Table 2. Management of common pediatric diseases in resource-limited settings.

Disease process	Evidenced-based adaptations for low-resource PICU	Evidenced-based adaptations for extremely limited PICU
Asthma	1. Beta-agonist via nebulizers 2. IV steroids 3. IV magnesium via continuous infusion 4. Nebulized ipratropium bromide or atropine 5. IV aminophylline 6. IV ketamine drip or intermittent bolus 7. Inhaled anesthetics	1. Beta-agonist via MDI with a spacer (homemade from bottle appropriate) 2. Steroids by mouth 3. IV magnesium via intermittent bolus Q2–4 h 4. SQ epinephrine or terbutaline 5. PO theophylline or aminophylline
Traumatic brain injury	1. Recognition of altered consciousness and lateralizing signs 2. Oxygen and if indicated, intubation and mechanical ventilation for children unable to protect their airway 3. IV fluid resuscitation with isotonic fluids (avoid overhydration) 4. CT scan if available 5. Hyperosmolar therapy (hypertonic saline (goal sodium 145–155), mannitol) 6. ICP monitoring with ventriculostomy (GCS 3–8). Goal ICP < 15 mm Hg 7. Surgical drainage of extra-axial blood (SDH, EDH) 8. Maintenance of euthermia 9. Provision of adequate nutrition via early enteral feeding and avoid hyperglycemia 10. IV sedation and analgesia for patient comfort 11. Antiseizure prophylaxis (phenytoin or fosphenytoin) for 7 d postinjury	1. Oxygen (via cylinder or concentrator) and if indicated, intubation with BVM ventilation for transport to higher level of care 2. Cranial X-ray to evaluate for fracture (four views) 3. Hyperosmolar therapy with intermittent mannitol to keep serum osmolality 300–320 mmol/L. Avoid hyponatremia 4. Ongoing close neurologic examination. Recognition of lateralizing signs 5. Burr hole if equipment and skilled provider available 6. IV or PO sedation and analgesia as needed for patient comfort 7. Antiseizure prophylaxis (phenobarbital or phenytoin) for 7 d postinjury
Blunt abdominal trauma	1. FAST exam to look for intraperitoneal fluid/blood. Where available, consider CT scan. If not available, get abdominal X-ray 2. Urinalysis 3. Fluid resuscitation with isotonic fluids 4. Close and ongoing monitoring of vital signs and hematologic indices 5. Transfusion with whole blood or PRBCs for Hb < 7 g/dL or hemodynamic instability 6. Surgical intervention for hemodynamic instability that persists despite fluids/blood products or free air on radiographic studies	1. If ultrasound not available, consider abdominal X-ray and/or diagnostic peritoneal lavage 2. If no transfusion capability, consider transfer to higher level of care for transfusion/surgical intervention
Sepsis 16	1. Recognize sepsis early and initiate treatment rapidly 2. Use adequate tissue perfusion as principal end point of resuscitation and target normal BP and HR in children 3. Maintain Sp o 2  > 90% with supplemental O 2 . If Sp o 2 unknown, place on NC O 2 empirically 4. Establish IV access immediately (IO if needed) 5. Within 15 min of presentation, start aggressive fluid resuscitation with 20 mL/kg crystalloid infusion a 6. In the first hour of presentation, treat infection with antibiotics based on suspected pathogen or with broad-spectrum empiric treatment. Repeat IV crystalloid boluses up to total of 60 mL/kg if continued signs of tissue hypoperfusion, but noted improvement after infusion 7. 2–6 h: If persistent hypotension and/or signs of poor perfusion after aggressive fluid resuscitation, start inotropes if available (epinephrine or dopamine). Continue to aggressively give fluid paying close attention to signs of fluid overload (hepatomegaly, rales, respiratory distress). b If signs of fluid overload, you must weigh risk/benefit of additional fluid depending on your ability to support respiratory status (NIPPV, vent) 8. Send appropriate diagnostic tests of tissue/fluid based on suspected site of infection and drain/debride infected tissue	No change in therapy in extremely limited settings other than continued vigilance at recognizing signs of fluid overload due to lack of respiratory support options
Respiratory failure	1. Recognize signs of central cyanosis and/or respiratory distress: tachypnea, retractions, nasal flaring, Sp o 2  < 90% 2. Oxygen therapy to maintain Sp o 2  > 90% (improve cyanosis) via nasal prongs 3. If hypoxia not improved, or signs of respiratory distress, use NIPPV with CPAP (conventional or bubble) 4. Salbutamol nebulizer if wheezing (see asthma therapy above) 5. Antibiotics for presumed pneumonia/infection. Testing as available for malaria, TB/AFB, CXR, blood cultures 6. If poor response, consider pneumothorax, pleural effusion, heart failure, poisoning, TB, HIV with PCP	1. Bubble CPAP 2. Salbutamol via MDI with spacer (see asthma therapy above)
Snakebites, poisonous	Neurotoxic snakes : 1. Early identification of neurotoxic symptoms using a single breath count, recognition of ptosis, dysphagia, and dysarthria. Continuous Sp o 2 monitoring if possible 2. Treatment with antisnake venom (lyophilized if possible since it does not require a cold chain) as soon as symptoms recognized 3. Early ventilatory support for children showing signs of respiratory failure Hemotoxic snakes : 1. Early identification of hematologic symptoms by measuring platelet count, PT/PTT, and fibrinogen, if available. Checking renal function by measuring creatinine and BUN 2. Treatment with antisnake venom for envenomed children 3. If bleeding complications, consider giving whole blood or blood products 4. Treatment of renal failure with peritoneal 18 or hemodialysis if available	Neurotoxic snakes : 1. As before except consider adding neostigmine as an adjunct in snake bites that affect the postsynaptic membrane ( Naja naja ) 2. Early intubation and manual bagging of an envenomed child until neurotoxic symptoms improve (usually improve in 24–48 h) Hemotoxic snakes : 1. Early identification of hematologic symptoms by using the 20-min whole blood clotting time 19 2. Treatment of renal failure with careful fluid restriction and furosemide until renal function improves
Severe malaria	1. IV artesunate until able to take orally then switch to oral ACTs 2. IV quinine (alternative) 3. Treat hypoglycemia 4. Transfuse if severe anemia (Hb < 5 g/dL) 5. Treat seizures 6. Correct fluid and electrolyte imbalance; sodium bicarbonate if severe acidosis 7. Maintenance fluids via IV and/or NGT 20	1. IM artemether 2. IV/IM quinine—can be given as one dose and referred to higher center or treatment continued till patient can take the ACTs orally to complete course 3. Glucose solution through NGT for hypoglycemia 4. Treatment of convulsions with rectal/IM diazepam
Poisonings	OP : 1. Early treatment with atropine in patients with cholinergic symptoms. Titrate atropine until bronchorrhea resolves. Avoid oximes in therapy due to cost and lack of efficacy 21 2. Recognition of IMS by daily assessment of neck flexion strength 22 3. Ventilatory support for patients with respiratory failure, consider tracheostomy if development of IMS since recovery can take several weeks Hydrocarbons : 1. Early recognition of aspiration based on respiratory distress or infiltrate on CXR 2. For children with respiratory distress, give oxygen, BiPAP, or intubation depending on severity	OP and hydrocarbons : 1. Same except palliative care for patients with severe IMS due to OP or ARDS due to hydrocarbon aspiration due to lack of access to ventilatory support. Usually unable to manually bag patients for the time required to recover from IMS
Tetanus	1. Treat with combination of benzodiazepines, phenobarbital, and IV magnesium. Consider switching to oral benzodiazepines via NGT to limit cost 2. If resources allow, consider magnesium infusion (can titrate with symptoms, presence or absence of knee jerks if levels unavailable) 3. Monitor with continuous pulse oximeter 4. Have positive pressure bag and mask available at all times 5. Intubation and ventilation may be best alternative if resources allow	1. Treat with combination of benzodiazepines, phenobarbital, and IV magnesium via intermittent bolus dosing every 2–4 h as needed 2. Remainder as previously mentioned
Seizures	Neonate : 1. IV/IM phenobarbitone 20 mg/kg stat, further 10 mg/kg can be given within 24 h, then maintenance doses of 5 mg/kg/d Age > 1 mo : 1. Quick ABC assessment, start oxygen 2. Rectal diazepam 0.5 mg/kg/dose or IV diazepam 0.3 mg/kg/dose for up to 2 doses only, 10 min apart 3. Give IV D10W 5 mL/kg 4. If seizures do not stop, IV phenobarbitone 15–20 mg/kg. May top up with 5–10 mg/kg if seizures do not stop in 20 min, then maintenance dose of 5 mg/kg/d 5. If seizures do not stop at 45 min, load with phenytoin 20 mg/kg 6. If at 1 h seizures continue, give midazolam 0.3 mg stat then infusion 0.01 mg/kg/h	Same up to step 4, then refer 11
Hypoglycemia	1. Treat neonates with 2–4 mL/kg of D10W 2. Older infants and young children with 1–2 mL/kg of D25W 3. Older children and adolescents with 0.5–1 mL/kg of D50W 4. May use IV bolus of any of these fluids if IV patency assured, however, if running continuously cannot use higher than D12.5W without central line	Same
Vomiting, dehydration, diarrhea with shock	1. 20–30 mL/kg IV over first 1–2 h re-evaluating frequently and increasing or decreasing rate as appropriate based on ongoing losses, perfusion, urine output, and signs of volume overload 2. Use only isotonic fluids for rehydration (i.e., NSS, RL) without glucose 3. Continue maintenance fluids at 1.5–2X maintenance. Add ORS as soon as shock resolved 4. Treat hypoglycemia with bolus glucose as needed during treatment of shock. Add glucose to maintenance fluids	1. As with higher resourced areas but consider ORS per nasogastric tube if unable to start IVFs or IO fluids

Abbreviations: ACT, activated clotting time; AFB, acid fast bacilli; ARDS, acute respiratory distress syndrome; BiPAP, Bilevel Positive Airway Pressure; BP, blood pressure; BVM, bag mask ventilation; CT, computed tomography; CXR, chest X-ray; EDH, epidural hematoma; FAST, focused assessment with sonography for trauma; GCS, Glasgow Coma Score; Hb, hemoglobin; HIV, human immunodeficiency virus; HR, heart rate; ICP, intracranial pressure; IMS, intermediate syndrome; IVFs, intravenous fluids; IV, intravenous; MDI, metered-dose inhaler; NC, nasal canula; NGT, nasogastric tube; NIPPV, noninvasive positive pressure ventilation; NSS, normal saline solution; OP, organophosphates; ORS, oral rehydration solution; PCP, pneumocystis carinii pneumonia; PICU, pediatric intensive care unit; PO, per os/by mouth; PRBC, packed red blood cell; PT, prothrombin time; PTT, partial thromboplastin time; RL, Ringer's Lactate; SDH, subdural hematoma; TB, tuberculosis.

^aIf dengue fever suspected, start fluid resuscitation with colloid if available rather than crystalloid.

^b Due to studies in children in Malawi with sepsis who were found to have increased mortality with overly aggressive fluid resuscitation be very attentive to signs of fluid overload. Higher risk noted in severely anemic patients and patients with malaria. ¹¹