pediatric emergencies for the school nurse · (free concussion apps, guidelines, resources for...

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Common Emergent and Urgent Health Issues in the School Setting

What School Nurses Need to Know

A. Biondi DNP, NNP CPNP

Objectives:

Review emergent and urgent health issues experienced by school age children

Discuss nursing assessment and triage of common health emergencies that can happen in school

Discuss red flags in various body systems as they relate to various pediatric health emergencies

School Nurses Need to be prepared for emergencies

School is the second only to home as the most common place injuries occur

School staff often see any health issue that interferes with academics as an emergency

Not all schools have standardized emergency equipment

available

Not all schools have a school nurse on site at all times, and “non licensed assistive” school staff have varied or limited abilities to deal with health issues of students

1 in 4 school children experience nonfatal serious illness or emergencies that require some type of limited activity and/or medical attention

NASN, 2011

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and a few more reasons………

In the past decade NC school nurses identified ~75k students with asthma, 18k students with severe allergies and almost 5k students with diabetes

School Nurses provided health counseling to over 80,000 students and staff, and lead over 30,000 preventative health education programs in 2008-09

NC Annual School Health Services Report 2012

Most commonly reported school emergencies nationally:

AAP, 2008

Top 12 reported injuries in NC 2012-2013 school year

Anaphylaxis

Abdominal/injuries

Heat related injuries

Psychiatric emergencies

Eye injuries

Respiratory emergencies

Lacerations

Fractures

Head injuries

Sprains or strains

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Confidence levels for managing school emergencies reported by the AAP

AAP, 2008

Preparing for school emergencies?

1. Know what emergencies to expect2. Know when to call for help and delegate 3. Know BLS skills4. Know your emergency resources in your

school area

Know when to call EMS Unconscious, semi conscious or confused

Airway difficulties ie: SOB, choking/obstruction

Pulseless

Uncontrolled bleeding

Hemoptysis

Suspected poisoning

Intractable or 1st time seizures

Head, spine, neck injury (moving the child could worsen the injury)

Sudden onset of severe, acute pain

Any injury that might leave the child permanently disabled

Distance or traffic issues would delay care

Anytime you are unsure and believe EMS or emergency skills are needed for the child

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Emergencies we will discuss:

Head Injury

Heat related illness

Seizures

Overdose

Cardiac arrest/syncope

Dental Emergencies

Diabetic shock

Anaphylaxis

Profuse bleeding

Eye emergencies

Respiratory distress

Head Injuries at School: evaluate and triage

Head injury: concussions Most are minor however, sports related head injuries can

be more serious

Concussions:

Increased awareness among HCP and coaches of long-term sequalae from concussions and how to manage these events

Can occur with or without a loss of consciousness, vomiting or some of the more typical associated symptoms

Can result in longer-term fogginess, dizziness, headache, lower attention span, short term memory issues

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Head injuries: concussions

Some coaches fail to understand the severity and risks and might want to get the athlete back out on the field to soon

Second impact syndrome: prolonged recovery and long term risks

Students suffering a concussion recover more quickly with REST, and should be restricted from activities until they are HEADACHE FREE.

Lots of controversy about concussion guidelines used uniformly across all fields of medicine

School nurse should understand “return to play” recommendations

• Castilleja.org

Other resources for concussions

AAN concussion resource Web page

(free concussion apps, guidelines, resources for nurses, parents, providers, Ppt presentations, PSAs and more!)

CDC: Heads Up return to play, work and school

(free concussion resources for providers, parents, coaches)

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Symptoms to look for: concussions: CDC.gov 2015

Can’t recall events prior

.Appears dazed or stunned.

Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent

.Moves clumsily

.Answers questions slowly

.Loses consciousness (even briefly)

.Shows mood, behavior, or personality changes.

Headache or “pressure” in head.

Nausea or vomiting.

Balance problems or dizziness, or double or blurry vision.

Bothered by light or noise.

Feeling sluggish, hazy, foggy, or groggy.

Confusion, or concentration or memory problems.

Just not “feeling right,” or “feeling down”.

What you observe: What the student reports:

Head injuries at school: other than head bumps without complaints

1. Suspect neck injury

2. Rest/lie student flat

3. Symptoms: Vomiting? Unconscious? Seizures? Neck pain? Responds to commands? Fluid in ear canal? MAEs? Sleepy or confused?

If yes to any of these

1.CALL EMS

2. Don’t leave student alone

3. Maintain an airway

Head injuries at school: other than head bumps without complaints

Is the student currently asymptomatic but was:

Briefly confused or has a headache now?

1. Contact school admin and fill out injury paperwork

2. Notify parent

3. Advocate for medical evaluation

4. Educate parents on delayed symptoms

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Heat related injuries: heat stroke and exhaustion

Past research led the medical community to believe:

Children are less effective at thermoregulatory control

Incur greater cardiovascular strain

Have lower exercise tolerance in heat compared with adults

More recent research suggests that children ages 9-12 have similar heat tolerance to adults…

AAP, 2011

Heat stress and exhaustion: risk factors

Previous illness (especially gastro related)

Hot/humid weather

Poor preparation (hydration, new to weather conditions, tired, poor conditioning)

Excessive exertion (tryouts)

Inadequate recovery periods + hi intensity exercise

Inadequate opportunities to rehydrate

Multi same day sessions

Clothing that holds in heat (marching band/football etc)

Symptoms of heat related injuryOSHA, 2015

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Treatment of heat related injuries at school:Look for symptoms: red, hot skin, weakness, cold hands, clammy

skin, vomiting, confusion, LOC

If conscious:

1.get the student to a cooler place

2.Rest

3. Frequent sips of clear fluids or Gatorade until symptoms are gone than notify parents/admin etc

If unconscious:

1. CPR: assess airway, pulse etc and call for help/EMS

2. Move student to cooler place

3. Cool rapidly with room temp water on clothing (no ice H20)

Seizures at School

Seizures: background information

A seizure is a paroxysmal electrical discharge of neurons in the brain resulting in an acceleration of behaviors.

The area of cortical involvement, the speed and direction of the discharge and the age of the child all contribute to the clinical manifestations of the seizure.

Epilepsy is a cluster of symptoms that is associated with neurologic and specific EEG findings

A continuous seizure lasting longer than 30 minutes or 2 or more seizures without a return to baseline function between events is known as status epilepticus

Blumstein & Freidman, 2007

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Seizures: background information Most common neurologic disorder of childhood

Children under the age of three have the highest incidence

~1% of all ER visits nationally

Oxygen and glucose consumption and carbon dioxide production are all increased during a seizure

If adequate ventilation is maintained the increased cerebral blood flow compensates for these changes

Seizures: background information

Seizures that occur with difficulties in maintaining a patent airway can result in:

hypoxia, hypercarbia, and respiratory acidosis

Prolonged seizures can result in:

lactic acidosis, hyperthermia, hypoglycemia

Brief seizures don’t typically cause long-term neurologic damage

Long-lasting seizures can result in permanent neurologic sequalae

Classification of SeizuresPartial seizures (a.k.a. focal or local): Often preceded by

an aura

Originate in one cerebral hemisphere

Can be conscious (simple): abnormal motor activity occurs

or

Unconscious (complex)

Lip smacking, dazed look, nausea, vomiting

Complex or simple partial seizures can develop into generalized in about 30% of the events.

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Seizures: classification of

Generalized: involves both cerebral hemispheres and can have a depressed level of consciousness

Can be convulsive, with bilateral motor activity or be non convulsive

Further classified into:

Petit mal (absence), myoclonic, atonic, tonic, clonic, grand mal (tonic-clonic)

Seizures at school:

1. Know your student’s history and emergency plan (onset, type, duration, after effects, meds)

2. During a seizure make the area safe for the student to avoid injury

3. Don’t restrain movements

4. Don’t place anything in the mouth

5. Observe for duration, exact behaviors, LOC, body parts involved: be ready to describe the specifics to EMS

6. Place the student on his/her side to maintain an airway

Seizures at school: steps in care

Longer than 5 min? Recurrent? No known history? Resp distress? (what signs of distress can you see and why?)

1. Call EMS

2. Administer medications if ordered for children with known seizures

3. Contact school authorities and parents/guardians

4. Follow steps in BLS after seizure is over if student’s airway is not maintained or respiratory distress is noted

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Post-ictal phase: after the event

Can last 15 min-1hr

Sleepy, confusion, speech unclear

Still need to monitor and protect the airway: how?

If the student has known seizures, encourage return to class activities once back to baseline

Record event and contact parents/guardian

Debrief staff as needed

NC Emergency Guide for School Nurses, 2009

Poisoning and OverdoseA Poison is: any product or substance that can harm someone if it is used in the

wrong way, by the wrong person, or in the wrong amount. (household products, chemicals, prescription, over-the-counter, herbal, or illegal drugs, snake bites, and spider bites.

In 2012, the Carolinas Poison Center answered over 100,000 calls from the public and healthcare providers of North Carolina.

Over 75% of the callers were managed at a non-healthcare facility (home, workplace, school, etc.).

Carolinas Poison Center answers and average of over 17,000 calls from doctors, nurses, and pharmacists assisting with the diagnosis, management, and treatment of poisoned patients.

In 2012, more than 26,000 calls from North Carolina residents involved pain medicines (analgesics), making pain medicines the most called about class of toxins.

Rates of poisoning among age 15-19 year old is second to MVC injuries in this age group and directly related to prescription drug overdose (CDC, 2015).

Highest number of poisoning are still in age group of 1-5 yr olds

NC Poison Control Center, 2010

Safekidsworldwide.org

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Methylphenidate Overdose (Concerta, Ritalin)

paranoia and hostility

Unusual changes in behavior

Suppressed appetite

Decreased sleep

Increased attention and focus

Increased blood pressure

Increased body temperature

Agitation and muscle twitching

Vomiting

Uncontrollable shaking of a body part

Loss of consciousness, seizures

Confusion and inappropriate happiness

Sweating, dilated pupils

Hallucinations and delirium

Toxic psychosis Headache

Flushing, fever, dry nose/mouth

Fast, pounding heartbeat

Overuse Overdose

Before calling the Poison Control Center:

1. Know age, weight of student (or best estimated weight)

2. Know what you believe the student swallowed

3. How much you believe the student swallowed

4. If you suspect the child ingested something at home before school find out what was available in the home

Poisoning and Overdoses: treatment

Poison in the Eyes

Flush eye immediately with a continuous flow of room temperature water for 10 to 15 minutes. Remove contact lens before flushing eye.

Rinse from the top of the nose toward the side of the face, away from the other eye.

DO NOT just splash water into eye or wipe with wet wash cloth.

DO NOT use eye drops.

Call Carolinas Poison Center at 1-800-222-1222 for further advice. NC Poison Control Center, 2010

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Treatment cont’d

Poison on the Skin (pesticides, sun, overuse of essential oils, lab chemicals). Main symptoms?

Remove any contaminated clothing with gloves.

Rinse affected area(s) with room temperature water and soap.

Call Carolinas Poison Center at 1-800-222-1222 for further advice.

A Carolinas Poison Center Specialist will tell you if the clothing can be cleaned or should be thrown away.


Treatment: cont’d

Inhaled Poison

Get the victim to fresh air as soon as possible.

Open doors and windows.

Avoid breathing fumes, then call Carolinas Poison Center at 1-800-222-1222 for further advice.

If the victim is unconscious or not breathing CALL 911 immediately and start artificial (mouth-to-mouth) respiration.

If you smell gas, call 911 or the fire department and your local gas company to check for gas leaks.


Treatment: cont’dSwallowed or Ingested Poison

Gently remove any remaining poison from the mouth.

Call Carolinas Poison Center at 1-800-222-1222 for further advice.

DO NOT wait for symptoms to appear.

NEVER make the victim throw up. A Carolinas Poison Center Specialist will tell you if this is necessary.

The Specialist may ask you to identify the ingredients, so bring the product with you to the phone.

If you have to go to the Emergency Department, take the container or substance with you.


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Treatment:

Injections (Bites or Stings)

STAY CALM-not all bites are harmful.

Emergency treatment varies depending on the type of bite.

The most common bites and stings are from bees and wasps, ticks, and nonpoisonous spiders. They are usually not harmful.

If bitten by a poisonous spider, snake, or aquatic creature: NEVER use a tourniquet

NEVER cover the bite area with ice

NEVER cut the skin and suck the venom

Do not try to kill a snake that has bitten you. It may bite again.

Call Carolinas Poison Center at 1-800-222-1222.


Spider Bites: Black Widow Common to NC; 15% of bites non-

envenomating

Rarely fatal; symptoms within 8hrs of bites; from latrotoxin causing tetany

Small puncture wound; swelling not always present.

Mistaken as skin infections

Neurotoxins cause: Abdominal, back and chest pain, muscle weakness, NV, cramping, tachycardia diaphoresis at site or on limb involved; can last up to 7days-mos. Seizures are late sign. Preterm labor

Symptoms usually begin to fade by 1-3 days

Clean bite site, elevate and apply ice to slow absorption of venom

Effectiveness of antivenom is controversial

VS monitoring for HTN

Blood pressure stability

Pain control

Muscle relaxants

Antibiotics if cellulitic injury; hospitalization with severe symptoms

Risk for: compartment syndrome, paralysis,

Brown Recluse Spider Bites

Complex wound issue: necrotic arachnidism

More common in S.E. US in rural areas

Bite not felt immediately

Syndrome:“Loxoscelism” from hemotoxic venom

Skin lesion with characteristic bluish/pale surrounding area in first few days after bite

Can progress with other symptoms in ~50%

rash, bullae, ulceration and necrosis, fever, chills, N/V, myalgia, hemolytic anemia, DIC, renal failure, death

Can be confirmed with ELISA based test for brown recluse venom

Careful assessment of wound

Did they bring the spider????

Elevation, ice, local wound care and tetanus update

Pain control; Opiods

Wound care: cephalosporins if clearly infected

Anti-inflammatory; prednisone

Dapsone: controversial; antibiotic powder that has anti-inflammatory properties, may help with necrosis

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Syncopal episodes at schoolWhat is syncope?

Transient (real or apparent) LOC with rapid onset, short duration, and spontaneous complete recovery

Can have prodromal period (lightheaded, nausea, sweating, weakness)

Can be vasovagal “the common faint” (emotional distress, fear, pain)

Situational (cough, sneeze, swallow, defecation, post-exercise)

Atypical: no apparent triggers

Orthostatic hypotension: drug induced, volume depletion, pure autonomic failure

Cardiac: bradycardia, tachycardia, drug induced, structural disease

carotid sinus (rare) European Society of Cardiology, 2009

Syncope: important hx questions

Position of student before syncopal event

Activity

Predisposing factors (crowded area, warm, fear, pain etc)

Any eyewitnesses? Was LOC complete

Chest pain?

How the fall occurred, and if any signs of seizures

Family hx, meds, drug abx?, diabetic? Nutrition, physical condition of the student (if related to exercise)

Did you get a BP? Pulse? Accucheck if diabetic?

Most dangerous reasons for syncope?

Prolonged QT, cardiomyopathy, and ventricular dysfunction

Syncope: prolonged QT

Prolonged QT:

1:5000 people have this disorder

One of the leading causes of sudden death in young people

Caused by genetic mutation in ion channels that control ventricular repolarization

EKGs can pick this up and should be part of the work up after a first time syncopal episode

Can be caused by some antidepressants, erythromycin, some antiarrhythmics

(50-75 deaths in the U.S. per year of sudden death in athletes)

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Syncope at School

Lie student down for prodromal symptoms

if unconscious keep student flat, raise feet, loosen tight clothing

Follow assessment for BLS and monitor breathing, have AED available

NC Emergency Care “urges medical care” if student regains consciousness (thoughts?)

EMS for unconscious student

Contact school admin, parents/guardian

Diabetic emergencies (DKA)

Most serious complication of diabetes mellitus caused by:

Glucose and Ketone overproduction and underutilization

Symptoms:

Diaphoresis, dehydration, confusion, hypovolemia from osmotic, LOC, diuresis

Metabolic acidosis with compensatory hyperventilation

Google images, 2011

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Diabetic emergencies (DKA) or hypoglycemia

1. Know your student’s emergency plan and educate others

2. Staff need to be trained in order to administer insulin

3. Call EMS for symptoms that include: LOC, seizures, rapid deep breathing

5. If alert, allow student to check blood sugar: Is glucose less than 60? Reading high on glucometer?

6. Options for hypoglycemia: fruit juice, sugar (3pkts), frosting, instant glucose

7. Sliding scale orders for hyperglycemia? Pump malfunction?

8. Contact school admin, parent/guardian

Anaphylaxis

Definition: A life threatening, severe allergic, that

can be a immunologically mediated reaction or the result of pharmacologic idiosyncrasies

Immunoglobulin E (IgE) mediated release of substances that produce a wave of end-organ responses such as:

Skin: urticaria (hives)

Lungs: bronchospasm, wheeze, upper airway edema

CV: vasodilatation, swelling, smooth muscle contraction

Can be delayed reaction (up to 2hrs after initial exposure)

Anaphylaxis

Approximately 6million children have food allergies in the

U. S.

16-18% are school age

25% of allergic reaction cases occur before the diagnosis is made

Mortality rates for cases that occur at school are related to a delay in treating the reaction with epinephrine

Research showing increase rates of allergic reactions (now 1:13, was 1:25)

Allergy Ready website for educators, school nurses

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Anaphylaxis: prevention and treatmentFAAN.org

First!

Make allergen known to school staff and have an emergency plan ready

Does the student have…..

Severe allergic rx: hives, SOB, swelling, difficulty swallowing, pallor, weakness?

Then:

BLS, call for help, review emergency plan, administer approved medications as indicated

Notify school admin/parent/guardian

Bleeding

All bleeding stops…….but the sooner the better right?

When a student is bleeding

1. Put on gloves!

2. Find the source(s) of bleeding and check for injury, amputation, pulsatile bleeding

3. Support the extremity and elevate if fx present

4. If amputation present, put in bag, in ice water and send to hospital with student

5. Hold pressure to bleeding areas, then bandage but not so tightly as to stop circulation to the body part

6. No tourniquets!

7. Large wounds? Call parents, and if uncontrolled bleeding call EMS

Bleeding: assessment and treatment

Profuse bleeding cont’d:

Student should be supine, raising legs 8-10 inches (if no back injury present)

Consider hypovolemic shock for uncontrolled bleeding, femur fractures, and keep child warm, check blood pressure, pulses, level of consciousness and continue to monitor closely until EMS arrives

Do not leave the student alone

NPO if large wound, or fracture

Check immunization records for tetanus

Contact parents (delegate this task to school admin)

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Fractures: classification

Classified by size, severity and extent of soft tissue lesion


Type I open fractures:

Wound is less than 1cm, usually a puncture from where the bone has punctured the skin

Usually simple, transverse fractures

Type II open fractures:

Wound is more than 1cm, but still minimal soft tissue damage is present

Usually associated with a crushing injury

Green and Swiontowski, 2008


Type III Fractures:

Extensive damage to soft tissue, muscles, skin and neurovascular structures, usually resulting from a high-velocity injury with a crushing component.

Type IIIa:

Same characteristics as type III but with periosteal stripping and bone exposure

Type IIIc:

Includes a vascular injury that requires repair

Green and Swiontoski, 2008

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Fractures: emergency care

Treat the entire body part as if it is fractured

Control bleeding if present

Assess for heat, swelling, discoloration, sensation, deformity, broken skin, avulsions

Call EMS for:

bony deformities, avulsions, loss of sensation

Cover broken skin area with a bandage but do not constrict

Try not to move fractured limb

Respiratory Distress

Causes of respiratory emergencies in the school age child:

1. Infection (croup, influenza)

2. Asthma (poorly controlled or during URI)

3. Allergic conditions (anaphylaxis)

4. Congenital illness (CF, congenital heart disease)

5. smoking

Respiratory Distress: how to prepare

Know the child’s emergency plan and make others aware

Know where asthma meds are (locked up? Who has access? Are the meds outdated? Asthma action plan?)

Have equipment ready for respiratory problems

Stethoscope, peak flow meter, epi pen

Know your student’s baseline respiratory status

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Assessment of Respiratory Distress

RR: increased (early) or decreased (ominous late sign)

Nasal flaring, use of accessory muscles, retractions, tripoding

Trouble swallowing, talking? Bluish lips, nail beds, SOB

Cough (productive, tight, dry, “barking”, persistent with struggle to catch breath in between)

Confusion, decreased LOC?

Rapid onset?

Wheeze-inspiratory/exp?

How “asthma friendly” is your school?National study 2006 (Jones et. al)

1.Tobacco free (entire campus)? (70%)

2.Can students carry their emergency inhalers or do they have easy access at all times? (81%)

3.Asthma plans updated? (91% have them, but updated status not reviewed in study

4.Do you teach other school staff about asthma emergencies? (78%)

5. Does your school test air quality? Reduce allergens? (51%)

6. Do PE teachers have training to recognize signs of respiratory distress? (43%)

Dental Emergencies at School

School staff: Limited knowledge of care for traumatic dental injuries (TDI) reported nationally and statewide in 2008 study (n =175 school nurses)

Highest incidence of TDIs in grades 2-5

(McIntiyre et., al, 2008)

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Dental Emergencies at School

Care for the child with the displaced tooth

1. Don’t force tooth back to correct position

2. Contact school admin, parents/guardian and advise

3. emergency dental care

Knocked out or broken tooth:

1. don’t touch root of tooth

2. Cleanse by rinsing in water (don’t scrub)

3. Place tooth back in socket (not baby teeth) and hold with gauze

4. Alternatively, place tooth in “save a tooth kit”, milk, NS, spit, or water as a last resort

Pediatric Eye Emergencies


Epidemiology 70% are males 11-15 yrs

More than 2million/yr in U.S.

> than 7000 hospitalizations

Leading cause of vision loss

>50% from sports injuries

Many occur at home

Risky sports Any sports with balls,

rackets

Darts, toy guns, air guns, paintball, BBs

Many of these risky sports are played by kids without eye safety gear

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History questions Get the details of the injury

circumstances

Mechanism and/or object that caused the injury

Detailed assessment of symptoms after the injury

Vision loss, pain, tearing etc

Chemical injury=vigorous irrigation immediately with Morgan’s lens

Assessment Look for external trauma

Examine the lids, conjunctiva, look for foreign body-Flourescein exam

PEARRLA, EOM, visual acuity, visual fields

Red reflex, retina, blood vessels, hematoma, bony step offs, edema

Corneal Abrasions/FB Most common eye injury

seen in the ER

Hx of FB sensation, mild eye trauma, environment irritant, tearing, pain

Evert eyelid with cutip

Topical anesthetic prior to flourescein for relief

Antibiotic ointments

Non narcotic pain control

Remove the FB if needed

If removal unsuccessful consult optho

Corneal lacerations Emergency optho consult

for surgical repair

Thorough history of injury and mechanism

Visual acuity test and shield eye due to danger of ocular tissue prolapsing through the laceration

Place IV for antibiotics

CT scan if suspected FB

Tetanus booster

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References:

AAP.org

McIntiyre et., al, 2008

Green and Swiontoski, 2008 Classification of Fractures

NASN, 2012

NC Poison Control Center Statement, 2012

Google images, 2011

European Society of Cardiology, 2009 Syncopal Events in Children

FAAN.org 2009 Anaphylaxis Treatment

NC Annual School Health Services Report 2012

Casteglia.org 2011, Head injuries in Children]

Blumstein & Freidman, 2007 Pediatric Seizures

References and links for review http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400202

/

http://rockymountainpediatricorthopedics.wordpress.com/2011/10/20/the-5-pediatric-orthopedic-emergencies-that-get-us-out-of-bed-at-night/

http://www.ppag.org/attachments/courses/core/Anatomic%20and%20Physiologic%20Differences%20Between%20Children%20and%20Adults.pdf

References and links for review Theheart.org

http://emedicine.medscape.com/article/811669-treatment.syncope

http:rockymountainpediatricorthopedics.wordpress.com/2011/10/20/the-5-pediatric-orthopedic-emergencies-that-get-us-out-of-bed-at-night/

www.pediatrics.emory.edu/pem/_epg/documents/62073. eyeemergencies

OSHA.gov

ATVSafety.gov

Sickle Cell Disease And Other Hemoglobinopathies: Approaches To Emergency\Diagnosis And Treatment (Freeman, Taylor & Lopez, 2001)

http://www.aafp.org/afp/2003/0201/p511.html Common Dental Emergencies

Journal of Emergency Medicine: near drowning

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References and links for review Emedicine.medscape.com/article/961963-overview

Starship Children’s Health Clinical Guideline: Bronchiolitis

Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty, 3rd edition

Roger’s Textbook of Pediatric Intensive Care, 4th edition

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