Pediatric Emergencies PDF

Pediatric Emergencies - The most common types of illnesses identified included respiratory emergencies, seizures/syncope, and dehydration. - Respiratory illness and seizures are among the most common pediatric emergencies in ambulatory settings but also identify psychia...

Pediatric Emergencies - The most common types of illnesses identified included respiratory emergencies, seizures/syncope, and dehydration. - Respiratory illness and seizures are among the most common pediatric emergencies in ambulatory settings but also identify psychiatric and behavioral emergencies are common events. - Standard interventions included most medication administration (albuterol, diphenhydramine, ondansetron, dextrose, and steroids), obtaining intravascular access, and administration of supplemental oxygen. Critical care interventions included the use of an artificial airway, cardiopulmonary resuscitation, administration of a fluid bolus, obtaining intraosseous access, bag-mask ventilation, and administration of epinephrine or benzodiazepine. - [Don't rely on the memory of normal vital signs during an emergency, must access charts that can tell us what is normal ] - Differ in anatomy, psychology, and physiology - Head- Larger than adults until age 4. Before age 4, suspect potential for head or neck injury due to undeveloped muscles to support head and disproportionate head weight - Newborn/Infant- Birth-1 - Toddler- 1-3 - Preschool- 3-5 - School- 6-12 - Adolescent- 13-18 - Be able to tell you exactly what happened or how they feel - Not as communicative or cooperative in front of parent or peers - Feel embarrassed about body, see cuts/bruises as hideous (body image concern) - Don't delay care, conduct exam with same sex person or witness that is same sex - Head: When laying infant flat, head tips forward, obstructing airway (position towels under shoulder). Fontanelles (soft spots on skull where not yet fused together, if fontanelles are sunken- blood loss, hypovolemia, dehydration, if bulging- hypertension, head injury) - Mouth/Nose: Smaller so more easily obstructed, tongue takes more space in mouth than adult. So, tongue is common form of airway obstruction in child. Don't develop mouth breathing until older, rely on diaphragm to breathe (intercostal muscles not well defined). Trachea is shorter, narrower and more flexible, so can be easily obstructed by swelling and foreign objects. Chest wall is softer, so can develop more trauma without breaking rib, chest is shorter, so abdominal contents prevent diaphragm from dropping enough to give good lung capacities (breathe primarily with diaphragm), when need to increase breathing occurs, abdominal contents get pushed down and out, so belly protrudes when taking a deep breath. Diaphragm is flat and adults are dome, so it sinks in (seesaw breathing, normal in infants, but not in older child). Do not do blind finger sweeps in children due to anatomy (easier obstruction). If blow to abdomen, won't show bruising, but will have severe injuries inside, with more organs being affected. Blood in abdomen- bruised, rigid, distended - Bones- don't break easily, pretty soft and pliable, so great deal of force - Surface Area- Larger than adults in proportion to body mass. Can easily lose heat to environment and become hypothermic. Less blood volume than adults, so even 3 tsp could be significant enough to be life threatening. - Psychological/Personality- Most cry when they see stranger, never let potential for upsetting delay care. - Interacting with Pediatric Patient- Tell them you called parents, determine if life threatening problems exist, if not, continue calmness by giving them a toy, kneel to child's eye level and speak in their language, touch hand or foot, explain equipment first, determine if they understand, never lie because they will lose all trust - Toddler- 1-3 - Preschool- 3-5 - School- 6-12 - Adolescent- 13-18 - Be able to tell you exactly what happened or how they feel - Not as communicative or cooperative in front of parent or peers - Feel embarrassed about body, see cuts/bruises as hideous (body image concern) - Don't delay care, conduct exam with same sex person or witness that is same sex - Supporting Parents - Child who broke femur- quite upset, immediate stress reaction that is anger, self-blame, in shock (denying), get in way - Ask to help by holding/comforting child, answer history questions - Assessing Pediatric Patient - From doorway: First approach to patient: Pediatric Assessment Triangle to conduct. Includes us looking at appearance: Do they look sick? Crying? Clutching caregiver, looking around, moving arms and legs is a hurt child but doing well. Whereas if child is moaning, eyes closed, this is appearance of sick child. Indications of working hard to breathe: nasal flaring, intercostal retractions, grunting, bobbing, seesaw respirations? Look at skin: cyanotic around periphery (hands, toes), could mean they are cold or hypoxia, color is pale and temperature. Sometimes, caregivers may not want to assess child and get in your way in cases of abuse. Children who have fever or rash, use PPE. Evaluate scene for clues of poisoning, and call poison control center, cover appropriately if only in diaper, can become hypothermic easily. - Pediatric Assessment Triangle - Look at appearance - Work of breathing - Skin circulation - Remainder of primary assessment: [Forming a general impression rapidly identifies critical patient, essential component of pediatric assessment] - Make note of mental status and emotional state - How they respond can be an indicated of how ill they are. Should be concerned about your present, be upright not lying flat, not working hard to breathe. Note quality of cry: loud and obnoxious cry is okay - Difficult to assess mental status: AVPG - Alert? Eyes open, looking around, recognize caregiver, respond to name? Respond to painful stimulus, if not, then tap and shout (do not shake), if unresponsive check breathing and pulse - A: Airway open and maintainable? Suction/Positioning? Need oxygen/ventilation? Tragus of ears pointing right at shoulder for neutral position, align with towel under shoulders - B: Breathing: Airway open and maintainable? Not maintainable, then jaw thrust, head tilt chin lift, oropharyngeal airway, do not hyperextend head (causes obstruction), extend head so tragus of ear points at shoulder, if tragus points upward, that's hyperextension, if tragus points downward, then hyperflexed. Look for cyanosis, nasal flaring, stridor (upper airway obstruction, inspiratory), wheezing (expiratory, bronchospasm), gurgling, crackles, grunting, head bobbing, intercostal retractions. First organ to show dysfunction is brain. Look for chest expansion, respiratory rate, color (should be warm, pink, dry. Flushed- fever, pale- shock, cyanotic- hypoxia, yellow- jaundice). - C: Circulation: Feel for pulse, check for cap refill (\> 2 sec is good indication of poor circulation). Assess differences between central and peripheral pulses (carotid and radial pulses should be same, if one is weak, then circulation issue) - Priority pediatric patients- who give poor general impression (unresponsive, trouble breathing, AMS, don't recognize parent, not comforted when held) - Compromised airway - Shock potential - Uncontrolled bleeding - Secondary Assessment - Want them to explain in their words, ask simple questions - Physical/trauma- start where child is most comfortable, vital signs (carotid vs radial pulse check instead of bp for child under 3) - Head- no direct pressure on fontanelles, meningitis and trauma can cause bulging especially in child not properly restrained in seat - Look for blood in nose and ears (does not take a lot of secretions to obstruct airway) - May deliver oxygen by blow by method, hold 6in-12in from face - Start at toes/trunk, work towards head, protect modesty, hold in parent's lap - Vulnerable to spinal cord injuries due to head weight: Have injury without breaking bones, meaning ligaments can be stretched/torn, whiplash, stiff neck - Place towel under shoulders for proper alignment. Use jaw thrust with spinal immobilization if trauma is suspected - Pelvis- check for stability of girdle by pushing wings together - Extremities- cap refill, distal pulses, move fingers/feet, sensation, deformities, contusions, abrasions - Reassessment - Reassess every 5 min if critical, and every 15 min if stable - Begins with primary survey (like never seen them before, so ABC) - D and E - Disability (pupils for head injury), blood sugar - Expose (rashes, temp, abuse signs, then cover back up) - Special Concerns - Maintaining open airway is difficult - Position of head, tongue size, small airway can cause obstructions - Use head tilt, chin lift if not a trauma and jaw thrust with spine immobilization trauma - Maintain body in sniffing position - Suction frequently because how small airway is - Oropharyngeal airway- tongue depressor, and place OPA normally, not upside down like in adults - Partial obstruction- can move air, but have a weak cry, offer HF oxygen - Complete obstruction- CPR (chest thrust and back flows) - Supplemental high flow oxygen- in respiratory distress, inadequate respirations, or shock - Oxygen mask can frighten child: Blow by. If using mask, should cover nose and mouth without pressure on eyeballs (can slow HR) - Pocket face mask: Thenar technique: thenar muscles of thumb hold on face and forefingers on each side of chin pulls chin upward and pulls tongue off throat - Avoid excess ventilation, keep good seal, avoid excessive pressure or volume - Flow restricted, oxygen powered ventilation devices such as demand valves are contraindicated in children (too great of pressure, cause barotrauma). Getting enough air if chest is rising. - Obstruction present: Chest will not rise with ventilation after positioning and suctioning. Try to reposition again and ventilate but if not successful, there is a foreign body present - Shock, rarely bleed to death but can lose enough blood to go into shock - Vomiting and diarrhea (dehydration) - Infection (septic shock) - Trauma (abdomen, rupture solid organs) - Blood loss - Allergic reaction - Poisoning - Heart problems are rare unless congenital defect - Signs of shock - Listless (Apathy, lack of vitality) - Glassy eyes - AMS - Skin- pale, cool, clammy - Tearless due to dehydration - Respiratory rate faster, seesaw breathing, head bobbing, nasal flaring, greater cap refill - Pulse weak and rapid - Last to go- falling blood pressure (in infant, unlikely to get bp) - Caring for child in shock - Open hemorrhage- tourniquet, direct pressure - Maintain open airway, high concentration oxygen - Keep flat and [WARM] (not producing heat due to lack of oxygen and energy) - Hypothermia- cover head, 85 degrees, handling roughly can cause irregular rhythm, avoid direct heat placement. Stop heat loss first and then start rewarming - Types of Pediatric Emergencies - Respiratory disorders- likeliest cause of cardiac arrest other than trauma. When assessing, figure out if its upper or lower problem. - Upper: Epiglottitis, croup, foreign body, swelling from burns/infections- can hear [stridor] (inspiratory noise), difficulty breathing and speaking - Affects mouth throat, larynx - Lower: Bronchoconstriction, pneumonia, asthma- can hear [wheezing], rhonchi, crackles (expiratory noise) - Affects large and small bronchiole tubes and alveoli - Intervene quickly so can avoid respiratory failure. Children can compensate well, but can quickly plummet into respiratory arrest then cardiac arrest - Role- recognize in respiratory distress and treat before they go into respiratory failure - Assessment: nasal flaring, intercostal retractions, use of abdominal muscles, wheezing, stridor, grunting on expiration (positive and expiratory pressure, or PEEP), breathing rate \> 60/min - When AMS begins, beginning of respiratory failure (brain is first to be affected), need to act quick to avoid arrest. Can see cyanosis (fingers, toes, lips, trunk), decreases respiratory/heart rate, diminished pulses - Chest compressions if AMS and respiratory rate \< 60 - Viral Infections - Croup: viral infection, mild fever, hoarseness, loud seal like cough [at night,] restless, pale, cyanotic. - Take outside in cool environment, humidification - Epiglottis- sudden with high fever, swelling due to viral infection. Hurts to swallow, will sit up and still and drool heavily. Looks sicker than croup - Fever care- towel soaked in 100-degree water, (want to avoid shivering) remove clothing, chips/sips of water. patient. - If febrile seizure occurs from sudden spike in temperature, do not submerge in cool water or rubbing alcohol to cool patient - Bacterial Infections - Meningitis: - Monitor ABCs, vitals, high flow oxygen, with NRB, ventilate with pocket mask or BV, CPR if pulse \< 60, be alert for seizures due to fevers, transport immediately - Have stiff neck - Cannot touch chin to chest because meninges are inflamed - Vomiting and Diarrhea - Dehydration- brain won't function - Open airway, provide oxygen, sips of water/chips if protocol allows - Seizure: tonic clonic/grandmal: muscles stiff, tongue biting, stool incontinence: roll to side, protect from any possible harm, assess breathing - AMS- from trauma, shock, poisoning, new onset diabetes - Need blood glucose measurement - Poisoning- contact poison control - Activated charcoal, oxygen (if vomits charcoal, can cause aspiration pneumonia which can be fatal in a matter of hours) - Open airway, suction, ventilation, tongue off back of throat - Rule out trauma - Drowning- biggest concern is hypoxia. Need immediate ventilation - Mouth to mouth as soon as child is at surface of water - Unresponsive, no pulse, or \< 60: perform CPR, have AED - Hypothermic - SIDS- sudden infant death syndrome - No reason on autopsy as to why baby died - Treat as any patient in cardiac or respiratory arrest: begin resuscitation unless rigimortis - Give emotional support to parents - Trauma Emergencies - Number one cause of death in children is TRAUMA - MVC- head and neck trauma if unrestrained due to increased head weight, abdominal and spinal if restrained - Struck by vehicle- head, abdominal, internal bleeding, lower extremity injuries (long bone fx) - Adolescent- concerned for body image, wants to be part of care - Head- propelled forward during deceleration causing head and neck injuries - Respiratory failure is common following head injury (may not breathe at all or breathe so erratically) - Assess fontanelles for bulging (hypertension, bleeding), sunken (hypovolemia) - Eyes: PERRLA - Neck: trachea midline, JVD, stiffness, crepitus touch chin to chest - Chest: bruising, equal fall and rise, crepitus, contents are closer together, so higher chance more organs will be damaged - less developed respiratory muscles, more elastic ribs - Abdomen: diaphragmatic breathing, distention, rigid, bruising, swelling, tenderness, guarding - Pelvis: push iliac crests together for crepitus or fracture (don't rock) - Extremities: examine each extremity individually for pulse, color, motor, sensation. - Back: Tenderness, crepitus - Burns: cover with nonadherent dressing (Ceran wrap), ensure open airway (soot), suction, spine immobilize - Child Abuse/Neglect- mandatory reporter - Psychological (emotional) abuse- difficult to prove so less reported, diagnosed by clinician. Child who is failing to thrive - Neglect- not providing enough shelter or food - If cannot make certain services like ear doctor or eye doctor, may just need access to resources, not neglect - Physical abuse- battered children. - Slaps, abrasions, incisions, lacerations, bruises in various stages of healing, cigar burns, cuts, fractures, bite marks, shaking infant (brain bleed), burn from curling iron or over open flame - Can have bleeding disorder, but stages of bruising would be the same - Department of Health and Human Services' responsibility to prove abuse, not providers - Preserve evidence: Avoid bathroom/shower, NPO, don't change clothes - Sexual abuse- torture children sexually - Genital injury unexplained, seminal fluid on body, STI, pregnancy, child tells you they were assaulted, they are definitely telling the truth and need to report immediately - Indications for abusing: smothering child with affection, talking for them, anger history, brink of emotional meltdown, have mental illness, depression, alcohol/drugs, suicidal thoughts - Role with abuse: gather info without expression of disbelief, talk with child alone, let them know you are a mandated reporter and will have to report it. Be very clear of any finding when reporting. Even if not confirmed abuse and suspected or possible, still need to report! DHHS will find out if it was in fact abuse. Abuser will be placed on registry for 10 years - Parent in possible abuse case reveals suicidal ideology: Parent needs help - Infants and Children with Common Challenges - Premature infants: lung disease, heart disease, neurologic disease, chronic disease (diabetes) - Tracheostomy tubes: can become obstructed, so assess need for suction/ventilation. If cannot relieve obstruction, replace tube - Home artificial ventilators: vent giving off all these errors: provide assisted ventilation with BVM - CVC- infection, crimped/cut lines. Replace after 4-5 years. Pulled out line: apply pressure - Gastrostomy tubes- can get pulled out, sit on right side to avoid aspiration, suction, oxygen - Shunts- in head of child, inability to drain CSF fluid through ventricles, shunt will drain into abdomen. If shunt occluded, CSF builds in head, maintain airway, oxygen