PEDIATRIC EMERGENCIES

1. PEDIATRIC EMERGENCIES

2. Pediatric Emergencies • Basic Approach to Pediatric Emergencies • Approaches to patient vary with age and nature of incident • Practice quick and specific questioning of the child • Key on your visual assessment • Begin your exam without instruments • Approach the child slowly and gently

3. Pediatric Emergencies • Basic Approach (cont..) • Do not separate the child from the mother unnecessarily • Be honest and allow the child to determine the order of the exam • Avoid touching painful areas until the child’s confidence has been gained

4. Pediatric Emergencies • Child’s response to emergencies • Primary response is fear • Fear of being separated from parents • Fear of being removed from home • Fear of being hurt • Fear of mutilation • Fear of the unknown • Combat the fear with calm, honest approach • Be honest - tell them it will hurt if it will • Use approach language

5. Development Stages -Keys to Assessment • Neonatal stage - birth to 1 month • Congenital problems and other illnesses often n noted • Personality development begins • Stares at faces and smiles • Easily comforted by mother and sometimes father • Rarely febrile, but if so, be cautious of meningitis

6. Development Stages -Keys to Assessment • Approach to Neonates • Keep child warm • Observe skin color, tone and respiratory activity • Absence of tears when crying indicates dehydration • Auscultate the lungs early when child is quiet • Have the child suck on a pacifier • Have child remain on the mother’s lap

7. Development Stages -Keys to Assessment • Ages 1-5 months - Characteristics • Birth weight doubles • Can follow movements with their eyes • Muscle control develops • History must be obtained from parents • Approach • Keep child warm and comfortable • Have child remain in mother’s lap • Use a pacifier or a bottle

8. Development Stages -Keys to Assessment • Ages 1-5 months - Common problems • SIDS • Vomiting and diarrhea/dehydration • Meningitis • Child abuse • Household accidents

9. Development Stages -Keys to Assessment • Ages 6-2 months - Characteristics • Ability to stand or walk with assistance • Very active and explore the world with their mouths • Stranger anxiety • Do not like lying supine • Cling to their mothers

10. Development Stages -Keys to Assessment • Ages 6-12 months - Common problems • Febrile seizures • Vomiting and diarrhea/dehydration • Bronchiolitis or croup • Car accidents and falls • Child abuse • Ingestions and foreign body obstructions • Meningitis

11. Development Stages -Keys to Assessment • Ages 6-12 months - Approach • Examine the child in the mothers lap • Progress from toe to head • Allow the child to get used to you

12. Development Stages -Keys to Assessment • Ages 1-3 years - Characteristics • Motor development, always on the move • Language development • Child begins to stray from mother • Child can be asked certain questions • Accidents prevail

13. Development Stages -Keys to Assessment • Ages 1-3 yrs - Common problems • Auto accidents • Vomiting and diarrhea • Febrile seizures • Croup, meningitis • Foreign body obstruction

14. Development Stages -Keys to Assessment • Ages 1-3 yrs - Approach • Cautious approach to gain confidence • Child may resist physical exam • Avoid “no” answers • Tell the child if something will hurt

15. Development Stages -Keys to Assessment • Ages 3-5 years - Characteristics • Tremendous increase in motor development • Language is almost perfect but patients may not wish to talk • Afraid of monsters, strangers; fear of mutilation • Look to parent for comfort and protection

16. Development Stages -Keys to Assessment • Ages 3-5 yrs - Common problems • Croup, asthma, epiglottitis • Ingestions, foreign bodies • Auto accidents, burns • Child abuse • Drowning • Meningitis, febrile seizures

17. Development Stages -Keys to Assessment • Ages 3-5 yrs - Approach • Interview child first, have parents fill in gaps • Use doll or stuffed animal to assist in assessment • Allow child to hold & use equipment • Allow them to sit on your lap • Always explain what you are going to do

18. Development Stages -Keys to Assessment • Ages 6-12 years - Characteristics • Active and carefree • Great growth, clumsiness • Personality changes • Strive for their parent’s attention • Common problems • Drowning • Auto accidents, bicycle accidents • Fractures, falls, sporting injuries

19. Development Stages -Keys to Assessment • Age 6-12 yrs - approach • Interview the child first • Protect their privacy • Be honest and tell them what is wrong • They may cover up information if they were disobeying

20. Development Stages -Keys to Assessment • Ages 12-15 - Characteristics • Varied development • Concerned with body image and very independent • Peers are highly important, as is interest in opposite sex

21. Development Stages -Keys to Assessment • Ages 12-15 - Common problems • Mononucleosis • Auto accidents, sports injuries • Asthma • Drug and alcohol abuse • Sexual abuse, pregnancy • Suicide gestures

22. Development Stages -Keys to Assessment • Ages 12-15 - Approach • Interview the child away from parent • Pay attention to what they are not saying

23. Development Stages -Keys to Assessment • Characteristics of Parents response to emergencies • Expect a grief reaction • Initial guilt, fear, anger, denial, shock and loss of control • Behavior likely to change during course of emergency

24. Development Stages -Keys to Assessment • Parent Management • Tell them your name and qualifications • Acknowledge their fears and concerns • Reassure them it is all right to feel as they do • Redirect their energies - help you care for child • Remain calm and in control • Keep them informed as to what you are doing • Don’t “talk down” to parents • Assure parents that everything is being done

25. General Approach to Pediatric Assessment • History • Be direct and specific with child • Focus on observed behavior • Focus on what child and parents say • Approach child gently, encourage cooperation • Get down to visual level of child • Use a soft voice and simple words

26. Physical Exam • Avoid touching painful areas until confidence has been gained • Begin exam without instruments • Allow child to determine order of exam if practical • Use the same format as adult physical exam

27. General Approach to Pediatric Assessment • Physical Exam (cont.) • Special concerns • Fontanels should be inspected in infants • Normal fontanels should be level with surface of the skull or slightly sunken and it may pulsate • Abnormal fontanels • Tight and bulging (increased ICP from trauma or meningitis) • Diminished or absent pulsation • Sunken if dehydrated

28. General Approach to Pediatric Assessment • Special concerns (cont..) • GI Problems • Disturbances are common • Determine number of episodes of vomiting, amount and color of emesis

29. Pediatric Vital Signs • Blood Pressure • Use right size cuff, one that is two-thirds the width of the upper arm • Pulse • Brachial, carotid or radial depending on child • Monitor for 30 seconds

30. Pediatric Vital Signs • Respirations • Observe the rate before the child starts to cry • Upper limit is 40 minus child’s age • Identify respiratory pattern • Look for retractions, nasal flaring, paradoxical chest movement • Level of consciousness • Observe and record

31. Noninvasive Monitoring • Prepare the child before using devices • Explain the device • Show the display and lights • Let child hear noises if devices makes them • Pulse oximetry-particularly useful since so many childhood emergencies are respiratory

32. Pediatric Trauma • Basics • Trauma is leading cause of death in children • Most common mechanisms-MVA, burns, drowning, falls, and firearms • Most commonly injured body areas-head, trunk, extremities • Steps much like those in adult trauma • Complete ABCDE’s of primary assessment • Correct life threatening conditions • Proceed to secondary assessment

33. National MVA 43% Burns 14.9% Drowning 14.6% Aspiration 3.4% Firearms 3.0% Falls 2.0% Oklahoma MVA 35% Drowning 14.5% Burns 14.0% Firearms 9.9% Aspiration 5.7% Stab/cut ? Causes of Death

34. Frequency of Injured Body Parts • Head 48% • Extremities 32% • Abdomen 11% • Chest 9%

35. Pediatric Trauma • Head, face, and neck injuries • Children prone to head injuries • Be alert for signs of child abuse • Facial injuries common secondary to falls • Always assume a spinal injury with head injury

36. Pediatric Trauma • Chest and abdominal injuries • Second most common cause of pediatric trauma deaths • Most result from blunt trauma • Spleen is most commonly injured organ • Treat aggressively for shock in blunt abdominal injury

37. Pediatric Trauma • Extremity injuries • Usually limited to fractures and lacerations • Most fractures are incomplete - bend, buckle,, and greenstick fractures • Watch for growth plate injuries

38. Pediatric Trauma • Burns • Second leading cause of pediatric deaths • Scald burns are most common • Rule of nine is different for children • Each leg worth 13.5% • Head worth 18%

39. Pediatric Trauma • Child abuse and neglect - Basics • Suspect if injuries inconsistent with history • Children at greater risk often seen as “special” and different • Premature or twins • Handicapped • Uncommunicative (autistic) • Boys or child of the “wrong” sex

40. Pediatric Trauma • Child abuse and neglect - The child abuser • Usually a parent or someone in the role of parent • Usually spends much time with child • Usually abused as a child

41. Pediatric Trauma • Sexual Abuse - Basics • Can occur at any age • Abuser is usually someone in family • Can be someone the child trusts • Stepchildren or adopted children at higher risk • Paramedic actions • Examine genitalia for serious injury only • Avoid touching the child or disturbing clothing • Provide caring support

42. Pediatric Trauma • Triggers to high index of suspicion for child neglect • Extreme malnutrition • Multiple insect bites • Long-standing skin infections • Extreme lack of cleanliness

43. Pediatric Trauma • Triggers to high index of suspicion for child abuse • Obvious fracture in child under 2 yrs old • Injuries in various stages of healing • More injuries than usually seen in children of same age • Injuries scattered on many areas of body • Bruises that suggest intentional infliction • Increased ICP in infant

44. Pediatric Trauma • Triggers to high index of suspicion for child abuse (cont.) • Suspected intra-abdominal trauma in child • Injuries inconsistent with history • Parent’s account vague or changes during interview • Accusations that child injured himself intentionally • Delay in seeking help • Child dresses inappropriately for situation

45. Pediatric Trauma • Management of potentially abused child • Treat all injuries appropriately • Protect the child from further abuse • Notify the proper authorities • Be objective while gaining information • Be supportive and nonjudgmental of parents • Don’t allow abuser to transport child to hospital • Inform ED staff of suspicions of child abuse • Document completely and thoroughly

46. Pediatric Medical Emergencies - Neurological • Pediatric seizures - Common causes • Fever, infections • Hypoxia • Idiopathic epilepsy • Electrolyte disturbances • Head trauma • Hypoglycemia • Toxic ingestion or exposure • Tumors or CNS malformations

47. Pediatric Medical Emergencies - Neurological • Febrile Seizures • Result from a sudden increase in body temperature • Most common between 6 months and 6 years • Related to rate of increase, not degree of fever • Recent onset of cold or fever often reported • Patients must be transported to hospital

48. Pediatric Medical Emergencies - Neurological • Assessment • Temperature - suspect febrile seizure if temp over 103 degrees F • History of seizure • Description of seizure activity • Position and condition of child when found • Head injury, Respirations • History of diabetes, family history • Signs of dehydration

49. Pediatric Medical Emergencies - Neurological • Management - Basic Steps • Protect seizing child • Manage the ABC’s, provide supplemental oxygen • Remove excess layers of clothing • IV of NS or LR TKO rate • Transport all seizure patients, support the parents

50. Pediatric Medical Emergencies - Neurological • Management - If status epilepticus • IV of NS or LR TKO rate • Perform a Dextrostix <80 mg/dl give D25 2 ml/kg IV/IO if child is less than 12 • 12 or older give D50 1ml/kg IV • Contact Medical Control if long transport