Pediatric emergencies. As pediatricians say Children are not small adults There are differences: Developmental Anatomical Physiological Different range.

Pediatric emergencies

As pediatricians sayChildren are not small adults

There are differences:

• Developmental

• Anatomical

• Physiological

Different range of emergencies and response to illness.

Epidemiology

Common causes of death• Accidents

– Motor vehicle accidents 50%– Falls 25-30%– Drowning 10%– Poisoning and assaults 15%

• Respiratory arrest – asthma, trauma, drug ingestion, drowning, sudden infant death syndrome (SIDS), infection, foreign body aspiration

Epidemiology

•Heart disease is rarely the primal cause of cardiac arrest in children.

•Cardiac arrest is due to respiratory insult.

•Prolonged period of hypoxia can lead to cardiac arrest (in mechanism of asystole or PEA).

•Better chance of brain recovery after than do adults after the same period of oxygen deprivation

Downward spiral

in the infant’s

condition

that leads to cardiopulmonary arrest

Age groups

Infants: 0 - 12 months• minimal language capability• minimal stranger anxiety• the greatest anatomical differences

Toddlers: 11 months – 3 years• uncooperative, crying• do not like to be touched, to remove their clothes• strong fear of pain

Age groups

Preschool: 3 – 6 years• period of intensive learning• varied levels of ability to express thoughts and

feelings• do not like being touched• fear pain• dislike having clothing removed• believe that they’re responsible for their illness• curious, communicative

Age groups

School age: 6 – 12 years• strong fear of disfigurement and permanent injury• feelings of modesty• fear of pain and bloodAdolescence: 12 – 18 years• changes of puberty• feel helpless and child-like under the stress• respect their „space” and allow them to retain as

much control as possible

General clues

• Keep the child and parent together whenever possible, separation causes anxiety

• Be calm, calm the parents• Be honest – do not say „This won’t hurt”, when it

will – no cooperation after loosing the child’s trust• Perform the trunk-to-head assessment –

examination around the face is most threatening to the child.

Concerns about Anatomy and Physiology

• In general, better ability to compensate physiologically – young ad healthy compensatory mechanisms

• Rapid deterioration of condition when compensatory mechanisms fail

• Recognize early signs of stress

Airway considerations

• small caliber airways at all levels• large tongue in relation to the airway with greater

potential for obstruction• the glottis lies anterior and superior compared with

adults• relatively large, U-shaped epiglottis• the cricoid ring is the narrowest part of the upper airway• soft membranous trachea – may kink if neck is

hyperextended• infants are obligatory nose breathers

Normal respiratory rates

Adult 12 - 20 breaths per minute

Child 15 - 30 breaths per minute

Infant 25 - 50 breaths per minute

Normal pulse rates

newborn- month 85 - 205 av.140

infant 100 - 190 av.130

child (2-10 yr) 60 - 140 av. 80

child (< 10 yr) 60 - 100 av. 75

adult 60 - 80 av. 72

Blood pressure

• Blood pressure increases with age• AHA formula to approximate the lower limit for SBP

in children above 2 years of age:SBP = 70 + (2 x age in years)

• The width of the cuff should cover approximately 2/3 of the length of the upper arm and the bladder should cover approx. 75% of the arm’s circumference.

• Systolic blood pressure of less than 70 mmHg with tachycardia and cool skin indicates the shock in children – according to The American College of Surgeons.

Metabolic differences

• higher baseline metabolic rate• higher oxygen and glucose consumption• greater skin surface area relative to body weight –

they lose heat and moisture through the skin more easily

• infants younger than 6 months of age cannot shiver in response to cold

• low energy stores• Remember – when the metabolic needs on a cellular

level are not met, shock results

Neurological differences

• because the head is large in relation to the body there’s a greater possibility of head injury

• the infant is capable of suffering blood loss within the cranium sufficient to cause shock

• infants and children are more prone to episodes of apnea with head trauma

• children have a greater chance of recovery from brain hypoxia or head trauma – better ability to compensate physiologically

Response to hypovolemia• hypovolemic shock is the most common type of shock

in children• dehydration (not enough water) is the primal cause of

hypovolemia– increased metabolic needs– poor intake– vomiting and diarrhea

• gradual loss of fluids is better tolerated (fluid shifts from the cells and interstitial fluid to maintain the plasma volume) – progression of signs of dehydratation

Signs of dehydration

• initially:– rapid pulse– less urine output– dry mucosal membranes

• progressed:– lack of tears– sunken fontanelle (in infant)– sunken eyes

Signs of dehydration

• late signs:– skin tenting– delayed capillary refill– hyperventilation– altered mental status– HYPOTENSION (very late sign)

Hypovolemia

• the average blood volume is 80 ml/kg• with healthy compensatory mechanisms, children

can maintain their blood pressure until nearly 40% of the blood volume is lost.

• hypotension is a late sign of hypovolemia!by the time the children are hypotensive, they’re in deep shock!

• treatment: fluids orally (if conscious), intra venous fluid replacement (if unconscious)

Assessment of the pediatric patient

• General impression – ability to conduct the initial evaluation „from the doorway” - general observation and initial handling of the child. Look for:– activity and playfulness

– color of the skin

– respiratory effort

– temperature

– quality of speech or crying

Respiratory assessment

Note:• Respiratory rate• Symmetrical chest expansions• Accessory muscles of breathing

involvement?• Retraction above the clavicles, between the

ribs and below the sternum?• Increased abdominal movement?

Key signs of respiratory distress

Respiratory assessment

• Listen for:– stridor – crowing sound made on inspiration

due to upper airway obstruction– grunting – rhythmic sound heard at the end of

exhalation – significant respiratory compromise– wheezing – „musical” sound heard during

exhalation caused by the narrowing of the lower airways (asthma, bronchiolitis)

Signs of respiratory distress

• Early signs– tachypnoe

– tachycardia

– retractions

– nasal flaring

– stridor

– wheezing

– grunting

• Increasing distress leading to respiratory failure– severe retractions or

grunting, or both– increased tachycardia

and tachypnoe– altered mental status– poor peripheral

perfusion– cyanosis– decreased muscle tone

Signs of respiratory distress

• Prerespiratory arrest– cyanosis or grayish hue to skin– bradycardia– shallow breathing or apnea– unconsciousness– weak distal pulses– limp muscle tone

Upper Airway Disease

The major serious upper airway diseases :

• Croup

• Epiglottitis

• Foreign body in airway

Croup

• a viral infection affecting the larynx, trachea and bronchi in children of age 6 months – 6 years

• causes airway narrowing especially at the level of cricoid ring

• hoarseness, low-grade fever, cough (as barking seal), inspiratory stridor, retractions with inspiratory effort

• severe cases can result in complete airway obstruction• management: humidification air, oxygenation, assist

ventilation

Epiglottitis

• infectious (bacterial) swelling of the epiglottis with rapid onset (2 to 6 years of age), potentially life-threatening (total airway obstruction)

• high fever, sore throat, dysphagia, occasional stridor, drooling (the most symptomatic)

• management: let the child stay in parents arms, be calm, offer humidified oxygen, hold the mask near the child’s face, if necessary (cyanosis) – mechanical ventilation (bag-valve-mask)

• transport to the hospital or call ambulance

Foreign body airway obstruction

Infant

• establish unresponsiveness

• open airway and try to ventilate

• give 5 back blows and 5 chest thrusts

• perform a tongue - jaw lift and if you see the object perform the finger sweep to remove

• repeat until effective

Previously healthy child with a history of choking

Abdominal thrust in unconscious child

Abdominal thrust in conscious child

Lower airway disease

• The most common causes of lower airways diseases– bronchiolitis in infants <1yr – asthma– pneumonia or other infectious process– foreign body in smaller airways

• Patient with difficulty breathing without upper respiratory problem is treated by:– reducing stress and exertion– administering humidified oxygen– transporting with monitoring to a hospital

Respiratory distress and respiratory failure protocol

1. Provide oxygen to all children with respiratory emergencies.

2. Assist ventilation for severe respiratory distress with:1. altered mental status

2. cyanosis with oxygen

3. poor muscle tone

4. ineffective respiratory efforts

3. Provide oxygen and artificial ventilation for respiratory arrest.

The febrile child

• Fever is the most common complaint in children

• Rapid rise of temperature can trigger the seizures – febrile seizure (4% children)

• Any febrile child should be transported to the emergency department and assessed by physician.

• Treating the febrile child: – cover him/her with a cloth soaked with tepid water

(do not use alcohol or cold water – possibility of vasoconstriction and hypothermia)

– administer paracetamol orally

Seizures

Definitions:• seizure- an isolated event from an abnormal electrical

discharge in the brain• epilepsy - the tendency to have recurrent seizures• convulsions - a seizure with a change in muscle or

motor activity• generalized convulsions - convulsions involving the

entire body that are associated with the loss of consciousness

Seizures

Definitions:

• focal seizure - involving one area of the body; not necessarily associated with an altered mental status

• petit mal seizures - extremely brief periods of loss of consciousness without loss of muscle tone

Seizures

• The most common cause in pediatric patient – fever

• Simple febrile seizure – brief, lasting less than 5 min, associated with fever and tonic-clonic generalized convulsions

• Complex febrile seizure – if greater than 15 min in duration, if focality (localized to a part of the body) present, multiple episodes within 24 hours.

• Status epilepticus – persistent generalized seizure lasting more than 20 min or series of recurrent seizures without the return of consciousness

Other causes of seizures

• infections - meningitis, encephalitis, roseola• metabolic disorders - hypoglycemia, hypoxia,

hyponatremia, hypocalcemia• toxic substances - poisons, drugs, drug

withdrawal• structural problems - head trauma, bleeding,

brain tumors• idiopathic - no known cause

Complications of seizures

• Respiratory problems: airway obstruction by the tongue, risk of aspiration, ineffective respiratory muscles

• Metabolic problems: rise of body temperature from persistent muscular activity, depletion of glycogen stores

• CNS problems: CNS affected by the prolonged electrical activity

Seizures protocol

• ensure an open airway

• position the patient on his or her side if no cervical spine injury is suspected

• have suction ready

• provide oxygen and ventilation

• transport to a hospital

Special situations

• Unconscious, breathing, pulse present – safety position

• Unconscious, not breathing, pulse present – mouth – mouth & nose ventilation – 40 breaths per minute

• Unconscious, not breathing, pulse absent – CPR• Breathing : chest compression ratio as 2:15 -

children younger than 8 years old, children older than 8 years – CPR as in adults 2:30

Airway management

Cover the infants mouth and nose with your mouth

External chest compression ratio 100 compressions per minute

breathing to chest compression 2 : 15 ; 1/3 depth of chest

External chest compression better method

Advanced CPR

• Check pulse on the brachial artery• 100% oxygen ventilation• Assess the mechanism of cardiac arrest – in

most cases asystole or PEA• Drugs: 10 mcg/kg epinephrine (0.1 ml/kg of

1 in 10 000 solution) every 3 minutes• In case of VF/VT defibrillation: 4 J/kg,

4 J/kg, 6 J/kg

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call AMBULANCE

30 chest compressions

2 rescue breaths

Adult BLS algorithm

Approach safely

Check response

Shout for help

Open airway

Breath absent or irregular

5 rescue breaths

30 chest compressions

2:30 (2:15) CPR

Pediatric BLS algorithm

After 1 min.of CPR

Call AMBULANCE

CPR 30:2Until defibrillator / monitor attached

AssessRhythm

Shockable(VF/ Pulsless VT)

Non-shockable(PEA / Asystole)

1 Shock4 J / kg or AED

adjusted for children

Immediately resume:

CPR 15:2 For 2 min

CallResuscitationTeam

During CPR:•Correct reversible causses•Check electrode position and contact•Attempt / verify:

•IV access•Airway and oxygen

•Give uninterrupted compressions when airway secure•Give adreanline every 3-5 mins•Consider: amiodarone, atropine, magnesium

* Reversible causesHipoxia Tension pneumothorax Hipovolaemia Tamponade cardiacHipo/Hiperkalaemia / Metabolic Toxins Hipothermia Thrombosis (coronary or

pulmonary)

Immediately resume:

CPR 15:2For 2 min