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Download pediatric emergencies - Texas Osteopathic Medical Association
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FERNANDO GONZALEZ, DO, FACOP SHANNON CLINIC PEDIATRICS SAN ANGELO, TEXAS I HAVE NO DISCLOSURES TO MAKE TOPIC OBJECTIVES TO LEARN THE BASIC PATHOPHYSIOLOGY & EMERGENCY RESPONSE FOR RESPIRATORY DISTRESS SHOCK BURNS BITES & STINGS & HEAT ILLNESS IN CHILDREN The primary mission in a pediatric emergency is the resuscitation & stabilization of the patient. Trauma is the #1 cause of death in children in the US after the first year. Pediatric arrest is usually respiratory in origin. Prolonged deterioration Associated with severe hypoxia and acidosis Outcomes are dismal Early intervention and action is critical HISTORY A focused medical history S- SIGNS & SYMPTOMS A- ALLERGIES & IMMUNIZATIONS M- MEDICATIONS P- PAST MEDICAL HISTORY & ILLNESS L- LAST MEAL When & what E- EVENTS PRECEDING ILLNESS OR INJURY Timing, duration, fever, treatments Hazards at scene EXAMINATION: ABCDE A focused physical exam which includes vital signs and pulse oximetry A- AIRWAY ASSESSMENT Look for chest wall movement, signs of obstruction, level of consciousness Listen for abnormal breath sounds Feel for air movement EXAMINATION AIRWAY INTERVENTIONS If no trauma, head tilt Place oropharyngeal airway if needed Immobilize spine if trauma is present Suction naso-oropharynx Visualize for foreign bodies & remove Intubate if necessary Perform cricothyroidotomy EXAMINATION B- BREATHING ASSESSMENT Look for signs of respiratory distress (a clinical state characterized by abnormal respiratory rate or effort) Tachypnea Bradypnea (an omnious sign) Apnea Retractions, flaring, grunting Cough, stridor, gurgling Chest wall motion Altered mental status (hypoxia) Cyanosis EXAMINATION BREATHING ASSESSMENT Listen for breath sounds Rales/crackles Wheezes/rhonchi Asymmetric breath sounds EXAMINATION BREATHING ASSESSMENT Feel for Crepitus Trachael deviation EXAMINATION BREATHING INTERVENTIONS Oxygen administration Ventilatory support Bag-mask ventilation Intubation & ventilator support Vapo-therm CPAP IMV Needle thoracotomy/Chest tube RESPIRATORY PROBLEMS RESPIRATORY FAILURE A clinical state of inadequate oxygenation or ventilation or both Requires intervention to avoid deterioration to cardiac arrest Causes Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing RESPIRATORY PROBLEMS UPPER AIRWAY OBSTRUCTION Foreign body aspiration Airway swelling (anaphylaxis, croup, epiglotittis) Mass (Peritonsillar abcess, tumor) Congenital airway abnormality (choanal stenosis/atresia or subglottic stenosis) Signs generally occur in inspiration RESPIRATORY PROBLEMS LOWER AIRWAY OBSTRUCTION Obstruction of lower trachea, bronchi & bronchioles Asthma, bronchiolitis Signs generally occur in exhalation RESPIRATORY PROBLEMS LUNG TISSUE DISEASE A heterogeneous group of clinical conditions affecting the lung at the alveolar level Characterized by small airway collapse & alveolar congestion Pneumonia, pulmonary edema (CHF, ARDS), aspiration pneumonitis, trauma, allergic reaction, toxins, vasculitis RESPIRATORY PROBLEMS DISORDERED CONTROL OF BREATHING An abnormal breathing pattern with signs of inadequate respiratory rate, effort or both Neurologic disorders (seizures, meningitis, head injury, brain tumor, neuromuscular disease) Altered mental status is typical “Breathing funny” EXAMINATION C- CIRCULATION ASSESSMENT Shock A critical condition resulting from inadequate oxygen & nutrient delivery to tissues Characterized by inadequate peripheral and end organ perfusion (Usually) Usually associated with low cardiac output EXAMINATION C- CIRCULATION ASSESSMENT Shock Tachycardia or bradycardia (most common cause is hypoxia) Delayed capillary refill time (< 2 seconds is normal) Cool extremities Pulses (Normal, bounding, weak or absent) Skin color (pallor, mottling, cyanosis) EXAMINATION C- CIRCULATION ASSESSMENT Shock Hypotension A late finding indicating impending arrest Results from failure of compensatory mechanisms Minimum systolic blood pressure: Newborn: > 60 Infants: > 70 1-10 years of age: (2 x age in years) + 70 Over 10 years: > 90 EXAMINATION C- CIRCULATION Shock Types Hypovolemic: Results from volume loss Most common type of shock in children V/D, hemorrhage, DKA, 3rd space loss, burns Distributive: Inadequate distribution of blood volume Vasodilation, increased capillary permeability Sepsis, anaphylaxis, neurogenic (head/spinal injury) Cardiogenic: Inadequate perfusion d/t cardiac dysfunction CHD, myocarditis, cardiomyopathy, trauma Obstructive: Impaired cardiac flow Tamponade, tension pneumothorax EXAMINATION C- CIRULATION INTERVENTIONS Shock Early intervention reduces morbidity and mortality Goals: Optimize oxygen content of blood Improve volume & distribution of cardiac output Reduce oxygen demand Correct metabolic derangements EXAMINATION C- CIRCULATION INTERVENTIONS Shock Intravenous access: Peripheral IV, IO Fluid resuscitation 20 ml/Kg NS/LR over 5-10 min, repeat prn Administer oxygen Medications Vasoactive agents (Central line) Antibiotics Epinephrine EXAMINATION D- DISABILITY A rapid evaluation of neurologic function Important indicators of cerebral function Decreased level of consciousness A: Alert, Active, Awake V: Voice P: Painful U: Unresponsive Glasgow Coma Scale (Head injury) Loss of muscular tone Seizures Pupil dilation EXAMINATION E- EXPOSURE Undress the patient Check for signs of trauma Bruising, bleeding, burns, deformity Check the core temperature Hypothermia Fever BURNS CLASSIFICATION Superficial (1st degree) Dry, warm, painful Partial thickness (2nd degree) Superficial dermis: Red, very painful, blistered Deep dermis: Dry, white, hyposensitive Full thickness (3rd degree) Anesthetic, dry, white, leathery BURNS MANAGEMENT Superficial: Heal in 10-14 days Analgesia, cool compresses Leave open Partial thickness: Heal in 2-3 weeks Debride, clean, dress daily, Silvadene/bacitracin ointment Leave blisters intact Accuzyme ointment Serial exams: refer for disfigurement/contractures Analgesics especially before dressing changes BURNS MANAGEMENT Full thickness ABCDE in severe injury Consultation with/transfer to PICU, Burn unit Fluids Volume replacement: 4 ml/Kg/%BSA burned for 1st 24 hrs (Parkland) Give ½ in 1st 8 hrs plus maintenance volume & remaining ½ over next 16 hours BURNS DISPOSITION Outpatient therapy for superficial & partial thickness burns Admission for major burns > 10% BSA with partial thickness burns > 2% BSA with full thickness burns Severe burns involving eyes, ears, face, hand/feet, or with associated fractures High voltage electrical burns Child abuse/ neglect Associated smoke inhalation BITES & STINGS ANIMAL BITES General Irrigate & debride if possible. Do not suture unless necessary for cosmetic reasons (face). X-ray head and hand bites (fractures, puncture skull). Surgical consultation if bite involves tendons, joints, deep fascial layers, major vasculature. Serious or infected wounds should be irrigated, debrided, explored and closed, if indicated, in OR. Consider most wild carnivores as rabid unless proven negative by brain fluorescein antibody test (skunk, raccoon, bat, fox) Remember tetanus vaccination if not up to date. Follow up in 24-48 hours. BITES & STINGS DOG BITES Most frequent cause of fatality from animal bites in children. Tearing/crushing type injuries Consider admission for cranial bites by a large animal. Prophylactic antibiotics do not improve outcomes in uncomplicated bites not involving the hands/feet. Culture if infected or if > 12 hrs since bite occurred. Staph aureus: trimethoprim/sulfamethoxazole Pasturella multocida: amoxicillin/clavulanic acid, 45 mg/Kg/day in 3 doses BITES & STINGS CATS Puncture type wounds Frequently infected Pasturella Amoxicillin/clavulanic acid prophylaxis BITES & STINGS HUMAN Frequently infected Staph, Strep, anaerobes, Eikenella Amoxicillin/clavulanic acid x 5-10 days Consider possible child abuse Evaluate risk of transmission of HBV, HIV, HSV BITES & STINGS RABIES PROPHYLAXIS Dogs, cats, ferrets If animal available & healthy, observe for 10 days No prophylaxis unless animal develops symptoms If rabid or suspected, euthanize and test brain Immediate immunization and rabies immunoglobulin Unknown Consult public health department Wild carnivores (Bat, fox, raccoon, skunk) Regard as rabid unless brain is tested and negative on fluorescein antibody test Immediate immunization and RIG BITES & STINGS RABIES PROPHYLAXIS Rabies Immunoglobulin (RIG) 20 IU/Kg Infiltrate wound(s) with RIG. May dilute 2-3 times to infiltrate all wound areas. Give remainder IM. May give at same time with vaccine but at different sites. It is preferred to begin RIG within 7 days of starting vaccine but, if indicated, use both regardless of interval between exposure and initiation of treatment. BITES & STINGS RABIES PROPHYLAXIS Immunization Vaccine reactions are rare in children. 3 vaccines available in US 1 ml IM on day 1, 3, 7, 14, 28 for 5 doses May discontinue if brain test is negative BITES & STINGS INSECTS Bees, wasps, fire ants, stinging caterpillars usually General measures Clean area Remove stinger if present Cool compresses, elevate Mild analgesics Oral antihistamines Consider corticosteroids for severe local reactions, severe swelling Check tetanus status BITES & STINGS INSECTS Anaphylaxis The most serious concern Symptoms Chest/neck tightness Dizziness/syncope Disorientation Swelling Upper airway obstruction Wheezing/Respiratory distress Urticaria Hypotension BITES & STINGS INSECTS Anaphylaxis Treatment ABCDE Administer oxygen Administer epinephrine 1:1,000; 0.01 mg/Kg SQ q 15 min prn or 1:10,000: 0.01 mg/Kg IV/IO q 3-5 minutes to max 1 mg if hypotensive for age. If patient remains hypotensive, give by continuous infusion, 0.1-1 umg/Kg/minute. Prescribe IM autoinjector (0.3 mg > 30 KG; 0.15 mg 10-30 Kg) Albuterol by nebulization for wheezing/respiratory distress. HEAT ILLNESS HYPOTHERMIA Definition: A core temperature of < 35 C (95 F) Causes Submersion accidents Septic shock Encephalopathy Accidental ingestions Metabolic disorders HEAT ILLNESS HYPOTHERMIA Peripheral vasoconstriction leads to increased muscle tone, increased metabolism & shivering. At < 28 C (82.4 F), pupils are fixed & dilated. There is no pulse or spontaneous respirations and the patient is rigid. Death cannot be declared until the patient is re-warmed to at least 30 C (86 F) and resuscitated. Patients can survive submersion times of up to 40 minutes and prolonged CPR of > 2 hrs. Re-warm with passive techniques, body cavity irrigation, ECMO (best) or cardiopulmonary bypass. HEAT ILLNESS HEAT STROKE Heat exposure resulting in a core temperature of > 40 C (104 F) with associated neurologic signs. Combative Disoriented If severe nuchal rigidity seizures posturing coma HEAT ILLNESS HEAT STROKE Complications Rhabdomyolysis Acute tubular necrosis DIC Hepatic degeneration Electrolyte derangements ARDS HEAT ILLNESS Heat Stroke Treatment ABCDE Cool patient (Cooling blankets, ice) IV fluids/fluid resuscitation Monitors Labs Admit HEAT ILLNESS HEAT CRAMPS Occurs during exercise with heat exposure Self limited Painful Temperature normal or only slightly elevated Rehydrate Occasionally requires IV fluids HEAT ILLNESS HEAT EXHAUSTION Temperature normal or only slightly elevated Symptoms Weakness Disorientation Nausea/vomiting Headache Increased thirst Muscle cramps No major CNS symptoms HEAT ILLNESS HEAT EXHAUSTION Treatment Fluid replacement Often requires IV access RESOURCES Pediatric Advanced Life Support, AHA/AAP, Provider Manual, 2011 The Harriet Lane Handbook, The Johns Hopkins Hospital, 18th edition American Academy of Pediatrics, Red Book, 27th edition Nelson’s Pocket Book of Pediatric Antimicrobial Therapy, 16th edition
