Pediatric emergencies

Barry Kidd 2010Barry Kidd 2010 11

PEDIATRIC EMERGENCIESPEDIATRIC EMERGENCIES


OVERVIEW: PediatricsOVERVIEW: Pediatrics CHILD DEVELOPMENTCHILD DEVELOPMENT PEDIATRIC EPIDEMIOLOGYPEDIATRIC EPIDEMIOLOGY PROVIDER/FAMILY INTERACTIONSPROVIDER/FAMILY INTERACTIONS PEDIATRIC ASSESSMENTPEDIATRIC ASSESSMENT MEDICAL EMERGENCIESMEDICAL EMERGENCIES PEDIATRIC TRAUMAPEDIATRIC TRAUMA PEDIATRIC RESUSCITATIONPEDIATRIC RESUSCITATION


Emotional & Behavioral Emotional & Behavioral Development: InfantDevelopment: Infant

Time of rapid change/physical growthTime of rapid change/physical growth Birth to 6 monthsBirth to 6 months

Recognize parents, has emotional tiesRecognize parents, has emotional ties Easier to examine, lacks strength Easier to examine, lacks strength Poor head controlPoor head control Rolls overRolls over Hands to and in mouth Hands to and in mouth


Behavioral & Emotional Behavioral & Emotional Development : InfantDevelopment : Infant

6 months to 1 year old6 months to 1 year old Infant has a clear need of parent/care Infant has a clear need of parent/care

providerprovider Infant has an ability to stand, crawl, exploreInfant has an ability to stand, crawl, explore Infant is distressed by separationInfant is distressed by separation Likely will resist being examinedLikely will resist being examined You will likely have parents hold/maintain You will likely have parents hold/maintain

contactcontact The infant crying/holding parents is a coping The infant crying/holding parents is a coping

mechanismmechanism


Behavioral & Emotional Behavioral & Emotional Development: Toddler (1-Development: Toddler (1-

3yrs.)3yrs.) Age of intense activity and discoveryAge of intense activity and discovery Holes need to be filled upHoles need to be filled up Taste and touch everything!Taste and touch everything! Only parents can be trustedOnly parents can be trusted Difficulty in examining/resistanceDifficulty in examining/resistance Have limited language/comprehensionHave limited language/comprehension Provide support (parents/toys/talk)Provide support (parents/toys/talk)


Behavioral & Emotional Behavioral & Emotional Development:Preschooler Development:Preschooler

(3-6)(3-6) The child has progressed from motor The child has progressed from motor

development to psychomotor skills development to psychomotor skills refinement.refinement.

Full awareness of body/body partsFull awareness of body/body parts Concrete thought process/interpretationConcrete thought process/interpretation Vivid imagination/dramatizesVivid imagination/dramatizes Fears the unknown/loss of body functionFears the unknown/loss of body function Thinks illness/injury is a punishmentThinks illness/injury is a punishment


Behavioral & Emotional Behavioral & Emotional Development: School Age (6-12)Development: School Age (6-12)

Differing levels of behavior/developmentDiffering levels of behavior/development Learning from school, peers,familyLearning from school, peers,family Understands rational explanationsUnderstands rational explanations Is easiest to examine and manageIs easiest to examine and manage Issues of modesty are importantIssues of modesty are important May regress to other level under stressMay regress to other level under stress Fear of death and disabilityFear of death and disability


Behavioral & Emotional Behavioral & Emotional Development: Adolescent (13-Development: Adolescent (13-

18)18) Mental development greatly advancedMental development greatly advanced Feel invincible/immune to illness-injuryFeel invincible/immune to illness-injury Preoccupied with body appearancePreoccupied with body appearance Capable of over-reacting/hysteriaCapable of over-reacting/hysteria Feel independent/adequate historiansFeel independent/adequate historians Fear of death and disabilityFear of death and disability Extremely modestExtremely modest


PEDIATRIC EMERGENCIES:PEDIATRIC EMERGENCIES:EpidemiologyEpidemiology

Trauma is the leading cause of death Trauma is the leading cause of death in infants and children (0-18 yrs. old)in infants and children (0-18 yrs. old)

Motor vehicle incidents most frequentMotor vehicle incidents most frequent BurnsBurns Drowning Drowning Falls Falls FirearmsFirearms


EPIDEMIOLOGY: TraumaEPIDEMIOLOGY: Trauma Head Trauma: #1 cause of mortalityHead Trauma: #1 cause of mortality Blunt Abdominal Trauma: #2 causeBlunt Abdominal Trauma: #2 cause Orthopedic TraumaOrthopedic Trauma Thoracic TraumaThoracic Trauma May be isolated or Multi-systems May be isolated or Multi-systems

traumatrauma


EPIDEMIOLOGY: MedicalEPIDEMIOLOGY: Medical Respiratory EmergenciesRespiratory Emergencies Altered Temperature ControlAltered Temperature Control SeizuresSeizures SepsisSepsis DehydrationDehydration Metabolic EmergenciesMetabolic Emergencies Congenital DefectsCongenital Defects Toxicological EmergenciesToxicological Emergencies


Provider-Family : Provider-Family : INTERACTIONS: FAMILYINTERACTIONS: FAMILY

When a child is ill or injured- the parents When a child is ill or injured- the parents are impacted as well.are impacted as well.

Parents reaction is one of “acute grief”Parents reaction is one of “acute grief” May view situation as “loss of control”May view situation as “loss of control” May be demanding to gain controlMay be demanding to gain control Relinquishing child to provider-feel helplessRelinquishing child to provider-feel helpless Want answers/directions-NOW!Want answers/directions-NOW! Will he/she walk again?/Will they die?Will he/she walk again?/Will they die?


Provider - Family: Provider - Family: INTERACTIONS: ProviderINTERACTIONS: Provider

Acknowledge the parents feelingsAcknowledge the parents feelings Provide reassuranceProvide reassurance Involve the parents with assessmentInvolve the parents with assessment Be very communicativeBe very communicative Remain calm/Project confidenceRemain calm/Project confidence Develop trust with parents/patientDevelop trust with parents/patient Give Information/Simple languageGive Information/Simple language Assure needs/care of other childrenAssure needs/care of other children


PEDIATRIC ASSESSMENTPEDIATRIC ASSESSMENT Anatomic & Physiological DifferencesAnatomic & Physiological Differences Approaches to the child/communicationApproaches to the child/communication Chief ComplaintChief Complaint AppearanceAppearance Physical ExaminationPhysical Examination

ABCsABCs Vital SignsVital Signs Review of SystemsReview of Systems


PEDIATRIC ASSESSMENT: PEDIATRIC ASSESSMENT: Anatomy & Physiology: Anatomy & Physiology:

(head)(head) Head is larger and heavier -Head is larger and heavier -

proportionately until age 4, v. adultproportionately until age 4, v. adult Infants have anterior fontanel which is Infants have anterior fontanel which is

normally soft and flat.normally soft and flat. Fontanels can be used as an indicator Fontanels can be used as an indicator

of increased ICP or dehydration.of increased ICP or dehydration. Bones are soft and separated by Bones are soft and separated by

cartilage until age twocartilage until age two


Anatomy & Physiology: Anatomy & Physiology: airwayairway

The face is smaller/flexible nasal bridgeThe face is smaller/flexible nasal bridge Newborns/infants are obligate nasal Newborns/infants are obligate nasal

breathers- passages easily obstructedbreathers- passages easily obstructed Tongue is large/mandibular muscles are Tongue is large/mandibular muscles are

immatureimmature Airway diameter is small (4 v. 20mm)Airway diameter is small (4 v. 20mm) Tracheal rings are more elasticTracheal rings are more elastic Vocal cords are high/more anteriorVocal cords are high/more anterior


Anatomy & Physiology: Anatomy & Physiology: (thoracic)(thoracic)

Ribs are elastic: more cartilageRibs are elastic: more cartilage Rib cage has greater complianceRib cage has greater compliance Diaphragm-primary respiratory muscleDiaphragm-primary respiratory muscle Chest muscles not well developedChest muscles not well developed Lung tissue fragile-pulmonary contusionLung tissue fragile-pulmonary contusion Mobile mediastinumMobile mediastinum Respiratory rates are fasterRespiratory rates are faster Cardiac rates are fasterCardiac rates are faster


Anatomy & Physiology: Anatomy & Physiology: (Abdomen)(Abdomen)

Abdominal breathers- observe Abdominal breathers- observe abdomen to determine resp-rateabdomen to determine resp-rate

Abdominal muscles are immatureAbdominal muscles are immature Limited protection of organs Limited protection of organs

resultant from lack of musculatureresultant from lack of musculature Increased vulnerability to blunt force Increased vulnerability to blunt force

traumatrauma


Anatomy & Physiology: Anatomy & Physiology: (extremities)(extremities)

Bones are softer until adolescenceBones are softer until adolescence Greater susceptibility to fractures due Greater susceptibility to fractures due

to bending and splinteringto bending and splintering Long bones develop from growth Long bones develop from growth

plates or epiphysis- fractures in these plates or epiphysis- fractures in these areas are more criticalareas are more critical

Increased activity level -types leads to Increased activity level -types leads to a variety of orthopedic traumaa variety of orthopedic trauma


Anatomy & Physiology: Anatomy & Physiology: (Nervous system)(Nervous system)

Development throughout childhoodDevelopment throughout childhood Motor development proceeds Motor development proceeds

bilaterally from head to toebilaterally from head to toe Sensation is present everywhere from Sensation is present everywhere from

the time of birth-infants feel painthe time of birth-infants feel pain All brain cells are present at birth but All brain cells are present at birth but

are not fully developed-increased are not fully developed-increased susceptibility to brain traumasusceptibility to brain trauma


Anatomy & Physiology: Anatomy & Physiology: (Integumentary System)(Integumentary System)

Body surface are is larger in Body surface are is larger in proportion to body mass.proportion to body mass.

Skin is thinner with less subcutaneous Skin is thinner with less subcutaneous fat.fat.

Neonates are further compromised Neonates are further compromised due to immature thermal regulation due to immature thermal regulation mechanisms.mechanisms.

Very susceptible to hypothermiaVery susceptible to hypothermia


PEDIATRIC: PEDIATRIC: Approach/CommunicationApproach/Communication

Evaluate location/position of childEvaluate location/position of child Look for environmental Look for environmental

clues/mechanisms of injuryclues/mechanisms of injury Observe the interactions of the child Observe the interactions of the child

with the parents or care providerswith the parents or care providers Take history from parents/providersTake history from parents/providers Don’t overlook the patient’s ability to Don’t overlook the patient’s ability to

provide you with informationprovide you with information


PEDIATRIC:PEDIATRIC:Approach-CommunicationApproach-Communication

Give the child a chance to trust you firstGive the child a chance to trust you first Use age appropriate languageUse age appropriate language Provide a toy and include EMS Provide a toy and include EMS

equipment as appropriateequipment as appropriate Project a calm demeanorProject a calm demeanor Use parent as a role model/involveUse parent as a role model/involve Ask questions to gain the child’s Ask questions to gain the child’s

participation- but don’t waste time!participation- but don’t waste time!


PEDIATRIC: Chief Complaint-PEDIATRIC: Chief Complaint-History of the Present Illness: History of the Present Illness:

hpihpi Why was the EMS initiated?Why was the EMS initiated? Present illness-symptomsPresent illness-symptoms Duration-chronology-onsetDuration-chronology-onset Pre-arrival treatment/physician contactPre-arrival treatment/physician contact

Birth weight, complications, neonatal hxBirth weight, complications, neonatal hx SAMPLE informationSAMPLE information


Pediatric Assessment: Pediatric Assessment: Appearance-Appearance-

Observe environment-mechanismsObserve environment-mechanisms Evaluate all subjective informationEvaluate all subjective information Observe for any apparent signsObserve for any apparent signs Observe for any apparent abnormalitiesObserve for any apparent abnormalities Listen to the child’s cry, voice, breathingListen to the child’s cry, voice, breathing Observe the skin colorObserve the skin color Observe level of orientation, attention Observe level of orientation, attention

span, l.o.c.,span, l.o.c.,


PHYSICAL EXAMINATION: PHYSICAL EXAMINATION: ABC’sABC’s

Determine level of Determine level of consciousness/responsivenessconsciousness/responsiveness

Airway-patent-secureAirway-patent-secure Breathing- adequacy-supplementBreathing- adequacy-supplement CirculationCirculation

Blood lossBlood loss Central pulsesCentral pulses Peripheral pulses-Capillary refill time (CRT)Peripheral pulses-Capillary refill time (CRT)


AIRWAY: assessmentAIRWAY: assessment Crying-talking = a patent airwayCrying-talking = a patent airway Hoarseness= an airway obstruction or Hoarseness= an airway obstruction or

inflammationinflammation Moaning = altered L.O.C.Moaning = altered L.O.C. Stridor= airway obstruction or vocal Stridor= airway obstruction or vocal

cord inflammationcord inflammation Wheezing= bronchial secretionsWheezing= bronchial secretions Grunting= severe respiratory distressGrunting= severe respiratory distress


AIRWAY: assessmentAIRWAY: assessment Gurgling= a penetrating chest woundGurgling= a penetrating chest wound Observe the abdomen to determine Observe the abdomen to determine

respiratory rate/characterrespiratory rate/character observe for nasal flaring, sternal observe for nasal flaring, sternal

retractions ,cyanosis or mottling as signs retractions ,cyanosis or mottling as signs of respiratory distressof respiratory distress

Auscultate the lungs: midaxillary, Auscultate the lungs: midaxillary, midclavicular-just beneath clavicles,listen midclavicular-just beneath clavicles,listen for breaths at end of cryfor breaths at end of cry


CIRCULATORY: assessmentCIRCULATORY: assessment Skin temp. is best indicator of early Skin temp. is best indicator of early

shockshock Use forehead, chin or sternumUse forehead, chin or sternum Estimate blood loss: 80cc/kg/wt =total Estimate blood loss: 80cc/kg/wt =total

blood volume (pediatric)blood volume (pediatric) Evaluate distal pulses/central pulsesEvaluate distal pulses/central pulses Determine blood pressure: 80+(2 x Determine blood pressure: 80+(2 x

age) = systolic BP (normotensive)age) = systolic BP (normotensive)


PEDIATRIC: Vital SignsPEDIATRIC: Vital Signs Pulse: Central & Peripheral/SpO2Pulse: Central & Peripheral/SpO2 Respiration: rate/character/strengthRespiration: rate/character/strength Blood Pressure (only for older Blood Pressure (only for older

children)children) TemperatureTemperature Skin colorSkin color


REVIEW of SYSTEMS: REVIEW of SYSTEMS: assessmentassessment

Head, Ears, Eyes, Nose, Throat- reassessment Head, Ears, Eyes, Nose, Throat- reassessment of airway, fontanelles- depressed of airway, fontanelles- depressed =dehydration, bulging= increased intracranial =dehydration, bulging= increased intracranial pressurepressure

Neck- trachea midline, JVD-difficultNeck- trachea midline, JVD-difficult Thorax-symmetry, sounds, abnormalities, Thorax-symmetry, sounds, abnormalities,

discolorationsdiscolorations Abdomen-resp. rate, shape-round, Abdomen-resp. rate, shape-round,

appearance, light palpation, intra abdominal appearance, light palpation, intra abdominal bleeding?bleeding?


REVIEW of SYSTEMS: REVIEW of SYSTEMS: assessmentassessment

Extremities- alignment, Range of motionExtremities- alignment, Range of motion Skin- temperature, color, textureSkin- temperature, color, texture Neurological- GCS, mentation, level of Neurological- GCS, mentation, level of

activity (active v. passive) posturing-activity (active v. passive) posturing-decortication/decerebration/rigiditydecortication/decerebration/rigidity

Reassessment of Vital SignsReassessment of Vital Signs Continuous observation: Continuous observation:

trends/changes-variationstrends/changes-variations


MEDICAL EMERGENCIESMEDICAL EMERGENCIES RESPIRATORY EMERGENCIES -most RESPIRATORY EMERGENCIES -most

commonly encountered-highest commonly encountered-highest mortality rate:mortality rate: AsthmaAsthma CroupCroup EpiglottitisEpiglottitis Foreign bodyForeign body General respiratory distressGeneral respiratory distress


ASTHMAASTHMA Chronic recurrent lower airway disease Chronic recurrent lower airway disease

with episodic attacks of bronchial with episodic attacks of bronchial constrictionconstriction

Response to allergen, stress, activityResponse to allergen, stress, activity Inspiratory/expiratory wheezingInspiratory/expiratory wheezing Coarse rhonchi, sometimes cyanoticCoarse rhonchi, sometimes cyanotic Apprehensive/combativeApprehensive/combative May lead to ventilatory failureMay lead to ventilatory failure


ASTHMA: EMS managementASTHMA: EMS management Assessment/oxygen via peds maskAssessment/oxygen via peds mask Assisted medications-bronchodilatorsAssisted medications-bronchodilators Status Asthmaticus .Status Asthmaticus . Minimal air movement/aggressive Minimal air movement/aggressive

mgmt.mgmt.


CROUPCROUP Upper respiratory viral infectionUpper respiratory viral infection swelling and inflammation of larynx, swelling and inflammation of larynx,

subglottic tissue and sometimes trachea subglottic tissue and sometimes trachea and bronchiand bronchi

More common in spring and fallMore common in spring and fall Usually with cold symptoms 1-3 days Usually with cold symptoms 1-3 days Barking-”seal like” coughBarking-”seal like” cough Moderate to severe respiratory distress with Moderate to severe respiratory distress with

associated signs/symptomsassociated signs/symptoms


CROUP: EMS ManagementCROUP: EMS Management Oxygen via NRB if toleratedOxygen via NRB if tolerated Blow-by oxygen in high concentration Blow-by oxygen in high concentration

otherwiseotherwise Keep quiet -do not agitateKeep quiet -do not agitate Do not attempt manual airway as Do not attempt manual airway as

croup may be confused with croup may be confused with epiglottitisepiglottitis

Rapid transport/Ventilate as indicatedRapid transport/Ventilate as indicated


EPIGLOTTITISEPIGLOTTITIS Bacterial infection localized to the Bacterial infection localized to the

epiglottisepiglottis Acute swelling of the epiglottis causing a Acute swelling of the epiglottis causing a

total airway obstructiontotal airway obstruction Affects children 3-6, but can occur in Affects children 3-6, but can occur in

anyoneanyone Sudden onset-child in tripod positionSudden onset-child in tripod position Secretions, drooling, respiratory distress is Secretions, drooling, respiratory distress is

severesevere


EPIGLOTTITIS-EPIGLOTTITIS-EMS ManagementEMS Management

Do not manipulate the airwayDo not manipulate the airway Maintain tolerable position-never Maintain tolerable position-never

supinesupine Oxygen via mask or blow byOxygen via mask or blow by Minimize movement/agitationMinimize movement/agitation Immediate transportImmediate transport Positive pressure ventilation -if Positive pressure ventilation -if

indicatedindicated


Altered Temperature Altered Temperature Control: Fever/hyperthermiaControl: Fever/hyperthermia Response to an infection or from brain’s Response to an infection or from brain’s

inability to effect thermoregulationinability to effect thermoregulation Greater than 38 C. is cause for concernGreater than 38 C. is cause for concern Can lead to febrile seizuresCan lead to febrile seizures Core temperature can rise which Core temperature can rise which

increases oxygen demand and can increases oxygen demand and can cause metabolic acidosiscause metabolic acidosis

Be aware of environmental factorsBe aware of environmental factors


Fever/hyperthermia:Fever/hyperthermia: EMS management EMS management

ABC’s, vital signs, ABC’s, vital signs, Treat seizures accordinglyTreat seizures accordingly Promote rapid cooling-sponging to lower Promote rapid cooling-sponging to lower

temperaturetemperature Give oral fluids based on LOC ( have parents Give oral fluids based on LOC ( have parents

administer)administer) Evaluate necessity for transportEvaluate necessity for transport Be concerned with a lethargic child having a Be concerned with a lethargic child having a

temperature over 39 C.temperature over 39 C.


HYPOTHERMIAHYPOTHERMIA Pediatric patients are at a high riskPediatric patients are at a high risk Larger ratio of body surface area/massLarger ratio of body surface area/mass Core body temperature below 35 C.Core body temperature below 35 C. EtiologyEtiology

EnvironmentalEnvironmental TraumaTrauma Metabolic conditionsMetabolic conditions SepsisSepsis


HYPOTHERMIA: HYPOTHERMIA: EMS Management EMS Management

Assessment/ABCsAssessment/ABCs Oxygen via mask-warm Oxygen via mask-warm

humidification?humidification? Warm environment-external re Warm environment-external re

warmingwarming Core temperature monitoringCore temperature monitoring Cautious with movement/re warmingCautious with movement/re warming


SEIZURESSEIZURES Abnormal electrical discharge in the Abnormal electrical discharge in the

brain which causes abnormal brain which causes abnormal movements and altered mental statusmovements and altered mental status

Varying etiologies-PediatricVarying etiologies-Pediatric Fever (febrile seizures)Fever (febrile seizures) TraumaTrauma Meningitis, encephalitisMeningitis, encephalitis Metabolic disorders -diabetic/toxic intakeMetabolic disorders -diabetic/toxic intake


SEIZURES-EMS ManagementSEIZURES-EMS Management Assessment /ABC’sAssessment /ABC’s High concentration oxygenHigh concentration oxygen Determine etiology/Status epilepticusDetermine etiology/Status epilepticus IV access: peripheral (if protocol IV access: peripheral (if protocol

allows)allows) Administer Dextrose 25%W-2-4ml/kgAdminister Dextrose 25%W-2-4ml/kg Appropriate tertiary facilityAppropriate tertiary facility


MENINGITISMENINGITIS Bacterial or viral infection of the meninges Bacterial or viral infection of the meninges

of the brain and/or spinal cord.of the brain and/or spinal cord. 5-10% mortality rate-treated: antibiotics5-10% mortality rate-treated: antibiotics 90% of cases in children (1 mo-5 yrs.)90% of cases in children (1 mo-5 yrs.) Abrupt onset of symptoms: petechiae, Abrupt onset of symptoms: petechiae,

fever, apprehension, fever, apprehension, Nuchal rigidity: Kerning’s/ Bruzinski’s signNuchal rigidity: Kerning’s/ Bruzinski’s sign


Bruzinski’s signBruzinski’s sign


MENINGITIS: MENINGITIS: EMS Management EMS Management

Wear gown, gloves, eye protection-Wear gown, gloves, eye protection-highly infectioushighly infectious

Assessment/Oxygen-ventilate if neededAssessment/Oxygen-ventilate if needed IV access via peripheralIV access via peripheral 20cc/kg fluid bolus if shock like signs and 20cc/kg fluid bolus if shock like signs and

symptomssymptoms Rapid transportRapid transport Appropriate facility- primary/tertiary?Appropriate facility- primary/tertiary?


SEPSIS/SEPTIC SHOCKSEPSIS/SEPTIC SHOCK SEPSIS-bacterial infection of the bloodSEPSIS-bacterial infection of the blood Associated frequently with meningitisAssociated frequently with meningitis Newborns at great risk-immune systemNewborns at great risk-immune system SEPTIC SHOCK-Complication of Sepsis: SEPTIC SHOCK-Complication of Sepsis:

pooling of blood in extremities, dilation pooling of blood in extremities, dilation of vesselsof vessels

Related to other illnesses, pallor, shock, Related to other illnesses, pallor, shock, mottling, poor sucking/feeding, ICP-upmottling, poor sucking/feeding, ICP-up


SEPSIS/SEPTIC SHOCKSEPSIS/SEPTIC SHOCKEMS: ManagementEMS: Management

Assessment /ABC’sAssessment /ABC’s Oxygen-ventilate as neededOxygen-ventilate as needed Intubate as requiredIntubate as required IV access via peripheralIV access via peripheral IV fluid bolus at 20cc/kg IV push-repeatIV fluid bolus at 20cc/kg IV push-repeat Rapid transport-don’t delayRapid transport-don’t delay Tertiary care facility is most appropriateTertiary care facility is most appropriate


DEHYDRATIONDEHYDRATION Acute loss of body fluids from numerous Acute loss of body fluids from numerous

causes: causes: Fever, Vomiting, diarrhea, Fever, Vomiting, diarrhea, Diabetic ketoacidosis-renal profusionDiabetic ketoacidosis-renal profusion Poor formula preparationPoor formula preparation Water is 75% of pediatric body weightWater is 75% of pediatric body weight Infants who are dehydrated can lose up Infants who are dehydrated can lose up

to 15% of body weightto 15% of body weight


DEHYDRATION: DEHYDRATION: EMS ManagementEMS Management

Assessment- ABCs: Sunken fontanellesAssessment- ABCs: Sunken fontanelles Historical data: last wet diaper?Historical data: last wet diaper? Severe dehydration=life threateningSevere dehydration=life threatening Administer CPR as needed for Administer CPR as needed for

circulatory collapsecirculatory collapse Transport to tertiary facility per Transport to tertiary facility per

medical control as indicatedmedical control as indicated


METABOLIC: KETOACIDOSISMETABOLIC: KETOACIDOSIS Cells cannot utilize glucose for energy -Cells cannot utilize glucose for energy -

body attempts to breakdown fatsbody attempts to breakdown fats known diabetic-unbalanced insulin doseknown diabetic-unbalanced insulin dose Early-polyuria, polydipsia (the patient Early-polyuria, polydipsia (the patient

displays excessive thirst) ,weight lossdisplays excessive thirst) ,weight loss Acute-ketone breath, Kussmaul Acute-ketone breath, Kussmaul

respirations, dehydration, rigid abdomen, respirations, dehydration, rigid abdomen, comatose conditioncomatose condition

Life threatening emergencyLife threatening emergency


METABOLIC: HypoglycemiaMETABOLIC: Hypoglycemia Inadequate levels of blood glucoseInadequate levels of blood glucose Variance in activity/growth in pediatricsVariance in activity/growth in pediatrics Mild- hunger, weakness, tachycardiaMild- hunger, weakness, tachycardia Severe - altered LOC, sweating, seizures, Severe - altered LOC, sweating, seizures,

: must replace glucose: must replace glucose Can occur in neonates - blood glucose Can occur in neonates - blood glucose

levels are routinely checked.levels are routinely checked. Can be life threateningCan be life threatening


METABOLIC EMERGENCIESMETABOLIC EMERGENCIESEMS ManagementEMS Management

Assessment-ABC’s- good historianAssessment-ABC’s- good historian Oxygen via mask-ventilate as Oxygen via mask-ventilate as

requiredrequired IV access via peripheralIV access via peripheral Administer D25%/W 2-4mg/kg as Administer D25%/W 2-4mg/kg as

required, required, Protect airwayProtect airway


CONGENITAL CONGENITAL ABNORMALITIES: PediatricABNORMALITIES: Pediatric

Congenital birth defects typically occur Congenital birth defects typically occur to the heart and the surrounding great to the heart and the surrounding great vessels.vessels.

When blood from the two circulatory When blood from the two circulatory pathways mix-hypoxemia occurs.pathways mix-hypoxemia occurs.

Talk to parents-What is normalTalk to parents-What is normal Dydrhythmias, CHF, cyanosis, mottlingDydrhythmias, CHF, cyanosis, mottling Respiratory distress-general precursorRespiratory distress-general precursor


Congenital Abnormalities: Congenital Abnormalities: EMS Management EMS Management

Assessment/ABCsAssessment/ABCs Parents know more than us!!Parents know more than us!! Oxygen/ventilateOxygen/ventilate For a cyanotic spell-the knee chest For a cyanotic spell-the knee chest

position is bestposition is best Contact medical controlContact medical control Tertiary facility where treated is the Tertiary facility where treated is the

most appropriate receivermost appropriate receiver


““HIGH TECH KIDS”HIGH TECH KIDS” Variety of chronic or terminal illnessesVariety of chronic or terminal illnesses Congenital defectsCongenital defects Cystic FibrosisCystic Fibrosis SIDS candidates/ PremiesSIDS candidates/ Premies Feeding disordersFeeding disorders TraumaTrauma Ventilators, Infusion pumps, central lines, Ventilators, Infusion pumps, central lines,

feeding tubes, trachs, hospicefeeding tubes, trachs, hospice


PEDIATRIC TOXICOLOGYPEDIATRIC TOXICOLOGY Poisoning is a major cause of death in Poisoning is a major cause of death in

children under 5 years oldchildren under 5 years old 90% occur in child’s home/parent 90% occur in child’s home/parent

present at timepresent at time Drug experimentation/suicide attemptsDrug experimentation/suicide attempts Any consumable material is suspectAny consumable material is suspect Toddlers are high risk group due to their Toddlers are high risk group due to their

exploratory natureexploratory nature


PEDIATRIC TOXICOLOGYPEDIATRIC TOXICOLOGYEMS: ManagementEMS: Management

Gather adequate history/environmental Gather adequate history/environmental assessment-labels, clues, residue etc.assessment-labels, clues, residue etc.

Assessment/ABCsAssessment/ABCs Oxygen via mask/ventilate-intubateOxygen via mask/ventilate-intubate Information assessment-poison controlInformation assessment-poison control Medical Control- advanced Medical Control- advanced

toxicological interventions- HazMat as toxicological interventions- HazMat as requiredrequired


PEDIATRIC TRAUMAPEDIATRIC TRAUMA Leading cause of death in childrenLeading cause of death in children Four times greater than cancerFour times greater than cancer MVI= 44% of deathsMVI= 44% of deaths Burns = 15%Burns = 15% Drowning= 14.6%Drowning= 14.6% Aspiration=3.5%Aspiration=3.5% Firearms= 4%Firearms= 4%


PEDIATRIC TRAUMA PEDIATRIC TRAUMA (frequency)(frequency)

Head:Head: 38%38% ExtremitiesExtremities 32%32% AbdomenAbdomen 11%11% ChestChest 9% 9% Blunt trauma is most common Blunt trauma is most common

mechanismmechanism Effective management is criticalEffective management is critical


Pediatric Trauma Pediatric Trauma AssessmentAssessment

Children with trauma die from hypoxia Children with trauma die from hypoxia and hypoperfusion secondary to specific and hypoperfusion secondary to specific injuriesinjuries

Airway (stabilize C-spine)Airway (stabilize C-spine) Breathing (O2/ventilate/intubate)Breathing (O2/ventilate/intubate) Circulation(bleeding,central/peripheral)Circulation(bleeding,central/peripheral) Disability (LOC / neuro)Disability (LOC / neuro) Exposure (thermoregulation)Exposure (thermoregulation)


Pediatric Trauma Pediatric Trauma ManagementManagement

Assure Scene SafetyAssure Scene Safety Effective Incident Size-UpEffective Incident Size-Up Effective Incident ManagementEffective Incident Management Request Additional ResourcesRequest Additional Resources Patient AssessmentPatient Assessment Determine Load/Go StatusDetermine Load/Go Status Rapid TransportRapid Transport Appropriate Patient CareAppropriate Patient Care


SPECIAL CONSIDERATIONS: SPECIAL CONSIDERATIONS: Pediatric TraumaPediatric Trauma

Capillary refill is the best indicator of Capillary refill is the best indicator of perfusion and early shock in peds.perfusion and early shock in peds.

Hyperventilation is indicated early on with Hyperventilation is indicated early on with suspected head trauma/monitor and suspected head trauma/monitor and manage the airway.manage the airway.

Understand ranges for pediatric vital Understand ranges for pediatric vital signs: watch for trends--signs: watch for trends--


NEONATAL RESUSCITATION:NEONATAL RESUSCITATION:Neonates in perspective:Neonates in perspective:

Neonates must make three Neonates must make three physiological adaptations after birth:physiological adaptations after birth:

Changing the circulatory patternChanging the circulatory pattern Emptying lungs/ventilationEmptying lungs/ventilation Maintaining thermoregulationMaintaining thermoregulation Only about 10-20% require Only about 10-20% require

resuscitative support to make these resuscitative support to make these transitionstransitions


Physiology of birth Physiology of birth (neonates)(neonates)

Chest is compressed during vaginal Chest is compressed during vaginal delivery: fluid forced out/recoil-air indelivery: fluid forced out/recoil-air in

Cutting the umbilical cord ends fetal Cutting the umbilical cord ends fetal circulation: Peripheral vascular resistance circulation: Peripheral vascular resistance begins-pulmonary circulationbegins-pulmonary circulation

Neonates lose heat rapidly after birthNeonates lose heat rapidly after birth Large body surface areaLarge body surface area Thin skin/little fat-insulationThin skin/little fat-insulation Conserve heat by flexion of extremitiesConserve heat by flexion of extremities


Anatomy/Physiology Anatomy/Physiology (neonates)(neonates)

37-40 weeks gestation (full term) 7.5 lbs37-40 weeks gestation (full term) 7.5 lbs Premature: less than 37 wks.: 1-4 lbsPremature: less than 37 wks.: 1-4 lbs Obligate nose breathers/irregular breathing with Obligate nose breathers/irregular breathing with

apnea/obstructed naresapnea/obstructed nares Maternal complications predicate \resuscitationMaternal complications predicate \resuscitation

Maternal illnessMaternal illness Substance abuseSubstance abuse HemorrhageHemorrhage Delivery complicationsDelivery complications


NEONATAL ASSESSMENTNEONATAL ASSESSMENT Maternal history/delivery complicationsMaternal history/delivery complications Presenting part-during birthPresenting part-during birth Presence of meconiumPresence of meconium Vital signs: BP:55/30-75/40 P: 120-160 R: Vital signs: BP:55/30-75/40 P: 120-160 R:

30-60, Temp: 96.8-98.630-60, Temp: 96.8-98.6 APGAR SCORE : (1-5 minutes after)APGAR SCORE : (1-5 minutes after) Reflexes: sucking,blinking, noise Reflexes: sucking,blinking, noise Management based on assessmentManagement based on assessment


APGAR SCORING ( 1 APGAR SCORING ( 1 min/5min)min/5min)

A: Appearance or colorA: Appearance or color P: PulseP: Pulse G: Grimace with cryingG: Grimace with crying A: Activity or muscle toneA: Activity or muscle tone R: Respiratory effortR: Respiratory effort Score of 7-10: normalScore of 7-10: normal Score of 4-6: stimulate,suction, oxygenScore of 4-6: stimulate,suction, oxygen Score of O-3: ResuscitationScore of O-3: Resuscitation


Neonatal ManagementNeonatal Management Suction, dry, position, Suction, dry, position,

stimulate,warm,stimulate,warm, Oxygenate : blow by o2Oxygenate : blow by o2 VentilateVentilate CPR: if rate less than (60-80)CPR: if rate less than (60-80) Meconium Aspiration: suctionMeconium Aspiration: suction


QUESTIONSQUESTIONS

Pediatric emergencies

Healthcare

Transcript of Pediatric emergencies