A Day in the Life of a Pediatric
Emergency Department & Level 1
•Pediatric Level I trauma center
•Patients seen in year 2010
•Upper respiratory infections
What is a Level 1 Trauma Center?
24 hour/day 7 day a week
Anesthesia in hospital 24 hours/day
Pediatric trauma surgeon 15 minutes away
All surgical services must be on call
All trauma team member mandatory education
Research 20 publication/3yrs
Injury prevention program
Children Can Have Most of the
Diseases/Injuries of Adults
Violent injuries Psychiatric diseases
Heart attacks Drug overdose/addiction
LET US BEGIN OUR
Jonathan with his dad presents to triage in
What brings you to the Emergency
“Jonathan has had a fever for several days he
has been very irritable and today his eyes
Does he have any medical problems? No
Does he have any other symptoms He has had this fever
that won’t go away and this morning he woke up with really
red eyes. Oh and he has a rash on his body.
How long has he had the fever? I would say about 4-5 days
Anything else? No , he is just not himself he is usually such a
The nurse takes a heart rate, respiratory rate and blood
pressure. She notes his heart rate and respiratory rate
are slightly elevated, and he has a fever of 101.5 (38.5
°C) but he has a normal blood pressure. His eyes are
bloodshot and he has a fine red rash over his legs and
lower body. She also notes some peeling of his hands.
He is alert and can answer questions.
In the ER
In the ER the physician examines Jonathan. The
physician also notes that Jonathans lips and tongue
are bright red and he has swelling of his lymph
nodes Based upon his exam he orders lab work.
C-reactive protein (CRP)
erythrocyte sedimentation rate (ESR)
As the nurse begins the testing the physician receives
In the ER
A 9 month old is coming by ambulance
paramedics are performing CPR…
Ways to drown
What do these have in common?
From 2000-2006 drowning was the second
leading cause of unintentional death of US
children ages 1-19.
2008- approx. 3800 children less than 20 years
were seen in an ED for a non fatal drowning
2006- 1100 US children died from drowning.
Time is important
Heimlich or other methods to remove
water from lungs have no proven value
and may delay resuscitation.
There are other children who
A 2 y.o. was found in the backseat of a car.
He had been missing for an undetermined
period of time. It is 95°F outside.
Arriving via ambulance. The team begins
to prepare for his arrival.
Heat can Kill
Heat exhaustion-known heat exposure with core body
temperature between 98.6 °F(37 °C) and 104 ° F (40° C)
with symptoms of tachycardia, sweating, N/V ,fatigue, weakness,
H/A, thirst, normal mental status.
Heat stroke- temperature > 104 ° F (40° C) with mental status
May have lack of sweating
Thermal Maximum- the degree when your body no longer can tol
heat and damage occurs. In humans this occurs at between 41.6-
42° C (107-108° F).
Heat can Kill
MYTH-You can leave a child in a car alone if you leave the windows
open a little and it is not too hot outside.
Reality: Dozens of children die each year from being left or becoming
trapped in a locked vehicle.
When the temperature outside the car is 80 – 100°F a car interior parked
in direct sunlight can reach between 131° and 172 °F.
On a day that is 83 °F — even with the windows rolled down 2 inches —
the inside of a car can reach 109 °F within 15 minutes.
On a day that is 93 °F the inside of a car can reach 125 °F in just 20
Heat can Kill
Since 1998 an average of 38 children have died
2010- 49 deaths
2011- 21 deaths (5 in texas)
Keep car locked when not in use (30% of
children trapped in cars have entered while
When child missing look in car first
Place an item that you must have beside infant
Make an agreement with the day care
Never, Never, Never, leave a child alone in a car.
Even for “just a minute”
WE NEED TO CHECK
Jonathan’s labs are abnormal
The physician orders further labs, a chest x-
ray and an echocardiogram of the heart.
Jonathan’s CXR & echocardiogram is
normal, however several of the labs are
abnormal. The physician has come to a
What is Jonathan’s diagnosis?
Let’s go back to triage…
A mother brings her 7 week old baby
This morning I was changing the baby’s diaper
and I noticed her left leg is swollen. She also
cries when I move it. She is usually a good
baby but she has been crying a lot today.
Does she have any medical problems? No
Does she have any other symptoms-No
Has anything happened to her? No nothing
she was fine when she went to bed.
In the ER the nurse practitioner arrives to
examine Emily. The child’s father is now
here and both parents are present.
Why have you brought Emily to the
emergency dept today?
Mother- She was fine last night I checked on
her when I got home from work she was fine.
This morning her leg is swollen and she keeps
The NP’s examination reveals a swollen
thigh left leg, the infant cries when
handled. No other injuries are noted. She
orders an x-ray of the leg.
Kawasaki disease is a rare condition in
children that involves inflammation of the
Occurs more often before age of 5 and in
Effects mucous membranes, blood vessels,
lymph nodes and the heart.
Cause is undetermined.
Crash and Burn (acronym for detecting kawasaki’s)
Rash on body
Arthritis (joint pain)
Hands (skin peeling may also be on feet)
Burn (high fever lasting longer than 5 days often abrupt
Unresponsive to antibiotic therapy given
The medical management of Kawasaki
disease primarily involves the use of
High-dose aspirin for a variable period of
time, followed by lower-dose aspirin for
its ant platelet effects
About 25% of children develop heart
disease involving the coronary arteries
which may result in aneurysms.
Patients should be screened every 1-2
years for heart problems.
Jonathan has been admitted to the
hospital for treatment.
LET’S GO BACK TO
The x-ray reveals that Emily has a fracture
of the femur of her left leg.
The NP orders a skeletal survey and a
head CT. She also calls the social worker.
She then reveals to the parents that Emily
has a fracture of her femur.
Father-Well last night she did roll off the
couch. I just left her on the couch for a
minute and she rolled off onto the floor. But
she was ok when I put her to bed. Nothing
Risk Factors for Child Abuse:
Age < 3 years
Premature birth/Low birth
Children with chronic illness
Wu, et al. Child Abuse and Neglect. 2004.
Risk Factors for Child Abuse:
Parents abused as children
Family stressors and lack of support
◦ Money, homelessness
Lack of appropriate parenting skills
Mother <20 years
Limited education (<high school)
Low self esteem/depression
Alcoholism, addiction, or psychosis
Unrealistic expectations of child’s
Wu, et al. Child abuse and neglect. 2004.
Indicators of Child Abuse and
History inconsistent with injuries
History incompatible with child’s
History that changes with time
Delay in seeking treatment
Teachers most common reporting source
Neglect >50% of abuse
◦ Fractures, head injury, neglect
◦ Bruises, skin injuries
Also found to have multiple rib fractures
Head CT was normal
Placed in a spica cast
Removed from her home by CPS
In two weeks was in her grandmother’s
Mom will eventually have Emily back
An Urgent Call Overhead…
A transport helicopter has landed carrying 1child from
a two car accident on the highway. Two other children
are arriving by ambulance. An adult in each car has
died and the other adults have been taken to various
Meet the Trauma Team
The 5 y.o. arrives remains unresponsive
◦ The examination is done in an organized way
◦ Airway-spine- breathing- circulation always come first!
◦ A tube is placed to assist his breathing
◦ A series of x-rays, CT and lab work is ordered
◦ A serious head injury is noted
◦ Neurosurgery is called and the OR goes on alert. It is going
to be a long night.
The 7 y.o. found inside the van
◦ Has a large head laceration
◦ Fractured forearm
◦ Fractured ankle
◦ Orthopedic surgeon is called
◦ All her injuries will heal
Car Seats Save Lives
Car Seat Information
Each year, an estimated 975 child occupants under 14
years of age die as a result of a motor vehicle incident.
Young children restrained in child safety seats have an
80 percent lower risk of fatal injury than those who are
Children 2 to 5 years of age using safety belts
prematurely are four times more likely to suffer a
serious head injury in a crash than those restrained in
child safety seats or booster seats.
Trauma and Children
Trauma is the leading cause of death and
disability in children, more than all other
Largest number of trauma deaths are due
to motor vehicle accidents.
Head trauma is the most common type of
Making Life Better for Children
Specialty pediatric trauma care
Providing the best emergency care to the
children of DFW
Committee on Sports Medicine and Fitness: American Academy
of Pediatrics (2000). Climatic heat stress and the exercising
child and adolescent. Pediatrics 106(1) 158-159.
Emergency nurses association. (2004). Emergency Nursing
Pediatric Course (3rd ed.). Des Plaines, Il.: Author.
Hampton, W.D. (2010) Heat Illness. Presented at 2010
Emergency Nurses Association Annual Conference.
Null, J. (2011). Hyperthermia deaths of children in vehicles: Fact
Sheet. Retrieved from
Sachdeva, R. (1999). Environmental emergencies. Critical Care
Clinics 15 (2).
Safe Kids USA (n.d.). Car Seats, Booster Seats and Seat Belts.
Retrieved August 2, 2010, from:
Us Department of Health & Human Services: Administration
for Children and Families (2003). The Role of Educators in
Preventing and Responding to Child Abuse and Neglect. Retrieved
Wexler, R. (2002). Evaluation and treatment of heat-related
illnesses. American Family Physician 65(11) 2307-2314.
World Health Organization (2010). Drowning. Retrieved from