PEDIATRIC EMERGENCIES

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PEDIATRIC EMERGENCIES
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Pediatric Emergencies

• Basic Approach to Pediatric Emergencies
• Approaches to patient vary with age and nature of
  incident
• Practice quick and specific questioning of the
  child
• Key on your visual assessment
• Begin your exam without instruments
• Approach the child slowly and gently

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Pediatric Emergencies

• Basic Approach (cont..)
• Do not separate the child from the mother
  unnecessarily
• Be honest and allow the child to determine the
  order of the exam
• Avoid touching painful areas until the childs
  confidence has been gained

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Pediatric Emergencies

• Childs response to emergencies
• Primary response is fear
• Fear of being separated from parents
• Fear of being removed from home
• Fear of being hurt
• Fear of mutilation
• Fear of the unknown
• Combat the fear with calm, honest approach
• Be honest - tell them it will hurt if it will
• Use approach language

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Development Stages -Keys to Assessment

• Neonatal stage - birth to 1 month
• Congenital problems and other illnesses often n
  noted
• Personality development begins
• Stares at faces and smiles
• Easily comforted by mother and sometimes father
• Rarely febrile, but if so, be cautious of
  meningitis

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Development Stages -Keys to Assessment

• Approach to Neonates
• Keep child warm
• Observe skin color, tone and respiratory activity
• Absence of tears when crying indicates
  dehydration
• Auscultate the lungs early when child is quiet
• Have the child suck on a pacifier
• Have child remain on the mothers lap

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Development Stages -Keys to Assessment

• Ages 1-5 months - Characteristics
• Birth weight doubles
• Can follow movements with their eyes
• Muscle control develops
• History must be obtained from parents
• Approach
• Keep child warm and comfortable
• Have child remain in mothers lap
• Use a pacifier or a bottle

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Development Stages -Keys to Assessment

• Ages 1-5 months - Common problems
• SIDS
• Vomiting and diarrhea/dehydration
• Meningitis
• Child abuse
• Household accidents

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Development Stages -Keys to Assessment

• Ages 6-2 months - Characteristics
• Ability to stand or walk with assistance
• Very active and explore the world with their
  mouths
• Stranger anxiety
• Do not like lying supine
• Cling to their mothers

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Development Stages -Keys to Assessment

• Ages 6-12 months - Common problems
• Febrile seizures
• Vomiting and diarrhea/dehydration
• Bronchiolitis or croup
• Car accidents and falls
• Child abuse
• Ingestions and foreign body obstructions
• Meningitis

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Development Stages -Keys to Assessment

• Ages 6-12 months - Approach
• Examine the child in the mothers lap
• Progress from toe to head
• Allow the child to get used to you

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Development Stages -Keys to Assessment

• Ages 1-3 years - Characteristics
• Motor development, always on the move
• Language development
• Child begins to stray from mother
• Child can be asked certain questions
• Accidents prevail

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Development Stages -Keys to Assessment

• Ages 1-3 yrs - Common problems
• Auto accidents
• Vomiting and diarrhea
• Febrile seizures
• Croup, meningitis
• Foreign body obstruction

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Development Stages -Keys to Assessment

• Ages 1-3 yrs - Approach
• Cautious approach to gain confidence
• Child may resist physical exam
• Avoid no answers
• Tell the child if something will hurt

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Development Stages -Keys to Assessment

• Ages 3-5 years - Characteristics
• Tremendous increase in motor development
• Language is almost perfect but patients may not
  wish to talk
• Afraid of monsters, strangers fear of mutilation
• Look to parent for comfort and protection

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Development Stages -Keys to Assessment

• Ages 3-5 yrs - Common problems
• Croup, asthma, epiglottitis
• Ingestions, foreign bodies
• Auto accidents, burns
• Child abuse
• Drowning
• Meningitis, febrile seizures

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Development Stages -Keys to Assessment

• Ages 3-5 yrs - Approach
• Interview child first, have parents fill in gaps
• Use doll or stuffed animal to assist in
  assessment
• Allow child to hold use equipment
• Allow them to sit on your lap
• Always explain what you are going to do

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Development Stages -Keys to Assessment

• Ages 6-12 years - Characteristics
• Active and carefree
• Great growth, clumsiness
• Personality changes
• Strive for their parents attention
• Common problems
• Drowning
• Auto accidents, bicycle accidents
• Fractures, falls, sporting injuries

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Development Stages -Keys to Assessment

• Age 6-12 yrs - approach
• Interview the child first
• Protect their privacy
• Be honest and tell them what is wrong
• They may cover up information if they were
  disobeying

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Development Stages -Keys to Assessment

• Ages 12-15 - Characteristics
• Varied development
• Concerned with body image and very independent
• Peers are highly important, as is interest in
  opposite sex

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Development Stages -Keys to Assessment

• Ages 12-15 - Common problems
• Mononucleosis
• Auto accidents, sports injuries
• Asthma
• Drug and alcohol abuse
• Sexual abuse, pregnancy
• Suicide gestures

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Development Stages -Keys to Assessment

• Ages 12-15 - Approach
• Interview the child away from parent
• Pay attention to what they are not saying

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Development Stages -Keys to Assessment

• Characteristics of Parents response to
  emergencies
• Expect a grief reaction
• Initial guilt, fear, anger, denial, shock and
  loss of control
• Behavior likely to change during course of
  emergency

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Development Stages -Keys to Assessment

• Parent Management
• Tell them your name and qualifications
• Acknowledge their fears and concerns
• Reassure them it is all right to feel as they do
• Redirect their energies - help you care for child
• Remain calm and in control
• Keep them informed as to what you are doing
• Dont talk down to parents
• Assure parents that everything is being done

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General Approach to Pediatric Assessment

• History
• Be direct and specific with child
• Focus on observed behavior
• Focus on what child and parents say
• Approach child gently, encourage cooperation
• Get down to visual level of child
• Use a soft voice and simple words

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Physical Exam

• Avoid touching painful areas until confidence has
  been gained
• Begin exam without instruments
• Allow child to determine order of exam if
  practical
• Use the same format as adult physical exam

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General Approach to Pediatric Assessment

• Physical Exam (cont.)
• Special concerns
• Fontanels should be inspected in infants
• Normal fontanels should be level with surface of
  the skull or slightly sunken and it may pulsate
• Abnormal fontanels
• Tight and bulging (increased ICP from trauma or
  meningitis)
• Diminished or absent pulsation
• Sunken if dehydrated

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General Approach to Pediatric Assessment

• Special concerns (cont..)
• GI Problems
• Disturbances are common
• Determine number of episodes of vomiting, amount
  and color of emesis

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Pediatric Vital Signs

• Blood Pressure
• Use right size cuff, one that is two-thirds the
  width of the upper arm
• Pulse
• Brachial, carotid or radial depending on child
• Monitor for 30 seconds

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Pediatric Vital Signs

• Respirations
• Observe the rate before the child starts to cry
• Upper limit is 40 minus childs age
• Identify respiratory pattern
• Look for retractions, nasal flaring, paradoxical
  chest movement
• Level of consciousness
• Observe and record

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Noninvasive Monitoring

• Prepare the child before using devices
• Explain the device
• Show the display and lights
• Let child hear noises if devices makes them
• Pulse oximetry-particularly useful since so many
  childhood emergencies are respiratory

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Pediatric Trauma

• Basics
• Trauma is leading cause of death in children
• Most common mechanisms-MVA, burns, drowning,
  falls, and firearms
• Most commonly injured body areas-head, trunk,
  extremities
• Steps much like those in adult trauma
• Complete ABCDEs of primary assessment
• Correct life threatening conditions
• Proceed to secondary assessment

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Causes of Death

• National
• MVA 43
• Burns 14.9
• Drowning 14.6
• Aspiration 3.4
• Firearms 3.0
• Falls 2.0

• Oklahoma
• MVA 35
• Drowning 14.5
• Burns 14.0
• Firearms 9.9
• Aspiration 5.7
• Stab/cut ?

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Frequency of Injured Body Parts

• Head 48
• Extremities 32
• Abdomen 11
• Chest 9

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Pediatric Trauma

• Head, face, and neck injuries
• Children prone to head injuries
• Be alert for signs of child abuse
• Facial injuries common secondary to falls
• Always assume a spinal injury with head injury

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Pediatric Trauma

• Chest and abdominal injuries
• Second most common cause of pediatric trauma
  deaths
• Most result from blunt trauma
• Spleen is most commonly injured organ
• Treat aggressively for shock in blunt abdominal
  injury

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Pediatric Trauma

• Extremity injuries
• Usually limited to fractures and lacerations
• Most fractures are incomplete - bend, buckle,,
  and greenstick fractures
• Watch for growth plate injuries

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Pediatric Trauma

• Burns
• Second leading cause of pediatric deaths
• Scald burns are most common
• Rule of nine is different for children
• Each leg worth 13.5
• Head worth 18

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Pediatric Trauma

• Child abuse and neglect - Basics
• Suspect if injuries inconsistent with history
• Children at greater risk often seen as special
  and different
• Premature or twins
• Handicapped
• Uncommunicative (autistic)
• Boys or child of the wrong sex

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Pediatric Trauma

• Child abuse and neglect - The child abuser
• Usually a parent or someone in the role of parent
• Usually spends much time with child
• Usually abused as a child

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Pediatric Trauma

• Sexual Abuse - Basics
• Can occur at any age
• Abuser is usually someone in family
• Can be someone the child trusts
• Stepchildren or adopted children at higher risk
• Paramedic actions
• Examine genitalia for serious injury only
• Avoid touching the child or disturbing clothing
• Provide caring support

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Pediatric Trauma

• Triggers to high index of suspicion for child
  neglect
• Extreme malnutrition
• Multiple insect bites
• Long-standing skin infections
• Extreme lack of cleanliness

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Pediatric Trauma

• Triggers to high index of suspicion for child
  abuse
• Obvious fracture in child under 2 yrs old
• Injuries in various stages of healing
• More injuries than usually seen in children of
  same age
• Injuries scattered on many areas of body
• Bruises that suggest intentional infliction
• Increased ICP in infant

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Pediatric Trauma

• Triggers to high index of suspicion for child
  abuse (cont.)
• Suspected intra-abdominal trauma in child
• Injuries inconsistent with history
• Parents account vague or changes during
  interview
• Accusations that child injured himself
  intentionally
• Delay in seeking help
• Child dresses inappropriately for situation

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Pediatric Trauma

• Management of potentially abused child
• Treat all injuries appropriately
• Protect the child from further abuse
• Notify the proper authorities
• Be objective while gaining information
• Be supportive and nonjudgmental of parents
• Dont allow abuser to transport child to hospital
• Inform ED staff of suspicions of child abuse
• Document completely and thoroughly

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Pediatric Medical Emergencies - Neurological

• Pediatric seizures - Common causes
• Fever, infections
• Hypoxia
• Idiopathic epilepsy
• Electrolyte disturbances
• Head trauma
• Hypoglycemia
• Toxic ingestion or exposure
• Tumors or CNS malformations

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Pediatric Medical Emergencies - Neurological

• Febrile Seizures
• Result from a sudden increase in body temperature
• Most common between 6 months and 6 years
• Related to rate of increase, not degree of fever
• Recent onset of cold or fever often reported
• Patients must be transported to hospital

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Pediatric Medical Emergencies - Neurological

• Assessment
• Temperature - suspect febrile seizure if temp
  over 103 degrees F
• History of seizure
• Description of seizure activity
• Position and condition of child when found
• Head injury, Respirations
• History of diabetes, family history
• Signs of dehydration

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Pediatric Medical Emergencies - Neurological

• Management - Basic Steps
• Protect seizing child
• Manage the ABCs, provide supplemental oxygen
• Remove excess layers of clothing
• IV of NS or LR TKO rate
• Transport all seizure patients, support the
  parents

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Pediatric Medical Emergencies - Neurological

• Management - If status epilepticus
• IV of NS or LR TKO rate
• Perform a Dextrostix lt80 mg/dl give D25 2 ml/kg
  IV/IO if child is less than 12
• 12 or older give D50 1ml/kg IV
• Contact Medical Control if long transport

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Pediatric Medical Emergencies - Neurological

• Meningitis - Basics
• Infection of the meninges
• Can result from virus or bacteria
• More common in children than in adults
• Infection can be fatal if unrecognized and
  untreated

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Meningitis

• Assessment
• History of recent illness
• Headache, stiff neck
• Child appears very ill
• Bulging fontanelles in infants
• Extreme discomfort in movement

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Meningitis

• Management
• Monitor ABCs and vital signs
• High flow O2, prepare to assist with ventilations
• IV/IO of LR or NS
• Fluid bolus of 20 ml/kg IV/IO push
• Repeat if no improvement
• Orotracheal intubation if child's condition
  warrants

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Pediatric Medical Emergencies - Neurological

• Reyes syndrome - Basics
• New disease - Correlated with ASA use
• Peak incident in patients between 5-15 years
• Frequency higher in winter
• Higher frequency in suburban and rural population
• No single etiology identified
• Possibly toxic or metabolic problem
• Tends to occur during influenza B outbreaks
• Associated with chicken pox virus
• Correlation with use of aspirin use in children

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Pediatric Medical Emergencies - Neurological

• Reyes syndrome - Complications
• Respiratory failure
• Cardiac arrhythmias
• Acute pancreatitis

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Pediatric Medical Emergencies - Neurological

• Assessment - Reyes Syndrome
• Severe nausea vomiting
• Hyperactivity or combative behavior
• Personality changes, irrational behavior
• Progression of restlessness, stupor, convulsions,
  coma
• Recent history of chicken pox in 10-20 of cases
• Recent upper respiratory infections or
  gastroenteritis
• Rapid deep respirations, may be irregular
• Pupils dilated sluggish
• Signs of increased ICP

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Pediatric Medical Emergencies - Neurological

• Reyes syndrome - Management
• General and supportive
• Maintain ABCs
• Administer supplemental oxygen
• Rapid transport

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Childs Airway vs.. Adults

• Smaller septum nasal bridge is flat and
  flexible
• Vocal cords located at C3-4 versus C5-6 in adults
• Contributes to aspiration if neck is
  hyperextended
• Narrowest at cricoid ring instead of vocal cords
• Airway diameter is 4 mm vs.. 20 mm in adult
• Tracheal rings more elastic cartilaginous, can
  easily crimp off trachea
• More smooth muscle , makes airway more reactive
  or sensitive to foreign substances

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5 Most Common Respiratory Emergencies

• Asthma
• Bronchiolitis
• Croup
• Epiglotitis
• Foreign bodies

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Asthma

• Pathophysiology
• Chronic recurrent lower airway disease with
  episodic attacks of bronchial constriction
• Precipitating factors include exercise,
  psychological stress, respiratory infections, and
  changes in weather temperature
• Occurs commonly during preschool years, but also
  presents as young as 1 year of age
• Decrease size of childs airway due to edema
  mucus leads to further compromise

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Asthma

• Assessment
• History
• When was last attack how severe was it
• Fever
• Medications, treatments administered
• Physical Exam
• SOB, shallow, irregular respirations, increased
  or decreased respiratory rate
• Pale, mottled, cyanotic, cherry red lips
• Restless scared
• Inspiratory expiratory wheezing, rhonchi
• Tripod position

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Asthma

• Management
• Assess monitor ABCs
• Big Os (Humidified if possible)
• IV of LR or NS at a TKO rate
• Assist with prescribed medications
• Prepare for vomiting
• Pulse oximeter
• Intubate if airway management becomes difficult
  or fails

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Bronchiolitis

• Basics
• Respiratory infection of the bronchioles
• Occurs in early childhood (younger than 1 yr)
• Caused by viral infection
• Assessment/History
• Length of illness or fever
• has infant been seen by a doctor
• Taking any medications
• Any previous asthma attacks or other allergy
  problems
• How much fluid has the child been drinking

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Bronchiolitis

• Signs symptoms
• Acute respiratory distress
• Tachypnea
• May have intercostal and suprasternal retractions
• Cyanosis
• Fever dry cough
• May have wheezes - inspiratory expiratory
• Confused anxious mental status
• Possible dehydration

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Bronchiolitis

• Management
• Assess maintain airway
• When appropriate let child pick POC
• Clear nasal passages if necessary
• Prepare to assist with ventilations
• IV LR or NS TKO rate
• Intubate if airway management becomes difficult
  or fails

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Croup

• Basics
• Upper respiratory viral infection
• Occurs mostly among ages 6 months to 3 years
• More prevalent in fall and spring
• Edema develops, narrowing the airway lumen
• Severe cases may result in complete obstruction

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Croup

• Assessment/History
• What treatment or meds have been given?
• How effective?
• Any difficulty swallowing?
• Drooling present?
• Has the child been ill?
• What symptoms are present how have they changed?

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Croup

• Physical exam
• Tachycardia, tachypnea
• Skin color - pale, cyanotic, mottled
• Decrease in activity or LOC
• Fever
• Breath sounds - wheezing, diminished breath
  sounds
• Stridor, barking cough, hoarse cry or voice

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Croup

• Management
• Assess monitor ABCs
• High flow humidified O2 blow by if child wont
  tolerate mask
• Limit exam/handling to avoid agitation
• Be prepared for respiratory arrest, assist
  ventilations and perform CPR as needed
• Do not place instruments in mouth or throat
• Rapid transport

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Epiglotitis

• Basics
• Bacterial infection and inflammation of the
  epiglottis
• Usually occurs in children 3-6 years of age
• Can occur in infants, older children, adults
• Swelling may cause complete airway obstruction
• True medical emergency

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Epiglotitis

• Assessment/History
• When did child become ill?
• Has it suddenly worsened after a couple of days
  or hours?
• Sore throat?
• Will child swallow liquids or saliva?
• Is drooling present?
• High fever (102-103 degrees F)
• Onset is usually sudden

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Epiglotitis

• Signs Symptoms
• May be sitting in Tripod position
• May be holding mouth open, with tongue protruding
• Muffled or hoarse cry
• Inspiratory stridor
• Tachycardia, tachypnea
• Pale, mottled, cyanotic skin
• Anxious, focused on breathing, lethargic
• Very sore throat
• Nasal flaring
• Look very sick with high fever

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Epiglotitis

• Management
• Assess monitor ABCs
• Do not make child lie down
• Do not manipulate airway
• High flow humidified O2 blow by if child wont
  tolerate mask
• Limit exam/handling to avoid agitation
• Be prepared for respiratory arrest, assist
  ventilations and perform CPR as needed
• Contact medical control

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Aspirated Foreign Body

• Basics
• Common among the 1-3 age group who like to put
  everything in their mouths
• Running or falling with objects in mouth
• Inadequate chewing capabilities
• Common items - gum, hot dogs, grapes and peanuts

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Aspirated Foreign Body

• Assessment
• Complete obstruction will present as apnea
• Partial obstruction may present as labored
  breathing, retractions, and cyanosis
• Objects can lodge in the lower or upper airways
  depending on size
• Object may act as one-way valve allowing air in,
  but not out

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Aspirated Foreign Body

• Management - Complete Obstruction
• Attempt to clear using BLS techniques
• Attempt removal with direct laryngoscopy and
  Magill forceps
• Cricothyrotomy may be indicated

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Aspirated Foreign Body

• Management - Partial obstruction
• Make child comfortable
• Administer humidified oxygen
• Encourage child to cough
• Have intubation equipment available
• Transport to hospital for removal with
  bronchoscope

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Mild, Moderate, Severe Dehydration

• History
• Previous seizures, when it began, how long
• Reason for seizure
• When were fluids last taken, how much, is it
  usual for the child
• Current fever or medical illness
• Behavior during seizure
• Last wet diaper
• Any vomiting or diarrhea
• Other medical problems

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Mild, Moderate, Severe Dehydration

• Physical Assessment/Signs symptoms
• Onset very abrupt
• Sudden jerking of entire body, tenseness, then
  relaxation
• LOC or confusion
• Sudden jerking of one body part
• Lip smacking, eye blinking, staring
• Sleeping following seizure

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Mild, Moderate, Severe Dehydration

• Physical Assessment/ Vital signs
• Capillary refill
• Skin color
• Alertness, activity level

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Mild, Moderate, Severe Dehydration

• Mild dehydration
• Infants lose up to 5 of their body weight
• Child lose up to 3-4 of their body weight
• Physical signs of dehydration are barely visable

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Mild, Moderate, Severe Dehydration

• Moderate Dehydration
• Infants lose up to 10 of their body weight
• Children lose up to 6-8 of their body weight
• Poor skin color turgor, dry mucous membranes,
  decreased urine output increased thirst, no
  tears

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Mild, Moderate, Severe Dehydration

• Severe Dehydration
• Infants lose up to 15 of their body weight
• Child lose up to 10-13 of their body weight
• Danger of life-threatening hypovolemic shock

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Mild, Moderate, Severe Dehydration

• Management
• If mild or moderate
• Give fluids orally if there is no abdominal pain,
  vomiting or diarrhea and is alert
• Severe
• High flow O2
• IV/IO with NS or LR
• Fluid bolus of 20 ml/kg IV/IO push
• Repeat fluid bolus if no improvement

85
Congenital Heart Disease

• Blood is permitted to mix in the 2 circulatory
  pathways
• Primary cause of heart disease in children
• Various structures may be defective
• Hypoxemia usually results

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Congenital Heart Disease

• History
• Name of defect to share with medical control
• Any meds taken routinely, were they taken today
• Any other home therapies (O2, feeding devices)
• Any recent illness or stress
• Child's color
• What kind of spell, how long did it last
• Ant treatment given

87
Congenital Heart Disease

• Signs symptoms
• Intercostal retractions, difficulty breathing,
  tachypnea, crackles or wheezing on auscultation
• Tachycardia, cyanosis with some defects
• Altered LOC, limpness of extremities, drowsiness
• Cool moist skin, cyanosis, pallor
• Tires easily, irritable if disturbed,
  underdeveloped for age
• Uncontrollable crying, irritability
• Severe breathing difficulty, progressive cyanosis
• Loss of consciousness, seizure, cardiac arrest

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Congenital Heart Disease

• Management
• Monitor ABCs vitals
• Maintain airway/administer high flow O2
• Assist ventilations as needed, intubate if needed
• Cyanotic spell, place in knee chest position
• Prepare to perform CPR
• Establish IV TKO if lengthy transport time is
  anticipated

89
Home High Technology Equipment

• Chronic terminal illness
• Respiratory cardiac
• Premature infants
• Cystic Fibrosis
• Heart defects post transplant patients

90
Home High Technology Equipment

• Ventilators
• Suction
• Oxygen
• Tracheostomy
• IV pumps
• Feeding pumps

91
Home High Technology Equipment

• Management
• Support efforts of parents
• Home equipment malfunction, attach child to yours
• Monitor ABCs treat as patients condition
  warrants
• Have hospital notify childs physician if possible