Pediatric emergencies

Barry Kidd 2010Barry Kidd 2010 11
PEDIATRIC EMERGENCIESPEDIATRIC EMERGENCIES

Barry Kidd 2010 2
OVERVIEW: PediatricsOVERVIEW: Pediatrics
 CHILD DEVELOPMENTCHILD DEVELOPMENT
 PEDIATRIC EPIDEMIOLOGYPEDIATRIC EPIDEMIOLOGY
 PROVIDER/FAMILY INTERACTIONSPROVIDER/FAMILY INTERACTIONS
 PEDIATRIC ASSESSMENTPEDIATRIC ASSESSMENT
 MEDICAL EMERGENCIESMEDICAL EMERGENCIES
 PEDIATRIC TRAUMAPEDIATRIC TRAUMA
 PEDIATRIC RESUSCITATIONPEDIATRIC RESUSCITATION

Barry Kidd 2010 3
Emotional & BehavioralEmotional & Behavioral
Development: InfantDevelopment: Infant
 Time of rapid change/physical growthTime of rapid change/physical growth
 Birth to 6 monthsBirth to 6 months
 Recognize parents, has emotional tiesRecognize parents, has emotional ties
 Easier to examine, lacks strengthEasier to examine, lacks strength
 Poor head controlPoor head control
 Rolls overRolls over
 Hands to and in mouthHands to and in mouth

Barry Kidd 2010 4
Behavioral & EmotionalBehavioral & Emotional
Development : InfantDevelopment : Infant
 6 months to 1 year old6 months to 1 year old
 Infant has a clear need of parent/careInfant has a clear need of parent/care
providerprovider
 Infant has an ability to stand, crawl, exploreInfant has an ability to stand, crawl, explore
 Infant is distressed by separationInfant is distressed by separation
 Likely will resist being examinedLikely will resist being examined
 You will likely have parents hold/maintainYou will likely have parents hold/maintain
contactcontact
 The infant crying/holding parents is a copingThe infant crying/holding parents is a coping
mechanismmechanism

Barry Kidd 2010 5
Development: Toddler (1-3yrs.)Development: Toddler (1-3yrs.)
 Age of intense activity and discoveryAge of intense activity and discovery
 Holes need to be filled upHoles need to be filled up
 Taste and touch everything!Taste and touch everything!
 Only parents can be trustedOnly parents can be trusted
 Difficulty in examining/resistanceDifficulty in examining/resistance
 Have limited language/comprehensionHave limited language/comprehension
 Provide support (parents/toys/talk)Provide support (parents/toys/talk)

Barry Kidd 2010 6
Development:Preschooler (3-6)Development:Preschooler (3-6)
 The child has progressed from motorThe child has progressed from motor
development to psychomotor skillsdevelopment to psychomotor skills
refinement.refinement.
 Full awareness of body/body partsFull awareness of body/body parts
 Concrete thought process/interpretationConcrete thought process/interpretation
 Vivid imagination/dramatizesVivid imagination/dramatizes
 Fears the unknown/loss of body functionFears the unknown/loss of body function
 Thinks illness/injury is a punishmentThinks illness/injury is a punishment

Barry Kidd 2010 7
Behavioral & Emotional Development:Behavioral & Emotional Development:
School Age (6-12)School Age (6-12)
 Differing levels of behavior/developmentDiffering levels of behavior/development
 Learning from school, peers,familyLearning from school, peers,family
 Understands rational explanationsUnderstands rational explanations
 Is easiest to examine and manageIs easiest to examine and manage
 Issues of modesty are importantIssues of modesty are important
 May regress to other level under stressMay regress to other level under stress
 Fear of death and disabilityFear of death and disability

Barry Kidd 2010 8
Development: Adolescent (13-18)Development: Adolescent (13-18)
 Mental development greatly advancedMental development greatly advanced
 Feel invincible/immune to illness-injuryFeel invincible/immune to illness-injury
 Preoccupied with body appearancePreoccupied with body appearance
 Capable of over-reacting/hysteriaCapable of over-reacting/hysteria
 Feel independent/adequate historiansFeel independent/adequate historians
 Fear of death and disabilityFear of death and disability
 Extremely modestExtremely modest

Barry Kidd 2010 9
PEDIATRIC EMERGENCIES:PEDIATRIC EMERGENCIES:
EpidemiologyEpidemiology
 Trauma is the leading cause of death inTrauma is the leading cause of death in
infants and children (0-18 yrs. old)infants and children (0-18 yrs. old)
 Motor vehicle incidents most frequentMotor vehicle incidents most frequent
 BurnsBurns
 DrowningDrowning
 FallsFalls
 FirearmsFirearms

Barry Kidd 2010 10
EPIDEMIOLOGY: TraumaEPIDEMIOLOGY: Trauma
 Head Trauma: #1 cause of mortalityHead Trauma: #1 cause of mortality
 Blunt Abdominal Trauma: #2 causeBlunt Abdominal Trauma: #2 cause
 Orthopedic TraumaOrthopedic Trauma
 Thoracic TraumaThoracic Trauma
 May be isolated or Multi-systems traumaMay be isolated or Multi-systems trauma

Barry Kidd 2010 11
EPIDEMIOLOGY: MedicalEPIDEMIOLOGY: Medical
 Respiratory EmergenciesRespiratory Emergencies
 Altered Temperature ControlAltered Temperature Control
 SeizuresSeizures
 SepsisSepsis
 DehydrationDehydration
 Metabolic EmergenciesMetabolic Emergencies
 Congenital DefectsCongenital Defects
 Toxicological EmergenciesToxicological Emergencies

Barry Kidd 2010 12
Provider-Family :Provider-Family :
INTERACTIONS: FAMILYINTERACTIONS: FAMILY
 When a child is ill or injured- the parents areWhen a child is ill or injured- the parents are
impacted as well.impacted as well.
 Parents reaction is one of “acute grief”Parents reaction is one of “acute grief”
 May view situation as “loss of control”May view situation as “loss of control”
 May be demanding to gain controlMay be demanding to gain control
 Relinquishing child to provider-feel helplessRelinquishing child to provider-feel helpless
 Want answers/directions-NOW!Want answers/directions-NOW!
 Will he/she walk again?/Will they die?Will he/she walk again?/Will they die?

Barry Kidd 2010 13
Provider - Family:Provider - Family:
INTERACTIONS: ProviderINTERACTIONS: Provider
 Acknowledge the parents feelingsAcknowledge the parents feelings
 Provide reassuranceProvide reassurance
 Involve the parents with assessmentInvolve the parents with assessment
 Be very communicativeBe very communicative
 Remain calm/Project confidenceRemain calm/Project confidence
 Develop trust with parents/patientDevelop trust with parents/patient
 Give Information/Simple languageGive Information/Simple language
 Assure needs/care of other childrenAssure needs/care of other children

Barry Kidd 2010 14
PEDIATRIC ASSESSMENTPEDIATRIC ASSESSMENT
 Anatomic & Physiological DifferencesAnatomic & Physiological Differences
 Approaches to the child/communicationApproaches to the child/communication
 Chief ComplaintChief Complaint
 AppearanceAppearance
 Physical ExaminationPhysical Examination
 ABCsABCs
 Vital SignsVital Signs
 Review of SystemsReview of Systems

Barry Kidd 2010 15
PEDIATRIC ASSESSMENT:PEDIATRIC ASSESSMENT:
Anatomy & Physiology: (head)Anatomy & Physiology: (head)
 Head is larger and heavierHead is larger and heavier
-proportionately until age 4, v. adult-proportionately until age 4, v. adult
 Infants have anterior fontanel which isInfants have anterior fontanel which is
normally soft and flat.normally soft and flat.
 Fontanels can be used as an indicator ofFontanels can be used as an indicator of
increased ICP or dehydration.increased ICP or dehydration.
 Bones are soft and separated by cartilageBones are soft and separated by cartilage
until age twountil age two

Barry Kidd 2010 16
Anatomy & Physiology: airwayAnatomy & Physiology: airway
 The face is smaller/flexible nasal bridgeThe face is smaller/flexible nasal bridge
 Newborns/infants are obligate nasalNewborns/infants are obligate nasal
breathers- passages easily obstructedbreathers- passages easily obstructed
 Tongue is large/mandibular muscles areTongue is large/mandibular muscles are
immatureimmature
 Airway diameter is small (4 v. 20mm)Airway diameter is small (4 v. 20mm)
 Tracheal rings are more elasticTracheal rings are more elastic
 Vocal cords are high/more anteriorVocal cords are high/more anterior

Barry Kidd 2010 17
Anatomy & Physiology:Anatomy & Physiology:
(thoracic)(thoracic)
 Ribs are elastic: more cartilageRibs are elastic: more cartilage
 Rib cage has greater complianceRib cage has greater compliance
 Diaphragm-primary respiratory muscleDiaphragm-primary respiratory muscle
 Chest muscles not well developedChest muscles not well developed
 Lung tissue fragile-pulmonary contusionLung tissue fragile-pulmonary contusion
 Mobile mediastinumMobile mediastinum
 Respiratory rates are fasterRespiratory rates are faster
 Cardiac rates are fasterCardiac rates are faster

Barry Kidd 2010 18
(Abdomen)(Abdomen)
 Abdominal breathers- observe abdomenAbdominal breathers- observe abdomen
to determine resp-rateto determine resp-rate
 Abdominal muscles are immatureAbdominal muscles are immature
 Limited protection of organs resultant fromLimited protection of organs resultant from
lack of musculaturelack of musculature
 Increased vulnerability to blunt forceIncreased vulnerability to blunt force
traumatrauma

Barry Kidd 2010 19
(extremities)(extremities)
 Bones are softer until adolescenceBones are softer until adolescence
 Greater susceptibility to fractures due toGreater susceptibility to fractures due to
bending and splinteringbending and splintering
 Long bones develop from growth plates orLong bones develop from growth plates or
epiphysis- fractures in these areas areepiphysis- fractures in these areas are
more criticalmore critical
 Increased activity level -types leads to aIncreased activity level -types leads to a
variety of orthopedic traumavariety of orthopedic trauma

Barry Kidd 2010 20
(Nervous system)(Nervous system)
 Development throughout childhoodDevelopment throughout childhood
 Motor development proceeds bilaterallyMotor development proceeds bilaterally
from head to toefrom head to toe
 Sensation is present everywhere from theSensation is present everywhere from the
time of birth-infants feel paintime of birth-infants feel pain
 All brain cells are present at birth but areAll brain cells are present at birth but are
not fully developed-increasednot fully developed-increased
susceptibility to brain traumasusceptibility to brain trauma

Barry Kidd 2010 21
(Integumentary System)(Integumentary System)
 Body surface are is larger in proportion toBody surface are is larger in proportion to
body mass.body mass.
 Skin is thinner with less subcutaneous fat.Skin is thinner with less subcutaneous fat.
 Neonates are further compromised due toNeonates are further compromised due to
immature thermal regulation mechanisms.immature thermal regulation mechanisms.
 Very susceptible to hypothermiaVery susceptible to hypothermia

Barry Kidd 2010 22
PEDIATRIC:PEDIATRIC:
Approach/CommunicationApproach/Communication
 Evaluate location/position of childEvaluate location/position of child
 Look for environmental clues/mechanismsLook for environmental clues/mechanisms
of injuryof injury
 Observe the interactions of the child withObserve the interactions of the child with
the parents or care providersthe parents or care providers
 Take history from parents/providersTake history from parents/providers
 Don’t overlook the patient’s ability toDon’t overlook the patient’s ability to
provide you with informationprovide you with information

Barry Kidd 2010 23
PEDIATRIC:PEDIATRIC:
Approach-CommunicationApproach-Communication
 Give the child a chance to trust you firstGive the child a chance to trust you first
 Use age appropriate languageUse age appropriate language
 Provide a toy and include EMS equipmentProvide a toy and include EMS equipment
as appropriateas appropriate
 Project a calm demeanorProject a calm demeanor
 Use parent as a role model/involveUse parent as a role model/involve
 Ask questions to gain the child’sAsk questions to gain the child’s
participation- but don’t waste time!participation- but don’t waste time!

Barry Kidd 2010 24
PEDIATRIC: Chief Complaint-PEDIATRIC: Chief Complaint-
History of the Present Illness: hpiHistory of the Present Illness: hpi
 Why was the EMS initiated?Why was the EMS initiated?
 Present illness-symptomsPresent illness-symptoms
 Duration-chronology-onsetDuration-chronology-onset
 Pre-arrival treatment/physician contactPre-arrival treatment/physician contact
Birth weight, complications, neonatal hxBirth weight, complications, neonatal hx
 SAMPLE informationSAMPLE information

Barry Kidd 2010 25
Pediatric Assessment:Pediatric Assessment:
Appearance-Appearance-
 Observe environment-mechanismsObserve environment-mechanisms
 Evaluate all subjective informationEvaluate all subjective information
 Observe for any apparent signsObserve for any apparent signs
 Observe for any apparent abnormalitiesObserve for any apparent abnormalities
 Listen to the child’s cry, voice, breathingListen to the child’s cry, voice, breathing
 Observe the skin colorObserve the skin color
 Observe level of orientation, attention span,Observe level of orientation, attention span,
l.o.c.,l.o.c.,

Barry Kidd 2010 26
PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:
ABC’sABC’s
 Determine level ofDetermine level of
consciousness/responsivenessconsciousness/responsiveness
 Airway-patent-secureAirway-patent-secure
 Breathing- adequacy-supplementBreathing- adequacy-supplement
 CirculationCirculation
 Blood lossBlood loss
 Central pulsesCentral pulses
 Peripheral pulses-Capillary refill time (CRT)Peripheral pulses-Capillary refill time (CRT)

Barry Kidd 2010 27
AIRWAY: assessmentAIRWAY: assessment
 Crying-talking = a patent airwayCrying-talking = a patent airway
 Hoarseness= an airway obstruction orHoarseness= an airway obstruction or
inflammationinflammation
 Moaning = altered L.O.C.Moaning = altered L.O.C.
 Stridor= airway obstruction or vocal cordStridor= airway obstruction or vocal cord
inflammationinflammation
 Wheezing= bronchial secretionsWheezing= bronchial secretions
 Grunting= severe respiratory distressGrunting= severe respiratory distress

Barry Kidd 2010 28
AIRWAY: assessmentAIRWAY: assessment
 Gurgling= a penetrating chest woundGurgling= a penetrating chest wound
 Observe the abdomen to determine respiratoryObserve the abdomen to determine respiratory
rate/characterrate/character
 observe for nasal flaring, sternal retractionsobserve for nasal flaring, sternal retractions
,cyanosis or mottling as signs of respiratory,cyanosis or mottling as signs of respiratory
distressdistress
 Auscultate the lungs: midaxillary, midclavicular-Auscultate the lungs: midaxillary, midclavicular-
just beneath clavicles,listen for breaths at end ofjust beneath clavicles,listen for breaths at end of
crycry

Barry Kidd 2010 29
CIRCULATORY: assessmentCIRCULATORY: assessment
 Skin temp. is best indicator of early shockSkin temp. is best indicator of early shock
 Use forehead, chin or sternumUse forehead, chin or sternum
 Estimate blood loss: 80cc/kg/wt =totalEstimate blood loss: 80cc/kg/wt =total
blood volume (pediatric)blood volume (pediatric)
 Evaluate distal pulses/central pulsesEvaluate distal pulses/central pulses
 Determine blood pressure: 80+(2 x age) =Determine blood pressure: 80+(2 x age) =
systolic BP (normotensive)systolic BP (normotensive)

Barry Kidd 2010 30
PEDIATRIC: Vital SignsPEDIATRIC: Vital Signs
 Pulse: Central & Peripheral/SpO2Pulse: Central & Peripheral/SpO2
 Respiration: rate/character/strengthRespiration: rate/character/strength
 Blood Pressure (only for older children)Blood Pressure (only for older children)
 TemperatureTemperature
 Skin colorSkin color

Barry Kidd 2010 31
REVIEW of SYSTEMS:REVIEW of SYSTEMS:
assessmentassessment
 Head, Ears, Eyes, Nose, Throat- reassessmentHead, Ears, Eyes, Nose, Throat- reassessment
of airway, fontanelles- depressed =dehydration,of airway, fontanelles- depressed =dehydration,
bulging= increased intracranial pressurebulging= increased intracranial pressure
 Neck- trachea midline, JVD-difficultNeck- trachea midline, JVD-difficult
 Thorax-symmetry, sounds, abnormalities,Thorax-symmetry, sounds, abnormalities,
discolorationsdiscolorations
 Abdomen-resp. rate, shape-round, appearance,Abdomen-resp. rate, shape-round, appearance,
light palpation, intra abdominal bleeding?light palpation, intra abdominal bleeding?

Barry Kidd 2010 32
REVIEW of SYSTEMS:REVIEW of SYSTEMS:
assessmentassessment
 Extremities- alignment, Range of motionExtremities- alignment, Range of motion
 Skin- temperature, color, textureSkin- temperature, color, texture
 Neurological- GCS, mentation, level ofNeurological- GCS, mentation, level of
activity (active v. passive) posturing-activity (active v. passive) posturing-
decortication/decerebration/rigiditydecortication/decerebration/rigidity
 Reassessment of Vital SignsReassessment of Vital Signs
 Continuous observation: trends/changes-Continuous observation: trends/changes-
variationsvariations

Barry Kidd 2010 33
MEDICAL EMERGENCIESMEDICAL EMERGENCIES
 RESPIRATORY EMERGENCIES -mostRESPIRATORY EMERGENCIES -most
commonly encountered-highest mortalitycommonly encountered-highest mortality
rate:rate:
 AsthmaAsthma
 CroupCroup
 EpiglottitisEpiglottitis
 Foreign bodyForeign body
 General respiratory distressGeneral respiratory distress

Barry Kidd 2010 34
ASTHMAASTHMA
 Chronic recurrent lower airway diseaseChronic recurrent lower airway disease
with episodic attacks of bronchialwith episodic attacks of bronchial
constrictionconstriction
 Response to allergen, stress, activityResponse to allergen, stress, activity
 Inspiratory/expiratory wheezingInspiratory/expiratory wheezing
 Coarse rhonchi, sometimes cyanoticCoarse rhonchi, sometimes cyanotic
 Apprehensive/combativeApprehensive/combative
 May lead to ventilatory failureMay lead to ventilatory failure

Barry Kidd 2010 35
ASTHMA: EMS managementASTHMA: EMS management
 Assessment/oxygen via peds maskAssessment/oxygen via peds mask
 Assisted medications-bronchodilatorsAssisted medications-bronchodilators
 Status Asthmaticus .Status Asthmaticus .
 Minimal air movement/aggressive mgmt.Minimal air movement/aggressive mgmt.

Barry Kidd 2010 36
CROUPCROUP
 Upper respiratory viral infectionUpper respiratory viral infection
 swelling and inflammation of larynx, subglotticswelling and inflammation of larynx, subglottic
tissue and sometimes trachea and bronchitissue and sometimes trachea and bronchi
 More common in spring and fallMore common in spring and fall
 Usually with cold symptoms 1-3 daysUsually with cold symptoms 1-3 days
 Barking-”seal like” coughBarking-”seal like” cough
 Moderate to severe respiratory distress withModerate to severe respiratory distress with
associated signs/symptomsassociated signs/symptoms

Barry Kidd 2010 37
CROUP: EMS ManagementCROUP: EMS Management
 Oxygen via NRB if toleratedOxygen via NRB if tolerated
 Blow-by oxygen in high concentrationBlow-by oxygen in high concentration
otherwiseotherwise
 Keep quiet -do not agitateKeep quiet -do not agitate
 Do not attempt manual airway as croupDo not attempt manual airway as croup
may be confused with epiglottitismay be confused with epiglottitis
 Rapid transport/Ventilate as indicatedRapid transport/Ventilate as indicated

Barry Kidd 2010 38
EPIGLOTTITISEPIGLOTTITIS
 Bacterial infection localized to the epiglottisBacterial infection localized to the epiglottis
 Acute swelling of the epiglottis causing a totalAcute swelling of the epiglottis causing a total
airway obstructionairway obstruction
 Affects children 3-6, but can occur in anyoneAffects children 3-6, but can occur in anyone
 Sudden onset-child in tripod positionSudden onset-child in tripod position
 Secretions, drooling, respiratory distress isSecretions, drooling, respiratory distress is
severesevere

Barry Kidd 2010 39
EPIGLOTTITIS-EPIGLOTTITIS-
EMS ManagementEMS Management
 Do not manipulate the airwayDo not manipulate the airway
 Maintain tolerable position-never supineMaintain tolerable position-never supine
 Oxygen via mask or blow byOxygen via mask or blow by
 Minimize movement/agitationMinimize movement/agitation
 Immediate transportImmediate transport
 Positive pressure ventilation -if indicatedPositive pressure ventilation -if indicated

Barry Kidd 2010 40
Altered Temperature Control:Altered Temperature Control:
Fever/hyperthermiaFever/hyperthermia
 Response to an infection or from brain’sResponse to an infection or from brain’s
inability to effect thermoregulationinability to effect thermoregulation
 Greater than 38 C. is cause for concernGreater than 38 C. is cause for concern
 Can lead to febrile seizuresCan lead to febrile seizures
 Core temperature can rise whichCore temperature can rise which
increases oxygen demand and can causeincreases oxygen demand and can cause
metabolic acidosismetabolic acidosis
 Be aware of environmental factorsBe aware of environmental factors

Barry Kidd 2010 41
Fever/hyperthermia:Fever/hyperthermia:
EMS managementEMS management
 ABC’s, vital signs,ABC’s, vital signs,
 Treat seizures accordinglyTreat seizures accordingly
 Promote rapid cooling-sponging to lowerPromote rapid cooling-sponging to lower
temperaturetemperature
 Give oral fluids based on LOC ( have parentsGive oral fluids based on LOC ( have parents
administer)administer)
 Evaluate necessity for transportEvaluate necessity for transport
 Be concerned with a lethargic child having aBe concerned with a lethargic child having a
temperature over 39 C.temperature over 39 C.

Barry Kidd 2010 42
HYPOTHERMIAHYPOTHERMIA
 Pediatric patients are at a high riskPediatric patients are at a high risk
 Larger ratio of body surface area/massLarger ratio of body surface area/mass
 Core body temperature below 35 C.Core body temperature below 35 C.
 EtiologyEtiology
 EnvironmentalEnvironmental
 TraumaTrauma
 Metabolic conditionsMetabolic conditions
 SepsisSepsis

Barry Kidd 2010 43
HYPOTHERMIA:HYPOTHERMIA:
 Assessment/ABCsAssessment/ABCs
 Oxygen via mask-warm humidification?Oxygen via mask-warm humidification?
 Warm environment-external re warmingWarm environment-external re warming
 Core temperature monitoringCore temperature monitoring
 Cautious with movement/re warmingCautious with movement/re warming

Barry Kidd 2010 44
SEIZURESSEIZURES
 Abnormal electrical discharge in the brainAbnormal electrical discharge in the brain
which causes abnormal movements andwhich causes abnormal movements and
altered mental statusaltered mental status
 Varying etiologies-PediatricVarying etiologies-Pediatric
 Fever (febrile seizures)Fever (febrile seizures)
 TraumaTrauma
 Meningitis, encephalitisMeningitis, encephalitis
 Metabolic disorders -diabetic/toxic intakeMetabolic disorders -diabetic/toxic intake

Barry Kidd 2010 45
SEIZURES-EMS ManagementSEIZURES-EMS Management
 Assessment /ABC’sAssessment /ABC’s
 High concentration oxygenHigh concentration oxygen
 Determine etiology/Status epilepticusDetermine etiology/Status epilepticus
 IV access: peripheral (if protocol allows)IV access: peripheral (if protocol allows)
 Administer Dextrose 25%W-2-4ml/kgAdminister Dextrose 25%W-2-4ml/kg
 Appropriate tertiary facilityAppropriate tertiary facility

Barry Kidd 2010 46
MENINGITISMENINGITIS
 Bacterial or viral infection of the meningesBacterial or viral infection of the meninges
of the brain and/or spinal cord.of the brain and/or spinal cord.
 5-10% mortality rate-treated: antibiotics5-10% mortality rate-treated: antibiotics
 90% of cases in children (1 mo-5 yrs.)90% of cases in children (1 mo-5 yrs.)
 Abrupt onset of symptoms: petechiae,Abrupt onset of symptoms: petechiae,
fever, apprehension,fever, apprehension,
 Nuchal rigidity: Kerning’s/ Bruzinski’s signNuchal rigidity: Kerning’s/ Bruzinski’s sign

Barry Kidd 2010 47
Bruzinski’s signBruzinski’s sign

Barry Kidd 2010 48
MENINGITIS:MENINGITIS:
 Wear gown, gloves, eye protection-highlyWear gown, gloves, eye protection-highly
infectiousinfectious
 Assessment/Oxygen-ventilate if neededAssessment/Oxygen-ventilate if needed
 IV access via peripheralIV access via peripheral
 20cc/kg fluid bolus if shock like signs and20cc/kg fluid bolus if shock like signs and
symptomssymptoms
 Rapid transportRapid transport
 Appropriate facility- primary/tertiary?Appropriate facility- primary/tertiary?

Barry Kidd 2010 49
SEPSIS/SEPTIC SHOCKSEPSIS/SEPTIC SHOCK
 SEPSIS-bacterial infection of the bloodSEPSIS-bacterial infection of the blood
 Associated frequently with meningitisAssociated frequently with meningitis
 Newborns at great risk-immune systemNewborns at great risk-immune system
 SEPTIC SHOCK-Complication of Sepsis:SEPTIC SHOCK-Complication of Sepsis:
pooling of blood in extremities, dilation ofpooling of blood in extremities, dilation of
vesselsvessels
 Related to other illnesses, pallor, shock,Related to other illnesses, pallor, shock,
mottling, poor sucking/feeding, ICP-upmottling, poor sucking/feeding, ICP-up

Barry Kidd 2010 50
SEPSIS/SEPTIC SHOCKSEPSIS/SEPTIC SHOCK
EMS: ManagementEMS: Management
 Assessment /ABC’sAssessment /ABC’s
 Oxygen-ventilate as neededOxygen-ventilate as needed
 Intubate as requiredIntubate as required
 IV fluid bolus at 20cc/kg IV push-repeatIV fluid bolus at 20cc/kg IV push-repeat
 Rapid transport-don’t delayRapid transport-don’t delay
 Tertiary care facility is most appropriateTertiary care facility is most appropriate

Barry Kidd 2010 51
DEHYDRATIONDEHYDRATION
 Acute loss of body fluids from numerousAcute loss of body fluids from numerous
causes:causes:
 Fever, Vomiting, diarrhea,Fever, Vomiting, diarrhea,
 Diabetic ketoacidosis-renal profusionDiabetic ketoacidosis-renal profusion
 Poor formula preparationPoor formula preparation
 Water is 75% of pediatric body weightWater is 75% of pediatric body weight
 Infants who are dehydrated can lose up toInfants who are dehydrated can lose up to
15% of body weight15% of body weight

Barry Kidd 2010 52
DEHYDRATION:DEHYDRATION:
 Assessment- ABCs: Sunken fontanellesAssessment- ABCs: Sunken fontanelles
 Historical data: last wet diaper?Historical data: last wet diaper?
 Severe dehydration=life threateningSevere dehydration=life threatening
 Administer CPR as needed for circulatoryAdminister CPR as needed for circulatory
collapsecollapse
 Transport to tertiary facility per medicalTransport to tertiary facility per medical
control as indicatedcontrol as indicated

Barry Kidd 2010 53
METABOLIC: KETOACIDOSISMETABOLIC: KETOACIDOSIS
 Cells cannot utilize glucose for energy -bodyCells cannot utilize glucose for energy -body
attempts to breakdown fatsattempts to breakdown fats
 known diabetic-unbalanced insulin doseknown diabetic-unbalanced insulin dose
 Early-polyuria, polydipsia (the patient displaysEarly-polyuria, polydipsia (the patient displays
excessive thirst) ,weight lossexcessive thirst) ,weight loss
 Acute-ketone breath, Kussmaul respirations,Acute-ketone breath, Kussmaul respirations,
dehydration, rigid abdomen, comatose conditiondehydration, rigid abdomen, comatose condition
 Life threatening emergencyLife threatening emergency

Barry Kidd 2010 54
METABOLIC: HypoglycemiaMETABOLIC: Hypoglycemia
 Inadequate levels of blood glucoseInadequate levels of blood glucose
 Variance in activity/growth in pediatricsVariance in activity/growth in pediatrics
 Mild- hunger, weakness, tachycardiaMild- hunger, weakness, tachycardia
 Severe - altered LOC, sweating,Severe - altered LOC, sweating,
seizures, : must replace glucoseseizures, : must replace glucose
 Can occur in neonates - blood glucoseCan occur in neonates - blood glucose
levels are routinely checked.levels are routinely checked.
 Can be life threateningCan be life threatening

Barry Kidd 2010 55
METABOLIC EMERGENCIESMETABOLIC EMERGENCIES
 Assessment-ABC’s- good historianAssessment-ABC’s- good historian
 Oxygen via mask-ventilate as requiredOxygen via mask-ventilate as required
 Administer D25%/W 2-4mg/kg asAdminister D25%/W 2-4mg/kg as
required,required,
 Protect airwayProtect airway

Barry Kidd 2010 56
CONGENITALCONGENITAL
ABNORMALITIES: PediatricABNORMALITIES: Pediatric
 Congenital birth defects typically occur toCongenital birth defects typically occur to
the heart and the surrounding greatthe heart and the surrounding great
vessels.vessels.
 When blood from the two circulatoryWhen blood from the two circulatory
pathways mix-hypoxemia occurs.pathways mix-hypoxemia occurs.
 Talk to parents-What is normalTalk to parents-What is normal
 Dydrhythmias, CHF, cyanosis, mottlingDydrhythmias, CHF, cyanosis, mottling
 Respiratory distress-general precursorRespiratory distress-general precursor

Barry Kidd 2010 57
Congenital Abnormalities:Congenital Abnormalities:
 Parents know more than us!!Parents know more than us!!
 Oxygen/ventilateOxygen/ventilate
 For a cyanotic spell-the knee chestFor a cyanotic spell-the knee chest
position is bestposition is best
 Contact medical controlContact medical control
 Tertiary facility where treated is the mostTertiary facility where treated is the most
appropriate receiverappropriate receiver

Barry Kidd 2010 58
““HIGH TECH KIDS”HIGH TECH KIDS”
 Variety of chronic or terminal illnessesVariety of chronic or terminal illnesses
 Congenital defectsCongenital defects
 Cystic FibrosisCystic Fibrosis
 SIDS candidates/ PremiesSIDS candidates/ Premies
 Feeding disordersFeeding disorders
 TraumaTrauma
 Ventilators, Infusion pumps, central lines,Ventilators, Infusion pumps, central lines,
feeding tubes, trachs, hospicefeeding tubes, trachs, hospice

Barry Kidd 2010 59
PEDIATRIC TOXICOLOGYPEDIATRIC TOXICOLOGY
 Poisoning is a major cause of death inPoisoning is a major cause of death in
children under 5 years oldchildren under 5 years old
 90% occur in child’s home/parent present90% occur in child’s home/parent present
at timeat time
 Drug experimentation/suicide attemptsDrug experimentation/suicide attempts
 Any consumable material is suspectAny consumable material is suspect
 Toddlers are high risk group due to theirToddlers are high risk group due to their
exploratory natureexploratory nature

Barry Kidd 2010 60
PEDIATRIC TOXICOLOGYPEDIATRIC TOXICOLOGY
EMS: ManagementEMS: Management
 Gather adequate history/environmentalGather adequate history/environmental
assessment-labels, clues, residue etc.assessment-labels, clues, residue etc.
 Oxygen via mask/ventilate-intubateOxygen via mask/ventilate-intubate
 Information assessment-poison controlInformation assessment-poison control
 Medical Control- advanced toxicologicalMedical Control- advanced toxicological
interventions- HazMat as requiredinterventions- HazMat as required

Barry Kidd 2010 61
PEDIATRIC TRAUMAPEDIATRIC TRAUMA
 Leading cause of death in childrenLeading cause of death in children
 Four times greater than cancerFour times greater than cancer
 MVI= 44% of deathsMVI= 44% of deaths
 Burns = 15%Burns = 15%
 Drowning= 14.6%Drowning= 14.6%
 Aspiration=3.5%Aspiration=3.5%
 Firearms= 4%Firearms= 4%

Barry Kidd 2010 62
PEDIATRIC TRAUMAPEDIATRIC TRAUMA
(frequency)(frequency)
 Head:Head: 38%38%
 ExtremitiesExtremities 32%32%
 AbdomenAbdomen 11%11%
 ChestChest 9%9%
 Blunt trauma is most common mechanismBlunt trauma is most common mechanism
 Effective management is criticalEffective management is critical

Barry Kidd 2010 63
Pediatric Trauma AssessmentPediatric Trauma Assessment
 Children with trauma die from hypoxia andChildren with trauma die from hypoxia and
hypoperfusion secondary to specifichypoperfusion secondary to specific
injuriesinjuries
 Airway (stabilize C-spine)Airway (stabilize C-spine)
 Breathing (O2/ventilate/intubate)Breathing (O2/ventilate/intubate)
 Circulation(bleeding,central/peripheral)Circulation(bleeding,central/peripheral)
 Disability (LOC / neuro)Disability (LOC / neuro)
 Exposure (thermoregulation)Exposure (thermoregulation)

Barry Kidd 2010 64
Pediatric Trauma ManagementPediatric Trauma Management
 Assure Scene SafetyAssure Scene Safety
 Effective Incident Size-UpEffective Incident Size-Up
 Effective Incident ManagementEffective Incident Management
 Request Additional ResourcesRequest Additional Resources
 Patient AssessmentPatient Assessment
 Determine Load/Go StatusDetermine Load/Go Status
 Rapid TransportRapid Transport
 Appropriate Patient CareAppropriate Patient Care

Barry Kidd 2010 65
SPECIAL CONSIDERATIONS:SPECIAL CONSIDERATIONS:
Pediatric TraumaPediatric Trauma
 Capillary refill is the best indicator of perfusionCapillary refill is the best indicator of perfusion
and early shock in peds.and early shock in peds.
 Hyperventilation is indicated early on withHyperventilation is indicated early on with
suspected head trauma/monitor and manage thesuspected head trauma/monitor and manage the
airway.airway.
 Understand ranges for pediatric vital signs:Understand ranges for pediatric vital signs:
watch for trends--watch for trends--

Barry Kidd 2010 66
NEONATAL RESUSCITATION:NEONATAL RESUSCITATION:
Neonates in perspective:Neonates in perspective:
 Neonates must make three physiologicalNeonates must make three physiological
adaptations after birth:adaptations after birth:
 Changing the circulatory patternChanging the circulatory pattern
 Emptying lungs/ventilationEmptying lungs/ventilation
 Maintaining thermoregulationMaintaining thermoregulation
 Only about 10-20% require resuscitativeOnly about 10-20% require resuscitative
support to make these transitionssupport to make these transitions

Barry Kidd 2010 67
Physiology of birth (neonates)Physiology of birth (neonates)
 Chest is compressed during vaginal delivery:Chest is compressed during vaginal delivery:
fluid forced out/recoil-air influid forced out/recoil-air in
 Cutting the umbilical cord ends fetal circulation:Cutting the umbilical cord ends fetal circulation:
Peripheral vascular resistance begins-pulmonaryPeripheral vascular resistance begins-pulmonary
circulationcirculation
 Neonates lose heat rapidly after birthNeonates lose heat rapidly after birth
 Large body surface areaLarge body surface area
 Thin skin/little fat-insulationThin skin/little fat-insulation
 Conserve heat by flexion of extremitiesConserve heat by flexion of extremities

Barry Kidd 2010 68
Anatomy/Physiology (neonates)Anatomy/Physiology (neonates)
 37-40 weeks gestation (full term) 7.5 lbs37-40 weeks gestation (full term) 7.5 lbs
 Premature: less than 37 wks.: 1-4 lbsPremature: less than 37 wks.: 1-4 lbs
 Obligate nose breathers/irregular breathing withObligate nose breathers/irregular breathing with
apnea/obstructed naresapnea/obstructed nares
 Maternal complications predicate resuscitationMaternal complications predicate resuscitation
 Maternal illnessMaternal illness
 Substance abuseSubstance abuse
 HemorrhageHemorrhage
 Delivery complicationsDelivery complications

Barry Kidd 2010 69
NEONATAL ASSESSMENTNEONATAL ASSESSMENT
 Maternal history/delivery complicationsMaternal history/delivery complications
 Presenting part-during birthPresenting part-during birth
 Presence of meconiumPresence of meconium
 Vital signs: BP:55/30-75/40 P: 120-160 R:Vital signs: BP:55/30-75/40 P: 120-160 R:
30-60, Temp: 96.8-98.630-60, Temp: 96.8-98.6
 APGAR SCORE : (1-5 minutes after)APGAR SCORE : (1-5 minutes after)
 Reflexes: sucking,blinking, noiseReflexes: sucking,blinking, noise
 Management based on assessmentManagement based on assessment

Barry Kidd 2010 70
APGAR SCORING ( 1APGAR SCORING ( 1
min/5min)min/5min)
 A: Appearance or colorA: Appearance or color
 P: PulseP: Pulse
 G: Grimace with cryingG: Grimace with crying
 A: Activity or muscle toneA: Activity or muscle tone
 R: Respiratory effortR: Respiratory effort
 Score of 7-10: normalScore of 7-10: normal
 Score of 4-6: stimulate,suction, oxygenScore of 4-6: stimulate,suction, oxygen
 Score of O-3: ResuscitationScore of O-3: Resuscitation

Barry Kidd 2010 71
Neonatal ManagementNeonatal Management
 Suction, dry, position, stimulate,warm,Suction, dry, position, stimulate,warm,
 Oxygenate : blow by o2Oxygenate : blow by o2
 VentilateVentilate
 CPR: if rate less than (60-80)CPR: if rate less than (60-80)
 Meconium Aspiration: suctionMeconium Aspiration: suction

Barry Kidd 2010 72
QUESTIONSQUESTIONS

Pediatric emergencies

More Related Content

What's hot

Viewers also liked

Similar to Pediatric emergencies

More from VASS Yukon

Recently uploaded

Pediatric emergencies