Transcript Specific Medical Emergencies

A
variety of pediatric medical problems can
activate the EMS system
 The majority of childhood medical
emergencies involve the respiratory system

Other systems may be involved
 Infectious
diseases may be caused by the
infection or infestation of the body by an
infectious agent

Virus, bacterium, fungus, or parasite
 Most
infections are self-limiting
 Some infections may be life threatening

Meningitis, pneumonia, and septicemia
Fever
 Chills
 Tachycardia
 Cough
 Sore throat
 Nasal congestion
 Malaise
 Tachypnea
 Cool or clammy skin
 Petechiae
 Respiratory distress

Poor appetite
 Vomiting
 Diarrhea
 Dehydration
 Hypoperfusion
 Purpura
 Seizures
 Severe headache
 Irritability
 Stiff neck
 Bulging fontanelle

 Take
all Standard Precautions
 Become familiar with the common pediatric
infections encountered in your area
 Previous exposure to disease and
vaccinations
 The
most common reason EMS is summoned
to care for a pediatric patient
 Your approach to the child with a respiratory
emergency will depend on the severity of
respiratory compromise
 Three



categories
Respiratory distress
Respiratory failure
Respiratory arrest
 Learn
in
to recognize the phase your patient is
 Mildest
form of respiratory impairment
 Increased work of breathing

Increase in respiratory rate


Frequently estimated
Should be measured for at least 30 seconds
 Normal
mental
status deteriorating
to irritability or
anxiety
 Tachypnea
 Retractions
 Nasal flaring (in
infants)
 Poor
muscle tone
 Tachycardia
 Head bobbing
 Grunting
 Cyanosis that
improves with
supplemental oxygen
 Occurs
when the respiratory system is not
able to meet the demands of the body for
oxygen intake and for carbon dioxide
removal
 Characterized by inadequate ventilation and
oxygenation
 Irritability
or anxiety
deteriorating to
lethargy
 Marked tachypnea
later deteriorating
to bradypnea
 Marked retractions
later deteriorating
to agonal
respirations
 Poor
muscle tone
 Marked tachycardia
later deteriorating
to bradycardia
 Central cyanosis
 The
end result of respiratory impairment
 The cessation of breathing

Typically follows a period of bradypnea and
agonal respirations
 Unresponsivenes
deteriorating to coma
 Bradypnea deteriorating to apnea
 Absent chest wall motion
 Bradycardia deteriorating to asystole
 Profound cyanosis
 Should
be based on the severity of the
problem
 Goals of management


Increasing ventilation
Increasing oxygenation
 Airway


Patency
Assure continued maintenance of the airway
 Breathing


Administer high-flow, high-concentration oxygen
If no improvement the patient should be treated
more aggressively
 Treatment
of late respiratory failure or
arrest




Mechanical ventilation with a BVM device
Endotracheal intubation
Consideration of gastric decompression
Consideration of needle decompression


If suspected pneumothorax
Consideration of cricothyrotomy
 Circulation

You should obtain venous access
 Transport
to an appropriate facility
 Continue to reassess the child
 Provide emotional and psychological support
 Upper




airway distress
Croup
Epiglottitis
Bacterial Tracheitis
Foreign Body Aspiration
 Viral
infection of
upper airway
 Occurs in children 6
months to 4 years of
age
 Leads to edema
beneath the glottis
and larynx
 Assessment



Child will have a mild cold or other infection
Develops loud, brassy cough at night
You should never examine the oropharynx

Difficult to distinguish from epiglottitis
 Management



Position of comfort
Cool, mist oxygen
Administration of racemic epinephrine or
albuterol may be considered
 An
acute infection and
inflammation of the
epiglottis
 Caused by a bacterial
infection

Haemophilus
influenzae type B
 Tends
to strike
children 3–7 years old
 Assessment

Child awakens with a high temperature and a
brassy cough



Pain upon swallowing, sore throat, high fever, shallow
breathing, dyspnea, inspiratory stridor, and drooling
Never attempt to visualize airway
Patients will often assume the “tripod position”
 Management


Appropriate airway
maintenance and
oxygen administration
If the airway becomes
obstructed:

Two-rescuer ventilation
with BVM is almost
always effective
© Ken Kerr
 Management

Intubation equipment is available



(cont.)
Contraindicated unless obstruction occurs
Immediate transport
Handle gently


Do not visualize airway
Avoid IV sticks
 Bacterial
infection of the airway, subglottic
region

Afflicts mainly infants and toddlers 1–5 years May
follow episode of croup
 Assessment



Presence of a high-grade fever accompanied by
coughing up of pus and/or mucous
Hoarse voice
Inspiratory or expiratory stridor
 Management

Manage airway and breathing


Ventilations may require high pressure


Oxygen by mask or blow-by
Depress pop-off valve on BVM
Consider intubation only in cases of complete
airway obstruction
 The
number one cause of in-home accidental
deaths in children under 6 years

Food or foreign objects
 Assessment


Partial
Complete
 Management

If the obstruction is partial:




Make the child as comfortable as possible and
administer humidified oxygen
Have intubation equipment available
Transport
If complete:


Utilize basic life support techniques
Visualize the airway with a laryngoscope
 Lower




Airway Distress
Asthma
Bronchiolitis
Pneumonia
Foreign Body Lower Airway Obstruction
 Chronic
inflammatory disorder of the lower
respiratory tract
 Pathophysiology



Characterized by bronchospasm and excessive
mucous production
Widespread, but variable, airflow obstruction
The airways become hyperresponsive
 Pathophysiology


(cont.)
“Triggers”
Two-phase reaction occurs


Release of chemical mediators such as histamine
 Bronchoconstriction
 Responds to bronchodilator medications
Inflammation of the bronchioles as cells of the immune
system invade the respiratory tract
 Additional edema and further decreases in expiratory
airflow
 Assessment

Can often be differentiated from other pediatric
respiratory illnesses by history



Medications may also be an indicator
Usually sitting up, leaning forward, and
tachypneic
Wheezing may be heard

An ominous finding is lack of wheezing
 Management



Establish an airway
Supplemental,
humidified oxygen
Pharmacological
interventions



Inhaled beta agonist
Nebulized
bronchodilator
medications
Steroid administration
© Ken Kerr
 Status




Asthmaticus
Severe, prolonged asthma attack that cannot be
broken by aggressive pharmacological
management
Child will have greatly distended chest
Patient is usually exhausted, severely acidotic,
and often dehydrated
Prepare for intubation
 Respiratory
infection of the medium-sized
airways
 Caused by a viral infection

Respiratory syncytial virus (RSV)
 Characterized
by prominent expiratory
wheezing and clinically resembles asthma
 Assessment
 Distinguish from


asthma
A low-grade fever often exists
Major distinguishing factor is age
 Asthma does not occur < 1 year of age
 Management
 Administer humidified



oxygen by mask or blow-by
method
Support ventilations
Equipment for intubation should be readily
available
Consider bronchodilator by nebulizer
 An

infection of the lower airway and lungs
Bacterial or viral
 Most
commonly appears in infants, toddlers,
and preschoolers ages 1–5 years
 Assessment


History of a respiratory infection
Low-grade fever, decreased breath sounds,
crackles, rhonchi, and pain in the chest area
 Management



Ensure a patent airway and administer
supplemental oxygen
Support ventilations as needed
Emotional and psychological support to the
parents
A
foreign body can enter the lower airway if
it is too small to lodge in the upper airway
 The foreign body can act as a one-way valve

May trap air in distal lung tissues or prevent
aeration of distal lung tissues
 Assessment



History often includes information about the
child having a foreign body in the mouth
Considerable, often intractable, coughing
May have diminished breath sounds
 Management

Management of an aspirated foreign body is
supportive
 Inadequate

Ultimately results in tissue hypoxia and
metabolic acidosis
 Shock

perfusion of the tissues
is an unusual occurrence in children
Will lead to cardiopulmonary arrest
 Causes

Hypothermia, dehydration, infection,
septicemia, trauma, and blood loss
 Compensated shock
 The body is able to compensate

for decreased
tissue perfusion through various physiological
mechanisms
Signs and symptoms








Irritability or anxiety
Tachycardia
Tachypnea
Weak peripheral pulses, full central pulses
Delayed capillary refill (more than 2 seconds in
children less than 6 years of age)
Cool, pale extremities
Systolic blood pressure within normal limits
Decreased urinary output
 Decompensated

Compensatory mechanisms begin to fail


Blood pressure falls
Signs and symptoms








Lethargy or coma
Marked tachycardia or bradycardia
Absent peripheral pulses, weak central pulses
Markedly delayed capillary refill
Cool, pale, dusky, mottled extremities
Hypotension
Markedly decreased urinary output
Absence of tears
 Irreversible



Treatment measures are inadequate or too late
to prevent significant tissue damage and death
Despite resuscitation, organ death occurs
Best treatment is prevention
 Shock




Cardiogenic
Hypovolemic
Obstructive
Distributive
 May


can be classified in a number of ways:
be classified into two categories:
Cardiogenic
Non-cardiogenic
 Hypovolemic


Results from loss of intravascular fluids
Treatment


Airway management
Fluid bolus
 20 mL/kg
 Children may require 80–100 mL/kg of fluid
 Distributive


Shock
A marked decrease in peripheral vascular
resistance
Causes include:



Septicemia from bacterial infection
Anaphylactic reaction
Damage to the brain and/or spinal cord
 Caused


by sepsis
Result of an infection
The septic child is critically ill
 Management


Supplemental oxygen
Intravenous Access


Fluid bolus
 20ml/kg
Consider initiating pressor therapy
 Epinephrine
 Dopamine
 Results
from exposure to an antigen to which
the patient has been previously exposed

Results in widespread vasodilation
 Signs and Symptoms
 Tachycardia
 Tachypnea
 Wheezing
 Urticaria (hives)
 Anxiousness
 Edema
 Hypotension
 Management


Airway maintenance
Intravenous access


Decompensated shock
 Administer epinephrine 1:10,000 intravenously
 Administer diphenhydramine
Compensated shock
 Administer epinephrine 1:1,000 subcutaneously
 Sudden


peripheral vasodilation
Interruption of nervous control of the peripheral
vascular system
Results from trauma
 Management


Stabilization of the injury and administration of
supplemental oxygen
Administration of a pressor agent
 Congenital


Primary cause of heart disease in children
Common symptom of congenital heart disease is
cyanosis


Heart Disease
Mixing of blood
Child with congenital heart disease may develop
respiratory distress, congestive heart failure, or
a “cyanotic spell”
 Congenital

Administer high-flow, high-concentration oxygen




Heart Disease (cont.)
Ventilate as necessary
Start an intravenous line
Monitor ECG
If the patient is having a cyanotic spell:


Place the child in the knee–chest position facing
downward
Older child can squat
 Cardiomyopathy

A disease or dysfunction of the cardiac muscle



Can be result of congenital heart disease or infection
Cardiomyopathy causes mechanical pump failure
Signs and symptoms

Early fatigue, crackles, jugular venous distension,
engorgement of the liver, and peripheral edema
 Cardiomyopathy


Supplemental oxygen should be administered
IV access


(cont.)
Restrict fluids
Should be treated with furosemide and pressor
agents (dobutamine, dopamine)
 Dysrhythmias

Dysrhythmias in children are uncommon



Bradydysrhythmias are most common
Dysrhythmias can cause pump failure ultimately
leading to cardiogenic shock
Very limited capacity to increase stroke volume
 Supraventricular

Narrow complex tachycardia



tachycardia
HR > 220 bpm
Does not allow time for adequate cardiac filling
Signs and symptoms

Irritability, poor feeding, jugular venous distension,
hepatomegaly (enlarged liver), and hypotension
 Ventricular



Tachycardia
Rare in children
Occasionally seen with drowning or following a
prolonged resuscitation attempt
Signs and symptoms

Poor feeding, irritability, and a rapid, wide complex
tachycardia
Click here to view the Tachycardia Management Algorithm.
Reproduced with permission from “2005 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care,” Circulation 2005, Volume 112, IV-177. © 2005 American
Heart Association.
 Most
common type of pediatric dysrhythmia
 Most frequently result from hypoxia
 Signs and symptoms


A slow, narrow complex rhythm
Child may be lethargic or exhibiting early signs of
congestive heart failure
Click here to view the Bradycardia Management Algorithm.
Reproduced with permission from “2005 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care,” Circulation 2005, Volume 112, IV-176. © 2005 American
Heart Association.
 Asystole
may be the initial rhythm seen in
cardiopulmonary arrest


Child with asystole is pulseless and apneic
Follow pulseless arrest algorithm
 Ventricular
fibrillation/ventricular
tachycardia



Exceedingly rare in children
May be result of electrocution or drug overdose
Follow pulseless arrest algorithm
 Pulseless


The presence of a cardiac rhythm without an
associated pulse
Due to noncardiogenic causes


Electrical Activity
Correct the underlying problem
Follow pulseless arrest algorithm
Click here to view the Pulseless Arrest Algorithm
Reproduced with permission from “2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care,” Circulation 2005, Volume 112, IV-173.© 2005 American Heart Association.
 Seizures


An abnormal discharge of neurons in the brain
May be partial or generalized


Status Epilepticus
Febrile seizures

Occur most commonly between the ages of 6 months
and 6 years
 Assessment

History is a major factor in determining seizure
type



Determine how many seizures occurred during the
incident
Note any current medications
The physical examination should be systematic
 Fever
 Hypoxia
 Infections
 Idiopathic
epilepsy
(of unknown origin)
 Electrolyte
disturbances
 Head
trauma
 Hypoglycemia
 Toxic ingestions or
exposure
 Tumor
 CNS malformations
 Management


Do not restrain patients
Maintain airway



Administer supplemental oxygen
Establish IV
Medications


Diazepam
 Can be administered rectally
Acetaminophen
 An


infection of the meninges
May be bacterial or viral
Bacterial infections can be rapidly fatal
 Assessment

History


Illness, fever, and stiff neck
Infants do not develop stiff neck
 Lethargy and poor feeding
 Assessment



(cont.)
The fontanelle may be
bulging or full
Extreme discomfort
with movement
Rash may develop
 Management


Supportive
Treat for shock
 Nausea

Symptoms of other disease processes




and Vomiting
Most common causes include fever, ear infections, and
respiratory infections
Gastroenteritis
Risk of dehydration and electrolyte imbalance
Treatment is primarily supportive
 Diarrhea



10 or more stools per day is considered diarrhea
The main concern associated with diarrhea is
dehydration
Treatment is primarily supportive
 Diabetes
can occur in very young children
 Diabetic children can have great swings in
their blood glucose levels

Hypo and hyperglycemia possible
 Very
young children can develop
hypoglycemia without having diabetes
 Diabetic
children increase their risk of
hypoglycemia through overly strenuous
exercise, too much insulin, and dehydration
from illness
 Assessment

Measure blood glucose with a glucometer
 Management




Monitor the ABCs
Obtain glucose
In the conscious, alert
patient, administer oral
fluids with sugar or oral
glucose
Glucagon or Dextrose
25%
© Ken Kerr
 Hyperglycemia
may lead to dehydration and
diabetic ketoacidosis
 Causes include:




Eating too much food relative to injected insulin
Missing an insulin injection
Defective insulin pump
Illness or stress
 Assessment
 Dehydration
 A blood sugar
reading of greater than 200 mg/dL
 Management



Monitor the ABCs and vital signs
If unable to obtain glucose, treat as
hypoglycemia
Obtain intravenous access

Administer an IV bolus of 20 mL/kg
 Accidental
poisoning is
a common childhood
emergency
 It is the leading cause
of preventable death
in children
 Management




Administer oxygen
Contact medical direction and/or the poison
control center
Consider the need for activated charcoal
Transport


of Responsive Patient
Be sure to take any pills, substances, and containers to
the hospital
Monitor the patient continuously
 Management






of Non-Responsive Patient
Ensure a patent airway
Administer oxygen
Be prepared to provide artificial ventilations
Contact medical direction and/or the poison
control center
Transport
Monitor the patient continuously
 Falls
 Motor
vehicle crashes
 Car vs. pedestrian injuries
 Drowning and near drowning
 Penetrating injuries
 Burns
 Physical abuse
 Falls


Most common type of
traumatic injury
Serious injury or
death from
accidental falls is
relatively uncommon
 Motor
Vehicle
Accidents


The leading cause of
traumatic death in
children
Prevention strategies
 Car

Particularly lethal form of trauma


Stature pushes child beneath vehicle
Two phases of injury



vs. Pedestrian Injuries
First phase occurs when the auto contacts the child
Second phase occurs as the child contacts the ground
or other objects
Prevention strategies
 Drownings



Third-leading cause of death in children between
birth and 4 years of age
Outcomes are better when the water is cold
Prevention strategies

Best time for drowning prevention programs is late
spring and early summer
 Penetrating



Injuries
An increase in violent crime has resulted in an
increasing number of children sustaining
penetrating trauma
Visual inspection of external injuries does not
provide adequate evaluation of internal injuries
Prevention strategies
 Burns


Children can sustain both burn injuries and
smoke inhalation in house fires
Prevention strategies
 Physical

Abuse
Factors leading to child abuse

Poverty, domestic disturbances, younger parents,
substance abuse, and community violence
 Airway



Control
Maintain in-line
stabilization in neutral
position
Administer 100% oxygen
Maintain airway with
suctioning and jawthrust
© Scott Metcalfe
 Airway




Control (cont.)
Be prepared to assist
ineffective respirations
Intubate the child when
the airway cannot be
maintained
Gastric tube
Cricothyrotomy
 Immobilization


Use appropriately sized pediatric immobilization
equipment
Keep the cervical spine in a neutral in-line
position by placing padding from the shoulders to
the hips
 Fluid

Insert a large-bore intravenous catheter into a
peripheral vein



Management
Do not delay transport to gain venous access
Intraosseous access in children less than 6 years
Initial fluid bolus of 20 mL/kg
 Pediatric


Pediatric injuries are painful
Commonly used analgesics


Analgesia and Sedation
Morphine and fentanyl
Certain pediatric emergencies may benefit from
sedation
 Traumatic

Pediatric head injury classifications




Brain Injury
Mild —Glasgow coma score is 13–15
Moderate —Glasgow coma score is 9–12
Severe —Glasgow coma score is less than or equal to 8
Signs of increased intracranial pressure




Elevated blood pressure
Bradycardia
Rapid, deep respirations progressing to slow, deep
respirations
Bulging fontanelle in infants
 Traumatic

Signs of herniation




Brain Injury
Asymmetrical pupils
Decorticate posturing
Decerebrate posturing
Consider hyperventilation if there is a
deterioration in the child’s condition indicating
herniation
 Administer
 Intubate
high-flow, high-concentration oxygen
if Glasgow coma score less than or equal
to 8

Consider using intravenous or tracheal lidocaine prior
to intubation
 Consider
rapid sequence intubation (RSI) for
children with a Glasgow coma score of less than
or equal to 8
 Head,

Injuries to the head are the most common cause
of death in pediatric trauma victims



Face, and Neck
Bicycle collisions, falls from trees, car-pedestrian
collisions, sporting activities, abuse
Diffuse injuries are common in children, while focal
injuries are rare
Facial injuries
 Chest


Significant injury may occur without external
evidence
Tension Pneumothorax




Injuries
Diminished breath sounds over the affected lung
Shift of the trachea to the opposite side
A progressive decrease in ventilatory compliance
Tamponade

Hypotension may be only sign
 Injuries

Blunt trauma to the abdomen can result in injury
to the spleen or liver



to the Abdomen
Spleen is most frequent organ injured
Signs and symptoms
Splenic and hepatic injuries can cause lifethreatening internal hemorrhage
 Extremities

Typically limited to fractures and lacerations



Bend fractures, buckle fractures, and greenstick
fractures
Some types of growth plate fractures can lead to
permanent disability
Management
 Burns


Most common
type of burn
injury
encountered by
EMS personnel is
scalding
Rule of Nines
 Burn
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Management
Prompt management of the airway
May need to use an endotracheal tube up to two
sizes smaller
Be sure to maintain body heat
With electrical burns, suspect musculoskeletal
injuries and perform spinal immobilization
 The
sudden death of an infant during the first
year of life from an illness of unknown etiology
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Occurs most frequently in the fall and winter months
More common in males
 Prevalence
Click here to view a video on sids.
 Infants
should be placed supine
 Avoid placing infants in overheated
environments
 Avoid overwrapping them with too many clothes
or blankets
 Avoid smoking before and after pregnancy
 Avoid filling the crib with soft bedding
 Assessment
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Normal state of nutrition and hydration
Skin may be mottled
Occasionally blood-tinged, fluids in and around
the mouth and nostrils
Vomitus may be present
 Management
 Common
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Characteristics
Child is seen as “special” and different from
others
Premature infants and twins
Less than 5 years of age
Physical and mental handicaps
Special needs
 Perpetrators


of Abuse or Neglect
Can come from any geographic, religious, ethnic,
racial, occupational, educational, or
socioeconomic background
Characteristics

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A parent or adult who seems capable of abuse
A child in one of the high-risk categories
The presence of a crisis in the family
 Child
abuse can take
several forms,
including:
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Psychological abuse
Physical abuse
Sexual abuse
Neglect (either physical
or emotional)
© Scott and White Hospital and Clinic
 Signs
of abuse or neglect can be startling
 Information in the medical history may also
raise the index of suspicion
 Management

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
Appropriate treatment of injuries
Protection of the child from further abuse
Notification of proper authorities
 Common
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home-care devices
Tracheostomy tubes
Apnea monitors
Home artificial ventilators
Central intravenous lines
Gastric feeding and gastrostomy tubes
Shunts
 Avoid
using the term disability in reference to
the child’s special need
 Never assume that the patient cannot
understand what you are saying
 Involve the parents, caregivers, or the patient,
if appropriate, in treatment
 Treat the patient with a special need with the
same respect as any other patient
 JumpSTART
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Pediatric MCI Triage Tool
To optimize the primary triage of injured children in
the MCI setting
To enhance the effectiveness of resource allocation
for all MCI victims
To reduce the emotional burden on triage personnel
who may have to make rapid life-or-death decisions
about the injured
 Role
of Paramedics in Pediatric Care
 General Approach to Pediatric Emergencies
 General Approach to Pediatric Assessment
 General Management of Pediatric Patients
 Specific Medical Emergencies
 Trauma Emergencies
 Sudden Infant Death Syndrome
 Child Abuse and Neglect
 Infants and Children with Special Needs
 Multiple Casualty Incidents Involving Children