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 in children under 8 years of age
ET cuffed
Developmental and Biologic Variances
Total blood volume is smaller – small blood loss may led
to hypovolemia and impaired profusion
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
Developmental and Biologic Differences
Respiratory arrest is more common in pediatric
population
Respiratory rate below 10 or above 60 are sign that child
may be headed for respiratory arrest without
interventions
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: infection and lack of immune
response
Type and cross match: blood type
Serum electrolytes: electrolyte imbalance
Radiographs: chest, abdomen, bones
Computed tomography – CT scan: detects bleeding or
masses
Shock
1. Hypovolemic shock
2. Distributive
3. Cardiogenic
4. Obstructive
Note: cardiogenic and obstructive more common in the
adult
Shock
The earlier you can recognize shock, establish priorities,
and start therapy, the better the child’s chance for a good
outcome.
Hypovolemic Shock
Most common cause of shock in children
Fluid and electrolyte losses associated with fluid loss
Blood loss from trauma
Etiology: caused by inadequate volume relative to the
vascular space
Hypovolemic Shock
Most common cause of shock in children worldwide
Fluid loss due to diarrhea is the leading cause
Other causes
Hemorrhage
Vomiting
Inadequate fluid intake
Osmotic diuresis (eg diabetic ketoacidosis
Third space losses (fluid leak into tissues
Burns
Sepsis
Physiology of Hypovolemic Shock
Characterized by decreased preload leading to reduced
stroke volume and low cardiac output.
Compensatory mechanisms are tachycardia, increased
contractility, and increased systemic vascular resistance.
Hypovolemic shock: Assessment
Cardiovascular
Tachycardia
Normal blood pressure or hypotension with a narrow pulse
pressure
Prolonged capillary refill > than or equal to 2 seconds
Weak, thready or absent peripheral pulses
End-organ function
Cool to cold, pale diaphoretic skin
Changes in mental status
Oliguria
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
Anaphylactic
Neurogenic shock (head injury, spinal injury)
Septic Shock
Most common form of distributive shock.
Caused by infectious organisms or their byproducts that
stimulates the immune system and trigger release or
activation of inflammatory mediators.
Uncontrolled activation of the inflammatory mediators
can lead to organ failure, particularly cardiovascular and
respiratory failure, systemic thrombosis and adrenal
dysfunction.
Assessment Findings
History or infection
History of poor feeding
Physical findings
Tachycardia: HR > 2 standard deviations above normal for age
Fever: > 38.5 or 2 standard deviations above normal for age
Altered mental status - lethargy
Petechiae / or purpura
Poor peripheral perfusion (capillary refill less than 2 seconds)
Hypotension – late sign
Laboratory Values
WBC
Greater than 12,000
Lower than 4,000 or more than 10% immature neutrophils
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
Sepsis with ARDS
Acute respiratory distress syndrome
Mechanical ventilation
Aggressive antibiotics to treat bacterial infection
Methylprednisone – anti-inflammatory
Anaphylactic Shock
Results from a severe reaction to a drug, vaccine, food
toxin, plant, venom or other antigen.
It is characterized by venodilation, systemic vasodilation,
and increased capillary permeability combined with
pulmonary vasoconstriction.
Vasoconstriction increased right heart work and may add
to hypotension by reducing the delivery of blood from
the right ventricle to the left ventricle
Assessment Findings
Anxiety or agitation
Nausea and vomiting
Urticaria (hives)
Angioedema (swelling of face, lips and tongue)
Respiratory distress with stridor or wheezing
Hypotension
Tachycardia
What is first drug of choice?
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, topical agents, cough and cold
preparations
Adolescents drug experimentation and suicide attempts
Questions: Why is OD on Tylenol (acetaminophen) a
problem?
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
#1 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