Pediatric Emergencies

Jan Bazner-Chandler RN, MSN, CNS, CPNP

Developmental and Biologic Variances Cricoid is the narrowest portion of the airway:

no cuffed ET tubes

ET cuffed

Developmental and Biologic Variances Decreased respiratory rate may mean the child

is tiring out Total blood volume is smaller – small blood loss

may led to hypovolemia and impaired profusion Respiratory arrest is more common in

pediatrics Healthy children in shock will maintain blood

pressure until more than 25% of blood volume is lost

Tachycardia and delayed capillary refill are early signs of shock

Decreased blood pressure is late sign

Triage To “pick or sort”. Goals of triage:

Rapidly identify seriously injured. Prioritize all patients using the emergency

department. Initiate therapeutic measures.

Triage Classification Resuscitation Emergent- needs to be seen within 10

minutes Urgent – need to be seen within 30 to 60

minutes Semi-urgent – need to be seen within 1to 2

hours Non-urgent – need to be seen within 2 to 3

hours

Assessment Across-the-room assessment Chief complaint Brief history (AMPLE Mnemonic)

Allergies Medications Past medical history Last meal Events surrounding the incident

Focused Physical Assessment Airway Breathing Circulation Disability Exposure Full vital signs Family presence Give comfort Head-to-toe assessment Inspect Isolate

Test and Procedures CBC with differential Type and cross match Serum electrolytes Radiographs: chest, abdomen, bones Computed tomography – CT scan

Shock Hypovolemic shock Distributive Cardiogenic Obstructive

Hypovolemic Shock Most common cause of shock in children

Fluid and electrolyte losses associated with diarrhea

Blood loss from trauma Etiology: caused by inadequate volume

relative to the vascular space

Hypovolemic shock: Assessment Tachycardia Prolonged capillary refill > than or equal to 2

seconds Weak, thready or absent peripheral pulses Cool extremities

Interdisciplinary Interventions IV fluids 20 mL/kg bolus of Crystalloid Solution

0.9% normal saline Ringer’s lactate

If signs of inadequate profusion after 2 or 3 boluses administer 10 mL / pg packed red blood cells

Control bleeding

Distributive Shock Septic shock Etiology: caused by inappropriate distribution

of blood flow an increased capillary permeability

Most common type of shock in newborn Gram negative organisms

Assessment Findings History or infection History of poor feeding Physical findings

Tachycardia Fever – in the neonate may hypothermia Tachypnea Altered mental status - lethargy Petechiae / or purpura Poor peripheral perfusion (capillary refill less than

2 seconds)

Laboratory Values WBC

Greater than 12,000 Lower than 4,000 or more than 10% immature

forms (bands) Platelets in the acute phase may be elevated

due to inflammation. Platelets may decrease in the case of DIC

Interdisciplinary Interventions Isolate if indicated IV fluids (crystalloid solution) to restore

circulating volume Inotropic agents as needed

Norepinephrine – alpha receptor agonist causes peripheral arterial vasoconstriction

Dopamine – beta receptor agonist to increase cardiac output

Cultures: blood, spinal fluid, urine Broad spectrum antibiotics: MRSA If hypoglycemic – IV glucose

Near Drowning Death resulting from suffocation by

submersion in a liquid Unsupervised submersion: bathtubs, buckets,

toilets, swimming pools, body of water Presentation

Varying degrees of neurologic insult from a state of alertness to cardiac arrest

Poorest outcomes when child presents in cardiac arrest

Poisoning The fifth leading cause of death in children

younger than 5 years Overdose in infants are often the result of

therapeutic overdosing Children younger than 6 years

Cleaning substances, analgesics, foreign bodies, topical agents, cough and cold preparations

Adolescents drug experimentation and suicide attempts

Poisoning Over a million children are poisoned annually. Ages of risk are 2 to 4 years and adolescents. Common poisons ingested:

Iron, lead, acetaminophen, hydrocarbons, liquid Drano, and plants.

Assessment Look at the child May present with no symptoms to coma

Focus History What was ingested? How much was ingested? When did it occur? What therapy was initiated before arrival in

the ED?

AAP Recommendations AAP – American Academy of Pediatrics Syrup of Ipecac no longer be used routinely in the

home to induce vomiting. Research has failed to show benefit for children

who were treated with Ipecac. Prevention is the best defense against

unintentional poisoning

Parent Teaching Post the universal phone number for poison

control center near the telephone 1-800-222-1222 Call 911 in the case of convulsions, cessation of

breathing or unconsciousness Do not make your child vomit

Emergency Treatment• Always assess the child to determine the care:

airway, breathing, LOC• History of what substance was swallowed• Ask parent to bring in container or sample of

substance swallowed• Activated charcoal may be given to help absorb

substance ingested

Lead Poisoning There are about 1.7 million children with

elevated lead levels. A large proportion are poor, African-American,

Mexican-American, and living in urban areas. Children are more susceptible because they

absorb and retain lead.

Lead Poisoning Lead interferes with normal cell function, and

adversely affects the metabolism of vitamin D and calcium.

Clinical manifestations depend on degree of toxicity.

Neurologic effects include decreased IQ scores, cognitive deficits, impaired hearing, and growth delays.

Lead Poisoning

Sources of lead: Lead based paint Soil and dust Drinking water from lead lined pipes Food growth in contaminated fields Contamination from occupations or hobbies

Lead Levels Blood lead levels between 10 and 19 ug/dL

are typically asymptomatic Teaching about hazards of lead

Blood levels between 20 to 44 ug/dL may present with increase motor impairment and lethargy (poor school performance) Home assessment Chelation therapy may be indicated

Levels greater than 70 ug/dL are considered an emergency

Prevention of Lead Poisoning Washing hands and toys Low-fat diet Check home for lead hazards Regularly clean home Take precautions when remodeling or working

on old cars, furniture, or pottery. Call 1-800-424-lead for guidelines