Pediatric emergencies
As pediatricians say
Children are not small adults
There are differences:
• Developmental
• Anatomical
• Physiological
Different range of emergencies and response
to illness.
Epidemiology
Common causes of death
• Accidents
– Motor vehicle accidents 50%
– Falls 25-30%
– Drowning 10%
– Poisoning and assaults 15%
• Respiratory arrest – asthma, trauma, drug
ingestion, drowning, sudden infant death
syndrome (SIDS), infection, foreign body
aspiration
Epidemiology
•Heart disease is rarely the primal cause of cardiac
arrest in children.
•Cardiac arrest is due to respiratory insult.
•Prolonged period of hypoxia can lead to cardiac
arrest (in mechanism of asystole or PEA).
•Better chance of brain recovery after than do adults
after the same period of oxygen deprivation
Downward spiral
in the infant’s
condition
that leads to
cardiopulmonary arrest
Age groups
Infants: 0 - 12 months
• minimal language capability
• minimal stranger anxiety
• the greatest anatomical differences
Toddlers: 11 months – 3 years
• uncooperative, crying
• do not like to be touched, to remove their clothes
• strong fear of pain
Age groups
Preschool: 3 – 6 years
• period of intensive learning
• varied levels of ability to express thoughts and
feelings
• do not like being touched
• fear pain
• dislike having clothing removed
• believe that they’re responsible for their illness
• curious, communicative
Age groups
School age: 6 – 12 years
• strong fear of disfigurement and permanent injury
• feelings of modesty
• fear of pain and blood
Adolescence: 12 – 18 years
• changes of puberty
• feel helpless and child-like under the stress
• respect their „space” and allow them to retain as
much control as possible
General clues
• Keep the child and parent together whenever
possible, separation causes anxiety
• Be calm, calm the parents
• Be honest – do not say „This won’t hurt”, when it
will – no cooperation after loosing the child’s trust
• Perform the trunk-to-head assessment –
examination around the face is most threatening to
the child.
Concerns about Anatomy
and Physiology
• In general, better ability to compensate
physiologically – young ad healthy
compensatory mechanisms
• Rapid deterioration of condition when
compensatory mechanisms fail
• Recognize early signs of stress
Airway considerations
• small caliber airways at all levels
• large tongue in relation to the airway with greater
potential for obstruction
• the glottis lies anterior and superior compared with
adults
• relatively large, U-shaped epiglottis
• the cricoid ring is the narrowest part of the upper airway
• soft membranous trachea – may kink if neck is
hyperextended
• infants are obligatory nose breathers
Normal respiratory rates
Adult 12 - 20 breaths per minute
Child 15 - 30 breaths per minute
Infant 25 - 50 breaths per minute
Normal pulse rates
newborn- month 85 - 205 av.140
infant 100 - 190 av.130
child (2-10 yr) 60 - 140 av. 80
child (< 10 yr) 60 - 100 av. 75
adult 60 - 80 av. 72
Blood pressure
• Blood pressure increases with age
• AHA formula to approximate the lower limit for SBP
in children above 2 years of age:
SBP = 70 + (2 x age in years)
• The width of the cuff should cover approximately 2/3
of the length of the upper arm and the bladder should
cover approx. 75% of the arm’s circumference.
• Systolic blood pressure of less than 70 mmHg with
tachycardia and cool skin indicates the shock in
children – according to The American College of
Surgeons.
Metabolic differences
• higher baseline metabolic rate
• higher oxygen and glucose consumption
• greater skin surface area relative to body weight –
they lose heat and moisture through the skin more
easily
• infants younger than 6 months of age cannot shiver in
response to cold
• low energy stores
• Remember – when the metabolic needs on a cellular
level are not met, shock results
Neurological differences
• because the head is large in relation to the body
there’s a greater possibility of head injury
• the infant is capable of suffering blood loss
within the cranium sufficient to cause shock
• infants and children are more prone to episodes
of apnea with head trauma
• children have a greater chance of recovery
from brain hypoxia or head trauma – better
ability to compensate physiologically
Response to hypovolemia
• hypovolemic shock is the most common type of
shock in children
• dehydration (not enough water) is the primal
cause of hypovolemia
– increased metabolic needs
– poor intake
– vomiting and diarrhea
• gradual loss of fluids is better tolerated (fluid
shifts from the cells and interstitial fluid to
maintain the plasma volume) – progression of
signs of dehydratation
Signs of dehydration
• initially:
– rapid pulse
– less urine output
– dry mucosal membranes
• progressed:
– lack of tears
– sunken fontanelle (in infant)
– sunken eyes
Signs of dehydration
• late signs:
– skin tenting
– delayed capillary refill
– hyperventilation
– altered mental status
– HYPOTENSION (very late sign)
Hypovolemia
• the average blood volume is 80 ml/kg
• with healthy compensatory mechanisms, children
can maintain their blood pressure until nearly 40%
of the blood volume is lost.
• hypotension is a late sign of hypovolemia!
by the time the children are hypotensive, they’re
in deep shock!
• treatment: fluids orally (if conscious), intra
venous fluid replacement (if unconscious)
Assessment of the pediatric patient
• General impression – ability to conduct the initial
evaluation „from the doorway” - general
observation and initial handling of the child. Look
for:
– activity and playfulness
– color of the skin
– respiratory effort
– temperature
– quality of speech or crying
Respiratory assessment
Note:
• Respiratory rate
• Symmetrical chest expansions
• Accessory muscles of breathing
involvement?
• Retraction above the clavicles, between the
ribs and below the sternum?
• Increased abdominal movement?
Key signs of respiratory distress
Respiratory assessment
• Listen for:
– stridor – crowing sound made on inspiration
due to upper airway obstruction
– grunting – rhythmic sound heard at the end of
exhalation – significant respiratory compromise
– wheezing – „musical” sound heard during
exhalation caused by the narrowing of the
lower airways (asthma, bronchiolitis)
Signs of respiratory distress
• Early signs • Increasing distress
– tachypnoe leading to respiratory
– tachycardia
failure
– severe retractions or
– retractions grunting, or both
– nasal flaring – increased tachycardia
– stridor and tachypnoe
– wheezing – altered mental status
– grunting – poor peripheral
perfusion
– cyanosis
– decreased muscle tone
Signs of respiratory distress
• Prerespiratory arrest
– cyanosis or grayish hue to skin
– bradycardia
– shallow breathing or apnea
– unconsciousness
– weak distal pulses
– limp muscle tone
Upper Airway Disease
The major serious upper airway diseases :
• Croup
• Epiglottitis
• Foreign body in airway
Croup
• a viral infection affecting the larynx, trachea and
bronchi in children of age 6 months – 6 years
• causes airway narrowing especially at the level of
cricoid ring
• hoarseness, low-grade fever, cough (as barking seal),
inspiratory stridor, retractions with inspiratory effort
• severe cases can result in complete airway obstruction
• management: humidification air, oxygenation, assist
ventilation
Epiglottitis
• infectious (bacterial) swelling of the epiglottis
with rapid onset (2 to 6 years of age), potentially
life-threatening (total airway obstruction)
• high fever, sore throat, dysphagia, occasional
stridor, drooling (the most symptomatic)
• management: let the child stay in parents arms, be
calm, offer humidified oxygen, hold the mask near
the child’s face, if necessary (cyanosis) –
mechanical ventilation (bag-valve-mask)
• transport to the hospital or call ambulance
Foreign body airway obstruction
Previously healthy child with a
history of choking
Infant
• establish unresponsiveness
• open airway and try to
ventilate
• give 5 back blows and 5
chest thrusts
• perform a tongue - jaw lift
and if you see the object
perform the finger sweep to
remove
• repeat until effective
Abdominal thrust in unconscious child
Abdominal thrust in conscious child
Lower airway disease
• The most common causes of lower airways diseases
– bronchiolitis in infants <1yr
– asthma
– pneumonia or other infectious process
– foreign body in smaller airways
• Patient with difficulty breathing without upper
respiratory problem is treated by:
– reducing stress and exertion
– administering humidified oxygen
– transporting with monitoring to a hospital
Respiratory distress and respiratory
failure protocol
1. Provide oxygen to all children with respiratory
emergencies.
2. Assist ventilation for severe respiratory distress with:
1. altered mental status
2. cyanosis with oxygen
3. poor muscle tone
4. ineffective respiratory efforts
3. Provide oxygen and artificial ventilation for
respiratory arrest.
The febrile child
• Fever is the most common complaint in
children
• Rapid rise of temperature can trigger the
seizures – febrile seizure (4% children)
• Any febrile child should be transported to the
emergency department and assessed by
physician.
• Treating the febrile child:
– cover him/her with a cloth soaked with tepid water
(do not use alcohol or cold water – possibility of
vasoconstriction and hypothermia)
– administer paracetamol orally
Seizures
Definitions:
• seizure- an isolated event from an abnormal electrical
discharge in the brain
• epilepsy - the tendency to have recurrent seizures
• convulsions - a seizure with a change in muscle or
motor activity
• generalized convulsions - convulsions involving the
entire body that are associated with the loss of
consciousness
Seizures
Definitions:
• focal seizure - involving one area of the
body; not necessarily associated with an
altered mental status
• petit mal seizures - extremely brief periods
of loss of consciousness without loss of
muscle tone
Seizures
• The most common cause in pediatric patient – fever
• Simple febrile seizure – brief, lasting less than 5 min,
associated with fever and tonic-clonic generalized
convulsions
• Complex febrile seizure – if greater than 15 min in
duration, if focality (localized to a part of the body)
present, multiple episodes within 24 hours.
• Status epilepticus – persistent generalized seizure lasting
more than 20 min or series of recurrent seizures without
the return of consciousness
Other causes of seizures
• infections - meningitis, encephalitis, roseola
• metabolic disorders - hypoglycemia, hypoxia,
hyponatremia, hypocalcemia
• toxic substances - poisons, drugs, drug
withdrawal
• structural problems - head trauma, bleeding,
brain tumors
• idiopathic - no known cause
Complications of seizures
• Respiratory problems: airway obstruction
by the tongue, risk of aspiration, ineffective
respiratory muscles
• Metabolic problems: rise of body
temperature from persistent muscular
activity, depletion of glycogen stores
• CNS problems: CNS affected by the
prolonged electrical activity
Seizures protocol
• ensure an open airway
• position the patient on his or her side if no
cervical spine injury is suspected
• have suction ready
• provide oxygen and ventilation
• transport to a hospital
Special situations
• Unconscious, breathing, pulse present – safety
position
• Unconscious, not breathing, pulse present – mouth
– mouth & nose ventilation – 40 breaths per
minute
• Unconscious, not breathing, pulse absent – CPR
• Breathing : chest compression ratio as 2:15 -
children younger than 8 years old, children older
than 8 years – CPR as in adults 2:30
Airway management
Cover the infants mouth and nose
with your mouth
External chest compression
ratio 100 compressions per minute
breathing to chest compression 2 : 15 ; 1/3 depth of chest
External chest compression
better method
Advanced CPR
• Check pulse on the brachial artery
• 100% oxygen ventilation
• Assess the mechanism of cardiac arrest – in
most cases asystole or PEA
• Drugs: 10 mcg/kg epinephrine (0.1 ml/kg of
1 in 10 000 solution) every 3 minutes
• In case of VF/VT defibrillation: 4 J/kg,
4 J/kg, 6 J/kg
Adult BLS algorithm
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call AMBULANCE
30 chest compressions
2 rescue breaths
Pediatric BLS algorithm
Approach safely
Check response
Shout for help
Open airway
Breath absent or irregular
5 rescue breaths
30 chest compressions
After 1 min.
of CPR 2:30 (2:15) CPR
Call AMBULANCE
CPR 30:2 Call
Until defibrillator / monitor attached Resuscitation
Team
Assess
Rhythm
Shockable Non-shockable
(VF/ Pulsless VT) (PEA / Asystole)
During CPR:
•Correct reversible causses
1 Shock •Check electrode position and contact
4 J / kg or AED •Attempt / verify:
adjusted for children •IV access
•Airway and oxygen
•Give uninterrupted compressions when airway
secure
•Give adreanline every 3-5 mins
•Consider: amiodarone, atropine, magnesium Immediately resume:
Immediately resume:
CPR 15:2 CPR 15:2
For 2 min For 2 min
* Reversible causes
Hipoxia Tension pneumothorax
Hipovolaemia Tamponade cardiac
Hipo/Hiperkalaemia / Metabolic Toxins
Hipothermia Thrombosis (coronary or
pulmonary)