fernando gonzalez, do, facop shannon clinic pediatrics san angelo, texas

PEDIATRIC EMERGENCIES

FERNANDO GONZALEZ, DO, FACOPSHANNON CLINIC

PEDIATRICSSAN ANGELO, TEXAS


I HAVE NO DISCLOSURES TO MAKE


TOPIC OBJECTIVES TO LEARN THE BASIC PATHOPHYSIOLOGY &

EMERGENCY RESPONSE FOR RESPIRATORY DISTRESS SHOCK BURNS BITES & STINGS & HEAT ILLNESS IN CHILDREN


The primary mission in a pediatric emergency is the resuscitation & stabilization of the patient. Trauma is the #1 cause of death in children in

the US after the first year. Pediatric arrest is usually respiratory in origin.

Prolonged deterioration Associated with severe hypoxia and acidosis Outcomes are dismal Early intervention and action is critical


HISTORY A focused medical history

S- SIGNS & SYMPTOMS A- ALLERGIES & IMMUNIZATIONS M- MEDICATIONS P- PAST MEDICAL HISTORY & ILLNESS L- LAST MEAL

When & what E- EVENTS PRECEDING ILLNESS OR INJURY

Timing, duration, fever, treatments Hazards at scene


EXAMINATION: ABCDE A focused physical exam which includes vital

signs and pulse oximetry A- AIRWAY ASSESSMENT

Look for chest wall movement, signs of obstruction, level of consciousness

Listen for abnormal breath sounds Feel for air movement


EXAMINATION AIRWAY INTERVENTIONS

If no trauma, head tilt Place oropharyngeal airway if needed Immobilize spine if trauma is present Suction naso-oropharynx Visualize for foreign bodies & remove Intubate if necessary Perform cricothyroidotomy


EXAMINATION B- BREATHING ASSESSMENT

Look for signs of respiratory distress (a clinical state characterized by abnormal respiratory rate or effort) Tachypnea Bradypnea (an omnious sign) Apnea Retractions, flaring, grunting Cough, stridor, gurgling Chest wall motion Altered mental status (hypoxia) Cyanosis


EXAMINATION BREATHING ASSESSMENT

Listen for breath sounds Rales/crackles Wheezes/rhonchi Asymmetric breath sounds


EXAMINATION BREATHING ASSESSMENT

Feel for Crepitus Trachael deviation


EXAMINATION BREATHING INTERVENTIONS

Oxygen administration Ventilatory support

Bag-mask ventilation Intubation & ventilator support

Vapo-therm CPAP IMV

Needle thoracotomy/Chest tube


RESPIRATORY PROBLEMS RESPIRATORY FAILURE

A clinical state of inadequate oxygenation or ventilation or both

Requires intervention to avoid deterioration to cardiac arrest

Causes Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing


RESPIRATORY PROBLEMS UPPER AIRWAY OBSTRUCTION

Foreign body aspiration Airway swelling (anaphylaxis, croup, epiglotittis) Mass (Peritonsillar abcess, tumor) Congenital airway abnormality (choanal

stenosis/atresia or subglottic stenosis) Signs generally occur in inspiration


RESPIRATORY PROBLEMS LOWER AIRWAY OBSTRUCTION

Obstruction of lower trachea, bronchi & bronchioles Asthma, bronchiolitis

Signs generally occur in exhalation


RESPIRATORY PROBLEMS LUNG TISSUE DISEASE

A heterogeneous group of clinical conditions affecting the lung at the alveolar level

Characterized by small airway collapse & alveolar congestion Pneumonia, pulmonary edema (CHF, ARDS),

aspiration pneumonitis, trauma, allergic reaction, toxins, vasculitis


RESPIRATORY PROBLEMS DISORDERED CONTROL OF BREATHING

An abnormal breathing pattern with signs of inadequate respiratory rate, effort or both Neurologic disorders (seizures, meningitis, head

injury, brain tumor, neuromuscular disease) Altered mental status is typical “Breathing funny”


EXAMINATION C- CIRCULATION ASSESSMENT

Shock A critical condition resulting from inadequate

oxygen & nutrient delivery to tissues Characterized by inadequate peripheral and end

organ perfusion (Usually) Usually associated with low cardiac output



Shock Tachycardia or bradycardia (most common cause is

hypoxia) Delayed capillary refill time (< 2 seconds is normal) Cool extremities Pulses (Normal, bounding, weak or absent) Skin color (pallor, mottling, cyanosis)



Shock Hypotension

A late finding indicating impending arrest Results from failure of compensatory mechanisms Minimum systolic blood pressure:

Newborn: > 60 Infants: > 70 1-10 years of age: (2 x age in years) + 70 Over 10 years: > 90


EXAMINATION C- CIRCULATION

Shock Types

Hypovolemic: Results from volume loss Most common type of shock in children

V/D, hemorrhage, DKA, 3rd space loss, burns

Distributive: Inadequate distribution of blood volume Vasodilation, increased capillary permeability

Sepsis, anaphylaxis, neurogenic (head/spinal injury)

Cardiogenic: Inadequate perfusion d/t cardiac dysfunction CHD, myocarditis, cardiomyopathy, trauma

Obstructive: Impaired cardiac flow Tamponade, tension pneumothorax


EXAMINATION C- CIRULATION INTERVENTIONS

Shock Early intervention reduces morbidity and mortality Goals:

Optimize oxygen content of blood Improve volume & distribution of cardiac output Reduce oxygen demand Correct metabolic derangements


EXAMINATION C- CIRCULATION INTERVENTIONS

Shock Intravenous access: Peripheral IV, IO Fluid resuscitation

20 ml/Kg NS/LR over 5-10 min, repeat prn Administer oxygen Medications

Vasoactive agents (Central line) Antibiotics Epinephrine


EXAMINATION D- DISABILITY

A rapid evaluation of neurologic function Important indicators of cerebral function

Decreased level of consciousness A: Alert, Active, Awake V: Voice P: Painful U: Unresponsive Glasgow Coma Scale (Head injury)

Loss of muscular tone Seizures Pupil dilation


EXAMINATION E- EXPOSURE

Undress the patient Check for signs of trauma

Bruising, bleeding, burns, deformity Check the core temperature

Hypothermia Fever


BURNS CLASSIFICATION

Superficial (1st degree) Dry, warm, painful

Partial thickness (2nd degree) Superficial dermis: Red, very painful, blistered Deep dermis: Dry, white, hyposensitive

Full thickness (3rd degree) Anesthetic, dry, white, leathery


BURNS MANAGEMENT

Superficial: Heal in 10-14 days Analgesia, cool compresses Leave open

Partial thickness: Heal in 2-3 weeks Debride, clean, dress daily, Silvadene/bacitracin

ointment Leave blisters intact Accuzyme ointment Serial exams: refer for disfigurement/contractures Analgesics especially before dressing changes


BURNS MANAGEMENT

Full thickness ABCDE in severe injury Consultation with/transfer to PICU, Burn unit Fluids

Volume replacement: 4 ml/Kg/%BSA burned for 1st 24 hrs (Parkland) Give ½ in 1st 8 hrs plus maintenance volume &

remaining ½ over next 16 hours


BURNS DISPOSITION

Outpatient therapy for superficial & partial thickness burns

Admission for major burns > 10% BSA with partial thickness burns > 2% BSA with full thickness burns Severe burns involving eyes, ears, face, hand/feet,

or with associated fractures High voltage electrical burns Child abuse/ neglect Associated smoke inhalation


BITES & STINGS ANIMAL BITES

General Irrigate & debride if possible. Do not suture unless necessary for cosmetic reasons (face). X-ray head and hand bites (fractures, puncture skull). Surgical consultation if bite involves tendons, joints, deep

fascial layers, major vasculature. Serious or infected wounds should be irrigated, debrided,

explored and closed, if indicated, in OR. Consider most wild carnivores as rabid unless proven

negative by brain fluorescein antibody test (skunk, raccoon, bat, fox)

Remember tetanus vaccination if not up to date. Follow up in 24-48 hours.


BITES & STINGS DOG BITES

Most frequent cause of fatality from animal bites in children.

Tearing/crushing type injuries Consider admission for cranial bites by a large

animal. Prophylactic antibiotics do not improve outcomes

in uncomplicated bites not involving the hands/feet. Culture if infected or if > 12 hrs since bite occurred. Staph aureus: trimethoprim/sulfamethoxazole Pasturella multocida: amoxicillin/clavulanic acid,

45 mg/Kg/day in 3 doses


BITES & STINGS CATS

Puncture type wounds Frequently infected

Pasturella Amoxicillin/clavulanic acid prophylaxis


BITES & STINGS HUMAN

Frequently infected Staph, Strep, anaerobes, Eikenella Amoxicillin/clavulanic acid x 5-10 days

Consider possible child abuse Evaluate risk of transmission of HBV, HIV, HSV


BITES & STINGS RABIES PROPHYLAXIS

Dogs, cats, ferrets If animal available & healthy, observe for 10 days

No prophylaxis unless animal develops symptoms If rabid or suspected, euthanize and test brain

Immediate immunization and rabies immunoglobulin

Unknown Consult public health department

Wild carnivores (Bat, fox, raccoon, skunk) Regard as rabid unless brain is tested and

negative on fluorescein antibody test Immediate immunization and RIG



Rabies Immunoglobulin (RIG) 20 IU/Kg Infiltrate wound(s) with RIG. May dilute 2-3 times to

infiltrate all wound areas. Give remainder IM. May give at same time with vaccine but at different

sites. It is preferred to begin RIG within 7 days of starting

vaccine but, if indicated, use both regardless of interval between exposure and initiation of treatment.



Immunization Vaccine reactions are rare in children. 3 vaccines available in US 1 ml IM on day 1, 3, 7, 14, 28 for 5 doses

May discontinue if brain test is negative


BITES & STINGS INSECTS

Bees, wasps, fire ants, stinging caterpillars usually

General measures Clean area Remove stinger if present Cool compresses, elevate Mild analgesics Oral antihistamines Consider corticosteroids for severe local reactions,

severe swelling Check tetanus status



Anaphylaxis The most serious concern Symptoms

Chest/neck tightness Dizziness/syncope Disorientation Swelling Upper airway obstruction Wheezing/Respiratory distress Urticaria Hypotension



Anaphylaxis Treatment

ABCDE Administer oxygen Administer epinephrine

1:1,000; 0.01 mg/Kg SQ q 15 min prn or 1:10,000: 0.01 mg/Kg IV/IO q 3-5 minutes to max 1 mg if

hypotensive for age. If patient remains hypotensive, give by continuous infusion,

0.1-1 umg/Kg/minute. Prescribe IM autoinjector (0.3 mg > 30 KG; 0.15 mg 10-30 Kg)

Albuterol by nebulization for wheezing/respiratory distress.


HEAT ILLNESS HYPOTHERMIA

Definition: A core temperature of < 35 C (95 F) Causes

Submersion accidents Septic shock Encephalopathy Accidental ingestions Metabolic disorders


HEAT ILLNESS HYPOTHERMIA

Peripheral vasoconstriction leads to increased muscle tone, increased metabolism & shivering.

At < 28 C (82.4 F), pupils are fixed & dilated. There is no pulse or spontaneous respirations and the patient is rigid.

Death cannot be declared until the patient is re-warmed to at least 30 C (86 F) and resuscitated. Patients can survive submersion times of up to 40 minutes and prolonged CPR of > 2 hrs.

Re-warm with passive techniques, body cavity irrigation, ECMO (best) or cardiopulmonary bypass.


HEAT ILLNESS HEAT STROKE

Heat exposure resulting in a core temperature of > 40 C (104 F) with associated neurologic signs. Combative Disoriented If severe

nuchal rigidity seizures posturing coma


HEAT ILLNESS HEAT STROKE

Complications Rhabdomyolysis Acute tubular necrosis DIC Hepatic degeneration Electrolyte derangements ARDS


HEAT ILLNESS Heat Stroke

Treatment ABCDE Cool patient (Cooling blankets, ice) IV fluids/fluid resuscitation Monitors Labs Admit


HEAT ILLNESS HEAT CRAMPS

Occurs during exercise with heat exposure Self limited Painful Temperature normal or only slightly elevated Rehydrate Occasionally requires IV fluids


HEAT ILLNESS HEAT EXHAUSTION

Temperature normal or only slightly elevated Symptoms

Weakness Disorientation Nausea/vomiting Headache Increased thirst Muscle cramps No major CNS symptoms


HEAT ILLNESS HEAT EXHAUSTION

Treatment Fluid replacement

Often requires IV access


RESOURCES Pediatric Advanced Life Support, AHA/AAP,

Provider Manual, 2011 The Harriet Lane Handbook, The Johns

Hopkins Hospital, 18th edition American Academy of Pediatrics, Red Book,

27th edition Nelson’s Pocket Book of Pediatric Antimicrobial

Therapy, 16th edition

fernando gonzalez, do, facop shannon clinic pediatrics san angelo, texas

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