Pediatric Emergencies
Jan Bazner-Chandler RN, MSN, CNS, CPNP
Developmental and Biologic Variances
Cricoid is the narrowest portion of the airway: no cuffed
ET tubes
ET cuffed
Developmental and Biologic Variances
Decreased respiratory rate may mean the child is tiring
out
Total blood volume is smaller – small blood loss may led
to hypovolemia and impaired profusion
Respiratory arrest is more common in pediatrics
Healthy children in shock will maintain blood pressure
until more than 25% of blood volume is lost
Tachycardia and delayed capillary refill are early signs of
shock
Decreased blood pressure is late sign
Triage
To “pick or sort”.
Goals of triage:
Rapidly identify seriously injured.
Prioritize all patients using the emergency department.
Initiate therapeutic measures.
Triage Classification
Resuscitation
Emergent- needs to be seen within 10 minutes
Urgent – need to be seen within 30 to 60 minutes
Semi-urgent – need to be seen within 1to 2 hours
Non-urgent – need to be seen within 2 to 3 hours
Assessment
Across-the-room assessment
Chief complaint
Brief history (AMPLE Mnemonic)
Allergies
Medications
Past medical history
Last meal
Events surrounding the incident
Focused Physical Assessment
Airway
Breathing
Circulation
Disability
Exposure
Full vital signs
Family presence
Give comfort
Head-to-toe assessment
Inspect
Isolate
Test and Procedures
CBC with differential
Type and cross match
Serum electrolytes
Radiographs: chest, abdomen, bones
Computed tomography – CT scan
Shock
Hypovolemic shock
Distributive
Cardiogenic
Obstructive
Hypovolemic Shock
Most common cause of shock in children
Fluid and electrolyte losses associated with diarrhea
Blood loss from trauma
Etiology: caused by inadequate volume relative to the
vascular space
Hypovolemic shock: Assessment
Tachycardia
Prolonged capillary refill > than or equal to 2 seconds
Weak, thready or absent peripheral pulses
Cool extremities
Interdisciplinary Interventions
IV fluids 20 mL/kg bolus of Crystalloid Solution
0.9% normal saline
Ringer’s lactate
If signs of inadequate profusion after 2 or 3 boluses
administer 10 mL / pg packed red blood cells
Control bleeding
Distributive Shock
Septic shock
Etiology: caused by inappropriate distribution of blood
flow an increased capillary permeability
Most common type of shock in newborn
Gram negative organisms
Assessment Findings
History or infection
History of poor feeding
Physical findings
Tachycardia
Fever – in the neonate may hypothermia
Tachypnea
Altered mental status - lethargy
Petechiae / or purpura
Poor peripheral perfusion (capillary refill less than 2 seconds)
Laboratory Values
WBC
Greater than 12,000
Lower than 4,000 or more than 10% immature forms (bands)
Platelets in the acute phase may be elevated due to
inflammation.
Platelets may decrease in the case of DIC
Interdisciplinary Interventions
Isolate if indicated
IV fluids (crystalloid solution) to restore circulating
volume
Inotropic agents as needed
Norepinephrine – alpha receptor agonist causes peripheral
arterial vasoconstriction
Dopamine – beta receptor agonist to increase cardiac output
Cultures: blood, spinal fluid, urine
Broad spectrum antibiotics: MRSA
If hypoglycemic – IV glucose
Near Drowning
Death resulting from suffocation by submersion in a liquid
Unsupervised submersion: bathtubs, buckets, toilets,
swimming pools, body of water
Presentation
Varying degrees of neurologic insult from a state of alertness
to cardiac arrest
Poorest outcomes when child presents in cardiac arrest
Poisoning
The fifth leading cause of death in children younger than 5
years
Overdose in infants are often the result of therapeutic
overdosing
Children younger than 6 years
Cleaning substances, analgesics, foreign bodies, topical agents,
cough and cold preparations
Adolescents drug experimentation and suicide attempts
Poisoning
Over a million children are poisoned annually.
Ages of risk are 2 to 4 years and adolescents.
Common poisons ingested:
Iron, lead, acetaminophen, hydrocarbons, liquid Drano, and
plants.
Assessment
Look at the child
May present with no symptoms to coma
Focus History
What was ingested?
How much was ingested?
When did it occur?
What therapy was initiated before arrival in the ED?
AAP Recommendations
AAP – American Academy of Pediatrics
Syrup of Ipecac no longer be used routinely in the home to
induce vomiting.
Research has failed to show benefit for children who were
treated with Ipecac.
Prevention is the best defense against unintentional poisoning
Parent Teaching
Post the universal phone number for poison control center
near the telephone
1-800-222-1222
Call 911 in the case of convulsions, cessation of breathing or
unconsciousness
Do not make your child vomit
Emergency Treatment
• Always assess the child to determine the care: airway, breathing,
LOC
• History of what substance was swallowed
• Ask parent to bring in container or sample of substance
swallowed
• Activated charcoal may be given to help absorb substance
ingested
Lead Poisoning
There are about 1.7 million children with elevated lead
levels.
A large proportion are poor, African-American, Mexican-
American, and living in urban areas.
Children are more susceptible because they absorb and
retain lead.
Lead Poisoning
Lead interferes with normal cell function, and adversely
affects the metabolism of vitamin D and calcium.
Clinical manifestations depend on degree of toxicity.
Neurologic effects include decreased IQ scores, cognitive
deficits, impaired hearing, and growth delays.
Lead Poisoning
Sources of lead:
Lead based paint
Soil and dust
Drinking water from lead lined pipes
Food growth in contaminated fields
Contamination from occupations or hobbies
Lead Levels
Blood lead levels between 10 and 19 ug/dL are typically
asymptomatic
Teaching about hazards of lead
Blood levels between 20 to 44 ug/dL may present with
increase motor impairment and lethargy (poor school
performance)
Home assessment
Chelation therapy may be indicated
Levels greater than 70 ug/dL are considered an
emergency
Prevention of Lead Poisoning
Washing hands and toys
Low-fat diet
Check home for lead hazards
Regularly clean home
Take precautions when remodeling or working on old
cars, furniture, or pottery.
Call 1-800-424-lead for guidelines