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Pediatric Emergencies Jan Bazner-Chandler RN, MSN, CNS, CPNP Developmental and Biologic Variances Cricoid is the narrowest portion of the airway: no cuffed ET tubes in children under 8 years of age ET cuffed Developmental and Biologic Variances Total blood volume is smaller – small blood loss may led to hypovolemia and impaired profusion 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 Developmental and Biologic Differences Respiratory arrest is more common in pediatric population Respiratory rate below 10 or above 60 are sign that child may be headed for respiratory arrest without interventions Triage To “pick or sort”. Goals of triage: Rapidly identify seriously injured. Prioritize all patients using the emergency department. Initiate therapeutic measures. 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 Assessment Across-the-room assessment Chief complaint Brief history (AMPLE Mnemonic) Allergies Medications Past medical history Last meal Events surrounding the incident Focused Physical Assessment Airway Breathing Circulation Disability Exposure Full vital signs Family presence Give comfort Head-to-toe assessment Inspect Isolate Test and Procedures CBC with differential: infection and lack of immune response Type and cross match: blood type Serum electrolytes: electrolyte imbalance Radiographs: chest, abdomen, bones Computed tomography – CT scan: detects bleeding or masses Shock 1. 2. 3. 4. Hypovolemic shock Distributive Cardiogenic Obstructive Note: cardiogenic and obstructive more common in the adult Shock The earlier you can recognize shock, establish priorities, and start therapy, the better the child’s chance for a good outcome. Hypovolemic Shock Most common cause of shock in children Fluid and electrolyte losses associated with fluid loss Blood loss from trauma Etiology: caused by inadequate volume relative to the vascular space Hypovolemic Shock Most common cause of shock in children worldwide Fluid loss due to diarrhea is the leading cause Other causes Hemorrhage Vomiting Inadequate fluid intake Osmotic diuresis (eg diabetic ketoacidosis Third space losses (fluid leak into tissues Burns Sepsis Physiology of Hypovolemic Shock Characterized by decreased preload leading to reduced stroke volume and low cardiac output. Compensatory mechanisms are tachycardia, increased contractility, and increased systemic vascular resistance. Hypovolemic shock: Assessment Cardiovascular Tachycardia Normal blood pressure or hypotension with a narrow pulse pressure Prolonged capillary refill > than or equal to 2 seconds Weak, thready or absent peripheral pulses End-organ function Cool to cold, pale diaphoretic skin Changes in mental status Oliguria 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 Distributive Shock Septic shock Anaphylactic Neurogenic shock (head injury, spinal injury) Septic Shock Most common form of distributive shock. Caused by infectious organisms or their byproducts that stimulates the immune system and trigger release or activation of inflammatory mediators. Uncontrolled activation of the inflammatory mediators can lead to organ failure, particularly cardiovascular and respiratory failure, systemic thrombosis and adrenal dysfunction. Assessment Findings History or infection History of poor feeding Physical findings Tachycardia: HR > 2 standard deviations above normal for age Fever: > 38.5 or < 36 (neonate may be hypothermic) Tachypnea: RR > 2 standard deviations above normal for age Altered mental status - lethargy Petechiae / or purpura Poor peripheral perfusion (capillary refill less than 2 seconds) Hypotension – late sign Laboratory Values WBC Greater than 12,000 Lower than 4,000 or more than 10% immature neutrophils Platelets in the acute phase may be elevated due to inflammation. Platelets may decrease in the case of DIC 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 Sepsis with ARDS Acute respiratory distress syndrome Mechanical ventilation Aggressive antibiotics to treat bacterial infection Methylprednisone – anti-inflammatory Anaphylactic Shock Results from a severe reaction to a drug, vaccine, food toxin, plant, venom or other antigen. It is characterized by venodilation, systemic vasodilation, and increased capillary permeability combined with pulmonary vasoconstriction. Vasoconstriction increased right heart work and may add to hypotension by reducing the delivery of blood from the right ventricle to the left ventricle Assessment Findings Anxiety or agitation Nausea and vomiting Urticaria (hives) Angioedema (swelling of face, lips and tongue) Respiratory distress with stridor or wheezing Hypotension Tachycardia What is first drug of choice? 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, topical agents, cough and cold preparations Adolescents drug experimentation and suicide attempts Questions: Why is OD on Tylenol (acetaminophen) a problem? 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. Assessment #1 Look at the child May present with no symptoms to coma Focus History What was ingested? How much was ingested? When did it occur? What therapy was initiated before arrival in the ED? 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 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 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 Lead Poisoning There are about 1.7 million children with elevated lead levels. A large proportion are poor, African-American, MexicanAmerican, and living in urban areas. Children are more susceptible because they absorb and retain lead. 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. 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 Lead Levels Blood lead levels between 10 and 19 ug/dL are typically asymptomatic Blood levels between 20 to 44 ug/dL may present with increase motor impairment and lethargy (poor school performance) Teaching about hazards of lead Home assessment Chelation therapy may be indicated Levels greater than 70 ug/dL are considered an emergency 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
