Transcript Training - Dl4a.org

PEDIATRIC EMERGENCIES
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
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
Pediatric Emergencies
• Child’s response to emergencies
– Primary response is fear
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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
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
Development Stages Keys to Assessment
• Approach to Neonates
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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
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
Development Stages Keys to Assessment
• Ages 1-5 months - Common problems
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SIDS
Vomiting and diarrhea/dehydration
Meningitis
Child abuse
Household accidents
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
Development Stages Keys to Assessment
• Ages 6-12 months - Common problems
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Febrile seizures
Vomiting and diarrhea/dehydration
Bronchiolitis or croup
Car accidents and falls
Child abuse
Ingestions and foreign body obstructions
Meningitis
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
Development Stages Keys to Assessment
• Ages 1-3 years - Characteristics
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Motor development, always on the move
Language development
Child begins to stray from mother
Child can be asked certain questions
Accidents prevail
Development Stages Keys to Assessment
• Ages 1-3 yrs - Common problems
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Auto accidents
Vomiting and diarrhea
Febrile seizures
Croup, meningitis
Foreign body obstruction
Development Stages Keys to Assessment
• Ages 1-3 yrs - Approach
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Cautious approach to gain confidence
Child may resist physical exam
Avoid “no” answers
Tell the child if something will hurt
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
Development Stages Keys to Assessment
• Ages 3-5 yrs - Common problems
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Croup, asthma, epiglottitis
Ingestions, foreign bodies
Auto accidents, burns
Child abuse
Drowning
Meningitis, febrile seizures
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
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
Development Stages Keys to Assessment
• Age 6-12 yrs - approach
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Interview the child first
Protect their privacy
Be honest and tell them what is wrong
They may cover up information if they were
disobeying
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
Development Stages Keys to Assessment
• Ages 12-15 - Common problems
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Mononucleosis
Auto accidents, sports injuries
Asthma
Drug and alcohol abuse
Sexual abuse, pregnancy
Suicide gestures
Development Stages Keys to Assessment
• Ages 12-15 - Approach
– Interview the child away from parent
– Pay attention to what they are not saying
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
Development Stages Keys to Assessment
• Parent Management
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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
General Approach to
Pediatric Assessment
• History
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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
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
General Approach to
Pediatric Assessment
• Physical Exam (cont.)
– Special concerns
• Fontanels should be inspected in infants
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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
General Approach to
Pediatric Assessment
• Special concerns (cont..)
– GI Problems
• Disturbances are common
• Determine number of episodes of vomiting, amount
and color of emesis
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
Pediatric Vital Signs
• Respirations
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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
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
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
Causes of Death
• National
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MVA
Burns
Drowning
Aspiration
Firearms
Falls
• Oklahoma
43%
14.9%
14.6%
3.4%
3.0%
2.0%
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MVA
Drowning
Burns
Firearms
Aspiration
Stab/cut
35%
14.5%
14.0%
9.9%
5.7%
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Frequency of Injured Body Parts
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Head
Extremities
Abdomen
Chest
48%
32%
11%
9%
Pediatric Trauma
• Head, face, and neck injuries
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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
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
Pediatric Trauma
• Extremity injuries
– Usually limited to fractures and lacerations
– Most fractures are incomplete - bend, buckle,,
and greenstick fractures
– Watch for growth plate injuries
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%
Pediatric Trauma
• Child abuse and neglect - Basics
– Suspect if injuries inconsistent with history
– Children at greater risk often seen as “special”
and different
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Premature or twins
Handicapped
Uncommunicative (autistic)
Boys or child of the “wrong” sex
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
Pediatric Trauma
• Sexual Abuse - Basics
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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
Pediatric Trauma
• Triggers to high index of suspicion for child
neglect
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Extreme malnutrition
Multiple insect bites
Long-standing skin infections
Extreme lack of cleanliness
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
Pediatric Trauma
• Triggers to high index of suspicion for child abuse
(cont.)
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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
Pediatric Trauma
• Management of potentially abused child
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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
Pediatric Medical Emergencies Neurological
• Pediatric seizures - Common causes
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Fever, infections
Hypoxia
Idiopathic epilepsy
Electrolyte disturbances
Head trauma
Hypoglycemia
Toxic ingestion or exposure
Tumors or CNS malformations
Pediatric Medical Emergencies Neurological
• Febrile Seizures
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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
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
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
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
Pediatric Medical Emergencies Neurological
• Meningitis - Basics
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Infection of the meninges
Can result from virus or bacteria
More common in children than in adults
Infection can be fatal if unrecognized and
untreated
Meningitis
• Assessment
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History of recent illness
Headache, stiff neck
Child appears very ill
Bulging fontanelles in infants
Extreme discomfort in movement
Meningitis
• Management
– Monitor ABC’s and vital signs
– High flow O2, prepare to assist with
ventilations
– IV/IO of LR or NS
– Fluid bolus of 20 ml/kg IV/IO push
• Repeat if no improvement
– Orotracheal intubation if child's condition
warrants
Pediatric Medical Emergencies Neurological
• Reye’s syndrome - Basics
– “New” disease - Correlated with ASA use
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Peak incident in patients between 5-15 years
Frequency higher in winter
Higher frequency in suburban and rural population
No single etiology identified
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Possibly toxic or metabolic problem
Tends to occur during influenza B outbreaks
Associated with chicken pox virus
Correlation with use of aspirin use in children
Pediatric Medical Emergencies Neurological
• Reye’s syndrome - Complications
– Respiratory failure
– Cardiac arrhythmias
– Acute pancreatitis
Pediatric Medical Emergencies Neurological
• Assessment - Reyes Syndrome
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Severe nausea & vomiting
Hyperactivity or combative behavior
Personality changes, irrational behavior
Progression of restlessness, stupor, convulsions, coma
Recent history of chicken pox in 10-20% of cases
Recent upper respiratory infections or gastroenteritis
Rapid deep respirations, may be irregular
Pupils dilated & sluggish
Signs of increased ICP
Pediatric Medical Emergencies Neurological
• Reye’s syndrome - Management
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General and supportive
Maintain ABC’s
Administer supplemental oxygen
Rapid transport
Child’s Airway vs.. Adults
• Smaller septum & nasal bridge is flat and flexible
• Vocal cords located at C3-4 versus C5-6 in adults
– Contributes to aspiration if neck is hyperextended
• Narrowest at cricoid ring instead of vocal cords
• Airway diameter is 4 mm vs.. 20 mm in adult
• Tracheal rings more elastic & cartilaginous, can easily
crimp off trachea
• More smooth muscle , makes airway more reactive or
sensitive to foreign substances
5 Most Common Respiratory
Emergencies
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Asthma
Bronchiolitis
Croup
Epiglotitis
Foreign bodies
Asthma
• Pathophysiology
– Chronic recurrent lower airway disease with episodic
attacks of bronchial constriction
• Precipitating factors include exercise, psychological stress,
respiratory infections, and changes in weather & temperature
• Occurs commonly during preschool years, but also presents as
young as 1 year of age
– Decrease size of child’s airway due to edema & mucus
leads to further compromise
Asthma
• Assessment
– History
• When was last attack & how severe was it
• Fever
• Medications, treatments administered
– Physical Exam
• SOB, shallow, irregular respirations, increased or decreased
respiratory rate
• Pale, mottled, cyanotic, cherry red lips
• Restless & scared
• Inspiratory & expiratory wheezing, rhonchi
• Tripod position
Asthma
• Management
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Assess & monitor ABC’s
Big O’s (Humidified if possible)
IV of LR or NS at a TKO rate
Assist with prescribed medications
Prepare for vomiting
Pulse oximeter
Intubate if airway management becomes difficult or
fails
Bronchiolitis
• Basics
– Respiratory infection of the bronchioles
– Occurs in early childhood (younger than 1 yr)
– Caused by viral infection
• Assessment/History
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Length of illness or fever
has infant been seen by a doctor
Taking any medications
Any previous asthma attacks or other allergy problems
How much fluid has the child been drinking
Bronchiolitis
• Signs & symptoms
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Acute respiratory distress
Tachypnea
May have intercostal and suprasternal retractions
Cyanosis
Fever & dry cough
May have wheezes - inspiratory & expiratory
Confused & anxious mental status
Possible dehydration
Bronchiolitis
• Management
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Assess & maintain airway
When appropriate let child pick POC
Clear nasal passages if necessary
Prepare to assist with ventilations
IV LR or NS TKO rate
Intubate if airway management becomes
difficult or fails
Croup
• Basics
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Upper respiratory viral infection
Occurs mostly among ages 6 months to 3 years
More prevalent in fall and spring
Edema develops, narrowing the airway lumen
Severe cases may result in complete obstruction
Croup
• Assessment/History
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What treatment or meds have been given?
How effective?
Any difficulty swallowing?
Drooling present?
Has the child been ill?
What symptoms are present & how have they changed?
Croup
• Physical exam
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Tachycardia, tachypnea
Skin color - pale, cyanotic, mottled
Decrease in activity or LOC
Fever
Breath sounds - wheezing, diminished breath sounds
Stridor, barking cough, hoarse cry or voice
Croup
• Management
– Assess & monitor ABC’s
– High flow humidified O2; blow by if child won’t
tolerate mask
– Limit exam/handling to avoid agitation
– Be prepared for respiratory arrest, assist ventilations
and perform CPR as needed
– Do not place instruments in mouth or throat
– Rapid transport
Epiglotitis
• Basics
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Bacterial infection and inflammation of the epiglottis
Usually occurs in children 3-6 years of age
Can occur in infants, older children, & adults
Swelling may cause complete airway obstruction
True medical emergency
Epiglotitis
• Assessment/History
– When did child become ill?
– Has it suddenly worsened after a couple of days or
hours?
– Sore throat?
– Will child swallow liquids or saliva?
– Is drooling present?
– High fever (102-103 degrees F)
– Onset is usually sudden
Epiglotitis
• Signs & Symptoms
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May be sitting in Tripod position
May be holding mouth open, with tongue protruding
Muffled or hoarse cry
Inspiratory stridor
Tachycardia, tachypnea
Pale, mottled, cyanotic skin
Anxious, focused on breathing, lethargic
Very sore throat
Nasal flaring
Look very sick with high fever
Epiglotitis
• Management
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Assess & monitor ABC’s
Do not make child lie down
Do not manipulate airway
High flow humidified O2; blow by if child won’t
tolerate mask
– Limit exam/handling to avoid agitation
– Be prepared for respiratory arrest, assist ventilations
and perform CPR as needed
– Contact medical control
Aspirated Foreign Body
• Basics
– Common among the 1-3 age group who like to
put everything in their mouths
– Running or falling with objects in mouth
– Inadequate chewing capabilities
– Common items - gum, hot dogs, grapes and
peanuts
Aspirated Foreign Body
• Assessment
– Complete obstruction will present as apnea
– Partial obstruction may present as labored
breathing, retractions, and cyanosis
– Objects can lodge in the lower or upper airways
depending on size
– Object may act as one-way valve allowing air
in, but not out
Aspirated Foreign Body
• Management - Complete Obstruction
– Attempt to clear using BLS techniques
– Attempt removal with direct laryngoscopy and
Magill forceps
– Cricothyrotomy may be indicated
Aspirated Foreign Body
• Management - Partial obstruction
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Make child comfortable
Administer humidified oxygen
Encourage child to cough
Have intubation equipment available
Transport to hospital for removal with
bronchoscope
Mild, Moderate, & Severe Dehydration
• History
– Previous seizures, when it began, how long
– Reason for seizure
– When were fluids last taken, how much, is it usual for
the child
– Current fever or medical illness
– Behavior during seizure
– Last wet diaper
– Any vomiting or diarrhea
– Other medical problems
Mild, Moderate, & Severe Dehydration
• Physical Assessment/Signs & symptoms
– Onset very abrupt
– Sudden jerking of entire body, tenseness, then
relaxation
– LOC or confusion
– Sudden jerking of one body part
– Lip smacking, eye blinking, staring
– Sleeping following seizure
Mild, Moderate, & Severe Dehydration
• Physical Assessment/ Vital signs
– Capillary refill
– Skin color
– Alertness, activity level
Mild, Moderate, & Severe Dehydration
• Mild dehydration
– Infants lose up to 5% of their body weight
– Child lose up to 3-4% of their body weight
– Physical signs of dehydration are barely visable
Mild, Moderate, & Severe Dehydration
• Moderate Dehydration
– Infants lose up to 10% of their body weight
– Children lose up to 6-8% of their body weight
– Poor skin color & turgor, dry mucous
membranes, decreased urine output & increased
thirst, no tears
Mild, Moderate, & Severe Dehydration
• Severe Dehydration
– Infants lose up to 15% of their body weight
– Child lose up to 10-13% of their body weight
– Danger of life-threatening hypovolemic shock
Mild, Moderate, & Severe Dehydration
• Management
– If mild or moderate
• Give fluids orally if there is no abdominal pain,
vomiting or diarrhea and is alert
– Severe
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High flow O2
IV/IO with NS or LR
Fluid bolus of 20 ml/kg IV/IO push
Repeat fluid bolus if no improvement
Congenital Heart Disease
• Blood is permitted to mix in the 2
circulatory pathways
– Primary cause of heart disease in children
– Various structures may be defective
– Hypoxemia usually results
Congenital Heart Disease
• History
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Name of defect to share with medical control
Any meds taken routinely, were they taken today
Any other home therapies (O2, feeding devices)
Any recent illness or stress
Child's color
What kind of spell, how long did it last
Ant treatment given
Congenital Heart Disease
• Signs & symptoms
– Intercostal retractions, difficulty breathing, tachypnea,
crackles or wheezing on auscultation
– Tachycardia, cyanosis with some defects
– Altered LOC, limpness of extremities, drowsiness
– Cool moist skin, cyanosis, pallor
– Tires easily, irritable if disturbed, underdeveloped for
age
– Uncontrollable crying, irritability
– Severe breathing difficulty, progressive cyanosis
– Loss of consciousness, seizure, cardiac arrest
Congenital Heart Disease
• Management
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Monitor ABC’s & vitals
Maintain airway/administer high flow O2
Assist ventilations as needed, intubate if needed
Cyanotic spell, place in knee chest position
Prepare to perform CPR
Establish IV TKO if lengthy transport time is
anticipated
Home High Technology Equipment
• Chronic & terminal illness
– Respiratory & cardiac
• Premature infants
• Cystic Fibrosis
• Heart defects & post transplant patients
Home High Technology Equipment
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Ventilators
Suction
Oxygen
Tracheostomy
IV pumps
Feeding pumps
Home High Technology Equipment
• Management
– Support efforts of parents
– Home equipment malfunction, attach child to
yours
– Monitor ABC’s & treat as patient’s condition
warrants
– Have hospital notify child’s physician if
possible