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pediatric-emergencies.pptx
- 1. Common Medical Emergencies in School Children By Dr JeremiahK.M. Ocloo KCMC Hospital
- 2. This presentation coversonly a snapshot of the subjects presented that are relevant for this setting- You are encouraged to do further research and dive deeper into each topic. Not all pediatric emergencies are covered in this presentation- only some common conditions.
- 3. Overview •Pediatric Patient Assessment •Allergic Reaction& Anaphylaxis •Asthma •Foreign Bodies •Croup •Hyperglycemia •Hypoglycemia •Hypovolemia •Seizures •Overdose & Poisoning •Cardiac arrest
- 4. Objectives • Identify commonpediatric medical emergencies that present in the prehospital environment. • Review BLS treatment for common pediatric medical emergencies. • Describe the signs and symptoms of respiratory distress and failure in a child • List and describe the anatomical and physiological differences between children and adults
- 5. INTRODUCTION As kids andteens grow and change, there’s a lot to keep track of. So, health care providers screen for different things at different times in a child’s life. They can do this in different ways. During the exam, health care providers can screen for issues with a child’s: •Growth/development •vision •hearing •dental health •spine Using a blood test or other kind of test, they can screen for: •lead poisoning •anemia •high cholesterol
- 6. Body mass index (BMI)is a person’s weight in kilograms divided by the square of height in meters. It is an inexpensive and easy way to screen for weight categories that may lead to health problems. For children and teens, BMI is age- and sex-specific and is often referred to as BMI-for-age.
- 8. Signs: are elicitedin the patient , they constitute the features of the condition in that patient that can be seen. Symptoms: are features which patients report.
- 10. Faceandbody habitus. • Doesthe patient's appearance suggest any particular diseases • Is there an abnormal distribution of body hair • Is there anything about the patient to trigger thoughts about Paget’s disease, Mar- Specific signs are associated with different diseases: consider the nails (koilonychia= iron deficiency), subcutaneous nodules (rheumatoid, neurofi broma?), and look for lymph nodes (cervical, axillary, inguinal).
- 11. Skin colour: • Blue/purple = cyanosis(can also be central only, p28). • Yellow = jaundice (yellow skin can also be caused by uraemia, pernicious anaemia,
- 12. Skin colour: • Pallor:this is non- specific; anaemia is assessed from the palmar skin creases (when spread) and conjunctivae the patient is probably anaemic. • Hyperpigmentation: Addison’s, haemochromatosis (slate-grey)
- 13. Pediatric Patient Assessment •Pulse/resp rates may change rapidly • Crying complicates • Stable appearance doesn’t mean no problem • All actions take into account developmental stage continued
- 14. Assessment Use clues basedon child’s behavior • Activity level • Eye contact • Irritable or agitated? • Response to teachers voice
- 15. Kids are not littleAdults
- 16. Anatomy and Physiology •Inherent differences in intellect, size, proportion, and metabolism • Large variations in behavior, vital signs, ability to cope occur at various stages of development
- 17. NOSE: Generally smaller,increased resistance, Smaller septum & nasal bridge is flat and flexible . . . Obligatory nose breathers VOCAL CORDS: located at C3-4 versus C5-6 in adults . . . Larynx is more anterior Contributes to aspiration if neck is hyperextended CRICOID RING Is the narrowest part of the airway 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 Airway: Child vs Adult
- 18. Airway • Relatively smallmouths and airways • Tongue is proportionally larger & bulbous until about age 8 • Tonsils & adenoids swelling can cause respiratory distress • Glottis opening is narrow • Foreign body obstruction concerns contin ued
- 19. Airway Trachea is shorter,smaller, softer, more flexible May collapse if neck is hyperextended
- 20. Body Surface Area Childrendo not have a larger body surface area than adults. They have a larger PERCENTAGE of surface area for their weight than adults do. This is because children do not have highly developed muscle. Most of their mass is fat and water which weighs less. Bones are also less dense at a younger age.
- 21. • Head toBody ratio and relative size and location of anatomic features make children more susceptible to head and abdominal injury • Underdeveloped anatomy leads to chest pliability and less protection of thoracic cage and less effective use of accessory muscles • Arrest – Cardiac arrest typically results from untreated respiratory arrest Child vs Adult
- 22. Skin, Bones, Joints •Surface area is greater, skin is thinner • Less muscle mass & body fat • Musculoskeletal system is immature and grows rapidly • Bones, joints, ligaments are softer & more flexible • Higher rate of internal organ injury • Greenstick fractures • Growth plate issues
- 23. Thorax - Childvs Adult • Horizontal ribs – more diaphragmatic breathing • Flatter Diaphragm • Ribs & Sternum is cartilage - less stability of chest wall, requires more use of diaphragm • Less pulmonary reserve • Heart takes up more thoracic space • Poor accessory muscle development • Larger abdominal organs - pushes up diaphragm
- 24.
- 25. Look for signsof airway obstruction • increased chest and abdominal movements (See-Saw) • Accessory Muscle Use • Central cyanosis • Absent to no Breath sounds • Depressed consciousness Treat airway obstruction as a medical emergency • In the majority of cases, simple methods of airway management are all that is necessary - - Positioning, • Chin Lift,
- 26. Look for generalsigns of respiratory distress, sweating, cyanosis, accessory muscle use – It is vital to diagnose and treat immediately life threatening conditions (Severe Asthma, Tension Pneumothorax, Foreign Body) •Respiratory Rate & rhythm •Equal chest expansion •Breath sounds •Stridor, Rales, Rhonchi, Wheezing •Air Exchange •Chest deformity •Abdominal distension
- 27. Respiratory pathology thatmay compromise circulatory state - - - tension pneumothorax • Look for signs of poor cardiac output • Peripheral and central pulses • Blood Pressure • Reduced level of consciousness • Low urine output (less wet diapers) • Reduced PO intake • Look for signs of bleeding In almost all medical/surgical emergencies, consider hypovolemia to be the primary cause of shock unless proven otherwise.
- 28. Signs of Disability- - coma/convulsion - -Common causes of unconsciousness include profound hypoxia, hypercapnea, cerebral hypoperfusion or recent sedative/analgesic drug ingestion •Review ABC’s – exclude hypoxia and hypotension • Assess tone, Pupil size • R/O Accidental Ingestion – give appropriate antagonist where available • Monitor LOC • Blood Glucose Level D can also stand for signs of dehydration • Signs of shock have already been looked for while assessing circulation but specific examination for skin turger, sunken eyes, dry mucus membranes
- 29. Check Temperature -- Kids will become hyper/hypo thermic faster than an adult Look all over the body - - - back, groin Assess in well lit area
- 30. Hyperglycemia (high bloodsugar) • What is it? • What causes it? • Almost exclusively related to diabetes mellitus type 1 in pediatric patients. • May have triggers. • Signs & Symptoms • The “3 P’s” of hyperglycemia • Polyuria • Polyphagia • Polydipsia • Headache • Altered mental status • Kussmaul respirations • Smell of ketones • Mngt: BLS • ABCs • Provide oxygen and ventilations as needed
- 31. Hypoglycemia (Low bloodsugar) • What is it? • What causes it? • Usually a complication of insulin administration in a child with type 1 diabetes. • Poor feeding/missed meal • Signs & Symptoms • Hunger • Irritability • Altered mental status • Pallor and diaphoresis • Usually a sudden onset • Treatment: BLS • ABCs • Provide oxygen and ventilations as needed • Oral glucose • IM glucagon
- 32. Hypovolemia (low bloodvolume) • What is it? • An inadequate amount of fluid in the body. • What causes it? • Bleeding due to injuries • Vomiting and diarrhea • Blood loss • Diabetic ketoacidosis • Exertion and/or poor fluid intake • Signs and Symptoms • Generalized weakness • Lethargy • Altered mental status • Pallor • Dry skin and mucus membranes • Sunken fontanelles • Poor skin turgor • Tachycardia • Hypotension Management: BLS • ABCs • Provide oxygen and ventilations as needed • Monitor glucose
- 33. Cardiac Arrest (Heartstops beating) • What is it? • The cessation of the mechanical activity of the heart. • What causes it? • Primary medical causes in children: • Airway or respiratory problems • Shock • Signs & Symptoms • Unresponsiveness • Apnea • No palpable pulse • Management: BLS • ABCs • Provide oxygen and ventilations as needed • IV/IO epinephrine 1:10,000 • Attach AED and follow prompts. • No AED use for newborns (<1 hour)
- 34. Respiratory Failure/Cardiac Arrest •Young children are susceptible • Heart and respiratory rate increase • Respiratory system becomes exhausted – fails • Hypoxia follows, then cardiac arrest • Bradycardia with resp distress is an ominous sign
- 35. Upper Airway Disease Croup Foreign Body Epiglottitis Bacterial Tracheitis Asthma Bronchiolitis Pneumonia ForeignBody Lower Airway Disease Noise during Inspiration Proximal to Thoracic Inlet Nose – Pharynx – Larynx • Awake/Crying • It child Improves • Nose/Pharynx • If child Deteriorates • Larynx Noise during Exhalation Distal to Thoracic Inlet Trachea, Bronchi, Peripheral Airways
- 36.
- 37. Basics Upper respiratory viral infection Occursmostly among ages 6 months to 3 years More prevalent in fall and spring Edema develops, narrowing the airway lumen (Steeple Sign) Severe cases may result in complete obstruction Croup
- 38. Croup • Physical exam/Assessment •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 • Any difficulty swallowing? • Drooling present
- 39. Management Assess & monitorABC’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 Croup
- 40. 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
- 41. Assessment Complete obstruction will presentas 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 Aspirated Foreign Body
- 42. Aspirated Foreign Body CompleteObstruction Attempt to clear using BLS techniques Attempt removal with direct laryngoscopy and Magill forceps Cricothyrotomy may be indicated Partial obstruction Make child comfortable Administer humidified oxygen Encourage child to cough Have intubation equipment available Transport to hospital for removal with bronchoscope
- 44. Lower Airway Disease • Narrower tracheaand bronchi • Poiseulle’s Law - Edema If radius is halved, resistance increases 16x
- 45.
- 46.
- 47. Asthma • What isit? • A completely reversible obstructive airway disease. • Three components: • Bronchospasm • Edema • Excessive mucus production • What causes it? • Environmental & genetic factors • Exacerbations are caused by a trigger. • Pollen, dust, smoke, animal dander • Temperature changes • Physical activity • Signs & Symptoms • Dyspnea • Wheezing • Coughing • Pertinent negatives • Treatment: BLS • ABCs • Provide oxygen & ventilations as needed • Assist with metered-dose inhaler • Epi-Pen or IM epinephrine administration
- 48. •Ingestion of apotentially toxic substance, drug, household or industrial chemical, plant or waste products Ingestions/Poisonings History Home environment Medications in home Where are chemicals stored? Hobby-related exposures Physical clues (open bottles, plants with missing leaves, etc)
- 49. Physical exam • Vitalsigns • Excitation or •Depression • Pupils • Mental Status • Skin • Management • ABC’s • Decontamination Unknown Ingestions Laboratory workup. Every child should have… Acetaminophen level Salicylate level Ethanol level Chemistry panel including LFT’s Calculate anion gap Urinalysis Consider urine toxicology screen, ABG, urine, pregnancy, imaging (CXR or KUB), Osmolality
- 50. Poisoning • Accidental poisoning •Often can’t tell the difference • Put things in their mouth • Small amounts have large effect
- 51. Ingestion Management Management: • Stabilizeand ABC’s as needed • Oxygen as needed • IV with Normal Saline (keep Hydrated) • NG if unconscious or will not drink •Give activated charcoal • If opiate poisoning • Narcan • If acetaminophen poisoning • N-acetylcysteine
- 52. Causes • Vaccines • Drugs •Insect bites • Food • Latex • Venoms Anaphylaxis Usually begins within a few minutes after exposure evident within 15” Symptoms – Sneezing, Coughing, Itching, Flushing of skin, Facial edema Anxiety, Palpitations, Nausea, Vomitting, Respiratory Distress, Hypotesnion
- 53. •Recumbent Position • ElevateFeet • Establish and maintain airway • Oxygen • Epinephrine per protocol Anaphylaxis Management
- 54. Seizures Common Age Range- 6 mos - 6 yrs The CNS of children is more immature, making children more likely to seize •1% of all patients in ED are Pediatric seizure patients • Occurs in 2-5% of pediatric patients • 80% are febrile • Other causes • Infection • CNS • Immunizations General considerations • Stabilize and ABC’s as needed • Oxygen as needed • Watch for aspiration • Watch glucose • Treat fever Febrile seizures that continue for more than five minutes should be treated.
- 55. Seizures • Febrile aremost common • 6 mos. To 5 years • Combination of infection, high temp • Most are generalized, short, harmless • Status epilepticus • Lasts longer than 10 mins. • Prolonged post-ictal state • 3 or more in a row, no return to normal • True emergency • Absence
- 57. Burns Second leading causeof pediatric deaths Scald burns are most common Rule of nine is different for children Each leg worth 13.5% Head worth 18% Thermal Injuries & Burns Risk Factors Excessive sun exposure Hot water heaters set too high Exposure to chemicals or electricity Thin skin Carelessness with burning cigarettes Faulty electrical wiring
- 58. Thermal Injuries Management ofBurns • Stabilize ABC’s •Primary Survey •Establish Airway and Assist Ventilation if needed •Keep saturations 97% •Fluid Resuscitation
- 59. Thermal Injuries Transfer toBurn Center • Second-degree burn over 10% BSA or any third degree burn • Electrical or lightening burns • Inhalation injury • Chemical Burn •Circumferential burn
- 60. Meningitis • Meningitis is causedby an infection • Develops over 1- 4 days, contagious • Lethargy, fever, headache, stiff neck • True medical emergency
- 61. Trauma • Chest/abdomen injuries transferenergy to organs • Contusions and internal bleeding may result • Commitio cordis is life threat • Blow to the chest, interrupts normal electrical pattern of heart • Extremities • Greenstick fractures may occur
- 62. Child Abuse andNeglect • Legal, not medical terms • Are crimes • Reporting requirements vary by state • Transcends culture, class, race, religion • Abusers are parents, relatives or close adults • It can also be teachers • Shaken baby syndrome.
- 63. Child Abuse andNeglect
- 64. Take-a-ways • Kids candeteriorate quickly – you constantly have to be on your toes! • Anatomy and Physiology is different than adults - - Be aware of the differences and the impact disease can make • Use the ABCDE Assessment tool • Do a thorough systematic approach and reassess often
- 65. Take home note: Rememberthat an adequate airway and oxygen-rich approach may be the difference between life and death Sick pediatric patients can be terrifying, but they usually only have one thing wrong. Support their airway, breathing and cardiovascular status and their amazing bodies will usually take care of the rest
- 66. THANKS •Does anyone haveany questions?
Editor's Notes
- #14 Discussion Points: The assessment slides, which actually include the next 6 slides as well, focus on the special considerations which must be made for children. As you discuss this you will see that the OEC Technician must take into account the age of the child, his/her behaviors, and whether or not the caregiver is present. Notable differences are that, in younger children, once the area of pain is noted that area will be palpated last, rather than first as with an adult, and that the child may need to be distracted or invited to participate in the assessment.
- #15 The pediatric assessment triangle.
- #17 Discussion Points: The book gives many more details than can be put on a slide – if you have students who are parents they will likely be aware of many of the variations children demonstrate at their various stages of development. Review the stages with your students.
- #19 Discussion Points: Review the A&P differences of the airway.
- #20 The respiratory anatomy of children compared to that of adults.
- #23 Discussion Points: Details in the text include the benefits to the child of their less developed body, but also the concerns related to the types of injury which might be seen.
- #25 Danger, response, send for help
- #31 Blood sugar levels are over 250, often over 300. DKA results in acidosis and electrolyte changes, causing a wide range of problems. Excess sugar spills into the urine, drawing water with it and causing dehydration. Diabetes mellitus type 1: AKA juvenile onset diabetes, insulin dependent diabetes. Autoimmune disease. The beta cells of the pancreas are destroyed over time. Beta cells are the insulin producing cells of the Islets of Langerhans in the pancreas. Insulin is required for cells to utilize glucose. Hyperglycemia can also occur in children with infections or other medical problems, especially if the have diabetes. Signs and Symptoms Polyuria: frequent urination, polyphagia: frequent eating/hunger, polydipsia: frequent drinking Kussmaul respirations are deep and rapid. Ketones have a fruity or alcoholic odor. GI distress is common and serious issues such as pancreatitis can be associated with DKA. Dehydration can lead to hypovolemic shock. Onset is usually occurs over at least 24 hours. Nancy Caroline’s Emergency Care in the Streets, 8th edition
- #32 What causes it? Usually due to taking too much insulin, taking insulin and not eating, or due to excessive exertion or illness. Signs and symptoms AMS can range from minor confusion to seizure and complete unresponsiveness. Nancy Caroline’s Emergency Care in the Streets, 8th edition The Maryland Medical Protocols for Emergency Medical Services Providers, 2018
- #33 Children are sensitive to fluid balance changes. Even just a day or two of vomiting and diarrhea can cause hypovolemia. Look for sunken fontanelles in children <2 years of age, especially in children <1 year of age. Test for skin tenting. Nancy Caroline’s Emergency Care in the Streets, 8th edition
- #34 Cardiac arrest in children is often due to a respiratory problem. Hypoxia causes bradycardia, quickly followed by cardiac arrest. Common shock states: hypovolemic, cardiogenic, septic, and anaphylaxic. Nancy Caroline’s Emergency Care in the Streets, 8th edition The Maryland Medical Protocols for Emergency Medical Services Providers, 2018
- #35 Discussion Points: The importance of this is noted in the text – that cardiac arrest in children is most often associated with respiratory failure.
- #44 Responsive infant: 5 back thrusts and 5 chest compressions, repeating. Unresponsive infant: CPR with airway visualization (remove object if seen). All others Responsive: Abdominal thrusts (Heimlich) Unresponsive: CPR with airway visualization (remove object if seen).
- #46 In asthma, inflammation of the airways reduces their diameter, causing respiratory difficulty.
- #48 Asthma is a chronic condition with reversible exacerbations. The smooth muscles of the bronchioles constrict, become swollen, and become obstructed with mucus. Difficult to diagnose in young children (bronchiolitis, RSV, etc.) Causes include genetic and environmental factors. Environmental factors include exposure to cockroaches, cigarette smoke, and air pollution. Asthma exacerbations always have a cause, even if the cause is not identified. Signs and symptoms A quiet chest is a bad chest! Look for nasal flaring, tripoding, retractions, accessory muscle use, etc. Cough may be productive or non-productive. Pertinent negatives: wet lungs sounds, fever, GI distress, rhinorrhea... Hx of asthma? Nancy Caroline’s Emergency Care in the Streets, 8th edition
- #56 Discussion Points: Seizures may be seen more often in children than adults, so understanding the types and characteristics is vital. Additional details are found in the text.
- #61 Discussion Points: We are still in topics that OEC techs may not see at their area, but they will be ready for real life applications.
- #62 Discussion Points: The 3 problems on this page may represent different age groups for patients, but any of these may be found on the slopes. The issue of internal bleeding, the ability of the younger child to compensate, and shock can be reviewed here.
- #63 Discussion Points: Additional information on recognizing abuse is found in a later slide. Here the issue is understanding a bit about the topics of abuse and neglect. In some states, not reporting suspected abuse is a crime, so this is a serious matter. You should inform students of the reporting requirements in your area.
- #64 • Physical abuse in a child: multiple fatal injuries. • Physical abuse in a child: cuts from restraints. • Physical abuse in a child: burns from a stove.