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 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
– 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
?

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 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