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  • 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 not saying
  • 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 • Oklahoma – MVA 43% – MVA 35% – Burns 14.9% – Drowning 14.5% – Drowning 14.6% – Burns 14.0% – Aspiration 3.4% – Firearms 9.9% – Firearms 3.0% – Aspiration 5.7% – Falls 2.0% – Stab/cut ?
  • 34. Frequency of Injured Body Parts• Head 48%• Extremities 32%• 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 childs 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 – Childs 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