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A Day in the Life of a Pediatric Emergency Department and Level

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					A Day in the Life of a Pediatric 
Emergency Department & Level 1 
Trauma Center
    About Us
•Pediatric Level I trauma center
•Patients seen in year 2010
  113,600
•Top diagnosis
    •Upper respiratory infections
    •Asthma
    •Bronchiolitis
    •Fever
    •Head injury
    •Pneumonia
    •Croup
    •Vomiting
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
 Pediatric ICU
 All trauma team member mandatory education
 Research 20 publication/3yrs
 Injury prevention program
 Rehabilitation program
Children Can Have Most of the
Diseases/Injuries of Adults

Violent injuries    Psychiatric diseases
Suicide             Rape
Heart attacks       Drug overdose/addiction
Strokes             Pregnancy
Cancer
LET US BEGIN OUR
DAY
Meet Jonathan
Jonathan with his dad presents to triage in
  the ED
Triage
What brings you to the Emergency
 Department?
Triage
“Jonathan has had a fever for several days he
  has been very irritable and today his eyes
  look red”.
Triage
History
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
  healthy child.
Triage
Physical Exam
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)
  (monitors inflammation)
As the nurse begins the testing the physician receives
 a call………..
In the ER
A 9 month old is coming by ambulance
 paramedics are performing CPR…
 Water safety
 Ways to drown
  Children 0-5




What do these have in common?
Water safety
 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
 event.
 2006- 1100 US children died from drowning.
Time is important
 Immediate resuscitation
 Heimlich or other methods to remove
 water from lungs have no proven value
 and may delay resuscitation.
Prevention
Family Presence
Managing grief
There are other children who
need us…
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
 changes
        May have lack of sweating
        Delirium/sz/coma
        Hyperventilation
        Pulmonary edema
        Arrthymias
        Rhabdomyolysis
        Shock
 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
  minutes!
Heat can Kill
 Since 1998 an average of 38 children have died
 per year
 2010- 49 deaths
 2011- 21 deaths (5 in texas)
Prevention
 Keep car locked when not in use (30% of
 children trapped in cars have entered while
 playing).
 When child missing look in car first
 Place an item that you must have beside infant
 in backseat
 Make an agreement with the day care
 Never, Never, Never, leave a child alone in a car.
 Even for “just a minute”
Treatment
WE NEED TO CHECK
ON JONATHAN
Jonathan
Jonathan’s labs are abnormal
The physician orders further labs, a chest x-
  ray and an echocardiogram of the heart.
Jonathan
 Jonathan’s CXR & echocardiogram is
 normal, however several of the labs are
 abnormal. The physician has come to a
 conclusion.

What is Jonathan’s diagnosis?
Let’s go back to triage…
A mother brings her 7 week old baby
                               (Emily)
Emily
Emily
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.
Emily
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.
Emily
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
  crying.
Emily
 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.
JONATHAN
Jonathan




  Kawasaki’s Disease
Kawasaki’s disease
 Kawasaki disease is a rare condition in
 children that involves inflammation of the
 blood vessels.
 Occurs more often before age of 5 and in
 boys.
 Effects mucous membranes, blood vessels,
 lymph nodes and the heart.
 Cause is undetermined.
Kawasaki’s disease
Crash and Burn (acronym for detecting kawasaki’s)
  Conjunctivitis
  Rash on body
  Arthritis (joint pain)
  Strawberry tongue
  Hands (skin peeling may also be on feet)
And
  Burn (high fever lasting longer than 5 days often abrupt
  in onset
  Unresponsive to antibiotic therapy given
Kawasaki’s disease
 The medical management of Kawasaki
 disease primarily involves the use of
 gamma globulin.
 High-dose aspirin for a variable period of
 time, followed by lower-dose aspirin for
 its ant platelet effects
Kawasaki’s disease

 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
 Jonathan has been admitted to the
 hospital for treatment.
LET’S GO BACK TO
EMILY
Emily
 The x-ray reveals that Emily has a fracture
 of the femur of her left leg.
Emily
 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.
Emily
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
  was wrong.
Risk Factors for Child Abuse:
Child Characteristics
 Age < 3 years
 Premature birth/Low birth
 weight
 Impaired bonding
 Children with chronic illness
 Physical disabilities
 Emotional/behavioral
 difficulties
 “Difficult” children
 Unwanted child
                                 Wu, et al. Child Abuse and Neglect. 2004.
Risk Factors for Child Abuse:
Parent Characteristics
  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
  behavior


                 Wu, et al. Child abuse and neglect. 2004.
Indicators of Child Abuse and
Neglect
 History inconsistent with injuries
 History incompatible with child’s
 development
 History that changes with time
 Contradictory histories
 Delay in seeking treatment
Abuse Facts
 Teachers most common reporting source
 Neglect >50% of abuse
  ◦ Supervisory
  ◦ Nutritional
  ◦ Medical
  ◦ Emotional
 Infants/young
  ◦ Fractures, head injury, neglect
 School age
  ◦ Bruises, skin injuries
Emily
 Also found to have multiple rib fractures
Emily
 Head CT was normal
 Placed in a spica cast
 Removed from her home by CPS
 In two weeks was in her grandmother’s
 home
 Mom will eventually have Emily back
 home
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
  hospitals.
Meet the Trauma Team
If only…
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.
    Time Heals…
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
 unrestrained.
 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
  causes combined.
Largest number of trauma deaths are due
  to motor vehicle accidents.
Head trauma is the most common type of
  injury
Summary



 Making Life Better for Children
 Community education
 Prevention
 Specialty pediatric trauma care
 Providing the best emergency care to the
 children of DFW
Questions?
References
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
   http://ggweather.com/heat/
Sachdeva, R. (1999). Environmental emergencies. Critical Care
  Clinics 15 (2).
References
Safe Kids USA (n.d.). Car Seats, Booster Seats and Seat Belts.
  Retrieved August 2, 2010, from:
  http://www.safekids.org/assets/docs/ourwork/research/c
  ar-
  seats.pdf#__utma=1.1182642272.1280755284.1280755
  284.1280755284.1&__utmb=1.13.10.1280755284&__ut
  mc=1&__utmx=-
  &__utmz=1.1280755284.1.1.utmcsr=(direct)|utmccn=(d
  irect)|utmcmd=(none)&__utmv=-&__utmk=228776220
References
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
  from
  http://www.childwelfare.gov/pubs/usermanuals/educator/educ
  atorj.cfm
Wexler, R. (2002). Evaluation and treatment of heat-related
  illnesses. American Family Physician 65(11) 2307-2314.
World Health Organization (2010). Drowning. Retrieved from
  http://www.who.int/violence_injury_prevention/other_injury/
  drowning/en/index.html

				
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