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Pediatric Emergencies Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN 2007 Revised 2011 by Lori.

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Presentation on theme: "Pediatric Emergencies Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN 2007 Revised 2011 by Lori."— Presentation transcript:

1 Pediatric Emergencies Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN 2007 Revised 2011 by Lori Barker, MS, RN, CEN Emergency Nursing Core Curriculum

2 Objectives For selected pediatric emergencies the participant will be able to: Compare the etiology Describe assessment findings Identify the clinical management

3 Pediatric Emergencies Overview Children account for 25- 35% of all ED visits Only 3 – 5 % of those children are acutely ill or injured Children cannot be cared for as small adults, need specialized equipment & training

4 PEDIATRICS The Assessment Triangle

5 Assessment Triangle An across-the-room assessment to establish severity of illness or injury and urgency of intervention Appearance (the look test) is the simplest and most effective assessment tool. Tone, interactibility, consolability, speech or cry. There are very few truly sick or injured children that can pass the look test. When children are sick they look sick Breathing- work of breathing. Be alert for nasal flaring, retractions, abnormal airway sounds, position of comfort, rate Circulation- color & temperature of skin. Assess for pallor, mottling, cyanosis If any of the three components of the triangle are abnormal – the urgency level increases

6 Pediatric Triage Rules Parents know their children better than you - if they say the child is sick - believe them! Start with the ABCs – look for the not so obvious; subtle presentation likely Children in shock compensate far better than adults – do not be fooled by normal vital signs Important to obtain childs weight in kilograms & birth weight if < 8 wks old

7 CIAMPEDS Pneumonic for pediatric assessment C hief Complaint I mmunizations Isolation A llergies M edications P ast Medical History Parents impression of childs condition E vents surrounding illness or injury D iet Diapers S ymptoms Associated with the illness or injury

8 PEDIATRICS Key Points Use parents, minimize separation Observe child while obtaining history Perform least intrusive interactions first Different anatomical & physiological characteristics

9 Anatomical & Physiological Differences Larger tongue, narrow nasal passages, & airway Relatively short respiratory tract, fewer alveoli, lack cartilaginous support, prone to airway collapse, immature intercostal muscles increase reliance on diaphragm for breathing Larger, heavier head in relation to body Less effective thermoregulation, greater body surface area to body mass, less subcutaneous fat Faster metabolism, increased need for oxygen Lower glycogen stores, at risk for hypoglycemia when under stress Poorly developed immune system, fewer defenses

10 Developmental Differences Infant: comforted through sensory (holding, singing, sucking) Toddler: offer limited choices minimize separation from caregiver School age: fear abandonment, body changes, being different from peers give honest, concrete answers offer choices (promotes sense of control) Adolescent: modest, want privacy

11 Assessment Mental status Alertness Level of consciousness Most reliable indicator of neuro change Unusual fatigue? Crying – lack of sleep - hunger Ability to relate to caregiver Terminology – lethargic, drowsy What stimulus does it take to elicit what response?

12 Vital Signs WT in kg T, HR, RR for all pediatric patients BP & O2 sat based on illness Typical SBP in children > 2 y/o: 90 + (2X age in yrs) Minimum SBP 1-10y/o: 70 + (2X age in yrs) Can compensate with HR to 25% blood volume loss without drop in BP HR > 160, fast for any age group Count RR X 1 min > 60/min fast at any age

13 HR RR SBP Newborn100-16040-6050-70 1 yr90-12030-4080-100 3 yr80-11025-3080-110 5 yr80-11020-2580-110 10 yr60-10015-2090-120 15 yr70-10015-2080-120 Average Vital Signs by Age

14 Broselow Pediatric Emergency Tape Standardized color-coded, length-based tape to estimate childs weight in an emergency Measure Red to the Head Reference with size-appropriate drug dosing, equipment selection

15 Drug Information Side

16 Equipment & Select Intervention Side

17 PEDIATRICS Respiratory Emergencies Most pediatric arrests occur secondary to respiratory compromise. Mortality rate of pediatric cardiopulmonary arrest is greater than 90%. Sudden onset of respiratory distress? Consider foreign body obstruction

18 PEDIATRICS Respiratory Emergencies

19 Respiratory Emergencies Asthma Affecting an increasing # of American children partly due to environmental factors Chronic inflammatory lung disease Symptom – wheezing Treatment: medication – inhaled β-agonist (Albuterol) steroid therapy fluids

20 Respiratory Emergencies Bronchiolitis Inflammation of bronchial mucosa Viral illness Affects children less than 18 months Can be life-threatening Low-grade fever Cough, wheezing

21 Respiratory Emergencies Respiratory syncytial virus (RSV) Most frequent cause of bronchiolitis Highly infectious – isolate! Seasonal incidence: late fall through early spring Peak incidence is age 2-8 months Treatment: bronchodilators antivirals (Ribavirin)

22 Respiratory Emergencies Croup Viral inflammation of larynx & subglottic area Peak incidence is up to age 3 Highest incidence in fall & winter Cold symptoms prior to onset of characteristic bark

23 Respiratory Emergencies Croup - treatment Treat gently Hydration Cool humidified oxygen Racemic epinephrine Steroids

24 Respiratory Emergencies Epiglottitis Emergent airway condition: Potential for complete airway obstruction Rapid onset of epiglottic inflammation Greatest incidence 2 - 5 years old Three Ds classic presentation: Drooling Dysphagia Distress

25 Respiratory Emergencies Epiglottitis - treatment Do not agitate: Supplemental oxygen in parents lap Position of comfort Prepare for airway management: (know where the equipment is!) Intubation Cricothyroidotomy Tracheostomy

26 Respiratory Emergencies Croup vs. Epiglottitis Epiglottitis: 1 - 6 years old Rapid onset Appears ill Dyspnea, drooling Fever Croup: 6 months to 3 years Insidious onset - preceded by URI Barking cough, stridor

27 Respiratory Emergencies Pertussis (whooping cough) Highly contagious Three phases: 1. Initial – indistinguishable from the common cold (most infectious) 2. Paroxysms of intense coughing lasting several minutes – whoop 3. Chronic cough that can last for weeks

28 Respiratory Emergencies Pertussis - treatment Isolate! RSV & Pertussis Swab: rayon swab, rotate in posterior nasopharynx & repeat in other nostril, transport in 1- 2ml viral transport media Minimize agitation Monitor, maintain airway Hydration Antibiotics

29 Respiratory Pearls of Wisdom Maintain patent airway Minimize respiratory distress Keep with parent in position of comfort Weigh necessity of oxygenation against need to keep child calm; consider blow-by Provide adequate oxygenation Kid-friendly lingo: Oxygen is fresh air The mask is a space mask or santa mask Blow by as a last resort. Consider the power of stickers (in a cup/concentrator at end of O2 tubing) Conserve energy Dont wake a sleeping child

30 Abdominal Emergencies – Pyloric Stenosis Hypertrophy of muscular layers of pylorus Obstruction More in males Age 2-8 wks Nonbilious projectile vomiting ? Visible peristalsis after eating Palpable hard, mobile, nontender olive

31 Abdominal Emergencies Intussusception Telescoping of the bowel Age range 3 months to 1 year Sudden onset colicky pain, currant jelly stool Treatment: barium enema both diagnostic and often therapeutic (un-telescopes bowel) if unsuccessful surgical intervention required

32 Abdominal Emergencies - Volvulus Torsion of the gut, life-threatening. Malrotation most common in neonates May be mistaken for colic Recurrent abdominal pain and vomiting Tenderness, irritability, bloody stools If untreated, may result in infarcted bowel Dx: Ultrasound, xray Tx: IVFs, O2, decompress stomach, Consult Surgeon

33 Abdominal Emergencies Dehydration Common pediatric presentation in the ED Most often due to viral syndrome: Vomiting, diarrhea, decreased urine output Absence of tears, saliva Cap refill > 2 sec Sunken eyes & fontanel Treatment: Monitor glucose Hydration Identification of cause Parental education

34 ORT = Oral Rehydration Therapy For mild to moderate dehydration & able to take oral fluids Calculate how much of an appropriate solution (ie, Pedialyte) to give in small amounts over certain period of time (ie, every 5 min. over 4 hrs) For most, 50-100 ml/Kg corrects fluid deficit

35 Shock Emergencies Volume Dehydration is primary cause of hypovolemia in children When output exceeds input - dehydration occurs The spiral - electrolyte disturbance causes increased nausea & vomiting, causing increased electrolyte disturbances

36 Shock Emergencies Volume – presentation & treatment Sunken eyes, fontanels Cap refill > 2 sec, pallor Dry mucous membranes Lethargy & confusion (ominous sign) Treatment: Adequate ventilation, oxygenation IV bolus 20 mL/kg normal saline

37 Calculating Maintenance IV Fluid Rates: Holliday-Segar Method: 4 ml/kg for 1 st 10kg BW 2 ml/kg for 2 nd 10kg BW + 1 ml/kg for remaining kgs of BW ie. 24 kg child (4 ml X 10kg)+ (2 ml X 10kg) + (1 ml X 4kg) = 64 ml/hr Provider may order variation (ie. 1.5 X maintenance, or 96 ml/hr in above example) D5 1/3 NS or D5 ¼ NS common maintenance fluids (less sodium). Use an IV pump, check site hourly

38 Pediatric IV Pearls of Wisdom Common IV sites: scalp (infants < 9mo old), hands, feet, & antecubital fossa Describe to child as a small straw Use non dominant hand/limb Wrap limb in warm towel to dilate vein Have sufficient help holding Chloraprep not used in children < 2 mos Advance needle slowly, flash delayed Secure extremity with appropriate-sized arm board in functional position Intraosseous access in critically ill (short term)

39 Shock Emergencies Sepsis Life-threatening bacterial infection Decreased perfusion Clinical Triad: Hyper or hypothermia Altered mental status Peripheral vasodilation (warm shock) or vasoconstriction (cool shock)

40 Shock Emergencies Treatment Ventilate and oxygenate Aggressive volume replacement Diagnostics: Cultures: blood, urine, cerebral spinal fluid if suspected meningitis Chest x-ray Intravenous antibiotics

41 Pediatric Shock Pitfalls Hypotension occurs LATE in the pediatric shock syndrome: Blood pressure unreliable indicator for severity of shock Bradycardia ominous sign

42 Fever Accounts for 20% of all pediatric visits to the emergency department Infants < 30 days with fever, get a full septic work up (CBC, Bld Cx, Chem, U/A, CXR, LP) Remember-No ibuprofen to children < 2 years of age. Use oral syringes for PO meds only Common Causes: Otitis media Viral infections Gastroenteritis Bacteremia, sepsis, meningitis

43 Sudden Infant Death Syndrome (SIDS) Definition: The unexpected death of a presumably health baby, generally younger than one year, in which an autopsy fails to identify the cause of death

44 Sudden Infant Death Syndrome History: Previously healthy infant found lying face down in crib pulseless & apneic Interventions: Initiate resuscitative measures Support caregivers: SIDS is neither preventable or predictable Allow caregivers to hold child Almost always a coroners case – explain the rational for this to caregivers

45 Status Epilepticus Prolonged, continuous seizure activity May be d/t anoxia, infection, trauma, ingestion, or metabolic disorder May result in cerebral anoxia Treatment Ensure childs safety Airway maintenance (suction, oral airway if not clenched) Oxygenation (BVM, may need intubation) Stop the seizure (anticonvulsants) Workup possible etiology

46 Trauma Injuries are the leading cause of death in US children 1- 14 y/o MVC, falls, bike accidents, burns, drowning, poisonings, firearms & abuse Child Safety Seats Children < 12yrs in the back seat Birth-1yr (20lbs), infant rear-facing 1-4yr (20-40lbs), forward-facing toddler seat 4-8yr (up to 49 tall), booster seats Children may have severe spinal cord injury without radiographic abnormality, SCIWORA Backboard positioning requires padding under shoulders to prevent neck flexion

47 Injury Prevention Each interaction is an opportunity to educate parent/child re: Home safety Medication safety Helmets Age-appropriate toys Swim lessons The best CPR is a poor second to PREVENTION!

48 Developing Your Skills in Pediatric Emergency Care: Pediatric Advanced Life Support (PALS) Emergency Nursing Pediatric Course (ENPC)- comprehensive 16hr ENA course, covers emergency nursing pediatric assessment, triage, common emergencies, trauma, transport & hands-on skills Pediatric Emergency Assessment, Recognition & Stabilization (PEARS)- 6hr AHA course Certified Pediatric Emergency Nurse (CPEN) credential- through the Board of Certification for Emergency Nursing Join ENA! Receive the journal & newsletter

49 Patient Family Education Follow-up care, use of medications (proper administration), safe storage Proper use of medical supplies, nebulizers, slings etc When to seek further help Prevention Assure and document understanding

50 Case Scenario A two year old is carried into the ED by the parents who give a history of sudden high fever and drooling. Interventions include: A. Establish IV access B. Let child remain in parents lap C. Apply oxygen via non-rebreather mask D. All of the above

51 Case Scenario A two year old is carried into the ED by the parents who give a history of sudden high fever and drooling. Interventions include: A. Establish IV access B. Let child remain in parents lap C. Apply oxygen via non-rebreather mask D. All of the above

52 Case Scenario Signs of hypovolemic shock include which of the following? A. Bradycardia B. Decreased level of consciousness C. Sunken fontanels D. Dry mucous membranes E. All of the above

53 Case Scenario Signs of hypovolemic shock include which of the following? A. Bradycardia B. Decreased level of consciousness C. Sunken fontanels D. Dry mucous membranes E. All of the above


55 References AAP Guidelines for Care of Children in the Emergency Dept.; 124/4/1233.pdf. ENA (2007) Trauma Nursing Core Course (6 th ed). DesPlaines, IL: ENA Foresman-Capuzzi, J (2009) More big help from little tools. JEN 35 (3) 260-262. Sheehy, SB (2003) Sheehys emergency nursing: principles and practice (5 th ed). St Louis: Mosby Vital Signs, Inc. (2007) Broselow Pediatric Emergency Tape. Armstrong Medical Industries, Inc.

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