Pediatric Emergencies Emergency Nursing Core Curriculum 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

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

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 Although not ‘small adults’ the systemic assessment of children is the same as adult population.

PEDIATRICS The Assessment Triangle General Appearance Work of Breathing Circulation to the Skin The pediatric assessment triangle is a “quick look” used to establish severity of illness or injury and urgency of intervention. Evaluation of appearance (the 30-second ‘look test’) is the simplest and most effective assessment tool. There are very few truly sick or injured children that can pass the look test. When children are sick they look sick. If any of the three components of the triangle are abnormal – the urgency level increases. The primary survey differs from the assessment triangle in that it is a rapid, systematic evaluation of all the key systems. .

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

Pediatric Triage Rules Parents know their children better than you - if they say the child is sick - believe them! Start with the ABC’s – 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 child’s weight in kilograms & birth weight if < 8 wks old In most cases parents are an invaluable resource to both the nurse and the child. Weigh infant without diapers or clothes The word parent is used in this presentation to describe any primary caretaker of the child.

CIAMPEDS Pneumonic for pediatric assessment Events surrounding illness or injury Diet Diapers Symptoms Associated with the illness or injury Chief Complaint Immunizations Isolation Allergies Medications Past Medical History Parents impression of child’s condition

PEDIATRICS Key Points Use parents, minimize separation Observe child while obtaining history Perform least intrusive interactions first Different anatomical & physiological characteristics Airway differences: infants obligate nose breathers, narrow nasal passages gag reflex immature trachea relatively short as compared to adults, more apt to tube bronchus tube much more prone to dislodgment Chest differences: ribs and sternum much more elastic can easily observe chest wall for retractions, respiratory effort and use of accessory muscles Circulation: normal faster heart rate, higher cardiac output compensate well - can lose up to 20% of total volume without any changes in vital signs

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

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

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?

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

Average Vital Signs by Age HR RR SBP Newborn 100-160 40-60 50-70 1 yr 90-120 30-40 80-100 3 yr 80-110 25-30 5 yr 20-25 10 yr 60-100 15-20 15 yr 70-100 80-120

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

Drug Information Side

Equipment & Select Intervention Side

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 Recognition and intervention are key in preventing deterioration into full cardiac arrest.

PEDIATRICS Respiratory Emergencies Reassess Cannot overemphasize the importance of reassessment in the pediatric respiratory distress patient: vital signs work of breathing breath sounds level of consciousness did the intervention work? is the patient better, the same or worse?

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 A recurrent reactive airway disease Wheezing is the most obvious sign beware of the child who does not wheezing - may signal minimal or no air movement Beware the child that looks fatigued – imminent respiratory collapse Treatment: standard of care: nebulized albuterol every 20 minutes x 3. Reassess. hydration - hyperventilation causes fluid loss Education - asthma has been called an urban epidemic

Respiratory Emergencies Bronchiolitis Inflammation of bronchial mucosa Viral illness Affects children less than 18 months Can be life-threatening Low-grade fever Cough, wheezing Viral infection - respiratory syncytial virus (RSV) most common organism Results in expiratory obstruction and air trapping. Treatment - aerosolized bronchodilators (albuterol)

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) ‘All that wheezes in not asthma’ – need to differentiate RSV is spread by direct contact with respiratory secretions or contaminated objects. When RSV infects a day-care center, it is not unusual to see 100% of the children become infected with an RSV.

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’ Inspiratory effort produces stridor. Characteristic – ‘barking seal’ sound.

Respiratory Emergencies Croup - treatment Treat gently Hydration Cool humidified oxygen Racemic epinephrine Steroids Treat gently - the stress of crying can increase the effort of breathing, increasing both stridor and retractions. Cool humidified O2 in a manner most comfortable for the child – usually do not tolerate a mask. Racemic epinephrine and steroids are used in severe cases to reduce mucosal edema.

Respiratory Emergencies Epiglottitis Emergent airway condition: Potential for complete airway obstruction Rapid onset of epiglottic inflammation Greatest incidence 2 - 5 years old Three ‘D’s classic presentation: Drooling Dysphagia Distress Occurs through the year The Hib vaccine introduced in 1985 dramatically decreased the incidence of epiglottis. Since then the average age of patients presenting with epiglottitis has increased. “Sniffing position" - nose pointed superiorly to maintain an adequate airway.

Respiratory Emergencies Epiglottitis - treatment Do not agitate: Supplemental oxygen in parent’s lap Position of comfort Prepare for airway management: (know where the equipment is!) Intubation Cricothyroidotomy Tracheostomy Epiglottitis may require emergent airway management: one of the few instances in which the ED physician may need to rapidly perform needle cricothyrotomy. Airway patency is primary goal - not temperature measurement, complete set of vital signs or IV insertion. Most often these patients have a lateral soft tissue of the neck then go directly to the operating room for a controlled intubation.

Respiratory Emergencies Croup vs. 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 The clinical triad of drooling, dysphagia, and distress is the classic presentation. Fever with associated respiratory distress or air hunger occurs in most patients. Drooling occurs in up to 80% of cases. Age of patient, prodrome, type of cough, and degree of toxicity can all contribute to differentiation of epiglottitis from severe croup. Usually, croup occurs in younger children and has a viral prodrome. Most importantly, the child with croup has a barking cough and rarely appears toxic. Bacterial tracheitis can mimic severe croup or epiglottitis. If the cause of epiglottitis is not infectious, the presentation may vary. A child presenting with upper airway respiratory distress without an obvious source or fever should be questioned regarding the possibility of ingestion of a toxic or hot liquid, or a traumatic event such as falling on an object with an open mouth or swallowing or having a foreign body removed.5

Respiratory Emergencies Pertussis (whooping cough) Highly contagious Three phases: Initial – indistinguishable from the common cold (most infectious) Paroxysms of intense coughing lasting several minutes – ‘whoop’ Chronic cough that can last for weeks Age – can affect all age groups. Incidence highest in spring & summer. Vaccination does not provide lifelong immunity. In older infants and toddlers, the cough is followed by a loud whoop and sometimes accompanied by vomiting and red face. Infants younger than 6 months & adults do not have the characteristic whoop.

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

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 Don’t wake a sleeping child

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”

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 Telescoping prevents passage of intestinal contents beyond the defect. Stools contain blood and mucus - results in a characteristic ‘currant jelly’ appearance. In most cases reduction is achieved by performing a barium enema. If unsuccessful - surgical intervention.

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

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 Children less than 5 at highest risk. May progress rapidly If both vomiting and diarrhea are present. Causes: Gastroenteritis most common cause Diabetic ketoacidosis (DKA). Febrile illness. Pharyngitis - decreased oral intake. Discharge education requires explicit instructions: What are clear liquids. What are small amounts. Define ‘frequently’ for small sips. clearly define need to return if worsening symptoms.

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

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 Medical intervention required to interrupt cycle.

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 Treatment: If IV access difficult consider intraosseous route.

Calculating Maintenance IV Fluid Rates: Holliday-Segar Method: 4 ml/kg for 1st 10kg BW 2 ml/kg for 2nd 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

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)

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)

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

Pediatric Shock Pitfalls Hypotension occurs LATE in the pediatric shock syndrome: Blood pressure unreliable indicator for severity of shock Bradycardia ominous sign Do not rely on blood pressure Signs & Symptoms: respiratory distress pallor, gray, ashen or mottles skin altered mental status diminished or absent response to painful interventions sunken fontanels bradycardia

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 History should include: immunization status fever control prior to arrival fluid intake exposure to other illnesses Teaching opportunity taking a temperature measuring & administering fever medications reinforce NO ASPIRIN. encourage fluids

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 It is the leading cause of death in infants between 1 and 12 months of age. Occurs more frequently in the fall and winter months, more males than females. Increased incidence in low birth weight, premature infants

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 coroner’s case – explain the rational for this to caregivers Infant often found lying face down in crib with blood-tinged fluid around the mouth and nose and clenched fists. Very difficult for healthcare providers to process.

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

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 4’9” tall), booster seats Children may have severe spinal cord injury without radiographic abnormality, SCIWORA Backboard positioning requires padding under shoulders to prevent neck flexion

The best CPR is a poor second to PREVENTION! 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!

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

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

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 parent’s lap C. Apply oxygen via non-rebreather mask D. All of the above Click to next slide for answer.

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 parent’s lap C. Apply oxygen via non-rebreather mask D. All of the above In suspected epiglottis the highest priority is maintaining airway patency.

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 Click to next slide for answer.

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 Re-emphasize importance of rapid assessment and intervention. Bradycardia is ominous sign.

QUESTIONS?

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