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PediatricEmergencies
Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN
2007Revised 2011 by Lori Barker, MS, RN, CEN
Emergency Nursing Core Curriculum
ObjectivesFor selected pediatric emergencies the
participant will be able to: Compare the etiology Describe assessment findings Identify the clinical management
Pediatric EmergenciesOverview
Children account for 25- 35% of all ED visits
Only 3 – 5 % of those children are acutely ill or injured
Children cannot be cared for as “small adults”, need specialized equipment & training
PEDIATRICSThe Assessment Triangle
Assessment TriangleAn “across-the-room” assessment to establish severity of illness or
injury and urgency of intervention
Appearance (the ‘look test’) is the simplest and most effective assessment tool. Tone, interactibility, consolability, speech or cry. There are very few truly sick or injured children that can pass the look
test. When children are sick they look sick
Breathing- work of breathing. Be alert for nasal flaring, retractions, abnormal airway sounds, position of comfort, rate
Circulation- color & temperature of skin. Assess for pallor, mottling, cyanosis
If any of the three components of the triangle are abnormal – the urgency level increases
Pediatric Triage Rules Parents know their children better than you -
if they say the child is sick - believe them! Start with the ABC’s – look for the not so
obvious; subtle presentation likely Children in shock compensate far better than
adults – do not be fooled by “normal” vital signs
Important to obtain child’s weight in kilograms & birth weight if < 8 wks old
CIAMPEDS Pneumonic for pediatric assessment Chief Complaint
Immunizations Isolation
Allergies
Medications
Past Medical History Parents impression of
child’s condition
Events surrounding illness or injury
Diet Diapers
Symptoms Associated with the illness or injury
PEDIATRICSKey Points Use parents, minimize
separation Observe child while
obtaining history Perform least
intrusive interactions first
Different anatomical & physiological characteristics
Anatomical & Physiological Differences Larger tongue, narrow nasal passages, & airway Relatively short respiratory tract, fewer alveoli, lack
cartilaginous support, prone to airway collapse, immature intercostal muscles increase reliance on diaphragm for breathing
Larger, heavier head in relation to body Less effective thermoregulation, greater body surface
area to body mass, less subcutaneous fat Faster metabolism, increased need for oxygen Lower glycogen stores, at risk for hypoglycemia when
under stress Poorly developed immune system, fewer defenses
Developmental Differences Infant:
comforted through sensory (holding, singing, sucking) Toddler:
offer limited choices minimize separation from caregiver
School age: fear abandonment, body changes, being different from
peers give honest, concrete answers offer choices (promotes sense of control)
Adolescent: modest, want privacy
Assessment Mental status
Alertness Level of consciousness
Most reliable indicator of neuro change Unusual fatigue? Crying – lack of sleep - hunger Ability to relate to caregiver Terminology – lethargic, drowsy What stimulus does it take to elicit what response?
Vital Signs WT in kg T, HR, RR for all pediatric patients BP & O2 sat based on illness
Typical SBP in children > 2 y/o: 90 + (2X age in yrs) Minimum SBP 1-10y/o: 70 + (2X age in yrs)
Can compensate with HR to 25% blood volume loss without drop in BP HR > 160, fast for any age group
Count RR X 1 min > 60/min fast at any age
HR RR SBP
Newborn 100-160 40-60 50-70
1 yr 90-120 30-40 80-100
3 yr 80-110 25-30 80-110
5 yr 80-110 20-25 80-110
10 yr 60-100 15-20 90-120
15 yr 70-100 15-20 80-120
Average Vital Signs by Age
Broselow Pediatric Emergency Tape
Standardized color-coded, length-based tape to estimate child’s weight in an emergency
Measure “Red to the Head” Reference with size-appropriate drug dosing, equipment
selection
Drug Information Side
Equipment & Select Intervention Side
PEDIATRICSRespiratory Emergencies
Most pediatric arrests occur secondary to respiratory compromise.
Mortality rate of pediatric cardiopulmonary arrest is greater than 90%.
Sudden onset of respiratory distress? Consider foreign body obstruction
PEDIATRICSRespiratory Emergencies
Respiratory Emergencies Asthma Affecting an increasing # of
American children partly due to environmental factors
Chronic inflammatory lung disease Symptom – wheezing Treatment:
medication – inhaled β-agonist (Albuterol)
steroid therapy fluids
Respiratory Emergencies Bronchiolitis Inflammation of bronchial mucosa Viral illness Affects children less than 18 months Can be life-threatening Low-grade fever Cough, wheezing
Respiratory Emergencies Respiratory syncytial virus (RSV) Most frequent cause of bronchiolitis Highly infectious – isolate! Seasonal incidence:
late fall through early spring Peak incidence is age 2-8 months Treatment:
bronchodilators antivirals (Ribavirin)
Respiratory Emergencies Croup Viral inflammation of larynx &
subglottic area Peak incidence is up to age 3 Highest incidence in fall & winter Cold symptoms prior to onset of
characteristic ‘bark’
Respiratory Emergencies Croup - treatment Treat gently Hydration Cool humidified oxygen Racemic epinephrine Steroids
Respiratory Emergencies Epiglottitis Emergent airway condition:
Potential for complete airway obstruction Rapid onset of epiglottic inflammation
Greatest incidence 2 - 5 years old Three ‘D’s classic presentation:
Drooling Dysphagia Distress
Respiratory Emergencies Epiglottitis - treatment Do not agitate:
Supplemental oxygen in parent’s lap
Position of comfort Prepare for airway management:
(know where the equipment is!) Intubation Cricothyroidotomy Tracheostomy
Respiratory Emergencies Croup vs. Epiglottitis
Epiglottitis: 1 - 6 years old Rapid onset Appears ill Dyspnea,
drooling Fever
Croup: 6 months to 3
years Insidious onset -
preceded by URI Barking cough,
stridor
Respiratory Emergencies Pertussis (whooping cough)
Highly contagious Three phases:
1. Initial – indistinguishable from the common cold (most infectious)
2. Paroxysms of intense coughing lasting several minutes – ‘whoop’
3. Chronic cough that can last for weeks
Respiratory Emergencies Pertussis - treatment
Isolate! RSV & Pertussis Swab: rayon
swab, rotate in posterior nasopharynx & repeat in other nostril, transport in 1-2ml viral transport media
Minimize agitation Monitor, maintain airway Hydration Antibiotics
Respiratory Pearls of Wisdom
Maintain patent airway Minimize respiratory distress
Keep with parent in position of comfort Weigh necessity of oxygenation against need to keep
child calm; consider blow-by Provide adequate oxygenation
Kid-friendly lingo: Oxygen is “fresh air” The mask is a “space mask” or “santa mask” Blow by as a last resort. Consider the power of
stickers (in a cup/concentrator at end of O2 tubing) Conserve energy
Don’t wake a sleeping child
Abdominal Emergencies – Pyloric Stenosis Hypertrophy of muscular layers of pylorus Obstruction More in males Age 2-8 wks Nonbilious projectile vomiting ? Visible peristalsis after eating Palpable hard, mobile, nontender “olive”
Abdominal Emergencies Intussusception Telescoping of the bowel Age range 3 months to 1 year Sudden onset colicky pain, currant jelly
stool Treatment:
barium enema both diagnostic and often therapeutic (un-telescopes bowel)
if unsuccessful surgical intervention required
Abdominal Emergencies - Volvulus Torsion of the gut, life-threatening. Malrotation most common in neonates May be mistaken for colic Recurrent abdominal pain and vomiting Tenderness, irritability, bloody stools If untreated, may result in infarcted bowel Dx: Ultrasound, xray Tx: IVFs, O2, decompress stomach, Consult
Surgeon
Abdominal Emergencies Dehydration Common pediatric presentation in the ED Most often due to viral syndrome:
Vomiting, diarrhea, decreased urine output Absence of tears, saliva Cap refill > 2 sec Sunken eyes & fontanel
Treatment: Monitor glucose Hydration Identification of cause Parental education
ORT = Oral Rehydration Therapy
For mild to moderate dehydration & able to take oral fluids
Calculate how much of an appropriate solution (ie, Pedialyte) to give in small amounts over certain period of time (ie, every 5 min. over 4 hrs)
For most, 50-100 ml/Kg corrects fluid deficit
Shock Emergencies Volume Dehydration is primary cause of
hypovolemia in children When output exceeds input -
dehydration occurs The spiral - electrolyte disturbance
causes increased nausea & vomiting, causing increased electrolyte disturbances
Shock Emergencies Volume – presentation & treatment
Sunken eyes, fontanels Cap refill > 2 sec, pallor Dry mucous membranes Lethargy & confusion (ominous sign) Treatment:
Adequate ventilation, oxygenation IV bolus 20 mL/kg normal saline
Calculating Maintenance IV Fluid Rates:
Holliday-Segar Method:4 ml/kg for 1st 10kg BW2 ml/kg for 2nd 10kg BW
+ 1 ml/kg for remaining kgs of BW
ie. 24 kg child(4 ml X 10kg)+ (2 ml X 10kg) + (1 ml X 4kg) = 64 ml/hr
Provider may order variation (ie. 1.5 X maintenance, or 96 ml/hr in above example)
D5 1/3 NS or D5 ¼ NS common maintenance fluids (less sodium). Use an IV pump, check site hourly
Pediatric IV Pearls of Wisdom
Common IV sites: scalp (infants < 9mo old), hands, feet, & antecubital fossa Describe to child as a small “straw” Use non dominant hand/limb Wrap limb in warm towel to dilate vein Have sufficient help holding Chloraprep not used in children < 2 mos Advance needle slowly, flash delayed
Secure extremity with appropriate-sized arm board in functional position
Intraosseous access in critically ill (short term)
Shock Emergencies Sepsis
Life-threatening bacterial infection Decreased perfusion Clinical Triad:
Hyper or hypothermia Altered mental status Peripheral vasodilation (“warm” shock) or
vasoconstriction (“cool” shock)
Shock Emergencies Treatment Ventilate and oxygenate Aggressive volume replacement Diagnostics:
Cultures: blood, urine, cerebral spinal fluid if suspected meningitis
Chest x-ray Intravenous antibiotics
Pediatric ShockPitfalls
Hypotension occurs LATE in the pediatric shock syndrome:Blood pressure unreliable
indicator for severity of shock
Bradycardia ominous sign
Fever Accounts for 20% of all pediatric visits to the
emergency department Infants < 30 days with fever, get a full septic
work up (CBC, Bld Cx, Chem, U/A, CXR, LP) Remember-No ibuprofen to children < 2 years of
age. Use oral syringes for PO meds only Common Causes:
Otitis media Viral infections Gastroenteritis Bacteremia, sepsis,
meningitis
Sudden Infant Death Syndrome
(SIDS)Definition:
The unexpected death of a presumably health baby, generally younger than one year, in which an autopsy fails to identify the cause of death
Sudden Infant Death Syndrome
History: Previously healthy infant found lying
face down in crib pulseless & apneic
Interventions: Initiate resuscitative measures Support caregivers: SIDS is neither
preventable or predictable Allow caregivers to hold child Almost always a coroner’s case –
explain the rational for this to caregivers
Status EpilepticusProlonged, continuous seizure activity May be d/t anoxia, infection, trauma, ingestion,
or metabolic disorder May result in cerebral anoxia Treatment
Ensure child’s safety Airway maintenance (suction, oral airway if not
clenched) Oxygenation (BVM, may need intubation) Stop the seizure (anticonvulsants) Workup possible etiology
Trauma Injuries are the leading cause of death in US children 1-
14 y/o MVC, falls, bike accidents, burns, drowning,
poisonings, firearms & abuse Child Safety Seats
Children < 12yrs in the back seat Birth-1yr (20lbs), infant rear-facing 1-4yr (20-40lbs), forward-facing toddler seat 4-8yr (up to 4’9” tall), booster seats
Children may have severe spinal cord injury without radiographic abnormality, SCIWORA
Backboard positioning requires padding under shoulders to prevent neck flexion
Injury PreventionEach interaction is an opportunity to educate parent/child re: Home safety Medication safety Helmets Age-appropriate toys Swim lessons
The best CPR is a poor second to PREVENTION!
Developing Your Skills in Pediatric Emergency Care: Pediatric Advanced Life Support (PALS) Emergency Nursing Pediatric Course (ENPC)-
comprehensive 16hr ENA course, covers emergency nursing pediatric assessment, triage, common emergencies, trauma, transport & hands-on skills
Pediatric Emergency Assessment, Recognition & Stabilization (PEARS)- 6hr AHA course
Certified Pediatric Emergency Nurse (CPEN) credential- through the Board of Certification for Emergency Nursing
Join ENA! Receive the journal & newsletter
Patient Family Education
Follow-up care, use of medications (proper administration), safe storage
Proper use of medical supplies, nebulizers, slings etc
When to seek further help Prevention Assure and document understanding
Case ScenarioA two year old is carried into the
ED by the parents who give a history of sudden high fever and drooling. Interventions include:
A. Establish IV access
B. Let child remain in parent’s lap
C. Apply oxygen via non-rebreather mask
D. All of the above
Case ScenarioA two year old is carried into the
ED by the parents who give a history of sudden high fever and drooling. Interventions include:
A. Establish IV access
B. Let child remain in parent’s lap
C. Apply oxygen via non-rebreather mask
D. All of the above
Case ScenarioSigns of hypovolemic shock
include which of the following?
A. Bradycardia
B. Decreased level of consciousness
C. Sunken fontanels
D. Dry mucous membranes
E. All of the above
Case ScenarioSigns of hypovolemic shock
include which of the following?
A. Bradycardia
B. Decreased level of consciousness
C. Sunken fontanels
D. Dry mucous membranes
E. All of the above
ReferencesAAP Guidelines for Care of Children in the Emergency Dept. http://aapolicy.aapublications.org/cgi/reprint/pediatrics; 124/4/1233.pdf.
ENA (2007) Trauma Nursing Core Course (6th ed). DesPlaines, IL: ENA
Foresman-Capuzzi, J (2009) More big help from little tools. JEN 35 (3) 260-262.
Sheehy, SB (2003) Sheehy’s emergency nursing: principles and practice (5th ed). St Louis: Mosby
Vital Signs, Inc. (2007) Broselow Pediatric Emergency Tape. Armstrong Medical Industries, Inc.