$+D%
!"."$0'$#.0-)% -"*$'.'T0B% '$% B#$@0'>#+B*(#$% +0)-+%
#1."$%:78%/'*$+D
If the blood remains incoagulable 4#+% C"#+*$"@%
?A% 89]I&H<% +0T% /'*$+% #1."$% ./"% 0-0.0#(% @'+"% '1%
#-.0>"-'CN% ./"% +#C"% @'+"% +/'*(@% ?"% $"6"#."@D%H/0+%
0+% ?#+"@% '-% ./"% '?+"$>#.0'-% ./#.N% 01% #% (#$)"% @'+"% '1%
#-.0>"-'C% 4C'$"% ./#-% "-'*)/% .'% -"*.$#(0O"% ./"%
>"-'C%6$'B'#)*(#-.%"-OAC"+<%0+%)0>"-%0-0.0#((AN%./"%
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'1%!%?$0-')"-%#-@%'./"$%B('..0-)%1#B.'$+%0+%h7m%/'*$+D
Vol. 3 - No.2 April - June 2016
40
In patients who continue to bleed briskly,%./"%@'+"%
'1%#-.0>"-'C%+/'*(@%?"%$"6"#."@%=0./0-%:78%/'*$+D
Maximum dose of ASV
Y"*$'.'T0B%q%89%>0#(+%
5-.0/"C'+.#.0B%%7%h9%>0#(+%
Treatment of neurotoxic envenoming
Y"'+.0)C0-"%q%0.%0+%*+"1*(%1'$%-"*$'C*+B*(#$%J*-B.0'-%
?('G#)"%B#*+"@%?A%-"*$'.'T0B%+-#G"%?0."+D%,.%0+%*+"1*(%
'-(A% 1'$% 6'+.+A-#6.0B% .A6"% '1% ?('G#)"% 4'BB*$0-)%
=0./% B'?$#% ?0."+<% #-@% -'.% 1'$% 6$"+A-#6.0B% ?('BG%
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5-% V@$'6/'-0*C% ."+.% B#-% 6$"@0B.% *+"71*((-"++% '1%
-"'+.0)C0-"%?*.%-'.%#>#0(#?("%0-%,-@0#%DH/"%$"+6'-+"%
.'%!%$+.%@'+"%0+%*+"1*(D%H/"%@'+"%0+%:9%.'%L9%C0B$')$#C^
G)%87L%/$(A%.0((%B'C6("."%-"*$'(')0B#(%$"B'>"$AD%,.%0+%
.'%?"%)0>"-%=0./%#.$'60-"
W"-.0(#.'$A%%+*66'$.%1'$%6#.0"-.+%=0./%$"+60$#.'$A%1#0(*$"
Key Messages
:D X0+.'$A% '1% +-#G"% ?0."% #-@% 1#-)% C#$G+% #$"% -'.
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-'$C#(% 6"$+'-N% +(""60-)% '-% "%''$% $"6'$.+% "#$(A
C'$-0-)% =0./% >'C0.0-)N% #?@'C0-#(% 6#0-% r
?*(?#$% 6#(+AN% 0.% +/'*(@% ?"% @0#)-'+"@% #+% F$#0.
"->"-'C#.0'-N%*-("++%6$'>"@%'./"$=0+"D
gD 5((%+-#G"%?0."+%@'%-'.%-""@%5EWD
;D 89% ]I&H% 0+% +0C6("N% B/"#6N% $"(0#?("% r% ?"@+0@"
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lD !'-d.%*-@"$"+.0C#."%('B#(%B'C6(0B#.0'-+%'1%+-#G"
?0."+N%0.%C#A%("#@%.'%)#-)$"-"%r%#C6*.#.0'-D
fD V-@'.$#B/"#(%0-.*?#.0'-%r%C"B/#-0B#(%>"-.0(#.0'#$"% '1% *.C'+.% 0C6'$.#-.% 0-% +#>0-)% #% B/0(@% =0./
-"*$'.'T0B%$"+60$#.'$A%6#$#(A+0+%0-%0+'(#.0'-%r%0B'C?0-#.0'-%=0./%5EWD
mD !'-d.% 0)-'$"% ?0."% ?A% +C#((% +-#G"+N% ?0."% #1."$
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JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -1
Snake Bite
:9D !'-d.%/#-@("%1$"+/(A%G0(("@%+-#G"+D%%I0."%$""%"T%0+
6$"+"$>"@%0-%./"C%r%B#-%("#@%.'%"->"-'C#.0'-D
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E'*./"#+.%5+0#-% $")0'-D% E'*./"#+.% #+0#-% J'*$-#(% '1% .$'60B#(
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!2N%("-@0-)/#C%2DbDb%#-@%=#$$$"((%!#%4"@0.'$+<D%Y"=%A'$G%a
ST1'$@%[-0>"$+0.A%3$"++%:mm;%36D::8L7L9D
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"->"-'C0-)%0-%="+."$-%U#/#$#+/.$#N%,-@0#D
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:9D I#=#+G#$% XED% E-#G"% ?0."% #-@% +B'$60'-% +.0-)+D,-Z
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nV@+o%Q$"P*"-.(A%#+G"@%P*"+.0'-+%5+G%,53a%#%+"$0"+D%I#+0B+
#-@%I"A'-@D%,53%5B.0'-%3(#-%899;Z%:9m7::
ConIOict of Interesta%Y'-"
Source of Fundinga%Y'-"
References
:D ]#$$"((% !5D% b*0@"(0-"+% 1'$% ./"% C#-#)"C"-.% '1% +-#G"% ?0."D
]XSZ%89:9a:7:g:
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hD X#-@?''G% '-% .$"#.C"-.% )*0@"(0-"+% 1'$% +-#G"% ?0."% #-@
EB'$60'-% +.0-)% H#C0(% Y#@*% X"#(./% EA+."C+% 3$'J"B.% X"#(./
#-@%Q#C0(A%]"(1#$"%!"6#$.C"-.%b'>"$-C"-.%'1%H#C0(%Y#@*N
&/"--#0D%899fZ%:7g;
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#-@% EB'$60'-% E.0-)D% p*#$."$(A% C"@0B#(% $">0"=% 899m% SB.7
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X'=%.'%B0."%./0+%#$.0B("a%F/#@+"%EDE-#G"%I0."D%2%3"@0#.$%&$0.%&#$"%89:;Z8ahh7L:D
X'=%.'%B0."%./0+%[MKa%F/#@+"%ED%E-#G"%I0."D%2%3"@0#.$%&$0.%&#$"%89:;Z8ahh7L:D%
5>#0(#?("%1$'Ca%a%/..6a^^===%J'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^%*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h9899mD/.C(
Vol. 3 - No.2 April - June 2016
41
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99:88
Envenomation -2
Scorpion Sting
Suchita Khadse
Pediatric Intensivist, CHILD Hospital, Nagpur
Received:15-Apr-2016 /Accepted:15-May-2016/Published online:20-May-2016
Keywordsa% EB'$60'-N% "->"-'C#.0'-N% +.0-)N% ?0."N% @#-)"$'*+D% ,-% ,-@0#% f;% +6"B0"+% '1% +B'$60'-% /#>"%
?""-% 0@"-.0!%"@D%5C'-)% ./"CN% U"+'?*./*+% .#C*(*+%
6'0+'-0-)
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EB'$60'-% +.0-)% 0+% #% (01"% ./$"#."-0-)% C"@0B#(% C"@0B#((AD% VTB"6.% X"C0+B'$60*+% +6"B0"+N% #((% ("./#(%
"C"$)"-BAD% H/"% "11"B.% '1% "->"-'C#.0'-+% )$"#."+.% +B'$60'-+%?"('-)%.'%./"%1#C0(A%B#(("@%./"%I*./0@#"D%
#C'-)% B/0(@$"-% ?"('=% g% A"#$+% '1% #)"D% U'$.#(0.A% 0-% H/"%("./#(%C"C?"$+%'1%I*./0@#"%1#C0(A%0-B(*@"%./"%
6$"%6$#O'B0-%"$#%=#+%#+%/0)/%#+%h9eD%,.%0+%='$./=/0("% )"-"$#% '1% I*./*+N% 3#$#?*./*+N% U"+'?*./*+N% H0.A*+%
.'%$"C"C?"$%!$DXDEDI#=#+G#$N%#%6$0>#."%6$#B.0.0'-"$% K"0*$*+N% 5-@$#B.'-*+% #-@% &"-.$*$'0@"+D% 5C'-)%
1$'C% U#/#$#+/.$#% =/'% 1'$% ./"% !%$+.% .0C"% 0-% ='$(@% ./"%h9%+B'$60'-%+6"B0"+%1'*-@%0-%[E5N%'-(A%'-"%'1%
/#+% 0-.$'@*B"@% ./"% *+"1*(-"++% '1% #(6/#% ?('BG"$% 0-% ./"C%0+%@#-)"$'*+%.'%/*C#-%?"0-)+DEB'$60'-+%(0>"%0-%
+B'$60'-%+.0-)%-"#$(A%8g%A"#$+%#)'%#-@%/#+%/"(6"@%.'% ."C6"$#."%#-@%.$'60B#(%$")0'-+%"+6"B0#((A%?".=""-%./"%
(#.0.*@"+%'1%g99%-'$./%#-@%g9 9 %+'*./%'1%"P*#.'$D%H/"%
$"@*B"%./"%C'$.#(0.AD
@0+.0-)*0+/0-)%1"#.*$"+%?".=""-%("./#(%#-@%-'-("./#(%
+B'$60'-+%#$"%6$'>0@"@%0-%H#?("%:D
Epidemiology
,-%,-@0#%%@"#./+%@*"%.'%+B'$60'-%+.0-)%'BB*$+%#B$'++% Table 1:%!0+.0-)*0+/0-)%1"#.*$"+%'1%("./#(%#-@%-'-7("./#(%+B'$60'./"% B'*-.$A% ?*.% @'% -'.% )".% @*"% #.."-.0'-D% K#$)"$% E.$*B.*$"%K"./#(%EB'$60'-%Y'-%("./#(%+B'$60'-%
lethal
Non-lethal
./"% +B'$60'-% 6'6*(#.0'-N% )$"#."$% 0+% ./"% -*C?"$% '1% Structure
6"-.#)'-#(
+B'$60'-% +.0-)% B#+"+D% EB'$60'-% +.0-)+% #$"% $"6'$."@% +."$-*C%+/#6" .$0#-)*(#$
30-B"$+
]"#G%(''G0-)
E.$'-)%#-@%/"#>A
C'$"%1$'C%$*$#(%#$"#+%#-@%./"%$*$#(%.'%*$?#-%$#.0'%0+%
#66$'T0C#."(A% ha:D% U'+.(A% +.0-)+% 'BB*$% ?".=""-% ;% I'@A%
H/0-%0-%#%"C6#./".0B% ./0BG
C#--"$
3DUD%.'%C0@7-0)/.%#-@%?".=""-%;%5DUD%.'%:8%Y''-N%
./0BG
./0=/0B/% B'$$"(#."% >"$A% ="((% =0./% /*C#-% #B.0>0.AD% H#0(
EB'$60'-%+.0-)%'BB*$%C'$"%0-%."C6"$#."%#-@%.$'60B#(%
EB'$60'-+% *+"% ./"0$% 60-B"$+% .'% )$#+6% ./"% 6$"AD% ,.%
O'-"+N%#-@%C'$"%@*$0-)%+*CC"$%./#-%=0-."$D
#$B/"+%0.+%.#0(%'>"$%0.+%?'@A%#-@%+.0-)+%0-.'%0.+%6$"AD%
H/*+%0.%0-J"B.+%0.+%>"-'CN%+'C".0C"+%C'$"%./#-%'-B"D%
Eco- biological aspects of scorpion
H/"%>"-'C%)(#-@+%#$"%+0.*#."@%0-%./"%.#0(D%H/"%+.$0#."@%
EB'$60'-+% #$"% +/A% B$"#.*$"+% #-@% -'.% #))$"++0>"% ?A% C*+B("+%0-%./"%+.0-)+%$")*(#."%./"%#C'*-.%'1%>"-'C%
#-@% (#$)"D% H/"+"% #$"% -'B.*$-#(% B$"#.*$"+% #-@% /*-.% 0-J"B."@D%]/"-%"-.0$"%>"-'C%0+%*+"@N%0.%.#G"+%+">"$#(%
1'$% ./"0$% 6$"A% #.% -0)/.D% EB'$60'-+% /0@"% -'$C#((A% @#A+%.'%$"6("-0+/%>"-'CD%EB'$60'-%=0./%(#$)"%>"-'C%
0-% B$">0B"+% #-@% ?*$$'=+% @*$0-)% @#A.0C"% .'% #>'0@% +#B+% +*B/% #+% 3#$#?*./*+% +6"B0"+% B#-% ">"-% +P*0$.%
(0)/.D% EB'$60'-+% #$"% 1'*-@% "(+"=/"$"% '*.+0@"% ./"% ./"0$%>"-'CD
"->0$'-C"-.#(% $#-)"D% ")N% #BB0@"-.#((A% B$#=(% 0-.'%
(*))#)"N%?'T"+N%B'-.#0-"$+N%'$%+/'"+N%60("%'1%?$0BG+N%
=''@"-% C#."$0#(+N!%$"=''@N% ".BD% H/"A% C#A% #(+'% ?"% Components of Venom and Mechanisms of action
.$#-+6'$."@% 0-% .$#>"(("$d+% (*))#)"% #-@% B#$)'DH/"$"% H/"% B'C6'-"-.+% '1% >"-'C% #$"% B#$@0'.'T0-N%
#$"% #?'*.% :g99% +B'$60'-% +6"B0"+% '1% =/0B/% g9% #$"% /"C'.'T0-N% -"6/$'.'T0-N% -"*$'.'T0-N% /A#(*$'-0@#+"+N%
6/'+6/'@0"+."$#+"+N% 6/'6/'(06#+"+N% )(AB'+#C0-')(A7
Correspondence
B#-+N% /0+.#C0-"N% +"$'.'-0-N% .$A6.'6/#-% #-@% BA.'G0-"%
!$%E*B/0.#%F/#@+"
$"("#+"$+D%5C'-)%#((N%./"%C'+.%6'."-.%0+%./"%-"*$'.'T0-D%
&'-+*(.#-.%3"@0#.$0B%,-."-+0>0+.N%&X,K!%X'+60.#(N%Y#)6*$%
H/"$"%#$"%.='%B(#++"+%'1%-"*$'.'T0-+%4('-)%B/#0-%r%+/'$.%
VC#0(a%@$+*B/0.#\)C#0(DB'CN%U'?0("a%vm:mf8h9h8m9f
Vol. 3 - No.2 April - June 2016
42
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -2
Scorpion Sting
B/#0-% 6'(A6"6.0@"<% =/0B/% #$"% /"#.% +.#?("N% /#>"% #% ('=% Table 4:%Y'-7-"*$'(')0B#(%+0)-+
C'("B*(#$% ="0)/.% #-@% #$"% $"+6'-+0?("% 1'$% B#*+0-)% B"((% w%&#$@0'>#+B*(#$%+0)-+
0C6#0$C"-.%0-%-"$>"+N%C*+B("+N%#-@%./"%/"#$.%?A%#(."$0-)% t%XA6'."-+0'+'@0*C%#-@%6'.#++0*C%B/#--"(%6"$C"#?0(0.AD%H/"%('-)% t%XA6"$."-+0'B/#0-% 6'(A6"6.0@"% -"*$'.'T0-% 0-@*B"+% B'-.0-*'*+N% t%H#B/AB#$@0#%4?$#@AB#$@0#%#.%
.0C"+<
6$'('-)"@N%$"6".0.0>"%!%$0-)%'1%+'C#.0BN%+AC6#./".0B%#-@%
t%&#$@0#B%@A+$/A./C0#
6#$#+AC6#./".0B% -"*$'-+% =/0B/% $"+*(.+% 0-% #*.'-'C0BN% t%H$#-+0"-.%#60B#(%6#-+A+.'(0B%
#-@% -"*$'C*+B*(#$% '>"$% "TB0.#.0'-% +AC6.'C+D% ,.% #(+'%
C*$C*$
6$">"-.+%-'$C#(%-"$>"%0C6*(+"%.$#-+C0++0'-+D%Q*$./"$N%0.% t%&#$@0'>#+B*(#$%B'((#6+"
$"+*(.+%0-%$"("#+"%'1%-"*$'.$#-+C0.."$+%>0ODN%"60-"6/$0-"N% t%&#$@0')"-0B%+/'BG
-'$7"60-"6/$0-"N%#B".A(B/'(0-"N%)(*.#C#."N%#-@%#+6#$.#."% t%&#$@0#B%@A+1*-B.0'"TB"++0>"(AD% H/"% +/'$.% B/#0-% 6'(A6"6.0@"% -"*$'.'T0-% w%M"+60$#.'$A%E0)-+
t%H#B/A6-'"#
?('BG+%./"%6'.#++0*C%B/#--"(+D
Clinical Course
&(0-0B#(% B'*$+"% '1% +B'$60'-% +.0-)% 0+% *+*#((A% ("++%
#(#$C0-)% ?*.% 0-% +'C"% B#+"+% 0.% C#A% 6$')$"++% .'%
C#T0C*C%+">"$0.A%0-%#?'*.%g%/'*$+%.'%:8%/'*$+%#-@%
+.#$.+% +*?+0@0-)% =0./0-% #% @#A% '$% .='D% V>"-% 01% ./"%
6#.0"-.% /#+% 1"#.*$"+% '1% #*.'-'C0B% -"$>'*+% +A+."C%
C#-01"+.#.0'-+N% 0.% C#A% +.#$.% +*?+0@0-)% ?A% :8% /'*$+%
#1."$% 0-0.0#.0-)% .$"#.C"-.D% H#B/AB#$@0#% *+*#((A%
+*?+0@"+% =0./0-% 8L% .'% Lf% /'*$+D% XA6"$."-+0'-% C#A%
(#+.%1'$%L%.'%f%/'*$+D
t%3*(C'-#$A%"@"C#
t%M"+60$#.'$A%1#0(*$"
w%b#+.$'%0-."+.0-#(%E0)-+
t%!A+6/#)0#
t%VTB"++0>"%+#(0>#.0't%Y#*+"#%#-@%>'C0.0-)
t%b#+.$0B%/A6"$@0+."-+0't%,-B$"#+"+%)#+.$0B%#B0@%'*.%6*.%
#-@%)#+.$0B%*(B"$
t%5B*."%6#-B$"#.0.0+
t%K0>"$%)(AB')"-'(A+0+
t%H'T0B%/"6#.0.0+
w%X"C#.'(')0B%E0)-+
t%3(#."(".%#))$")#.0't%!0++"C0-#."@%0-.$#%>#+B*(#$%
B'#)*(#.0'-%4!,W&<
w%U".#?'(0B%E0)-+
t%XA6"$)(AB"C0#
t%,-B$"#+"@%(#B.0B%#B0@'+0+
t%V("B.$'(A."%0C?#(#-B"
w%b"-0.'*$0-#$A%E0)-+
t%5B*."%$"-#(%1#0(*$"
t%M/#?@'CA'(A+0+
t%3$0#60+C
w%5(("$)0B%E0)-+
t%[$.0B#$0#
t%5-)0'"@"C#
t%I$'-B/'+6#+C
t%5-#6/A(#T0+
w%3$")-#-BA%E0)-+
t%H'T0-%0-@*B"@%*."$0-"%
B'-.$#B.0'-
Table 2:%,-"%*"-B0-)%1#B.'$+%1'$%+AC6.'C+%#-@%+0)-+%EB'$60'-%E.0-)%E.#.*+%'1%./"%6#.0"-.
Scorpion
E6"B0"+
t%5)"N%+0O"%#-@
t%-*.$0.0'-#(%+.#.*+
t%E.0-)0-)%#66#$#.*+
4."(+'-<
Sting
H0C"%'1%+.0-)
t%Y*C?"$%'1%+.0-)+
t%p*#-.0.A%'1%>"-'C%0-J"B."@%4('=%@'+"%q#@$"-"$)0BN%/0)/%
@'+"%q%B/'(0-"$)0B<
t%!"6./%'1%./"%+.0-)%6"-".$#.0't%E0."%'1%+.0-)%,W^E&^,U
t%&'C6'-"-.+%'1%>"-'C
Status of patient
5)"%'1%./"%6#.0"-.
t%X"#(./%+.#.*+
t%&'C'$?0@%B'[email protected]'-+
t%]"0)/.%'1%./"%>0B.0C
t%3/A+0'(')0B#(%$"+6'-+"%'1%./"%0-@0>0@*#(
t%E"-+0.0>0.A%'1%./"%+A+.}C%.'%./"%
-"*$'.$#-+C0.."$+%#-@%H'T0-+
Table 3:%K'B#(%"11"B.+%#.%./"%+0."%'1%+.0-)
Non lethal local signs
3#0t%V$A./"C#
t%,-@*$#.0't%]/"#(%4@*"%.'%
#B.0>#.0'-%'1%G0-0-+%
#-@%+('=%$"("#+0-)%
+*?+.#-B"+%'1%>"-'C<
Non lethal local signs
Neurotoxic local signs at the site of the sting
t%K'B#(%"11"B.%'1%+.0-)
t%C0-0C#(%'$%#?+"-.
t%H0++*"%-"B$'+0+%4$#$"<
t%E/#$6%?*$-0-)%6#0t%V$A./"C#
t%K'B#(%.0++*"%+="((0-)
t%5+B"-@0-)%/A6"$#+./"+0#%46#$"+./"+0#%6"$+0+.+%1'$%
+">"$#(%=""G+%#-@%./"%(#+.%+AC6.'C%.'%$"+'(>"<
Neurotoxic local signs at the site of the sting
3'+0.0>"%jH#6%."+.k7%43#$"+./"+0#%='$+"-+%=0./%
)"-.("%.#660-)%#.%./"%+0."%'1%+.0-)<
t%XA6"$+"-+0.0>"%.'%.'*B/%#-@%."C6"$#.*$"
Cytotoxic local signs at the site of the sting
566"#$#-B"%'1%#%C#B*("%'$%6#6*("%=0./0-%!%$+.%/'*$
t%!0#C"."$%'1%./"%("+0'-%>#$A%=0./%P*#-.0.A%'1%
>"-'C%0-J"B."@
t%3$')$"++%'1%./"%("+0'-%.'%#%6*$6*$0B%6(#P*"%=/0B/%
=0((%-"B$'+"%#-@%*(B"$#."
Cytotoxic local signs at the site of the sting
KAC6/#-)0.0+%401%./"%>"-'C%0+%.$#-+1"$$"@%./$'*)/%
(AC6/#.0B+<
EA+."C0B%+0)-+%#$"%)$'*6"@%0-.'%-"*$'(')0B%+0)-+%#-@%-'-7-"*$'(')0B%+0)-+D
Vol. 3 - No.2 April - June 2016
43
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -2
Scorpion Sting
Table 5: Y"*$'(')0B#(%+0)-+
Nervous system
Central Nervous
system signs
7H/#(#C*+%0-@*B"@%+A+."C0B%
6#$"+./"+0#
7&"$"?$#(%./$'C?'+0+
75(."$"@%B'-+B0'*+-"++
7M"+.("++-"++
7&'-1*+0'7!"(0$0*C
75?-'$C#(%?"/#>0'*$
75.#T0#
7&'->*(+0'-+
Cranial Nerve signs
7M'.#.'$A%"A"%C'>"C"-.+%
46.'+0+N%-A+.#)C*+N%
r%?(*$$"@%>0+0'-<
7UA@$0#+0+
7H'-)*"%1#+B0B*(#.0'-+
7!A+6/#)0#N%@A+#$./$0#N%
r%+.$0@'$
7VTB"++0>"%+#(0>#.0'-%
r%@$''(0-)
Sympathetic signs
7XA6"$./"$C0#
7H#B/A6-'"#
7H#B/AB#$@0#
7XA6"$."-+0'75$$/A./C0#+
7XA6"$G0-".0B%
6*(C'-#$A%"@"C#
7XA6"$)(AB"C0#
7!0#6/'$"+0+
730('"$"B.0'7M"+.("++-"++
7566$"/"-+0'7XA6"$"TB0.#?0(0.A
7&'->*(+0'-+
Parasympathetic
signs
7I$'-B/'%
B'-+.$0B.0'7I$#@AB#$@0#
7XA6'."-+0'7E#(0>#.0'7K#B$0C#.0'7[$0-#.0'7!0#$$/'"#
7b#+.$0B%"C"+0+
7M/0-'$$/'"#
7b''+"%60C6("%+G07K'++%'1%?'="(%r%
?(#@@"$%B'-.$'(
73$0#60+C
7!A+6/#)0#
7U0'+0+
7b"-"$#(0+"@%
="#G-"++
XA6'."-+0'-% #-@% ?$#@AB#$@0#% #$"% "-B'*-."$"@%
*+*#((A%=0./0-%8%/'*$+D%S-B"%.$"#.C"-.%0+%+.#$."@N%./"%
+0)-+% '1% $"B'>"$A% ?")0-+% =0./0-% Lf% '$% l8% /'*$+D% ,-%
+'C"%B#+"+%6*(C'-#$A%"@"C#%C#A%@">"('6%=0./0-%h9%
C0-*."+%.'%h%/'*$+N%*+*#((A%+"B'-@#$A%.'%CA'B#$@0#(%
@A+1*-B.0'-D% [-1'$.*-#."(A% +'C"% B#+"+% '1% +B'$60'-%
+.0-)% C#A% @0"% =0./0-% h9% C0-*."+% #-@% ./0+% C#A% ?"%
$"(#."@% .'% >"-.$0B*(#$% #$$/A./C0#+% '$% -'-% B#$@0#B%
6*(C'-#$A%"@"C#%@*"%.'%5M!E%n'1."-%$"6'$."@%1$'C%
I$#O0(oD%&"-.$#(%-"$>'*+%+A+."C%C#-01"+.#.0'-+%=0./
Vol. 3 - No.2 April - June 2016
44
Autonomic
Nervous
system
signs
Peripheral Nervous
system sign
7I*$-0-)%6#0-%('B#(
7E="((0-)%#.%+0."
75+B"-@0-)%-*C?-"++%r%
.0-)(0-)
73#$#(A+0+
Somatic signs
7M0)0@%+6#+.0B%
C*+B("+%'1%./"%
(0C?+%r%.'$+'
7,->'(*-.#$A%C*+B("%
+6#+C^%.=0.B/0-)^%
B('-*+^%B'-.$#.*$"
7,-B$"#+"@%."-@'-%
$""%"T"+
73$'('-)#.0'-%'1%
$"(#T#.0'-%6/#+"
730('%"$"B.0'-%=0./%
)''+"%60C6("+
'$%=0./'*.%B'->*(+0'-+%C#A%'BB*$%=0./0-%'-"%.'%.='%
/'*$+%0-%1#.#(%B#+"+D
Treatment
&*$$"-.(A%$"B'CC"-@"@%Q0$+.%#0@
M%y%M"#++*$"%./"%6#.0"-.D
,%y%,CC'?0(0O#.0'-%'1%./"%(0C?%0-%./"%+#C"%=#A%#+%#%
1$#B.*$#(%(0C?D
bD%XD%y%b".%.'%X'+60.#(%,CC"@0#."(AD
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -2
Scorpion Sting
@o 5+G% 1'$% B(0-0B#(% +AC6.'C+% #-@% B'$$"(#."% =0./
./"% 6$')$"++0'-% '1% +AC6.'C+% #-@% +0)-+% @*"% .'%
+B'$60'-%+.0-)%
Table 6:%,->"+.0)#.0'-+
Haematology
7%&'C6("."%I(''@%&'*-.%4&I&<
7%K"*G'BA.'+0+
7%X"C'(A+0+%4>#$0#?("<
7%&'#)*(#.0'-%6$'!%("
7%!"!%?$0-#.0'-%n01%$"P*0$"@o
Imaging studies
t%&/"+.%T%q%$#A
Other investigations
t%V("B.$'%B#$@0')$#C%
45$$'=/"#@%."-."@%H%=#>"%
0-@0B#."+%#B*."%0-J*$AD%H"-.%
+/#6"@%0-@0B#."+%$"B'>"$AD%
UA'B#$@0#(%0-1#$B.0'-%(0G"%
6#.."$-N%#.$0#(%#$$/A./C0#+N%
-'-7+*+.#0-"@%>"-.$0B*(#$%
#$$/A./C0#+%rB'-@*B.0'-%
@"1"B.%7%0-J*$A%.'%B'-@*B.0-)%
+A+."CD%3pME%'$%H%
=#>"%#(."$#.0'-+7%+"$0'*+%
CA'B#$@0#(%0-J*$AD%K'=%
>'(.#)"N%=0@"%pME%B'C6("TN%
.#B/AB#$@0#N%/"C0?('BGN%
C#$G$@%EH%+")C"-.%
@"6$"++0'-%7%?#@%6$')-'+0+D%
Blood Chemistry
7%I(''@%+*)#$
7%E"$*C%B$"#.0-0-"
7%E"$*C%B$"#.0-"%G0-#+"
7%E"$*C%#CA(#+"%^%(06#+"
7%E"$*C%#+6#$.#."%^%#(#-0-"%
#C0-'%.$#-+1"$#+"
7%5$."$0#(%?(''@%)#+%45Ib<%
#-#(A+0+%n01%$"P*0$"@o
Special investigations n01%
$"P*0$"@o
t%VB/'B#$@0')$#C%^%#-@%
$"6"#.%1'$%1'(('=%*6%
+.*@0"+
t%&'('$7!'66("$
t%3*(C'-#$A%#$."$A%
B#./"."$0+#.0'-%+.*@0"+
t%E"$0#(%+60$'C".$A%.'%
C"#+*$"%6*(C'-#$A%
1*-B.0'-+
t%X'$C'-"%+.*@0"+
t%V+.0C#.0'-%'1%@011"$"-.%
BA.'G0-"+
t%E"$*C%>"-'C%(">"(
3) Assess the following quickly.
#o 50$=#AN%I$"#./0-)%#-@%&0$B*(#.0'?o W0.#(+%XMN%MMN%I3%#-@%3*(+"%'T0C".$A
Bo E0."% '1% +.0-)% #-@% ./"% 6$'?#?("% $'*."% '1
"->"-'C#.0'-% 7% 4,-.$#>"-'*+% /#>"% 0CC"@0#."%
"11"B.+N% =/0("% +*?B*.#-"'*+% #-@% 0-.$#C*+B*(#$%
$'*."+%.#G"%+">"$#(%C0-*."+%.'%/'*$+%.'%B#*+"%"11"B.<
@o &/"+.%"T6#-+0'"o &(0-0B#((A%1$'C%/"#@%.'%1''.%#+%="((%#+%?#BG
1o Q'$%#++'B0#."@%B'7C'$?0@%0((-"++n"+o
)o Q'$%B'-+*C0-)%#-A%C"@0B#.0'-n+o
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Vol. 3 - No.2 April - June 2016
45
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -2
Scorpion Sting
Measures to be adopted while using Prazosin
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Vol. 3 - No.2 April - June 2016
46
JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -2
Scorpion Sting
SCORPION STING
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Vol. 3 - No.2 April - June 2016
47
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JOURNAL OF PEDIATRIC CRITICAL CARE
ENVENOMATION -2
Scorpion Sting
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References
:D I#=#+G#$% XEN% I#=#+G#$% 3XDEB'$60'-% +.0-)a% *6@#."% 253,D
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8D I#=#+G#$% XEN% I#=#+G#$% 3XD% U#-#)"C"-.% '1% +-#G"% ?0."% #-@
+B'$60'-%+.0-)D%p*#$."$(A%C"@0B#(%$">0"=%899m%'B.7%@"BZ%;9N%-'D%L%
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+B'$60'-%+.0-)%H#C0(%Y#@*%/"#(./%+A+."C+%6$'J"B.%/"#(./%#-@%
1#C0(A%="(1#$"%!"6#$.C"-.N%&/"--#0D%899fZ%Lg7;L
LD I#=#+G#$%XEN%EB'$60'-%+.0-)D%HMEHUX%lfaL:L7L:gD
gD I#=#+G#$% XEN% I#=#+G#$% 3XDV1!%B#BA% #-@% +#1".A% '1% +B'$60'#-.0>"-'C% 6(*+% 6$#O'+0-% B'C6#$"@% =0./% 6$#O'+0-% #('-"% 1'$
>"-'C'*+% +B'$60'-% 4C"+'?*./*+% .#C*(*+<% +.0-)a% $#-@'C0+"@
'6"-%(#?"(%B(0-0B#(%.$0#(D%IU2%89::Z%hL8aBl:h;D
X'=%.'%B0."%./0+%#$.0B("a%F/#@+"%EDEB'$60'-%+.0-)D%2%3"@0#.$%&$0.%&#$"%89:;Z8aL87LfD
X'=%.'%B0."%./0+%[MKa%F/#@+"%ED%EB'$60'-%+.0-)D%2%3"@0#.$%&$0.%&#$"%89:;Z8aL87LfD
5>#0(#?("%1$'Ca%a%/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h989:9D/.C(
Vol. 3 - No.2 April - June 2016
48
JOURNAL OF PEDIATRIC CRITICAL CARE
Clinical Pearls
Guidelines on Bronchiolitis
Clinical AAP Guidelines summary: Bronchiolitis
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Vol. 3 - No.2 April - June 2016
49
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::L
Case Report
Migratory Foreign Body in the Airway Manifesting as Recurrent
Cardio-respiratory Arrest: A rare case report
Goyal VK*, Singh A**, Nagar R***, Singh S***
*Assistant Professor **Professor ***PG Resident, Department of Pediatrics, Dr S N Medical College, Jodhpur
Received:3-Apr-2016/accepted:16-May-2016/Published online:18-May-2016
Abstract
Q'$"0)-%?'@A%#+60$#.0'-%0-%B/0(@$"-%B'CC'-(A%6$"+"-.+%=0./%B'*)/0-)N%@A+6-"#N%=/""O0-)N%BA#-'+0+%#-@%
+.$0@'$D%S*$%B#+"%6$"+"-."@%=0./%B#$@0'7$"+60$#.'$A%#$$"+.%4&M5<N%#-@%=#+%+*BB"++1*((A%$">0>"@N%?*.%+*11"$"@%
$"B*$$"-.%&M5N%#-@%!%-#((A%?"."(%-*.%=#+%$".$0">"@%1$'C%./"%#0$=#AD%%X"$"%B(0-0B#(%B'*$+"%'1%./"%6#.0"-.%
1#>'*$+%C0)$#.0'-%'1%1'$"0)-%?'@A%("#@0-)%.'%$"B*$$"-.%B#$@0'7$"+60$#.'$A%#$$"+.D%Q'$"0)-%?'@A%C0)$#.0'-%0-%
#0$=#A%0+%#-%*-*+*#(%6/"-'C"-'-N%#-@%0.+%6$"+"-.#.0'-%#+%$"B*$$"-.%B#$@0'7$"+60$#.'$A%#$$"+.%0+%>"$A%$#$"D
Keywords:%U0)$#.'$A%1'$"0)-%?'@AN%$"B*$$"-.%B#$@0'7$"+60$#.'$A%#$$"+.
Introduction
Q'$"0)-%?'@A%0-%./"%#0$=#A%0+%#-%0C6'$.#-.%B#*+"%'1%
C'[email protected]% #-@% C'$.#(0.A% 0-% 6"@0#.$0B% #)"% )$'*6% #-@%
6'+"+% @0#)-'+.0B% #+% ="((% #+% ./"$#6"*.0B% B/#(("-)"+:D%
&'*)/0-)N% @A+6-"#N% =/""O0-)N% BA#-'+0+% #-@%
+.$0@'$% #$"% ./"% B(#++0B#(% C#-01"+.#.0'-+% '1% 1'$"0)-%
?'@A% #+60$#.0'-D% ,-% #.A60B#(% B#+"+N% 0.% C#A% 6$"+"-.%
=0./% #6/'-0#N% C#++0>"% +*?B*.#-"'*+% "C6/A+"C#N%
?$'-B/0#(% #+./C#N% /"C'6.A+0+% #-@% ?$'-B/0"B.#+0+N%
?*.%%6$"+"-.#.0'-%0-%B#$@0#B%#$$"+.%0+%$#$"8NhNLD%
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6$"+"-."@% .'% *+% 0-% B#$@0'7$"+60$#.'$A% #$$"+.% #-@% =#+%
+*BB"++1*((A%$">0>"@D%!*$0-)%6'+.7$"+*+B0.#.0'-%6"$0'@N%
+/"% #)#0-% @">"('6"@% B#$@0'7$"+60$#.'$A% #$$"+.+% .=0B"%
'-%>"-.0(#.'$%+*66'$.N%#-@%">"$A%.0C"%=#+%$">0>"@%=0./%
B#$@0'76*(C'-#$A%$"+*+B0.#.0'-%4&3M<D%E/"%/#@%-'-"%
'1% ./"% .A60B#(% 1"#.*$"+% '1% 1'$"0)-% ?'@A% #+60$#.0'-% #.%
#@C0++0'-% ?*.% $"B*$$"-.% "60+'@"+% '1% +*@@"-% B#$@0#B%
#$$"+.+%'-%>"-.0(#.'$%+*66'$.%6$'C6."@%*+%.'%B'-@*B.%
#%?$'-B/'+B'6AN%=/0B/%$">"#("@%?"."(%-*.%0-%./"%$0)/.%
C#0-%?$'-B/*+D%M"B*$$"-.%B#$@0#B%#$$"+.+%6"$%+"%0+%$#$"%
0-%B/0(@$"-N%#-@%C#0-(A%$"+*(.+%1$'C%#$$/A./C0#+%"0./"$%
6$0C#$A% 4C'+.(A% B/#--"('6#./0"+<% '$% +"B'-@#$A% .'%
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Correspondence
!$%M#G"+/%Y#)#$N%M''C%Y'D%8:L%3b%!'B.'$+%X'+."(N%[C#0@%
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VC#0(a%$G-D+C+\)C#0(DB'C
Vol. 3 - No.2 April - June 2016
50
Case
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JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Migratory Foreign Body in the Airway Manifesting as Recurrent Cardio-respiratory Arrest: A rare case report
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Vol. 3 - No.2 April - June 2016
51
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::g
Case Report
Waterhouse Friderichsen Syndrome in a Case of Staphylococcal Toxic
Shock Syndrome
Devdeep Mukherjee*, Prabhas Prasun Giri**, Suman Poddar***
*Senior resident, **Assistant Professor, Department of Pediatrics, ***Assistant Professor, Department of Microbiology,
Institute of Child Health, Kolkata
Received:2-Apr-2016/accepted:16-May-2016/Published online:18-May-2016
ABSTRACT
E.#6/A('B'BB#(%.'T0B%+/'BG%+A-@$'C"%4HEE<%0+%#%$#$"%#-@%6'."-.0#((A%1#.#(%C*(.0%+A+."C%@A+1*-B.0'-D%H/"%
+A-@$'C"%'BB*$+%6$0C#$0(A%@*"%.'%HEE%H'T0-7:%4HEE7:<%(0?"$#."@%?A%E.#6/A('B'BB*+%#*$"*+%4E5<D%Q">"$%
=0./%$#+/%1'(('="@%?A%C*(.0%'$)#-%@A+1*-B.0'-%0-%./"%1'$C%'1%#B*."%G0@-"A%0-J*$AN%$#0+"@%(0>"$%.$#-+#C0-#+"+%
#-@%$"1$#B.'$A%/A6'."-+0'-%0-@0B#."+%./"%6'++0?("%@0#)-'+0+%'1%#%HEEN%C'$"%B'CC'-(A%?A%E.#6/A('B'BB*+D%
X"$"N%#%l%A"#$%'(@%?'A%6$"+"-."@%=0./%#((%./"%1"#.*$"+%'1%.'T0B%+/'BG%+A-@$'C"N%@">"('6"@%/A6'-#.$"C0#N%
/A6"$G#("C0#N%$"1$#B.'$A%/A6')(AB#"C0#%#-@%/A6'."-+0'-%#-@%+*BB*C?"@%=0./0-%:8%/'*$+%'1%#@C0++0'-%
#-@%*(.0C#."(A%=#+%@0#)-'+"@%.'%?"%#%B#+"%'1%E.#6/A('B'BB#(%.'T0B%+/'BG%+A-@$'C"%@*"%.'%UEE5%=0./%
]#."$/'*+"%Q$0@"$0B/+"-%EA-@$'C"%4]QE<D
Keywords:% U"./0B0((0-% +"-+0.0>"% E.#6/A('B'BB*+% #*$"*+% 4UEE5<N% H'T0B% E/'BG% EA-@$'C"% 4HEE<N%
]#."$/'*+"%Q$0@"$0B/+"-%EA-@$'C"%4]QE<D
Introduction
]QEN% #(+'% B#(("@% #+% /"C'$$/#)0B% #@$"-#(0.0+N% *+*#((A%
'BB*$+% 1'(('=0-)% 1*(C0-#-.% C"-0-)'B'BB#(% +"6+0+D%
X'=">"$%./"$"%#$"%$"6'$.+%'1%./0+%'BB*$$0-)%1'(('=0-)%
+">"$"% 0-1"B.0'-% =0./% /#"C'(A.0B% E.$"6.'B'BB0N%
3-"*C'B'BB0N%
UAB'?#B."$0*C%
.*?"$B*('+0+N%
V+B/"$0B/0#% B'(0:% #-@% X"C'6/0(*+% 0-"%*"-O#8D% ]QE%%
B/#$#B."$0+"@% ?A% 1">"$N% $#+/N% B'#)*('6#./AN% $#60@(A%
+6$"#@0-)% 6"."B/0#(% $#+/N% $"1$#B.'$A% /A6'."-+0'-% #-@%
#@$"-#(% /#"C'$$/#)"N% 'BB*$$0-)% 1'(('=0-)% 0-1"B.0'-%
=0./% U"./0B0((0-% +"-+0.0>"% E.#6/A('B'BB*+% #*$"*+%
4UEE5<% 0+% "T.$"C"(A% $#$"D% X"$"% ="% $"6'$.% #% l% A"#$+%
C#("%B/0(@%=0./%]QE%1'(('=0-)%0-1"B.0'-%=0./%UEE5D
Case Report
l%A"#$+%C#("%B/0(@%=#+%#@C0.."@%#.%-0)/.%4h%5DU<%=0./%
#%/0+.'$A%'1%/0)/%)$#@"%1">"$%#-@%>'C0.0-)%1'$%L%@#A+%
4C#T%:9h%Q<%=0./%#%)"-"$#(0+"@%"$A./"C#.'*+%C#B*(#$%
$#+/%1$'C%@#A%h%'1%1">"$D%X"%=#+%0-0.0#((A%.$"#."@%=0./%
6#$#B".#C'(%#-@%'$#(%#-.0?0'.0B+%6$0'$%.'%#@C0++0'-D
S-%#@C0++0'-N%/"%=#+%1"?$0("%4:9hDL%Q<%=0./%6"."B/0#"%
Correspondence
3$#?/#+%3$#+*-%b0$0N%5++0+.#-.%3$'1"++'$%S1%3"@0#.$0B+%
,-+.0.*."%S1%&/0(@%X"#(./N%F'(G#.#N%3/'-"%vm:m9g:mgfL89N%
V7C#0(a%@$D6$#?/#+\A#/''DB'D0-
Vol. 3 - No.2 April - June 2016
52
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JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Waterhouse Friderichsen Syndrome in a Case of Staphylococcal Toxic Shock Syndrome
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Vol. 3 - No.2 April - June 2016
53
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Discussion
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JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Waterhouse Friderichsen Syndrome in a Case of Staphylococcal Toxic Shock Syndrome
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Source of Fundinga%Y'-"%%%%ConIOict of InterestaY'-"
Acknowledgement:%5)-0%E"G/#$%E#/#
References
:D X*"C"$%bU:N%I'-#..0%XN%!*-+.%FUD%3*$6*$#%1*(C0-#-+%@*"
.'%VD%B'(0%+"6.0B"C0#D%]0"-%F(0-%]'B/"-+B/$D%899L%Q"?%:;Z
::;4h<af8D
8D 2#B'?+%MQN%X+0%EN%]0(+'-%&IN%I"-J#C0-%!N%EC0./%5KN%U'$$'=
MD%566#$"-.% C"-0-)'B'BB"C0#a% B(0-0B#(% 1"#.*$"+% '1% @0+"#+"
@*"% .'% X#"C'6/0(*+% 0-"%*"-O#"% #-@% Y"0++"$0#% C"-0-)0.0@0+D
3"@0#.$0B+D%:mfh%SB.Zl84L<aL;m7l8
hD Q$0@"$0B/+"-% &D% ]#."$/'*+"qQ$0@"$0B/+"-% +A-@$'C"% 4]DqQD
ED<D%5B.#%V-@'B$0-'(%:mggZ:faLf8qm8D
LD 3#.$0B0#%WD%5@"CN%UD!DN%&/$0+.'6/"$%3D%U'-.)'C"$AN%UD!DN
5(0A#% YD% X*+#0-N% UD!DN% H$#BA% FD% F'')("$N% UD!DN% W#("$0"
5$#-)"('>0B/N%UD!DN%U0B/"(%X*C0(0"$N%UD!DN%E*+#-%I'A("7
W#>$#N% 3/D!DN% #-@% M'?"$.% ED% !#*CN% UD!D% E.#6/A('B'BB*+
#*$"*+%E"6+0+%#-@%./"%]#."$/'*+"qQ$0@"$0B/+"-%EA-@$'C"%0&/0(@$"-D%Y%V-)(%2%U"@%899gZhgha:8Lg7g:
gD &"-."$+% 1'$% !0+"#+"% &'-.$'(% #-@% 3$">"-.0'-% 4&!&<D% H'T0B
+/'BG%+A-@$'C"77[-0."@%E.#."+D%:mf9Z%UU]M%U'$?%U'$.#(
]G(A%M"6D%:mml%2*-%;ZL;488<aLm87hZ%@0+B*++0'-%LmL7g
;D Q% U0("+N% K% W'++N% V% E")"@0-N% I% 2% 5-@"$+'-D% M">0"=% '1
E.#6/A('B'BB*+% #*$"*+% 0-1"B.0'-+% $"P*0$0-)% #@C0++0'-% .'% #
6#"@0#.$0B%0-."-+0>"%B#$"%*-0.D%5$B/%!0+%&/0(@%899gZm9a:8lLq
:8lfD%@'0a%:9D::h;^#@BD899gD9lL88m
lD b#$A% MD% F$#>0.ON% !#>0@% 2D% !$0"+N% U#$-0"% KD% 3"."$+'-N
#-@% 3#.$0BG% UD% EB/(0">"$.D% 3*$6*$#% Q*(C0-#-+% !*"% .'
E.#6/A('B'BB*+% #*$"*+D% &(0-0B#(% ,-1"B.0'*+% !0+"#+"+% 899gZ
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!N% V.0"--"% 2N% M0B/".% XD% &'CC*-0.A7#BP*0$"@% C"./0B0((0-7
$"+0+.#-.% E.#6/A('B'BB*+% #*$"*+% 0-1"B.0'-+% 0-% Q$#-B"a
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:9D W#$@#G#+%FÄ:N%U#../#0'*%!FN%Q#(#)#+%UVD%&'C6#$0+'-%'1
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E/'BG%EA-@$'C"D%2%3"@0#.$%&$0.%&#$"%89:;Z8ag87gLD
X'=%.'%B0."%./0+%[MKa%U*G/"$J""%!N%b0$0%33N%3'@@#$%ED%]#."$/'*+"%Q$0@"$0B/+"-%+A-@$'C"%0-%#%B#+"%'1%E.#6/A('B'BB#(%.'T0B%
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5>#0(#?("%1$'Ca%/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h9899hD/.C(
Vol. 3 - No.2 April - June 2016
54
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::;
Case Report
Bradyarrythmia in Acute Phase of Viral Hemorrhagic Fever
Maniya N*, Ohri A*,Sharma R**, Lal N**, Khilnani P***
*Fellow PICU, **Consultant PICU, ***Director PICU, BLK Superspeciality Hospital, New Delhi
Received:7-Apr-2016/accepted:17-May-2016/Published online:19-May-2016
ABSTRACT
&#$@0'>#+B*(#$%B'C6(0B#.0'-+%#$"%G-'=-%.'%'BB*$%@*$0-)%@"-)*"%1">"$%0-B(*@0-)%?'./%.#B/A#$$/A./C0#+%
#-@% ?$#@A#$$A./C0#+D% ]"% $"6'$.% #% B#+"% '1% :g% A"#$% '(@% ?'A% =0./% +">"$"% @"-)*"% 1">"$% =/'% /#@% $/A./C%
@0+.*$?#-B"%+/'=0-)%#%8a:%/"#$.%?('BG%=0./%/"C'@A-#C0B%0-+.#?0(0.A%@*$0-)%#B*."%6/#+"%'1%0((-"++D%H/"%
B/0(@%$"+6'-@"@%.'%#.$'60-"%#-@%@0@%-'.%$"P*0$"%#-A%1*$./"$%0-."$>"-.0'-%$"P*0$0-)%#%6#B"C#G"$D
Key words:%!"-)*"N%#$$/A./C0#N%>0$#(%/"C'$$/#)0B%1">"$N%3"@0#.$0B
Introduction
H#B/A#$$/A./C0#+% #$"% ./"% B'CC'-"+.% #?-'$C#(0.A%
1'*-@%0-%B#$@0#B%0->'(>"C"-.%0-%@"-)*"%1">"$%@*$0-)%
./"%#B*."%6/#+"%'1%0((-"++D%5C'-)%./'+"%#?-'$C#(0.0"+%
+0-*+%.#B/AB#$@0#%0+%6$'?#?(A%./"%C'+.%1$"P*"-.(A%+""-%
6/"-'C"-'-D% S./"$% B'CC'-(A% +""-% C#-01"+.#.0'-+%
0-B(*@"%H%=#>"%#?-'$C#(0.0"+N%EH%+")C"-.%@"6$"++0'-+%
#-@%"(">#.0'-N%+0-*+%6#*+"+N%"B.'60B%./#.%#$"%"0./"$%#.$0#(%
'$% >"-.$0B*(#$% 0-% '$0)0-N% >"-.$0B*(#$% .$0)"C0-AN% #.$0#(%
!%?$0((#.0'-D% I$#@A#$$A./C0#+% 0-B(*@0-)N% /"#$.% ?('BG+%
+*B/%#+%!%$+.7@")$""%?('BG%#-@%U'?0.O%.A6"%,%+"B'-@7
@")$""% 5W% ?('BGN% ?*-@("% ?$#-B/% ?('BG+% #-@% $#$"(A%
B'C6("."%#.$0'7>"-.$0B*(#$%@0++'B0#.0'-%B#-%#(+'%'BB*$D%
I$#@AB#$@0#%0+%C'$"%B'CC'-(A%+""-%0-%@"1"$>"+B"-B"%
#-@%B'->#("+B"-B"N%@*"%.'%6#$#+AC6#./".0B%#B.0>0.A:N8D%
H/"$"% #$"% 1"=% B#+"% $"6'$.+% '1% ?$#@A#$$A./C0#+% 0-%
./"%(0."$#.*$"%@*$0-)%./"%B'->#("+B"-B"%6/#+"D%,-%'*$%
B#+"%B/0(@%/#@%?$#@A#$$A./C0#+%@*$0-)%#B*."%6/#+"%'1%
!"-)*"%0((-"++%=/0B/N%.'%'*$%G-'=("@)"%/#+%-'.%?""-%
$"6'$."@%0-%6#+.D
Case Report
:g%A"#$+%'(@N%C#("%B/0(@%=#+%#@C0.."@%4'-%!#A%h%'1%
0((-"++<%0-%./"%=#$@%#+%#%B#+"%'1%!"-)*"%1">"$D%51."$%
;% /'*$+% '1% #@C0++0'-N% B/0(@% @">"('6"@% @01!%B*(.A% 0-%
?$"#./0-)%#-@%$"+.("++-"++D%&/0(@%=#+%.$#-+1"$$"@%.'%
3"@0#.$0B%0-."-+0>"%B#$"%*-0.%43,&[<D%S-%"T#C0-#.0'-%
B/0(@% /#@% .#B/AB#$@0#% =0./% .#B/A6-"#N% C#0-.#0-0-)%
Correspondence
!$%M#B/-#%E/#$C#N%&'-+*(.#-.%3"@0#.$0B%,-."-+0>0+.N%IKF%
E*6"$+6"B0#(0.A%X'+60.#(N%Y"=%!"(/0N%3/'-"a%vm:%mf:9;9l89fN%
V7C#0(a%$#B/-#m*+\)C#0(DB'C
Vol. 3 - No.2 April - June 2016
55
'TA)"-% +#.*$#.0'-% ffe% '-% $''C% #0$D% X0+% I(''@%
6$"++*$"%=#+%:89^lh%CCX)%=0./%=#$C%"T.$"C0.0"+D%
S-%#*+B*(.#.0'-%./"$"%=#+%#%+0)-0!%B#-.%@"B$"#+"@%#0$%
"-.$A%$0)/.%+0@"%#-@%#+B0.0+D%&/0(@%=#+%6*.%'-%I0(">"(%
6'+0.0>"% #0$=#A% 4I0353<% +*66'$.% =0./% ./"% +"..0-)+%
'1% 0-+60$#.'$A% 6"#G% #0$=#A% 6$"++*$"% 40353<% '1% :;%
BC%'1%=#."$%#-@%#-%"T60$#.'$A%6$"++*$"%4"353<%'1%f%
BC% '1% X8S% % =0./% Q0% S8% '1% 9Dg% #-@% =#+% B'-.0-*"@%
'-% C#0-."-#-B"% ,W% "%*0@+D% &/"+.% u$#A% $">"#("@%
?0(#."$#(% 6("*$#(% "11*+0'-% M0)/.{K"1.% 4Q0)D:<D% I(''@%
$"6'$.+% +/'="@% X?7:hD8)C^@"B0(0."$N% 3&W7L:DgN%
3(#."(".+7:gN999^B*% CCN% HK&7% hf99^B*% CCN% ,YM7
8D;N%%EbSH7l8;N%Eb3H7L:gD
Figure 1:%+/'=0-)%%$0)/.%6("*$#(%"11*+0'-%B/"+.%$#@0')$#6/
5.% :8% /'*$+% '1% #@C0++0'-N% B/0(@% ?"B#C"%
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5.%./#.%.0C"%="%#(+'%-'.0B"@%B/0(@%=#+%/#>0-)%C#$G"@%
"%*B.*#.0'-% 0-% /0+% +A+.'(0B% % I3% 1$'C% ;97:f9% CC/)%
#('-)% =0./% B/#-)"+% 0-% /"#$.% $#."% 4XM<% #+% XM% ='*(@%
B'C"% @'=-% ./"% % I(''@% 6$"++*$"% ='*(@% % 0-B$"#+"% *6%
.'%#+%/0)/%#+%8L9%CCX)D%3'++0?0(0.A%'1%XA6'>'("C0#%
#-@%!A+"("B.$'(A."C0#%'$%6'++0?(A%$#0+"@%0-.$#B$#-0#(%
JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Bradyarrythmia in Acute Phase of Viral Hemorrhagic Fever
."-+0'-% =#+% B'-+0@"$"@D% 5-% VB/'B#$@0')$#C%%
6"$1'$C"@% #.% ./"% ?"@+0@"% % +/'="@% -'$C#(% "J"B.0'-%
1$#B.0'-% =0./% C0-0C#(% 6"$0B#$@0#(% "11*+0'-D% V&b%
+/'="@%6$')$"++0>"(A%0-B$"#+"@%37M%0-."$>#(%=0./%8a:%
/"#$.%?('BG%4Q0)D8<D%5%B#$@0'(')A%B'-+*(.%=#+%'?.#0-"@%
#-@%*6'-%@0+B*++0'-%=0./%3"@0#.$0B%&#$@0'(')0+.%0.%=#+%%
6(#--"@%.'%)0>"%5.$'60-"%#-@%+""%./"%$"+6'-+"D
Figure 2:%V&ba%3$')$"++0>"(A%0-B$"#+"@%3M%0-."$>#(%8a:%?('BG
51."$% )0>0-)% #.$'60-"% V&b% +/'="@% $")*(#$% $/A./C%
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&/0(@%/#@%-'%1*$./"$%"60+'@"+%'1%$/A./C%@0+.*$?#-B"+%
#-@% /"% =#+% @0+B/#$)"@% '-% :9./% @#A% '1% #@C0++0'-D%
H/"% B/0(@% /#+% ?""-% 1'(('="@% *6% 1'$% 8% C'-./+% =0./%
-'% +AC6.'C+% $"(#."@% .'% 6#(60.#.0'-N% @0OO0-"++% '$%
$"+60$#.'$A%@0+.$"++%'$%#-A%'./"$%+0)-0!%B#-.%B'C6(#0-.+D
Discussion
H/"'$".0B#((A% V("B.$'(A."% 0C?#(#-B"% 4/A6'-#.$"C0#%%
#-@%/A6'G#("C0#<%#-@%CA'B#$@0#(%0-"%#CC#.0'-%%0-%
@"-)*"% B#-% B#*+"% #$$/A./C0#+D% H/"% 0-B0@"-B"% '1%
"("B.$'B#$@0')$#6/0B%%#?-'$C#(0.0"+%%0+%+'C"=/"$"%0-%
./"%$#-)"%'1%LL%7%lge%%0-%B#+"+%'1%>0$#(%/"C'$$/#)0B%
1">"$8D%E0-*+%?$#@AB#$@0#%#-@%6$'('-)#.0'-%'1%./"%3M%
Vol. 3 - No.2 April - June 2016
56
0-."$>#(% ="$"% B'CC'-(A% '?+"$>"@N% /'=">"$N% #.$0'7%
>"-.$0B*(#$% ?('BG+% ?"A'-@% !%$+.% @")$""% #$"N% #% $#$"%
B'C6(0B#.0'-% '1% @"-)*"% CA'B#[email protected]+D% ,-% '-"% $">0"=%
?A%b"'$)"%#-@%K*Ch%0-%:mml%/#+%@"+B$0?"@%>#$A0-)%
@")$""+%'1%-'@#(%?('BG%@*$0-)%B'->#("+B"-B"%6"$0'@%
0-%@"-)*"%6#.0"-.+D%,-%'*$%B#+"%./"%B/0(@%/#@%#%B#$@0#B%
$/A./C% @0+.*$?#-B"% @"C'-+.$#.0-)% 8a:% /"#$.% ?('BG%
@*$0-)% ./"% #B*."% 6/#+"% '1% 0((-"++% 4@#A% h% '1% 0((-"++<%
=0./%C#$G"@%"%*B.*#.0'-%0-%./"%?(''@%6$"++*$"%D%H/"+"%
#BB'C6#-0"@% +=0-)+% 0-% ./"% ?(''@% 6$"++*$"% B#-% ?"%
"T6(#0-"@%?A%./"%$#60@%+/01.+%0-%./"%"%*0@%=/0B/%0+%+""-%
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#*.'-'C0B%@0+.*$?#-B"+D
I$#@A#$$A./C0#+% C#A% ?"% #..$0?*."@% .'% .$#-+0"-.%
1*-B.0'-#(% 4$#./"$% ./#-% #-#.'C0B#(<% 0C6#0$C"-.%
0-% ./"% #*.'-'C0B% .'-"N% #@"-'+0-"% C".#?'(0+CN% '$%
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B"((+L7;D%Salgado et al6 0-%89:9%%1*$./"$%@"C'-+.$#."@%
./"% #?-'$C#(0.0"+% '1% B#(B0*C% #+% ="((% #+% ('B#(0O"@%
6#./'(')A% +*B/% #+% C0-*."% ?(""@0-)+% 0-% ./"% #$"#+% '1%
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6"@0#.$0B%6#.0"-.+D%
5W% ?('BG% 0-% #-% #+AC6.'C#.0B% 6#.0"-.% @*$0-)% ./"%
$"B'>"$A% 6/#+"% '1% @"-)*"% 1">"$% C#A% ?"% ?"-0)-N%
#-@% B#$"1*(% '?+"$>#.0'-% #('-"% 0-% +*B/% #% 6#.0"-.%
C#A%%+*1!%B"D Khongphatthallayothin%et al5 $"6'$."@%
.='% B#+"+% '1% U'?0.O% .A6"% :% +"B'-@% @")$""% #.$0'7
>"-.$0B*(#$%?('BG%@*$0-)%$"B'>"$A%1$'C%/#"C'$$/#)0B%
@"-)*"Z%?'./%/#@%+6'-.#-"'*+%$"+'(*.0'-D%X'=">"$N%
0-% './"$% B#+"% +"$0"+% ?A% Donegani and Briceno
et% al7 =/"$"% 1'*$% B/0(@$"-% =0./% @"-)*"% =/'% /#@%
@">"('6"@%B'C6("."%#.$0'7>"-.$0B*(#$%?('BGN%$"P*0$"@%
#% 6"$C#-"-.% 6#B"C#G"$D% ,-% '*$% B#+"N% ./"% B/0(@% /#@%
/"C'@A-#C0B%0-+.#?0(0.A%#('-)%=0./%./"%!%$+.%@")$""%
/"#$.%?('BG%?*.%/"%$"+6'-@"@%.'%'-"%@'+"%'1%#.$'60-"%
=0./%#%$"+.'$"@%/"C'@A-#C0B%+.#?0(0.A%#-@%$"B'>"$"@%
B'C6("."(A%1'(('=0-)%%-#.*$#(%B'*$+"%'1%./"%@0+"#+"D%
Conclusion
&#$@0'>#+B*(#$% +A+."C% 0->'(>"C"-.% C#A% 'BB*$%
#+% #% B'C6(0B#.0'-% @*$0-)% #-A% 6/#+"% '1% >0$#(% 0((-"++%
#-@% ("#@% .'% #-% 0-B$"#+"@% C'[email protected]% #-@% C'$.#(0.AD%
H0C"(A% 0-."$6$".#.0'-% '1% B(0-0B#(% 6#$#C"."$+% #-@%
"("B.$'B#$@0')$#6/0B% #?-'$C#(0.0"+% =0((% /"(6% 0-%
0-+.0.*.0'-% '1% ./"% #66$'6$0#."% C#-#)"C"-.% #-@% /"(6%
JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Bradyarrythmia in Acute Phase of Viral Hemorrhagic Fever
#>'0@%*--"B"++#$A%0->#+0>"%0-."$>"-.0'-D%
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References
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KN% ".% #(D% UA'B#$@0#(% @A+1*-B.0'-% 0-% B/0(@$"-% =0./% @"-)*"%
/#"C'$$/#)0B%1">"$D%Y#.(%U"@%2%,-@0#D%:mmfZ::agm7;:D
8% I''-% ]XD% &#$@0#B% 0->'(>"C"-.% 0-% /"C'$$/#)0B% 1">"$D% 2%
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h% b"'$)"%MN%K*C%K&ED%&(0-0B#(%+6"B.$*C%'1%@"-)*"%0-1"B.0'-D
,-a%b*?("$%!2N%F*-'%bN%"@+D%!"-)*"%#-@%@"-)*"%/"C'$$/#)0B%
1">"$D%&#C?$0@)"a%&5I%,-."$-#.0'-#(N%[-0>"$+0.A3$"++N%:mmla%
:9L7gD
X'=%.'%B0."%./0+%#$.0B("a%U#-0A#%YN%S/$0%5N%E/#$C#%MN%K#(%YN%F/0(-#-0%3D%I$#@A#$$A./C0#%0-%5B*."%3/#+"%'1%W0$#(%/"C'$$/#)0B%
1">"$D%2%3"@0#.$%&$0.%&#$89:;Z%8agg7glD
X'=%.'%B0."%./0+%[MKa%U#-0A#%YN%S/$0%5N%E/#$C#%MN%K#(%YN%F/0(-#-0%3D%I$#@A#$$A./C0#%0-%5B*."%3/#+"%'1%W0$#(%/"C'$$/#)0B%
1">"$D%2%3"@0#.$%&$0.%&#$%89:;Z%8a%gg7glD
5>#0(#?("%1$'Ca%/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h9899LD/.C(
Vol. 3 - No.2 April - June 2016
57
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99:89
Case Report
Acute Intermittent Porphyria in Childhood Presenting with
Hypertensive Emergency and Posterior Reversible Encephalopathy
Syndrome
Rishab Bharadwaj*, Pallavi P Dagli**, Aasheeta S Shah**
*Resident,**Associate Professor, Dept. of Paediatrics,*** Professor and Head, Dept. of Paediatrics, Smt. NHL Municipal
Medical College and V.S. General Hospital, Ellis Bridge, Ahmedabad
Received:17-Apr-2016/accepted:19-May-2016/Published online:22-May-2016
ABSTRACT
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6'$6/'?0(0-')"-% @"#C0-#+"% ./#.% B#-% #11"B.% ./"% #*.'-'C0BN% 6"$06/"$#(% #-@% B"-.$#(% -"$>'*+% +A+."CD% ]"%
$"6'$.%#-%f%A"#$%'(@%1"C#("%=/'%/#@%6$"+"-."@%=0./%/A6'-#.$"C0#N%6+AB/0#.$0B%C#-01"+.#.0'-+N%+"0O*$"+N%
/A6"$."-+0'-% #-@% 3'+."$0'$% M">"$+0?("% V-B"6/#('6#./A% EA-@$'C"% 43MVE<% =0./% #% @"(#A"@% @0#)-'+0+% '1%
5B*."%,-."$C0.."-.%3'$6/A$0#D%5+%6'$6/A$0#%0+%./'*)/.%.'%?"%>"$A%$#$"%0-%6$"76*?"$.#(%#)"N%0-%>0"=%'1%./"%
6'."-.0#((A%1#.#(%'*.B'C"%'1%#%+">"$"%#..#BGN%#%/0)/%0-@"T%'1%+*+60B0'-%0+%"++"-.0#(D
Key words:%5B*."% 0-."$C0.."-.% 6'$6/A$0#N% 3'+."$0'$% $">"$+0?("% "-B"6/#('6#./A% +A-@$'C"N% /A6"$."-+0>"%
B$0+0+D
Introduction
5B*."% 0-."$C0.."-.% 6'$6/A$0#% 45,3<% 0+% '-"% '1% ./"%
6'$6/A$0#+N% #% )$'*6% '1% @0+"#+"+% 0->'(>0-)% @"1"B.%
0-% /"C"% C".#?'(0+C% #-@% ./#.% $"+*(.+% 0-% "TB"++0>"%
+"B$".0'-% '1% 6'$6/A$0-+% #-@% 6'$6/A$0-% 6$"B*$+'$+D%
5,3% 0+% #-% #*.'+'C#(% @'C0-#-.% @0+"#+"% ./#.% $"+*(.+%
1$'C% @"1"B.+% 0-% ./"% "-OAC"% 6'$6/'?0(0-')"-7
@"#C0-#+"D% H/0+% "-OAC"% +6""@+% ./"% B'->"$+0'-% '1%
6'$6/'?0(0-')"-%.'%/A@$'TAC"./A(?0(#-"D%,-%5,3N%./"%
6'$6/A$0-% 6$"B*$+'$+N% 6'$6/'?0(0-')"-% #-@% #C0-'7
(">*(0-0B%#B0@%45K5<N%#BB*C*(#."D%H/"%6$"@'C0-#-.%
6$'?("C% #66"#$+% .'% ?"% -"*$'(')0B% @#C#)"% ./#.%
("#@+%.'%6"$06/"$#(%#-@%#*.'-'C0B%-"*$'6#./0"+%#-@%
6+AB/0#.$0B%C#-01"+.#.0'-+D%5,3%#11"B.+%='C"-%C'$"%
./#-% C"-N% =0./% #% $#.0'% '1% :Dg78a:D:% U'+.% 6#.0"-.+%
?"B'C"%+AC6.'C#.0B%?".=""-%#)"+%:f7L9%A"#$+D:%
Case Report
H/"%6#.0"-.%=#+%#-%f%A"#$%'(@%1"C#("%U*+(0C%B/0(@N%
?'$-% '1% -'-7B'-+#-)*0-'*+% C#$$0#)"N% 1$'C% ('="$%
+'B0'7"B'-'C0B%B(#++D%5.%./"%.0C"%'1%!%$+.%#@C0++0'-N%
6#.0"-.% 6$"+"-."@% =0./% B'C6(#0-.+% '1% 6"$+0+."-.%
Correspondence
M0+/#?% I/#$#@=#JN% 57hN% M#J% 56#$.C"-.+N% F'B/#$#?% M'#@N%
V((0+?$0@)"N% 5/C"@#?#@% 7% hf999;N% 3/'-"a% mlm:L988;8N%
ml:8mh:h9;D%V7C#0(a%$0+/#?::\)C#0(DB'C
Vol. 3 - No.2 April - June 2016
58
>'C0.0-)N%1'B#(%B'->*(+0'-N%>#)*"%#?@'C0-#(%6#0-%#-@%
6+AB/0#.$0B% C#-01"+.#.0'-+% (0G"% B'-1*+0'-N% #)0.#.0'-%
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4E"$*C%+'@0*C%q%:8fCVP^K<D%M"6"#."@%?(''@%6$"++*$"%
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*6.'%::;^l9%4m9./%6"$B"-.0("%1'$%#)"%q%::l^l;<D%&H%+B#-%
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JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Acute Intermittent Porphyria in Childhood Presenting with Hypertensive Emergency and
Posterior Reversible Encephalopathy Syndrome
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Vol. 3 - No.2 April - June 2016
59
C#-01"+.#.0'-+%0-%1#C0(A%C"C?"$+D%[6'-%@0#)-'+0+%'1%
5,3N%W#(6$'#."%=#+%@0+B'-.0-*"@%#-@%+/"%=#+%+.#$."@%
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Discussion
5(./'*)/% 'BB*$$"-B"% '1% /A6"$."-+0'-% @*$0-)% #B*."%
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JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
Acute Intermittent Porphyria in Childhood Presenting with Hypertensive Emergency and
Posterior Reversible Encephalopathy Syndrome
#-@% +"0O*$"+;D% &(#++0B#((AN% UM,% % $">"#(+% "@"C#.'*+%
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Conclusion
5,3%B#*+"+%(01"7./$"#."-0-)%#..#BG+%'1%-"*$'>0+B"$#(%
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References
:D F(0")C#-N% E.#-.'-N% E.D% b"C"N% EB/'$N% I"/$C#-D% Y"(+'H"T.?''G%'1%3#"@0#.$0B+%:m./%[email protected]'-D%V(+">0"$D
8D 5-@"$++'-% &N% K0./-"$% QD% XA6"$."-+0'-% #-@% $"-#(% @0+"#+"
0-% 6#.0"-.+% =0./% #B*."% 0-."$C0.."-.% 6'$6/A$0#D% 2% ,-."$-% U"@
:mmLZ%8h;a:;m7lgD
hD W%E0-)/N%F#C#(%E*@N%XE%F'/(0N%FK%b*6.#N%W%E#G/*J#D%5B*."
,-."$C0.."-.% 3'$6/A$0#% a% 5-% [-*+*#(% &#*+"% '1% U#(0)-#-.
XA6"$."-+0'-D%253,%899h%Q"?Z%W'(D%g:a%88g78;D
LD 5$'$#% E*-0.#N% 3#$C#$% E/="./#D% 3"$06/"$#(% -"*$'6#./A% =0./
+">"$"% 0-.$#B.#?("% /A6'-#.$"C0#% #+% #% 6$"+"-.#.0'-% '1%5B*."
,-."$C0.."-.% 3'$6/A$0#D% H/"% ]"+.% K'-@'-% U"@0B#(% 2'*$-#(
89::Z%W'(D%h%48<a%89%q%8LD
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#-@% =#."$% C".#?'(0+C% 0-% #B*."% 0-."$C0.."-.% 6'$6/A$0#D% H/"
.$#-+0"-.%0-#66$'6$0#."%+"B$".0'-%'1%#-.0@0*$".0B%/'$C'-"D%5C
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;D YDED%Y"G0N%H#C0(%U#-0D%3'+."$0'$%M">"$+0?("%V-B"6/#('6#./A
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X'=%.'%B0."%./0+%[MKa%I/#$#@=#J%MN%!#)(0%3N%E/#/%5D%5B*."%0-."$C0.."-.%6'$6/A$0#%0-%B/0(@/''@%6$"+"-.0-)%=0./%/A6"$."-+0>"%
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5>#0(#?("%1$'Caa%/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^*+"$!%("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h9899fD/.C(
Vol. 3 - No.2 April - June 2016
60
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99:8h
Case Report
A Case of Landau-Kleffner Syndrome
Manjunath S Pandit*, Ashok Gupta**, Priyanshu Mathur***, Manish Sharma****, Manisha Garg*****
*Resident, **Professor and Unit Head, ***Assistant Professor, ****Consultant Paediatrician and In Charge Accident
Emergency, *****Senior Resident, Department of Paediatrics, SMS Medical College, Jaipur
Received:14-Apr-2016/accepted:16-May-2016/Published online:26-May-2016
ABSTRACT
H/"%K#-@#*7F("11-"$%+A-@$'C"%'$%./"%+A-@$'C"%'1%#BP*0$"@%"60("6.0B%#6/#+0#%=#+%!%$+.%@"+B$0?"@%0-%:mglD%
H/"%@0+'$@"$%0+%B/#$#B."$0O"@%?A%)$#@*#(%'$%$#60@%('++%'1%(#-)*#)"%0-%#%6$">0'*+(A%-'$C#(%B/0(@D%5BP*0$"@%
"60("6.0B%#6/#+0#%45V5<%.A60B#((A%@">"('6+%0-%/"#(./A%B/0(@$"-%=/'%#B*."(A%'$%6$')$"++0>"(A%('+"%$"B"6.0>"%
#-@%"T6$"++0>"%(#-)*#)"%#?0(0.A%B'0-B0@"-.%=0./%./"%#66"#$#-B"%'1%6#$'TA+C#(%"("B.$'"-B"6/#(')$#6/0B%4VVb<%
B/#-)"+D%,-%C'+.%B#+"+%@"+B$0?"@%0-%@".#0(N%#%B("#$(A%-'$C#(%6"$0'@%'1%C'.'$%#-@%(#-)*#)"%@">"('6C"-.%'BB*$+%
?"1'$"% #BP*0$"@% "60("6.0B% #6/#+0#% +AC6.'C+% #66"#$D% I"B#*+"% ./0+% +A-@$'C"% #66"#$+% @*$0-)% +*B/% #% B$0.0B#(%
6"$0'@%'1%(#-)*#)"%#BP*0+0.0'-%0-%#%B/0(@d+%(01"N%+6""B/%6$'@*B.0'-%C#A%?"%#11"B."@%J*+.%#+%+">"$"(A%#+%(#-)*#)"%
B'C6$"/"-+0'-D%H/"%'-+".%'1%KFE%0+%.A60B#((A%?".=""-%:f%C'-./+%#-@%:h%A"#$+D%H/"%6$">#("-B"%'1%B(0-0B#(%
+"0O*$"+%0-%#BP*0$"@%"60("6.0B%#6/#+0#%4KFE<%0+%l97fgeD%H/"%+A-@$'C"%B#-%?"%@01!%B*(.%.'%@0#)-'+"%#-@%C#A%?"%
C0+@0#)-'+"@%#+%#*.0+CN%6"$>#+0>"%@">"('6C"-.#(%@0+'$@"$N%/"#$0-)%0C6#0$C"-.N%("#$-0-)%@0+#?0(0.AN%#*@0.'$A^
>"$?#(% 6$'B"++0-)% @0+'$@"$N% #.."-.0'-% @"!%B0.% @0+'$@"$N% 0-."(("B.*#(% @0+#?0(0.AN% B/0(@/''@% +B/0O'6/$"-0#N% '$%
"C'.0'-#(^?"/#>0'*$#(%6$'?("C+D%5-%VVb%4"("B.$'"-B"6/#(')$#C<%."+.%0+%0C6"$#.0>"%.'%#%@0#)-'+0+D
Key wordsa%56/#+0#N%V60("6+AD
Introduction
Landau–Kleffner syndrome (LKS) #(+'% B#(("@%
infantile acquired aphasiaN% acquired epileptic
aphasia1% '$% aphasia with convulsive disorder% 0+% #%
$#$"% B/0(@/''@% -"*$'(')0B#(% +A-@$'C"D% ,.% 0+% -#C"@%
#1."$% ]0((0#C% K#-@#*% #-@% Q$#-G% F("11-"$N% =/'%
B/#$#B."$0O"@%0.%0-%:mglD
5BP*0$"@%"60("6.0B%#6/#+0#%45V5<%.A60B#((A%@">"('6+%
0-% /"#(./A% B/0(@$"-% =/'% #B*."(A% '$% 6$')$"++0>"(A%
('+"% $"B"6.0>"% #-@% "T6$"++0>"% (#-)*#)"% #?0(0.A%
B'0-B0@"-.% =0./% ./"% #66"#$#-B"% '1% 6#$'TA+C#(%
"("B.$'"-B"6/#(')$#6/0B% 4VVb<% B/#-)"+8D% ,-% C'+.%
B#+"+% @"+B$0?"@% 0-% @".#0(N% #% B("#$(A% -'$C#(% 6"$0'@%
'1% C'.'$% #-@% (#-)*#)"% @">"('6C"-.% 'BB*$+% ?"1'$"%
#BP*0$"@% "60("6.0B% #6/#+0#% +AC6.'C+% #66"#$8D% H/"%
(#-)*#)"% @"!%B0.% B#-% "-B'C6#++% ?'./% $"B"6.0>"% #-@%
"T6$"++0>"% +G0((+% .'% >#$A0-)% @")$""+D% M"B"6.0>"%
(#-)*#)"% +G0((+% /#>"% $#-)"@% 1$'C% #-% #?0(0.A% .'%
Correspondence
!$%U#-J*-#./%E%3#[email protected]%M"+0@"-.
!"6#$.C"-.%'1%3#"@0#.$0B+N%EUE%C"@0B#(%B'((")"N%2#06*$N
V7C#0(a%C#-J*Å+6:f\A#/''DB'C
Vol. 3 - No.2 April - June 2016
61
1'(('=% +0C6("% >"$?#(% B'CC#-@+% .'% #% .'.#(% 0-#?0(0.A%
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+"-."-B"% B'C6("T0.AD% E6""B/% /#+% ?""-% -'."@% .'%
@"B$"#+"%.'%./"%*+"%'1%'-(A%+0-)("%='$@+N%J#$)'-N%'$%
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6$"B"@"@% ?A% #% @"B$"#+"% 0-% #*@0.'$A% B'C6$"/"-+0'-N%
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+60G"7=#>"%B'C6("T"+lD%,.%+/'*(@%?"%-'."@N%/'=">"$N%
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#(./'*)/% f9% 6"$B"-.% *(.0C#."(A% @'N% *+*#((A% ?A% 87h%
JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
A Case of Landau-Kleffner Syndrome
A"#$+% #1."$% '-+".% '1% (#-)*#)"% ('++D% Q'$.A% 6"$B"-.% '1%
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Case Report
5%:9%A"#$%'(@%?'A%=#+%?'*)/.%0-%VC"$)"-BA%M''C%0-%
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Discussion
H/"% 6#./'6/A+0'(')A% '1% KFE% $"C#0-+% *-G-'=-N%
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Vol. 3 - No.2 April - June 2016
62
JOURNAL OF PEDIATRIC CRITICAL CARE
CASE REPORT
A Case of Landau-Kleffner Syndrome
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#11"B."@% B/0(@$"-% C#A% /#>"% #% 6"$C#-"-.% +">"$"%
(#-)*#)"% @0+'$@"$N% =/0("% './"$+% C#A% $")#0-% C*B/% '1%
./"0$%(#-)*#)"%#?0(0.0"+%4#(./'*)/%0.%C#A%.#G"%C'-./+%
'$% A"#$+<D% ,-% +'C"% B#+"+N% $"C0++0'-% #-@% $"(#6+"% C#A%
'BB*$D% H/"% 6$')-'+0+% 0+% ?".."$% =/"-% ./"% '-+".% '1% ./"%
@0+'$@"$% 0+% #1."$% ./"% #)"% '1% ;% A"#$+% #-@% =/"-% +6""B/%
./"$#6A%0+%+.#$."@%"#$(AD%E"0O*$"+%)"-"$#((A%@0+#66"#$%?A%
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Conclusion
,-% B'-B(*+0'-% 5BP*0$"@% "60("6.0B% #6/#+0#% 0+% #% $#$"%
"-.0.A%#-@%"#+0(A%C0+@0#)-'+"@%#+%#*.0+CN%6"$>#+0>"%
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?"/#>0'*$#(% 6$'?("C+D% V#$(A% $"B')-0.0'-% #-@% "#$(A%
0-0.0#.0'-% '1% +6""B/% ./"$#6AN% #-.07B'->*(+#-.+% #-@%
+."$'0@+%C#A%?"-"!%.D
$POGMJDUPG*OUFSFTU/POF4PVSDFPG'VOEJOH/POF
References
:D jK#-@#*7F("11-"$%+A-@$'C"k%#.%Dorland’s Medical Dictionary
8D 3#.$A% bN% KA#)'*?0% EN% H#++0-#$0% &5D% E*?B(0-0B#(% j"("B.$0B#(
+.#.*+% "60("6.0B*+k% 0-@*B"@% ?A% +(""6% 0-% B/0(@$"-D%5% B(0-0B#(
#-@% "("B.$'"-B"6/#(')$#6/0B% +.*@A% '1% +0T% B#+"+D% Arch
NeurolD%:ml:%U#$D%8L4h<a%8L87g8D
hD ]'$+."$7!$'*)/.% &D% :ml:D% 5-% *-*+*#(% 1'$C% '1% #BP*0$"@
#6/#+0#%0-%B/0(@$"-D%!">%U"@%&/0(@%Y"*$'(%:ha%g;h7gl:D
LD E/'*C#G"$% M!N% I"--"..% !MN% I$#A% 3MN% &*$("++% MbD% :mlLD
&(0-0B#(% #-@% VVb% C#-01"+.#.0'-+% '1% #-% *-*+*#(% #6/#+0B
+A-@$'C"%0-%B/0(@$"-%D%Y"*$'(')A%:9a:97:;D
gD W#-% X#$+G#C6% QN% >#-% !'-)"-% XMN% K''-"-% U&ID% 4:mlf<D
5BP*0$"@% #6/#+0#% =0./% B'->*(+0>"% @0+'$@"$+% 0-% B/0(@$"-D% 5%
B#+"%+.*@A%=0./%#%+">"-7A"#$%1'(('=7*6D%I$#0-%K#-)%;a%:L:7
:LfD
;D U#-.'>#-0% 2QN% K#-@#*% ]UD% :mf9D% 5BP*0$"@% #6/#+0#% =0./
B'->*(+0>"% @0+'$@"$a% B'*$+"% #-@% 6$')-'+0+D% Y"*$'(')A% h9a%
g8L7g8mD%
lD !"'--#% HN% I"#*C#-'0$% 5N% b#0((#$@% QN% 5++#(% bD% 4:mll<D
5BP*0$"@% #6/#+0#% 0-% B/0(@/''@% =0./% +"0O*$"% @0+'$@"$a% #%
/"."$')"-"'*+%+A-@$'C"D%Y"*$0#.$0"%fa8;h78lhD
fD U0(("$%2QN%&#C6?"((%HQN%&/#6C#-%MEN%]"0+C"$%EVD%4:mfL<D
K#-)*#)"% ?"/#>0'$% 0-% #BP*0$"@% B/0(@/''@% #6/#+0#D% ,-a%
X'((#-@% 5N% "@D% K#-)*#)"% !0+'$@"$+% 0-% &/0(@/''@% M"B"-.%
5@>#-B"+D%E#-%!0")'N%&5a%&'((")"7X0((%3$"++N%gl7mmD
X'=%.'%B0."%./0+%#$.0B("a%3#-@0.%UEN%b*6.#%5N%U#./*$%3N%E/#$C#%UN%b#$)%UD%5%&#+"%'1%K#-@#*7F("11-"$%EA-@$'C"D%2%3"@0#.$%
&$0.%&#$"%89:;Z8a;:7;hD
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5>#0(#?("%1$'Ca%/..6a^^===DJ'*$-#('16"@0#.$0BB$0.0B#(B#$"DB'C^[+"$Q0("+^89:;^9h987J6BB7#6$7J*-789:;^23&&9h989::DKWPO
Vol. 3 - No.2 April - June 2016
63
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::h
Best Evidence
Journal Scan
Sharma R*, Lal N*, Maniya N**, Vasudevan V**, Ohri A**, Khilnani P***
*Consultant PICU ** Fellow PICU *** Director PICU, Pediatric Intensive Care Unit (PICU)
BLK Superspeciality Hospital, New Delhi
Received:24-Apr-2016/accepted:15-May-2016/Published online:18-May-2016
Articles Reviewed
1. Early administration of azithromycin and
prevention of severe lower respiratory tract
illnesses in preschool children with a history of
such illnesses---A randomized clinical trial
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Study Design
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Measurements and results
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#B.0'-%6(#-+N%'>"$%#%:87%./$'*)/%:f7C'-./%6"$0'@D
Vol. 3 - No.2 April - June 2016
64
JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
H/"% 6$"+"-.% +.*@A% =#+% @'-"% .'% ">#(*#."% 01% "#$(A%
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Vol. 3 - No.2 April - June 2016
65
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JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
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Objectives
=0./%#%3#&S8%{%Lg%CCX)N%./"$"%="$"%-'%+0)-0!%B#-.%
H/"% #0C% '1% ./0+% +.*@A% =#+% .'% ">#(*#."% ./"% B(0-0B#(% @011"$"-B"+%0-%./"%#?'>"%'*.B'C"%>#$0#?("+%?".=""-%
'*.B'C"+% '1% /0)/% "%'=% -#+#(% B#-*(#% 4XQY&<% 0-% ./"%.='%)$'*6+D
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Study design
'TA)"-% ./"$#6A% 0+% #++'B0#."@% =0./% +/'$."$% ,&[% +.#A%%
M".$'+6"B.0>"% +.*@A% =#+% 6"$1'$C"@% 0-% 8f7?"@"@% #-@%?".."$%.'("$#."@%0-%6#.0"-.+%=0./%3VMQD%,-%+*?J"B.+%
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6#.0"-.+%=/'%$"B"0>"@%.$"#.C"-.%1$'C%56$0(%899l%.'%
U#$B/%899mN%=/0("%./"%+"B'-@%)$'*6%4XQY&%)$'*6<% Reviewer’s comments
0-B(*@"@% 6#.0"-.+% =/'% *-@"$="-.% .$"#.C"-.% 1$'C% H/0+%%+.*@A%+/'="@%./#.%XXQY&%"T/0?0."@%#%+0C0(#$%
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"1!%B#BA%.'%Y,W%0-%."$C+%'1%#>'0@#-B"%'1%$"70-.*?#.0'-%
0-%6#.0"-.+%=0./%3VMQD%,-%#@@0.0'-N%XQY&%=#+%?".."$%
Measurements and results
.'("$#."@N%#-@%#++'B0#."@%=0./%#%+/'$."$%,&[%+.#A%#+%
U"@0B#(% 6#.0"-.+% •% :f% A"#$+% '(@% =/'% @">"('6"@% ="((%#+%('="$%,&[%#-@%0-7/'+60.#(%C'$.#(0.A%$#."+%./#-%
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B'-.$#B.0'-%'1%./"%#BB"++'$A%$"+60$#.'$A%C*+B("+<%./#.% H/"%"#$(A%*+"%'1%XQY&%0+%"11"B.0>"%#-@%+#1"%+.$#.")A%
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#-%#$."$0#(%6X%s%lDhg%=0./%#%3&S8%{%Lg%CCX)<Z48<% /0)/% "%'=% '1% 'TA)"-N% ./"% 6/#$A-)"#(% @"#@% +6#B"% 0+%
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Vol. 3 - No.2 April - June 2016
66
JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
"-$'(("@%6#.0"-.+N%./"%6'++0?0(0.A%'1%+"("B.0'-%?0#+%B#-%
-'.%?"%"TB(*@"@D%E"B'-@N%#+%#%+0-)("7B"-."$%B'/'$.%=#+%
#-#(AO"@N%./"%$"+*(.+%B#--'.%?"%)"-"$#(0O"@D%H/0$@N%./"%
)$'*6%'1%6#.0"-.+%=0./%/A6"$B#6-0B%3VMQ%=#+%+C#((N%
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+*B/%B#+"+%+/'*(@%?"%>"$0!%"@D
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6'6*(#.0'-% -'.% '-(A% 1'$% @"(0>"$0-)% 'TA)"-% ./"$#6A%
?*.%#(+'%#+%#%+*?+.0.*."%1'$%-#+#(%&353D%,-%3"@0#.$0B+%
#.% /0)/% "%'=% '1% 8(0.^G)^C0-N% *+0-)% #66$'6$0#."% -#+#(%
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3D Ef cacy and toxicity of aerosolised colistin
in
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pneumonia:
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prospective, randomised trial
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?"-"!%B0#(%#-@%+#1"%0-%./"$#6A%'1%)$#C7-")#.0>"%W53%
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Study design
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.$0#(% B'-@*B."@% 0-% #% C"@0B#(% ,&[% '1% #% ."$.0#$A% B#$"%
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("-)./%'1%+.#A%#-@%8f7@#A%C'$.#(0.AD
+.#$.0-)% % '-% "C60$0B#(% ./"$#6AN% 0-B(*@0-)% ,C"6"-"C%%
#-@%#"$'+'(0+"@%45E<%B'(0+.0-%40-."$>"-.0'-%)$'*6Z%-%y%
lh<%'$%0C"6"-"C%#-@%0-.$#>"-'*+%4,W<%B'(0+.0-%4B'-.$'(
)$'*6Z% -% y% l;<D% Q*$./"$% :;% 6#.0"-.+% ="$"% "TB(*@"@%
@*$0-)% ./"% +.*@A% 6"$0'@% ?"B#*+"% '1% +*+6"-+0'-% '1%
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B(0-0B#(% B*$"% $#."% =#+% ;lD:% e% 0-%5E% )$'*6% #-@% l8%
e% 0-% ,W% )$'*6% 46% y% 9Dgm<D% ]/"-% #@C0-0+."$"@% 0-%
C'-'./"$#6A%'$%0-%B'C?0-#.0'-N./"%5E%$")0C"-%=#+%
#+%"11"B.0>"%#+%,W%$")0C"-D%3#.0"-.+%0-%5E%)$'*6%/#@%
+0)-0!%B#-.(A% ('="$% 0-B0@"-B"% '1%5MQ% 4:lDf% >+% hmDL%
eN%6%y%9D99L<N%C'$"%1#>'*$#?("%0C6$'>"C"-.%'1%3^Q%
$#.0'%4hLm%>+%h:;%#.%@#A%:LN%6%y%9D9:8<N%+/'$."-"@%.0C"%
.'%?#B."$0#(%"$#@0B#.0'-%4HIV<%4mDfm%>+%::D8;%@#A+N%6%
y%9D98h<%#-@%"#$(0"$%="#-0-)%1$'C%>"-.0(#.'$%0-%,&[%
+*$>0>'$+%=0./%#%C"#-%)#0-%0-%>"-.0(#.'$71$""%@#A+%'1%
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#-@%./"%8f7@#A%C'$.#(0.AD
Conclusion
5"$'+'(0+"@% B'(0+.0-% +""C+% .'% ?"% ?"-"!%B0#(D% ,.%
6$'>0@"@% #% ./"$#6"*.0B% "11"B.0>"-"++% -'-70-1"$0'$% .'%
6#$"-."$#(% B'(0+.0-% 0-% ./"$#6A% '1% U!M% ?#B0((0% W53%
=0./%#%('="$%-"6/$'.'T0B0.AN%#%?".."$%0C6$'>"C"-.%'1%
Measurements and results
3^Q%$#.0'N%#%+/'$."-"@%?#B."$0#(%"$#@0B#.0'-%.0C"%#-@%
H'.#(%:Lm%6#.0"-.+%'1%W53%="$"%"-$'(("@D%5-%"60+'@"%
"#$(0"$%="#-0-)%1$'C%>"-.0(#.'$%0-%,&[%+*$>0>'$+D
'1%W53%=#+%@"!%-"@%#+%#%&(0-0B#(%3*(C'-#$A%,-1"B.0'-%
EB'$"%4&3,E<%'1%C'$"%./#-%+0T%41"#.*$"+%0-B(*@"@%="$"% Reviewer comments
1">"$N%("*G'BA.'+0+N%6*$*("-.%+"B$".0'-+N%/A6'T"C0#%'$% H/0+% +.*@A% ">#(*#."+% ./"% "1!%B#BA% #-@% +#1".A% '1%
$#@0'(')0B#(% 0-!%(.$#."<D% ,-% #((% B#+"+% =/"$"% % W53% =#+% #"$'+'(0+"@%B'(0+.0-%B'C6#$"@%=0./%6#$"-."$#(%B'(0+.0-%
+*+6"B."@% .$#B/"#(% #+60$#."% =#+% 6"$1'$C"@% ?"1'$"% #-@%-'.%#+%#@J*-B.0>"%./"$#6A%.'%0-.$#>"-'*+%B'(0+.0-%0-%
Vol. 3 - No.2 April - June 2016
67
JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
6#.0"-.+%=0./%)$#C%-")#.0>"%W53D%I'./%="$"%"P*#((A%
"1!%B#B0'*+% #-@% ./"% './"$% ?"-"!%.+% '1% 5E% B(0+.0-% =#+%
+/'=-%#.%+">"$#(%6'0-.+a%#%+0)-0!%B#-.%('="$%0-B0@"-B"%
'1%-"6/$'.'T0B0.A%4:lDf%>+%hmDL%eN%6%y%9D99L<N%#%)$"#."$%
0C6$'>"C"-.% '1% 3^Q% $#.0'N% #% 1#+."$% .0C"% .'% 6#./')"-%
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6$'."B.0>"% +6#B"% 1'$% ?#B."$0#D% K'B#(% +0@"% "11"B.+%
=0./% ,-/#("@% B'(0+.0-% /#+% ?""-% $"6'$."@% % (0G"% ./$'#.%
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4D Hyperoxia Is Associated With Poor Outcomes
in Pediatric Cardiac Patients Supported on
Venoarterial
Extracorporeal
Membrane
Oxygenation
EO-AB"$7H#*?%YMZ%K'="$A%MZ%%R*%EZ%S="-+%EHZ
X0$+B/7M'C#-'%2&Z%S="-+%bVD
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U"C?$#-"% STA)"-#.0'-% 4W57V&US<% #1."$% B#$@0#B%
+*$)"$AD
Setting
5% $".$'+6"B.0>"% B/#$.% $">0"=% '1% #((% 0-1#-.+% =#+%
6"$1'$C"@% 4s% :% A$% '(@<% =/'% ="$"% 6(#B"@% '-.'%
W57V&US% #1."$% +*$)"$A% 1'$% B'-)"-0.#(% /"#$.%
@0+"#+"% 1$'C% 2*(A% :N% 899lN% .'% 2*-"% h9N% 89:hN% #.% ./"%
[-0>"$+0.A% '1% U0B/0)#-D% H/"% 6$0C#$A% '*.B'C"% =#+%
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'1% +.#AN% 0-7/'+60.#(% C'$.#(0.AN% -""@% 1'$% @0#(A+0+N% #-@%
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#+%+"0O*$"N%+.$'G"N%'$%0-.$#B$#-0#(%/"C'$$/#)"<D%
Measurements and Main Results
5%.'.#(%'1%mh%6#.0"-.+%="$"%0-B(*@"@%0-%./"%+.*@AD%H/"%
C"@0#-% #)"% #.% ./"% .0C"% '1% +*$)"$A% =#+% l% @#A+N% #-@%
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C"#-%3#'8%)$"#."$%./#-%:mh%CC%X)D
Conclusions
,-%./"%6'+.'6"$#.0>"%6"$0'@N%#%C"#-%3#'8%)$"#."$%./#-%
:mh%CC%X)%=/0("%'-%V&US%=#+%#-%0-@"6"-@"-.%$0+G%
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Objective
Reviewer’s Comments
H'%"T#C0-"%./"%6'."-.0#(%"11"B.%'1%/A6"$'T0#%'-%0-1#-.+%
=/'% ="$"% 6(#B"@% '-.'% >"-'#$."$0#(% VT.$#B'$6'$"#(% 5%$">0"=%'1%./"%B*$$"-.%(0."$#.*$"%0-@0B#."+%./#.%#B$'++%
Vol. 3 - No.2 April - June 2016
68
JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
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5. Limiting and withdrawing life support in the
PICU: for whom are these options discussed?
F""("%KZ%U""$.%FKZ%I"$)%M5Z%!#(.'-%XZ%Y"=./
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U"@%89:;Z:l48<a::97:89
Vol. 3 - No.2 April - June 2016
69
Objectives
H/"% '?J"B.0>"% '1% ./0+% +.*@A% =#+% .'% @"+B$0?"% ./"%
B(0-0B#(% B/#$#B."$0+.0B+% #-@% '*.B'C"+% '1% B/0(@$"-%
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+*66'$.%@0+B*++0'-+D
Design
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1$'C%#%$#-@'C%+#C6("%'1%B/0(@$"-%#@C0.."@%.'%3,&[+%
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Y".='$GD
Measurements and Main Results
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JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
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QN%b0(0'%5V%&$0.%&#$"%U"@D%89:g%Y'>Z%Lh4::<a88m87
h98
Conclusions
&(0-0B#(%1#B.'$+%$""%"B.0-)%.A6"%#-@%+">"$0.A%'1%0((-"++N% Objective
+'B0'@"C')$#6/0B+N% #-@% 0-+.0.*.0'-#(% 6$#B.0B"+% C#A% H'%+.*@A%=/0B/%!%$+.7(0-"%>#+'#B.0>"%@$*)%0+%./"%?"+.%
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+*66'$.%0+%@0+B*++"@%=0./%1#C0(0"+%'1%3,&[%6#.0"-.+D%
U'+.% B/0(@$"-% =/'+"% 1#C0(0"+% @0+B*++% (0C0.#.0'-% '$% Study Design
=0./@$#=#(% '1% (01"% +*66'$.% @0"% @*$0-)% ./"0$% 3,&[% H/0+%0+%./"%!%$+.%6$'+6"B.0>"N%B'-.$'(("@N%$#-@'C0O"@%
@'*?("%?(0-@%%.$0#(%B'-@*B."@%0-%#%+0-)("%B"-.$"%1$'C%
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Q"?$*#$A%:N%899mN%.'%2*(A%h:N%89:h%0-%B/0(@$"-%=0./%
Reviewer’s comments
"%*0@7$"1$#B.'$A% +"6.0B% +/'BGD% &/0(@$"-% =/'% ="$"% :%
X0)/7P*#(0.A% B'CC*-0B#.0'-% 0+% #-% 0C6'$.#-.% #+6"B.% C'-./% .'% :g% A"#$+% '(@% #-@% C".% ./"% B(0-0B#(% B$0."$0#%
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Controlled Trial of Dopamine Versus 4:LD8e<%'*.%'1%=/0B/%%:h%489D;e<%0-%./"%@'6#C0-"%
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Vol. 3 - No.2 April - June 2016
70
JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
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Conclusions
!'6#C0-"% =#+% #++'B0#."@% =0./% #-% 0-B$"#+"@% $0+G%
'1% @"#./% #-@% /"#(./B#$"7#++'B0#."@% 0-1"B.0'-D%
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Reviewer’s comments
H/0+% $0)'$'*+(A% B'-@*B."@% $#-@'C0O"@% B'-.$'(("@%
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Vol. 3 - No.2 April - June 2016
71
+/'BG%j+*))"+."@%-'$"60-"6/$0-"%0-+."#@%'1%@'6#C0-"%
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Critically Ill Children
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Conclusions
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Study Design
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Vol. 3 - No.2 April - June 2016
72
JOURNAL OF PEDIATRIC CRITICAL CARE
BEST EVIDENCE
Journal Scan
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Vol. 3 - No.2 April - June 2016
73
JOURNAL OF PEDIATRIC CRITICAL CARE
!S,7:9D8:h9L^89:;D9h98D99::l
Critical Thinking
PICU Quiz
Praveen Khilnani
BLK Superspeciality Hospital, New Delhi & Mediclinic City Hospital, Dubai
Received:10-May-2016/Accepted:17-May-2016 /Published online:19-May-2016
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Vol. 3 - No.2 April - June 2016
74
JOURNAL OF PEDIATRIC CRITICAL CARE
CRITICAL THINKING
PICU Quiz
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Vol. 3 - No.2 April - June 2016
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CRITICAL THINKING
PICU Quiz
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Answers
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8D 5-+%I
hD 5-+%V
LD 5-+%!
gD 5-+%!
;D 5-+%I
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Vol. 3 - No.2 April - June 2016
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NCPCC 2016
Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE
Vol. 3 - No.2 April - June 2016
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JOURNAL OF PEDIATRIC CRITICAL CARE