Medical Emergencies Occurring at School

Francisco J Cervantes MD FAAPAugust 5th, 2014www.laredopediatrics.com

Pediatric Emergency Quick Assessment Goals:

• Identify Children in Need of Pediatric Emergency care

• Identify signs of possible emergency care• Identify or list pediatric Emergencies

Statistics for Laredo

• LISD: yearly average of 25,000 enrolled students and over 4,500 employees

• UISD: 43,321 students for 2012-2013

Children In need of Emergency Care

• Special Care Needs Children

• Chronic Illness Children

• Everybody else

Special Services at School

• Approximately 8% of children entering kindergarten and 16% of adolescents entering high school have a chronic physical, developmental, behavioral, or emotional condition that requires health and related services of a type or amount beyond that generally required by children

Special Health Care Needs

• Children with special health care needs attending schools require special equipment, preparation and training of personnel, medications and supplies, and/or transport decisions and arrangements.

Procedures at Schools

• children with special health care needs – Requiring special procedures, ie • G-Tube feeding• Trach• Oxygen• Cath• Nebulizer Treatments

School Population

• 25% Children attending school have special health care needs or chronic medical conditions

Chronic Medical Conditions

– Asthma– ADHD– Diabetes– Epilepsy– Cerebral Palsy

Types of Emergencies at Schools

• injury-related• status asthmaticus• diabetic crises• status epilepticus• sudden cardiac death• other medical emergencies

Injuries at School

• Injuries are the leading cause of death and disability in the United States,

• 70% of injury deaths occurring in school-aged youth (5–19 years of age)

• It is estimated that 10% to 25% of injuries to children occur while they are in school

• A national survey of 573 school nurses conducted by Olympia et al* revealed that 68% of the school nurses managed a life-threatening emergency requiring EMS activation in the school year before the survey. Although 86% of the surveyed schools reported having a medical emergency-response plan, 35% of the schools had not tested it during a drill.

*Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children: a national survey of school nurses. Pediatrics.2005;116 (6). Available at: www.pediatrics.org/cgi/content/full/116/6/e738

Never underestimate the importance of your role as school

nurse.

CALL 911 IF……• The child is unconscious, semi-conscious or unusually confused.• The child’s airway is blocked.• The child is not breathing.• The child is having difficulty breathing, shortness of breath or is choking.• The child has no pulse.• The child has bleeding that won’t stop.• The child is coughing up or vomiting blood.• The child has been poisoned.• The child has a seizure for the first time or a seizure that lasts more than five minutes.• The child has injuries to the neck or back.• The child has sudden, severe pain anywhere in the body.• The child’s condition is limb-threatening (for example, severe eye injuries, amputations)• The child’s condition could worsen or become life-threatening on the way to the hospital.• Moving the child could cause further injury.• The child needs the skills or equipment of paramedics or emergency medical technicians.• Distance or traffic conditions would cause a delay in getting the child to the hospital.

• If any of the previous conditions exist,• or if you are not sure,

Call 9-1-1.

Non Urgent Care

Student may require:• referral for routine medical care. • Minor or non-acute conditions.• Minor abrasions or bruises• Muscle sprains and strains

Urgent CareStudent requires medical intervention within 2 hours.

• Deformity suggesting fracture of a long bone without• circulatory compromise• Lacerations in which sutures are required but

bleeding is controlled and there is no significant blood loss

• Moderate pain following abdominal trauma• Head injury with brief loss of consciousness• Minor burns• Persistent nausea, vomiting, or diarrhea

Emergentrequires immediate medical attention.

Condition is acute and has the potential to threaten life, limb, or vision

• Cardiopulmonary arrest• Shock (hypovolemic, cardiogenic, or distributive)• Severe respiratory distress or failure• Major burns• Cervical spine compromise• Severe medical problems, such as diabetic complications• Poisoning or overdose• Emergency childbirth• Acute seizure states• Prolonged loss of consciousness• Caustic chemical spills in the eyes

Conducting the Initial Assessment

Accurately determine the severity of the student’s condition

Initial Assessment minimizes the possibility that you will overlook important physical and historical

findings.

Components of Assessment:

• Across-the-room • Scene safety • Brief physical • Brief health history

Across-the-Room Assessment

• Is your first contact with the ill or injured student.– Quickly observe the student’s general appearance,

airway status, work of breathing, circulatory status, and disability (neurologic status),

– The entire assessment should take less than a minute.

Scene Safety Assessment

For incidents taking place outside the health office, assess the scene to determine whether you can safely approach the student. Before rendering aid, you must ensure your own safety as well as that of bystanders and of the student. Look for hazards in the form of :• Substances: blood or other body fluids, noxious fumes,

toxic chemicals• Situational dangers: an armed perpetrator, hostages,

weapons• Environmental dangers: an unstable structure, fire,

electrical hazards

Physical Assessment

• Airway: Position, sounds, obstruction.• Breathing: Work of breathing, adventitious

sounds, rate, effort, odors.• Circulation: Skin color, temperature, and

moisture; capillary refill time; rate and quality of pulses; bleeding.

• Disability: Activity level, mentation, pupil size and reactivity, emotional state. Orientation to time, place, and person. AVPU level of consciousness

Brief health history

• Past medical history: Record information about preexisting physical or psychological disabilities.

• A history of previous trauma or a chronic condition is particularly relevant.

• Make sure immunization status is current, including tetanus prophylaxis.

Sudden Cardiac Arrest

• Sudden cardiac arrest has an estimated annual incidence of 0.7 to 1.0 per 1000 population and is responsible for 50% of all deaths attributable to cardiovascular disease in the United States.

• If no CPR is provided, each minute that defibrillation is delayed decreases the chances of survival for victims of sudden cardiac arrest attributable to ventricular fibrillation by 8% to 10%

• High school athlete sudden death is rare, However, sudden cardiac deaths in adult spectators have been reported, and schools need to prepare for them

Classroom EmergencyIn the event a student or adult collapses in the classroom and is unresponsive, the following steps should be taken:

• Using either the phone in the room or a cell phone, someone should call 911.– a) Confirm the location of the patient.– b) Confirm the situation with the 911 operator.

• Using either another phone or sending a student to the adjacent room, the administrative office should be called.– a) The administrative office should overhead page for the First Responder

team to respond to the affected classroom.– b) The administrative office will also send someone with the Automated

External Defibrillator (AED) to the classroom.– c) Someone should be placed outside to direct EMS to the proper location.

Classroom Emergency Cont…• Assess the victim: airway, breathing and circulation• Initiate CPR, if needed, while the AED is brought to the scene.• Upon arrival, place the AED near the victim’s head, close to the AED operator• Prepare to use the AED.

– a) Make sure power is on.– b) Bare and prepare the chest for AED use.– c) Attach the AED to the victim, considering appropriate use of pediatric or adult pads.– d) Stop CPR while the device analyzes the heart rhythm.– e) Follow the device prompts for further action. If a shock is indicated, be sure all rescuers

and bystanders are “clear” before the shock is administered.– f) If no shock is indicated, follow prompts to reassess and continue CPR.

• Upon arrival, EMS shall take charge of the situation.– a) Provide victim information: name, age, known medical problems, and time of incident.– b) Provide information as to current condition and number of shocks administered

*If the patient has suffered any trauma or a fall, the patient should not be moved unless the scene is unsafe.*Prior to EMS arrival, someone in the administrative office should get the patient’s emergency contact informationfrom the file.

Pediatric Advanced Life Support (PALS)Task Force of the International Liaison Committee on Resuscitation (October

2002):

• Automated external defibrillators (AEDs) may be used for children 1 to 8 years of age who have no signs of circulation. Ideally the device should deliver a pediatric dose. The arrhythmia detection algorithm used in the device should demonstrate high specificity for pediatric shockable rhythms, ie, it will not recommend delivery of a shock for non-shockable rhythms (Class IIb).

Upon arrival at the scene the school nurse/AED responder will• Assess responsiveness

– If unresponsive, activate emergency response system by calling 911– Verify 911 has been contacted

• Check ABC’s (Airway, Breathing, Circulation)– If no breathing, provide rescue breathing– If no circulation, perform CPR and prepare for defibrillation

• If chest is wet----DRY IT• If chest is hairy----SHAVE IT• If heart device implanted----WORK AROUND IT• If jewelry is in place----REMOVE IT

• DO NOT USE AED ON A VICTIM <8 YEARS OLD OR 55LBS/25KGS• REMOVE VICTIM FROM CONTACT WITH WATER AND DRY CHEST

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American Heart Association Guidelines for AED/CPR Integration*

• For a sudden, witnessed collapse in a child, use the AED first. Prepare AED to check heart rhythm and deliver 1 shock as necessary. Then, immediately begin 30 CPR chest compressions followed by 2 normal rescue breaths. Complete 5 cycles of CPR (30 compressions to 2 breaths). Then prompt another AED assessment and shock. Continue with cycles of 2 minutes CPR to 1 AED rhythm check.

• For unwitnessed cardiac arrest, start CPR first. Continue for 5 cycles or about 2 minutes. Then prepare the AED to check the heart rhythm and deliver a shock as needed. Continue with cycles of 2 minutes CPR to 1 AED rhythm check.

*Currents in Emergency Cardiovascular Care, American Heart Association, Winter 2005-2006.

Rationale for AED Use

• The primary determinant of survival from VF cardiac arrest is the time interval from collapse until defibrillation. Out-of-hospital defibrillation within the first 3 minutes of witnessed adult VF arrest results in survival rates >50%. But the success of resuscitative efforts decreases dramatically with the passage of time. For every 1-minute delay in defibrillation, the survival rate may decrease by 7% to 10%, although this number is influenced by the presence and quality of bystander CPR. After >12 minutes of VF, the survival rate of adults is <5%.

Pediatric Ventricular Fibrillation (VF)

• All commercially available AEDs use algorithmic rhythm analysis programs derived from in vitro rhythm libraries of adult shockable and non-shockable rhythms. AED developers use an empirical, iterative process to create and adjust filters, measurements, and decision rules. This process enables the AED to “decide” to recommend a shock for the highest possible percentage of shockable rhythms (maximum sensitivity) and to avoid shocking the highest possible percentage of non-shockable rhythms (maximum specificity).

Pediatric Ventricular Fibrillation (VF)

• Gutgesell and colleagues conducted the largest clinical study of an effective defibrillation dose for children. They retrospectively evaluated the efficacy of defibrillation attempts at energy doses of 2 J/kg. The authors reviewed 71 transthoracic defibrillation attempts in 27 children whose ages ranged from 3 days to 15 years and who weighed from 2.1 to 50 kg. The authors reported that 91% of shocks within 10 J of the standard 2 J/kg dose successfully terminated VF.

EKG Variants

AEDs in Pediatrics

• The success of defibrillation depends on delivery of sufficient current flow (amperes) for a sufficient length of time to depolarize a critical mass of myocardium. In the 1970s, animal studies established that inadequate current through the myocardium led to unsuccessful defibrillation, whereas too much current resulted in post resuscitation myocardial damage. These studies further established that the density of current through the myocardium determined the balance between effectiveness of the shock and myocardial damage.

AEDs in Pediatrics

• Current evidence suggests that AEDs are capable of appropriate sensitivity and specificity for pediatric arrhythmias and are both safe and effective for defibrillation of children 1 to 8 years of age. Ideally pediatric pads/cables should be used, whenever available, to deliver a child dose. Each specific AED model must be tested against a library of pediatric arrhythmias to document its efficacy in detection of shockable and nonshockable rhythms.

AEDs in Pediatrics

• The basic principles of electrical cardiac defibrillation have been reviewed. For any given waveform, current flow increases with higher shock energy (J) and decreases with higher impedance or resistance (ohms). Several factors increase impedance along the path between defibrillator paddles or electrode pads and decrease current through the myocardium. These factors include a paddle or electrode pad that is too small, large lung volumes, and lack of conducting gel between the skin and defibrillator paddles or electrode pads.

Current Recommendations in Pediatric Guidelines for Use of AEDs

The 2000 International Guidelines recommend use of AEDs for:• rhythm identification in children 8 years of age (Class IIb). • Attempted defibrillation of VF/pulse less VT detected by an AED may

be considered in these older children (Class Indeterminate). Attempted defibrillation of children less than approximately 8 years of age is not recommended, however. The average 8-year-old child weighs 25 kg. The current recommended initial dose of 150 to 200 J would provide 6 to 8 J/kg for the average 8-year-old. If the initial shock fails to eliminate VF, some AEDs are programmed to provide escalating doses to a maximum dosage of up to 360 J. Thus, second and subsequent doses deliver 150 to 360 J, resulting in a shock of 1 to 4 J/kg in an adult who weighs 80 to 125 kg and 6 to 15 J/kg in an 8-year-old child who weighs 25 kg.

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Why Do People Faint?

• Fainting is pretty common in teens. The good news is that most of the time it's not a sign of something serious.

• When someone faints, it's usually because changes in the nervous system and circulatory system

• circulatory system cause a temporary drop in the amount of blood reaching the brain. When the blood supply to the brain is decreased, a person loses consciousness and falls over. After lying down, a person's head is at the same level as the heart, which helps restore blood flow to the brain. So the person usually recovers after a minute or two.

Causes of Fainting

• Physical triggers: Getting too hot or being in a crowded, poorly ventilated setting are common causes of fainting in teens. People can also faint after exercising too much or working out in excessive heat and not drinking enough fluids (so the body becomes dehydrated). Fainting also can be triggered by other causes of dehydration, as well as hunger or exhaustion. Sometimes just standing for a very long time or getting up too quickly after sitting or lying down can cause someone to faint.

Causes of Fainting

• Emotional stress. Emotions like fright, pain, anxiety, or shock can affect the body's nervous system, causing blood pressure to drop. This is the reason why people faint when something frightens or horrifies them, like the sight of blood.

• Hyperventilation. A person who is hyperventilating is taking fast breaths, which causes carbon dioxide (CO2) to decrease in the blood. This can make a person faint. People who are extremely stressed out, in shock, or have certain anxiety disorders may faint as a result of hyperventilation.

• Drug use. Some illegal drugs (like cocaine or methamphetamine) or using inhalants ("huffing") can cause fainting.

Causes of Fainting • Low blood sugar. The brain depends on a constant supply of sugar from the blood

to work properly and keep a person awake. People who are taking insulin shots or other medications for diabetes can develop low blood sugar and pass out if they take too much medicine or don't eat enough. Sometimes people without diabetes who are starving themselves (as with crash dieting) can drop their blood sugar low enough to faint.

• Anemia. A person with anemia has fewer red blood cells than normal, which decreases the amount of oxygen delivered to the brain and other tissues. Girls who have heavy periods or people with iron-deficiency anemia for other reasons (like not getting enough iron in their diet) may be more likely to faint.

• Pregnancy. During pregnancy the body normally undergoes a lot of changes, including changes in the circulatory system. This leads to low blood pressure that may cause a woman to faint. In addition, the body's fluid requirements are increased, so pregnant women may faint if they aren't drinking enough. And as the uterus grows, it can press on and partially block blood flow through large blood vessels, which can decrease blood supply to the brain.

Causes of Fainting

• Eating Disorders: People with anorexia or bulimia may faint for a number of reasons, including dehydration, low blood sugar, and changes in blood pressure or circulation caused by starvation, vomiting, or over exercising.

• Cardiac problems. An abnormal heartbeat and other heart problems can cause a person to faint. If someone is fainting a lot, especially during exercise or exertion, doctors may suspect heart problems and run tests to look for a heart condition.

• Some medical conditions — like seizures or a rare type of migraine headache — can cause people to seem like they are fainting. But what's happening is not the same thing as fainting and is handled differently.

Helping Someone Who Faints• Make sure the person is lying flat, but avoid moving the person if

you think he or she might have been injured when falling (moving an injured person can make things worse).

• Loosen any tight clothing — such as belts, collars, or ties — to help restore blood flow. Propping the person's feet and lower legs up on a backpack or jacket can also help move blood back toward the brain.

• Someone who has fainted will usually recover quickly. Because it's normal to feel a bit weak after fainting, be sure the person stays lying down for a bit. Getting up too quickly may bring on another fainting spell.

• Call 911 if someone who has fainted does not regain consciousness after about a minute or is having difficulty breathing.

Primary hypertension:

• Significant health problem, with overweight/obesity being a major contributor to much of the pre-hypertension and stage1 hypertension.

• Body mass index (BMI) should be calculated and plotted on the CDC growth curves in pediatric patients.

• The prevalence of hypertension increases with increased BMI; hypertension is present in about 30 percent of those with BMI above the 95th percentile

Resources

• School Nurse Emergency Care Course. Maywood, IL: Illinois Emergency Medical Services for Children; 2003.

• The American Heart Association recommends schools develop an emergency response plan http://circ.ahajournals.org/cgi/content/full/109/2/278#SEC4.

• “Guidelines for Emergency Medical Care in Schools” available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/2/435 .