1. 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

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 % 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.

4. 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. .

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 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.

7. 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

8. 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

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. Average Vital Signs by AgeHR RR
SBP
Newborn
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

14. 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

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

18. 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?

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
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

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
Viral infection - respiratory syncytial virus (RSV) most common organism
Results in expiratory obstruction and air trapping.
Treatment - aerosolized bronchodilators (albuterol)

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)
‘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.

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

23. 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.

24. Respiratory Emergencies Epiglottitis
Emergent airway condition:
Potential for complete airway obstruction
Rapid onset of epiglottic inflammation
Greatest incidence years old
Three ‘D’s classic presentation:
Drooling
Dysphagia
Distress
Occurs through the year
The Hib vaccine introduced in 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.

25. 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.

26. 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

27. 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.

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
Don’t 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
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.

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
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.

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, 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
Medical intervention required to interrupt cycle.

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
Treatment:
If IV access difficult consider intraosseous route.

37. 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

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
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

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
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

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
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

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 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.

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 child’s 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 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

47. 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!

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

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 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.

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
Click to next slide for answer.

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

54. QUESTIONS?

55. References
AAP Guidelines for Care of Children in the Emergency Dept /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)
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.