Pediatric Emergencies Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN 2007 Revised 2011 by Lori.

PediatricEmergencies

Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN

2007Revised 2011 by Lori Barker, MS, RN, CEN

Emergency Nursing Core Curriculum

ObjectivesFor selected pediatric emergencies the

participant will be able to: Compare the etiology Describe assessment findings Identify the clinical management

Pediatric EmergenciesOverview

Children account for 25- 35% of all ED visits

Only 3 – 5 % of those children are acutely ill or injured

Children cannot be cared for as “small adults”, need specialized equipment & training

PEDIATRICSThe Assessment Triangle

Assessment TriangleAn “across-the-room” assessment to establish severity of illness or

injury and urgency of intervention

Appearance (the ‘look test’) is the simplest and most effective assessment tool. Tone, interactibility, consolability, speech or cry. There are very few truly sick or injured children that can pass the look

test. When children are sick they look sick

Breathing- work of breathing. Be alert for nasal flaring, retractions, abnormal airway sounds, position of comfort, rate

Circulation- color & temperature of skin. Assess for pallor, mottling, cyanosis

If any of the three components of the triangle are abnormal – the urgency level increases

Pediatric Triage Rules Parents know their children better than you -

if they say the child is sick - believe them! Start with the ABC’s – look for the not so

obvious; subtle presentation likely Children in shock compensate far better than

adults – do not be fooled by “normal” vital signs

Important to obtain child’s weight in kilograms & birth weight if < 8 wks old

CIAMPEDS Pneumonic for pediatric assessment Chief Complaint

Immunizations Isolation

Allergies

Medications

Past Medical History Parents impression of

child’s condition

Events surrounding illness or injury

Diet Diapers

Symptoms Associated with the illness or injury

PEDIATRICSKey Points Use parents, minimize

separation Observe child while

obtaining history Perform least

intrusive interactions first

Different anatomical & physiological characteristics

Anatomical & Physiological Differences Larger tongue, narrow nasal passages, & airway Relatively short respiratory tract, fewer alveoli, lack

cartilaginous support, prone to airway collapse, immature intercostal muscles increase reliance on diaphragm for breathing

Larger, heavier head in relation to body Less effective thermoregulation, greater body surface

area to body mass, less subcutaneous fat Faster metabolism, increased need for oxygen Lower glycogen stores, at risk for hypoglycemia when

under stress Poorly developed immune system, fewer defenses

Developmental Differences Infant:

comforted through sensory (holding, singing, sucking) Toddler:

offer limited choices minimize separation from caregiver

School age: fear abandonment, body changes, being different from

peers give honest, concrete answers offer choices (promotes sense of control)

Adolescent: modest, want privacy

Assessment Mental status

Alertness Level of consciousness

Most reliable indicator of neuro change Unusual fatigue? Crying – lack of sleep - hunger Ability to relate to caregiver Terminology – lethargic, drowsy What stimulus does it take to elicit what response?

Vital Signs WT in kg T, HR, RR for all pediatric patients BP & O2 sat based on illness

Typical SBP in children > 2 y/o: 90 + (2X age in yrs) Minimum SBP 1-10y/o: 70 + (2X age in yrs)

Can compensate with HR to 25% blood volume loss without drop in BP HR > 160, fast for any age group

Count RR X 1 min > 60/min fast at any age

HR RR SBP

Newborn 100-160 40-60 50-70

1 yr 90-120 30-40 80-100

3 yr 80-110 25-30 80-110

5 yr 80-110 20-25 80-110

10 yr 60-100 15-20 90-120

15 yr 70-100 15-20 80-120

Average Vital Signs by Age

Broselow Pediatric Emergency Tape

Standardized color-coded, length-based tape to estimate child’s weight in an emergency

Measure “Red to the Head” Reference with size-appropriate drug dosing, equipment

selection

Drug Information Side

Equipment & Select Intervention Side

PEDIATRICSRespiratory Emergencies

Most pediatric arrests occur secondary to respiratory compromise.

Mortality rate of pediatric cardiopulmonary arrest is greater than 90%.

Sudden onset of respiratory distress? Consider foreign body obstruction

PEDIATRICSRespiratory Emergencies

Respiratory Emergencies Asthma Affecting an increasing # of

American children partly due to environmental factors

Chronic inflammatory lung disease Symptom – wheezing Treatment:

medication – inhaled β-agonist (Albuterol)

steroid therapy fluids

Respiratory Emergencies Bronchiolitis Inflammation of bronchial mucosa Viral illness Affects children less than 18 months Can be life-threatening Low-grade fever Cough, wheezing

Respiratory Emergencies Respiratory syncytial virus (RSV) Most frequent cause of bronchiolitis Highly infectious – isolate! Seasonal incidence:

late fall through early spring Peak incidence is age 2-8 months Treatment:

bronchodilators antivirals (Ribavirin)

Respiratory Emergencies Croup Viral inflammation of larynx &

subglottic area Peak incidence is up to age 3 Highest incidence in fall & winter Cold symptoms prior to onset of

characteristic ‘bark’

Respiratory Emergencies Croup - treatment Treat gently Hydration Cool humidified oxygen Racemic epinephrine Steroids

Respiratory Emergencies Epiglottitis Emergent airway condition:

Potential for complete airway obstruction Rapid onset of epiglottic inflammation

Greatest incidence 2 - 5 years old Three ‘D’s classic presentation:

Drooling Dysphagia Distress

Respiratory Emergencies Epiglottitis - treatment Do not agitate:

Supplemental oxygen in parent’s lap

Position of comfort Prepare for airway management:

(know where the equipment is!) Intubation Cricothyroidotomy Tracheostomy

Respiratory Emergencies Croup vs. Epiglottitis

Epiglottitis: 1 - 6 years old Rapid onset Appears ill Dyspnea,

drooling Fever

Croup: 6 months to 3

years Insidious onset -

preceded by URI Barking cough,

stridor

Respiratory Emergencies Pertussis (whooping cough)

Highly contagious Three phases:

1. Initial – indistinguishable from the common cold (most infectious)

2. Paroxysms of intense coughing lasting several minutes – ‘whoop’

3. Chronic cough that can last for weeks

Respiratory Emergencies Pertussis - treatment

Isolate! RSV & Pertussis Swab: rayon

swab, rotate in posterior nasopharynx & repeat in other nostril, transport in 1-2ml viral transport media

Minimize agitation Monitor, maintain airway Hydration Antibiotics

Respiratory Pearls of Wisdom

Maintain patent airway Minimize respiratory distress

Keep with parent in position of comfort Weigh necessity of oxygenation against need to keep

child calm; consider blow-by Provide adequate oxygenation

Kid-friendly lingo: Oxygen is “fresh air” The mask is a “space mask” or “santa mask” Blow by as a last resort. Consider the power of

stickers (in a cup/concentrator at end of O2 tubing) Conserve energy

Don’t wake a sleeping child

Abdominal Emergencies – Pyloric Stenosis Hypertrophy of muscular layers of pylorus Obstruction More in males Age 2-8 wks Nonbilious projectile vomiting ? Visible peristalsis after eating Palpable hard, mobile, nontender “olive”

Abdominal Emergencies Intussusception Telescoping of the bowel Age range 3 months to 1 year Sudden onset colicky pain, currant jelly

stool Treatment:

barium enema both diagnostic and often therapeutic (un-telescopes bowel)

if unsuccessful surgical intervention required

Abdominal Emergencies - Volvulus Torsion of the gut, life-threatening. Malrotation most common in neonates May be mistaken for colic Recurrent abdominal pain and vomiting Tenderness, irritability, bloody stools If untreated, may result in infarcted bowel Dx: Ultrasound, xray Tx: IVFs, O2, decompress stomach, Consult

Surgeon

Abdominal Emergencies Dehydration Common pediatric presentation in the ED Most often due to viral syndrome:

Vomiting, diarrhea, decreased urine output Absence of tears, saliva Cap refill > 2 sec Sunken eyes & fontanel

Treatment: Monitor glucose Hydration Identification of cause Parental education

ORT = Oral Rehydration Therapy

For mild to moderate dehydration & able to take oral fluids

Calculate how much of an appropriate solution (ie, Pedialyte) to give in small amounts over certain period of time (ie, every 5 min. over 4 hrs)

For most, 50-100 ml/Kg corrects fluid deficit

Shock Emergencies Volume Dehydration is primary cause of

hypovolemia in children When output exceeds input -

dehydration occurs The spiral - electrolyte disturbance

causes increased nausea & vomiting, causing increased electrolyte disturbances

Shock Emergencies Volume – presentation & treatment

Sunken eyes, fontanels Cap refill > 2 sec, pallor Dry mucous membranes Lethargy & confusion (ominous sign) Treatment:

Adequate ventilation, oxygenation IV bolus 20 mL/kg normal saline

Calculating Maintenance IV Fluid Rates:

Holliday-Segar Method:4 ml/kg for 1st 10kg BW2 ml/kg for 2nd 10kg BW

+ 1 ml/kg for remaining kgs of BW

ie. 24 kg child(4 ml X 10kg)+ (2 ml X 10kg) + (1 ml X 4kg) = 64 ml/hr

Provider may order variation (ie. 1.5 X maintenance, or 96 ml/hr in above example)

D5 1/3 NS or D5 ¼ NS common maintenance fluids (less sodium). Use an IV pump, check site hourly

Pediatric IV Pearls of Wisdom

Common IV sites: scalp (infants < 9mo old), hands, feet, & antecubital fossa Describe to child as a small “straw” Use non dominant hand/limb Wrap limb in warm towel to dilate vein Have sufficient help holding Chloraprep not used in children < 2 mos Advance needle slowly, flash delayed

Secure extremity with appropriate-sized arm board in functional position

Intraosseous access in critically ill (short term)

Shock Emergencies Sepsis

Life-threatening bacterial infection Decreased perfusion Clinical Triad:

Hyper or hypothermia Altered mental status Peripheral vasodilation (“warm” shock) or

vasoconstriction (“cool” shock)

Shock Emergencies Treatment Ventilate and oxygenate Aggressive volume replacement Diagnostics:

Cultures: blood, urine, cerebral spinal fluid if suspected meningitis

Chest x-ray Intravenous antibiotics

Pediatric ShockPitfalls

Hypotension occurs LATE in the pediatric shock syndrome:Blood pressure unreliable

indicator for severity of shock

Bradycardia ominous sign

Fever Accounts for 20% of all pediatric visits to the

emergency department Infants < 30 days with fever, get a full septic

work up (CBC, Bld Cx, Chem, U/A, CXR, LP) Remember-No ibuprofen to children < 2 years of

age. Use oral syringes for PO meds only Common Causes:

Otitis media Viral infections Gastroenteritis Bacteremia, sepsis,

meningitis

Sudden Infant Death Syndrome

(SIDS)Definition:

The unexpected death of a presumably health baby, generally younger than one year, in which an autopsy fails to identify the cause of death

Sudden Infant Death Syndrome

History: Previously healthy infant found lying

face down in crib pulseless & apneic

Interventions: Initiate resuscitative measures Support caregivers: SIDS is neither

preventable or predictable Allow caregivers to hold child Almost always a coroner’s case –

explain the rational for this to caregivers

Status EpilepticusProlonged, continuous seizure activity May be d/t anoxia, infection, trauma, ingestion,

or metabolic disorder May result in cerebral anoxia Treatment

Ensure child’s safety Airway maintenance (suction, oral airway if not

clenched) Oxygenation (BVM, may need intubation) Stop the seizure (anticonvulsants) Workup possible etiology

Trauma Injuries are the leading cause of death in US children 1-

14 y/o MVC, falls, bike accidents, burns, drowning,

poisonings, firearms & abuse Child Safety Seats

Children < 12yrs in the back seat Birth-1yr (20lbs), infant rear-facing 1-4yr (20-40lbs), forward-facing toddler seat 4-8yr (up to 4’9” tall), booster seats

Children may have severe spinal cord injury without radiographic abnormality, SCIWORA

Backboard positioning requires padding under shoulders to prevent neck flexion

Injury PreventionEach interaction is an opportunity to educate parent/child re: Home safety Medication safety Helmets Age-appropriate toys Swim lessons

The best CPR is a poor second to PREVENTION!

Developing Your Skills in Pediatric Emergency Care: Pediatric Advanced Life Support (PALS) Emergency Nursing Pediatric Course (ENPC)-

comprehensive 16hr ENA course, covers emergency nursing pediatric assessment, triage, common emergencies, trauma, transport & hands-on skills

Pediatric Emergency Assessment, Recognition & Stabilization (PEARS)- 6hr AHA course

Certified Pediatric Emergency Nurse (CPEN) credential- through the Board of Certification for Emergency Nursing

Join ENA! Receive the journal & newsletter

Patient Family Education

Follow-up care, use of medications (proper administration), safe storage

Proper use of medical supplies, nebulizers, slings etc

When to seek further help Prevention Assure and document understanding

Case ScenarioA two year old is carried into the

ED by the parents who give a history of sudden high fever and drooling. Interventions include:

A. Establish IV access

B. Let child remain in parent’s lap

C. Apply oxygen via non-rebreather mask

D. All of the above

Case ScenarioA two year old is carried into the

ED by the parents who give a history of sudden high fever and drooling. Interventions include:

A. Establish IV access

B. Let child remain in parent’s lap

C. Apply oxygen via non-rebreather mask

D. All of the above

Case ScenarioSigns of hypovolemic shock

include which of the following?

A. Bradycardia

B. Decreased level of consciousness

C. Sunken fontanels

D. Dry mucous membranes

E. All of the above

Case ScenarioSigns of hypovolemic shock

include which of the following?

A. Bradycardia

B. Decreased level of consciousness

C. Sunken fontanels

D. Dry mucous membranes

E. All of the above

ReferencesAAP Guidelines for Care of Children in the Emergency Dept. http://aapolicy.aapublications.org/cgi/reprint/pediatrics; 124/4/1233.pdf.

ENA (2007) Trauma Nursing Core Course (6th ed). DesPlaines, IL: ENA

Foresman-Capuzzi, J (2009) More big help from little tools. JEN 35 (3) 260-262.

Sheehy, SB (2003) Sheehy’s emergency nursing: principles and practice (5th ed). St Louis: Mosby

Vital Signs, Inc. (2007) Broselow Pediatric Emergency Tape. Armstrong Medical Industries, Inc.