pediatric emergencies

pediatric/paediatric emergencies
for underradiate. post graduate. residents, trainee

1. PEDIATRIC EMERGENCIES

2. 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

3. 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
child’s confidence has been gained

4. Pediatric Emergencies
•Child’s 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

5. 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

6. 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 mother’s lap

7. 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 mother’s lap
–Use a pacifier or a bottle

8. Development Stages -
Keys to Assessment
•Ages 1-5 months -Common problems
–SIDS
–Vomiting and diarrhea/dehydration
–Meningitis
–Child abuse
–Household accidents

9. 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

10. 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

11. 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

12. 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

13. Development Stages -
Keys to Assessment
•Ages 1-3 yrs -Common problems
–Auto accidents
–Vomiting and diarrhea
–Febrile seizures
–Croup, meningitis
–Foreign body obstruction

14. 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

15. 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

16. 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

17. 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

18. Development Stages -
Keys to Assessment
•Ages 6-12 years -Characteristics
–Active and carefree
–Great growth, clumsiness
–Personality changes
–Strive for their parent’s attention
•Common problems
–Drowning
–Auto accidents, bicycle accidents
–Fractures, falls, sporting injuries

19. 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

20. 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

21. 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

22. Development Stages -
Keys to Assessment
•Ages 12-15 -Approach
–Interview the child away from parent
–Pay attention to what they are notsaying

23. 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

24. 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
–Don’t “talk down” to parents
–Assure parents that everything is being done

25. 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

26. 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

27. 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

28. General Approach to
Pediatric Assessment
•Special concerns (cont..)
–GI Problems
•Disturbances are common
•Determine number of episodes of vomiting,
amount and color of emesis

29. 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

30. Pediatric Vital Signs
•Respirations
–Observe the rate before the child starts to
cry
–Upper limit is 40 minus child’s age
–Identify respiratory pattern
–Look for retractions, nasal flaring,
paradoxical chest movement
•Level of consciousness
–Observe and record

31. 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

32. 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 ABCDE’s of primary assessment
•Correct life threatening conditions
•Proceed to secondary assessment

33. Causes of Death
•National
–MVA 43%
–Burns 14.9%
–Drowning 14.6%
–Aspiration3.4%
–Firearms
3.0%
–Falls 2.0%
•Oklahoma
–MVA 35%
–Drowning 14.5%
–Burns 14.0%
–Firearms
9.9%
–Aspiration5.7%
–Stab/cut
?

34. Frequency of Injured Body
Parts
•Head 48%
•Extremities32%
•Abdomen 11%
•Chest 9%

35. 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

36. 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

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

38. 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%

39. 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

40. 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

41. 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

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

43. 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

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

45. 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
–Don’t allow abuser to transport child to hospital
–Inform ED staff of suspicions of child abuse
–Document completely and thoroughly

46. 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

47. 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

48. 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

49. Pediatric Medical
Emergencies -Neurological
•Management -Basic Steps
–Protect seizing child
–Manage the ABC’s, provide supplemental
oxygen
–Remove excess layers of clothing
–IV of NS or LR TKO rate
–Transport all seizure patients, support the
parents

50. Pediatric Medical
Emergencies -Neurological
•Management -If status epilepticus
–IV of NS or LR TKO rate
–Perform a Dextrostix <80 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

51. 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

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

53. Meningitis
•Management
–Monitor ABC’s 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

54. Pediatric Medical Emergencies -
Neurological
•Reye’s 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

55. Pediatric Medical Emergencies -
Neurological
•Reye’s syndrome -Complications
–Respiratory failure
–Cardiac arrhythmias
–Acute pancreatitis

56. 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

57. Pediatric Medical Emergencies -
Neurological
•Reye’s syndrome -Management
–General and supportive
–Maintain ABC’s
–Administer supplemental oxygen
–Rapid transport

58. Child’s 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

59. 5 Most Common Respiratory
Emergencies
•Asthma
•Bronchiolitis
•Croup
•Epiglotitis
•Foreign bodies

60. 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 child’s airway due to edema &
mucus leads to further compromise

61. 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

62. Asthma
•Management
–Assess & monitor ABC’s
–Big O’s (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

63. 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

64. 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

65. 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

66. 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

67. 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?

68. 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

69. Croup
•Management
–Assess & monitor ABC’s
–High flow humidified O2; blow by if child won’t
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

70. 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

71. 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

72. 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

73. Epiglotitis
•Management
–Assess & monitor ABC’s
–Do not make child lie down
–Do not manipulate airway
–High flow humidified O2; blow by if child won’t
tolerate mask
–Limit exam/handling to avoid agitation
–Be prepared for respiratory arrest, assist
ventilations and perform CPR as needed
–Contact medical control

74. 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

75. 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

76. Aspirated Foreign Body
•Management -Complete Obstruction
–Attempt to clear using BLS techniques
–Attempt removal with direct laryngoscopy
and Magill forceps
–Cricothyrotomy may be indicated

77. 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

78. 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

79. 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

80. Mild, Moderate, & Severe
Dehydration
•Physical Assessment/ Vital signs
–Capillary refill
–Skin color
–Alertness, activity level

81. 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

82. 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

83. 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

84. 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

86. 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

88. Congenital Heart Disease
•Management
–Monitor ABC’s & 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 ABC’s & treat as patient’s condition
warrants
–Have hospital notify child’s physician if
possible