Pediatric Emergencies

1. Pediatric Emergencies Jan Bazner-Chandler RN, MSN, CNS, CPNP

2. Developmental and Biologic Variances • Cricoid is the narrowest portion of the airway: no cuffed ET tubes ET cuffed

3. 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

4. Triage • To “pick or sort”. • Goals of triage: • Rapidly identify seriously injured. • Prioritize all patients using the emergency department. • Initiate therapeutic measures.

5. 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

6. Assessment • Across-the-room assessment • Chief complaint • Brief history (AMPLE Mnemonic) • Allergies • Medications • Past medical history • Last meal • Events surrounding the incident

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

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

9. Shock • Hypovolemic shock • Distributive • Cardiogenic • Obstructive

10. 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

11. Hypovolemic shock: Assessment • Tachycardia • Prolonged capillary refill > than or equal to 2 seconds • Weak, thready or absent peripheral pulses • Cool extremities

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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.

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

21. Focus History • What was ingested? • How much was ingested? • When did it occur? • What therapy was initiated before arrival in the ED?

22. 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

23. 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

24. 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

25. 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.

26. 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.

27. 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

28. 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

29. 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