Presentation on theme: "Pediatric Emergencies"— Presentation transcript:
1 Pediatric Emergencies Emergency Nursing Core CurriculumAcknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN2007Revised 2011 by Lori Barker, MS, RN, CEN
2 ObjectivesFor selected pediatric emergencies the participant will be able to:Compare the etiologyDescribe assessment findingsIdentify the clinical management
3 Pediatric Emergencies Overview Children account for % of all ED visitsOnly 3 – 5 % of those children are acutely ill or injuredChildren cannot be cared for as “small adults”, need specialized equipment & trainingAlthough not ‘small adults’ the systemic assessment of children is the same as adult population.
4 PEDIATRICS The Assessment Triangle General AppearanceWork of BreathingCirculation to the SkinThe 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 TriangleAn “across-the-room” assessment to establish severity of illness or injury and urgency of interventionAppearance (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 sickBreathing- work of breathing. Be alert for nasal flaring, retractions, abnormal airway sounds, position of comfort, rateCirculation- color & temperature of skin. Assess for pallor, mottling, cyanosisIf 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 likelyChildren in shock compensate far better than adults – do not be fooled by “normal” vital signsImportant to obtain child’s weight in kilograms & birth weight if < 8 wks oldIn most cases parents are an invaluable resource to both the nurse and the child.Weigh infant without diapers or clothesThe 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 injuryDietDiapersSymptoms Associated with the illness or injuryChief ComplaintImmunizationsIsolationAllergiesMedicationsPast Medical HistoryParents impression of child’s condition
8 PEDIATRICS Key Points Use parents, minimize separation Observe child while obtaining historyPerform least intrusive interactions firstDifferent anatomical & physiological characteristicsAirway differences:infants obligate nose breathers, narrow nasal passagesgag reflex immaturetrachea relatively short as compared to adults, more apt to tube bronchustube much more prone to dislodgmentChest differences:ribs and sternum much more elasticcan easily observe chest wall for retractions, respiratory effort and use of accessory musclesCirculation:normal faster heart rate, higher cardiac outputcompensate well - can lose up to 20% of total volume without any changes in vital signs
9 Anatomical & Physiological Differences Larger tongue, narrow nasal passages, & airwayRelatively short respiratory tract, fewer alveoli, lack cartilaginous support, prone to airway collapse, immature intercostal muscles increase reliance on diaphragm for breathingLarger, heavier head in relation to bodyLess effective thermoregulation, greater body surface area to body mass, less subcutaneous fatFaster metabolism, increased need for oxygenLower glycogen stores, at risk for hypoglycemia when under stressPoorly developed immune system, fewer defenses
10 Developmental Differences Infant:comforted through sensory (holding, singing, sucking)Toddler:offer limited choicesminimize separation from caregiverSchool age:fear abandonment, body changes, being different from peersgive honest, concrete answersoffer choices (promotes sense of control)Adolescent:modest, want privacy
11 Assessment Mental status Alertness Level of consciousness Most reliable indicator of neuro changeUnusual fatigue? Crying – lack of sleep - hungerAbility to relate to caregiverTerminology – lethargic, drowsyWhat 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 illnessTypical 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 BPHR > 160, fast for any age groupCount RR X 1 min> 60/min fast at any age
13 Average Vital Signs by Age HRRRSBPNewborn40-6050-701 yr90-12030-4080-1003 yr80-11025-305 yr20-2510 yr60-10015-2015 yr70-10080-120
14 Broselow Pediatric Emergency Tape Standardized color-coded, length-based tape to estimate child’s weight in an emergencyMeasure “Red to the Head”Reference with size-appropriate drug dosing, equipment selection
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 obstructionRecognition and intervention are key in preventing deterioration into full cardiac arrest.
18 PEDIATRICS Respiratory Emergencies ReassessCannot overemphasize the importance of reassessment in the pediatric respiratory distress patient:vital signswork of breathingbreath soundslevel of consciousnessdid 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 factorsChronic inflammatory lung diseaseSymptom – wheezingTreatment:medication – inhaled β-agonist (Albuterol)steroid therapyfluidsA recurrent reactive airway diseaseWheezing is the most obvious signbeware of the child who does not wheezing - may signal minimal or no air movementBeware the child that looks fatigued – imminent respiratory collapseTreatment:standard of care: nebulized albuterol every 20 minutes x 3. Reassess.hydration - hyperventilation causes fluid lossEducation - asthma has been called an urban epidemic
20 Respiratory Emergencies Bronchiolitis Inflammation of bronchial mucosaViral illnessAffects children less than 18 monthsCan be life-threateningLow-grade feverCough, wheezingViral infection - respiratory syncytial virus (RSV) most common organismResults in expiratory obstruction and air trapping.Treatment - aerosolized bronchodilators (albuterol)
21 Respiratory Emergencies Respiratory syncytial virus (RSV) Most frequent cause of bronchiolitisHighly infectious – isolate!Seasonal incidence:late fall through early springPeak incidence is age 2-8 monthsTreatment:bronchodilatorsantivirals (Ribavirin)‘All that wheezes in not asthma’ – need to differentiateRSV 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 areaPeak incidence is up to age 3Highest incidence in fall & winterCold symptoms prior to onset of characteristic ‘bark’Inspiratory effort produces stridor.Characteristic – ‘barking seal’ sound.
23 Respiratory Emergencies Croup - treatment Treat gentlyHydrationCool humidified oxygenRacemic epinephrineSteroidsTreat 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 obstructionRapid onset of epiglottic inflammationGreatest incidence years oldThree ‘D’s classic presentation:DroolingDysphagiaDistressOccurs through the yearThe 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 lapPosition of comfortPrepare for airway management: (know where the equipment is!)IntubationCricothyroidotomyTracheostomyEpiglottitis 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 oldRapid onsetAppears illDyspnea, droolingFeverCroup:6 months to 3 yearsInsidious onset -preceded by URIBarking cough, stridorThe 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 contagiousThree phases:Initial – indistinguishable from the common cold (most infectious)Paroxysms of intense coughing lasting several minutes – ‘whoop’Chronic cough that can last for weeksAge – 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 mediaMinimize agitationMonitor, maintain airwayHydrationAntibiotics
29 Respiratory Pearls of Wisdom Maintain patent airwayMinimize respiratory distressKeep with parent in position of comfortWeigh necessity of oxygenation against need to keep child calm; consider blow-byProvide adequate oxygenationKid-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 energyDon’t wake a sleeping child
30 Abdominal Emergencies – Pyloric Stenosis Hypertrophy of muscular layers of pylorusObstructionMore in malesAge 2-8 wksNonbilious projectile vomiting? Visible peristalsis after eatingPalpable hard, mobile, nontender “olive”
31 Abdominal Emergencies Intussusception Telescoping of the bowelAge range 3 months to 1 yearSudden onset colicky pain, currant jelly stoolTreatment:barium enema both diagnostic and often therapeutic (un-telescopes bowel)if unsuccessful surgical intervention requiredTelescoping 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 neonatesMay be mistaken for colicRecurrent abdominal pain and vomitingTenderness, irritability, bloody stoolsIf untreated, may result in infarcted bowelDx: Ultrasound, xrayTx: IVFs, O2, decompress stomach, Consult Surgeon
33 Abdominal Emergencies Dehydration Common pediatric presentation in the EDMost often due to viral syndrome:Vomiting, diarrhea, decreased urine outputAbsence of tears, salivaCap refill > 2 secSunken eyes & fontanelTreatment:Monitor glucoseHydrationIdentification of causeParental educationChildren less than 5 at highest risk.May progress rapidly If both vomiting and diarrhea are present.Causes:Gastroenteritis most common causeDiabetic 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 fluidsCalculate 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 childrenWhen output exceeds input - dehydration occursThe spiral - electrolyte disturbance causes increased nausea & vomiting, causing increased electrolyte disturbancesMedical intervention required to interrupt cycle.
37 Calculating Maintenance IV Fluid Rates: Holliday-Segar Method:4 ml/kg for 1st 10kg BW2 ml/kg for 2nd 10kg BW+ 1 ml/kg for remaining kgs of BWie. 24 kg child(4 ml X 10kg)+ (2 ml X 10kg) + (1 ml X 4kg) = 64 ml/hrProvider 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 fossaDescribe to child as a small “straw”Use non dominant hand/limbWrap limb in warm towel to dilate veinHave sufficient help holdingChloraprep not used in children < 2 mosAdvance needle slowly, flash delayedSecure extremity with appropriate-sized arm board in functional positionIntraosseous access in critically ill (short term)
39 Shock Emergencies Sepsis Life-threatening bacterial infectionDecreased perfusionClinical Triad:Hyper or hypothermiaAltered mental statusPeripheral vasodilation (“warm” shock) or vasoconstriction (“cool” shock)
40 Shock Emergencies Treatment Ventilate and oxygenateAggressive volume replacementDiagnostics:Cultures: blood, urine, cerebral spinal fluid if suspected meningitisChest x-rayIntravenous antibiotics
41 Pediatric Shock Pitfalls Hypotension occurs LATE in the pediatric shock syndrome:Blood pressure unreliable indicator for severity of shockBradycardia ominous signDo not rely on blood pressureSigns & Symptoms:respiratory distresspallor, gray, ashen or mottles skinaltered mental statusdiminished or absent response to painful interventionssunken fontanelsbradycardia
42 FeverAccounts for 20% of all pediatric visits to the emergency departmentInfants < 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 onlyCommon Causes:Otitis mediaViral infectionsGastroenteritisBacteremia, sepsis, meningitisHistory should include:immunization statusfever control prior to arrivalfluid intakeexposure to other illnessesTeaching opportunitytaking a temperaturemeasuring & administering fever medicationsreinforce 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 deathIt 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 & apneicInterventions:Initiate resuscitative measuresSupport caregivers: SIDS is neither preventable or predictableAllow caregivers to hold childAlmost always a coroner’s case – explain the rational for this to caregiversInfant 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 disorderMay result in cerebral anoxiaTreatmentEnsure child’s safetyAirway 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 & abuseChild Safety SeatsChildren < 12yrs in the back seatBirth-1yr (20lbs), infant rear-facing1-4yr (20-40lbs), forward-facing toddler seat4-8yr (up to 4’9” tall), booster seatsChildren may have severe spinal cord injury without radiographic abnormality, SCIWORABackboard positioning requires padding under shoulders to prevent neck flexion
47 The best CPR is a poor second to PREVENTION! Injury PreventionEach interaction is an opportunity to educate parent/child re:Home safetyMedication safetyHelmetsAge-appropriate toysSwim lessonsThe 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 skillsPediatric Emergency Assessment, Recognition & Stabilization (PEARS)- 6hr AHA courseCertified Pediatric Emergency Nurse (CPEN) credential- through the Board of Certification for Emergency NursingJoin ENA! Receive the journal & newsletter
49 Patient Family Education Follow-up care, use of medications (proper administration), safe storageProper use of medical supplies, nebulizers, slings etcWhen to seek further helpPreventionAssure and document understanding
50 Case ScenarioA 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 accessB. Let child remain in parent’s lapC. Apply oxygen via non-rebreather maskD. All of the aboveClick to next slide for answer.
51 Case ScenarioA 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 accessB. Let child remain in parent’s lapC. Apply oxygen via non-rebreather maskD. All of the aboveIn suspected epiglottis the highest priority is maintaining airway patency.
52 Case ScenarioSigns of hypovolemic shock include which of the following?A. BradycardiaB. Decreased level of consciousnessC. Sunken fontanelsD. Dry mucous membranesE. All of the aboveClick to next slide for answer.
53 Case ScenarioSigns of hypovolemic shock include which of the following?A. BradycardiaB. Decreased level of consciousnessC. Sunken fontanelsD. Dry mucous membranesE. All of the aboveRe-emphasize importance of rapid assessment and intervention.Bradycardia is ominous sign.
55 ReferencesAAP Guidelines for Care of Children in the Emergency Dept. 124/4/1233.pdf.ENA (2007) Trauma Nursing Core Course (6th ed). DesPlaines, IL: ENAForesman-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: MosbyVital Signs, Inc. (2007) Broselow Pediatric Emergency Tape. Armstrong Medical Industries, Inc.