Paediatric emergencies

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Paediatric emergencies

  1. 1. PEDIATRIC EMERGENCIESDr Varsha Atul Shah
  2. 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. 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. 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. 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. 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. 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. 8. Development Stages - Keys to Assessment Ages1-5 months - Common problems – SIDS – Vomiting and diarrhea/dehydration – Meningitis – Child abuse – Household accidents
  9. 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. 10. Development Stages - Keys to Assessment Ages6-12 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 28. General Approach to Pediatric Assessment Special concerns (cont..) – GI Problems  Disturbancesare common  Determine number of episodes of vomiting, amount and color of emesis
  29. 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. 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. 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 Pulseoximetry-particularly useful since so many childhood emergencies are respiratory
  32. 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. 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 – Firearms 9.9% 3.0% – Aspiration 5.7% – Falls 2.0% – Stab/cut ?
  34. 34. Frequency of Injured Body Parts Head 48% Extremities 32% Abdomen 11% Chest 9%
  35. 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. 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. 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. 38. Pediatric Trauma Burns – Second leading cause of pediatric deaths – Scald burns are most common – Rule of nine is different for children  Eachleg worth 13.5%  Head worth 18%
  39. 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. 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. 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. 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. 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
  44. 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. 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. 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. 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. 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. 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. 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. 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. 52. Meningitis Assessment – History of recent illness – Headache, stiff neck – Child appears very ill – Bulging fontanelles in infants – Extreme discomfort in movement
  53. 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. 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. 55. Pediatric Medical Emergencies - Neurological Reye’s syndrome - Complications – Respiratory failure – Cardiac arrhythmias – Acute pancreatitis
  56. 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. 57. Pediatric Medical Emergencies - Neurological Reye’s syndrome - Management – General and supportive – Maintain ABC’s – Administer supplemental oxygen – Rapid transport
  58. 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. 59. 5 Most Common Respiratory Emergencies Asthma Bronchiolitis Croup Epiglotitis Foreign bodies
  60. 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. 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. 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. 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
  64. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 80. Mild, Moderate, & Severe Dehydration Physical Assessment/ Vital signs – Capillary refill – Skin color – Alertness, activity level
  81. 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. 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. 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. 84. Mild, Moderate, & Severe Dehydration Management – If mild or moderate  Givefluids 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. 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. 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. 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
  88. 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. 89. Home High Technology Equipment Chronic & terminal illness – Respiratory & cardiac  Premature infants  Cystic Fibrosis  Heart defects & post transplant patients
  90. 90. Home High Technology Equipment Ventilators Suction Oxygen Tracheostomy IVpumps Feeding pumps
  91. 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

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