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Pediatric Emergencies. Jan Bazner-Chandler RN, MSN, CNS, CPNP. Developmental and Biologic Variances. Cricoid is the narrowest portion of the airway: no cuffed ET tubes in children under 8 years of age. ET cuffed. Developmental and Biologic Variances.

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pediatric emergencies

Pediatric Emergencies

Jan Bazner-Chandler RN, MSN, CNS, CPNP

developmental and biologic variances
Developmental and Biologic Variances
  • Cricoid is the narrowest portion of the airway: no cuffed ET tubes in children under 8 years of age

ET cuffed

developmental and biologic variances1
Developmental and Biologic Variances
  • Total blood volume is smaller – small blood loss may led to hypovolemia and impaired profusion
  • Healthy children in shock will maintain blood pressure until more than 25% of blood volume is lost
  • Tachycardiaand delayed capillary refill are early signs of shock
  • Decreased blood pressure is late sign
developmental and biologic differences
Developmental and Biologic Differences
  • Respiratory arrest is more common in pediatric population
  • Respiratory rate below 10 or above 60 are sign that child may be headed for respiratory arrest without interventions
triage
Triage
  • To “pick or sort”.
  • Goals of triage:
    • Rapidly identify seriously injured.
    • Prioritize all patients using the emergency department.
    • Initiate therapeutic measures.
triage classification
Triage Classification
  • Resuscitation
  • Emergent- needs to be seen within 10 minutes
  • Urgent – need to be seen within 30 to 60 minutes
  • Semi-urgent – need to be seen within 1to 2 hours
  • Non-urgent – need to be seen within 2 to 3 hours
assessment
Assessment
  • Across-the-room assessment
  • Chief complaint
  • Brief history (AMPLE Mnemonic)
    • Allergies
    • Medications
    • Past medical history
    • Last meal
    • Events surrounding the incident
focused physical assessment
Focused Physical Assessment
  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure
  • Full vital signs
  • Family presence
  • Give comfort
  • Head-to-toe assessment
  • Inspect
  • Isolate
test and procedures
Test and Procedures
  • CBC with differential: infection and lack of immune response
  • Type and cross match: blood type
  • Serum electrolytes: electrolyte imbalance
  • Radiographs: chest, abdomen, bones
  • Computed tomography – CT scan: detects bleeding or masses
shock
Shock
  • Hypovolemic shock
  • Distributive
  • Cardiogenic
  • Obstructive

Note: cardiogenic and obstructive more common in the adult

shock1
Shock
  • The earlier you can recognize shock, establish priorities, and start therapy, the better the child’s chance for a good outcome.
hypovolemic shock
Hypovolemic Shock
  • Most common cause of shock in children
    • Fluid and electrolyte losses associated with fluid loss
    • Blood loss from trauma
  • Etiology: caused by inadequate volume relative to the vascular space
hypovolemic shock1
Hypovolemic Shock
  • Most common cause of shock in children worldwide
  • Fluid loss due to diarrhea is the leading cause
  • Other causes
    • Hemorrhage
    • Vomiting
    • Inadequate fluid intake
    • Osmotic diuresis (eg diabetic ketoacidosis
    • Third space losses (fluid leak into tissues
      • Burns
      • Sepsis
physiology of hypovolemic shock
Physiology of Hypovolemic Shock
  • Characterized by decreased preload leading to reduced stroke volume and low cardiac output.
  • Compensatory mechanisms are tachycardia, increased contractility, and increased systemic vascular resistance.
hypovolemic shock assessment
Hypovolemic shock: Assessment
  • Cardiovascular
    • Tachycardia
    • Normal blood pressure or hypotension with a narrow pulse pressure
    • Prolonged capillary refill > than or equal to 2 seconds
    • Weak, thready or absent peripheral pulses
  • End-organ function
    • Cool to cold, pale diaphoretic skin
    • Changes in mental status
    • Oliguria
interdisciplinary interventions
Interdisciplinary Interventions
  • IV fluids 20 mL/kg bolus of Crystalloid Solution
    • 0.9% normal saline
    • Ringer’s lactate
  • If signs of inadequate profusion after 2 or 3 boluses administer 10 mL / pg packed red blood cells
  • Control bleeding
distributive shock
Distributive Shock
  • Septic shock
  • Anaphylactic
  • Neurogenic shock (head injury, spinal injury)
septic shock
Septic Shock
  • Most common form of distributive shock.
  • Caused by infectious organisms or their byproducts that stimulates the immune system and trigger release or activation of inflammatory mediators.
  • Uncontrolled activation of the inflammatory mediators can lead to organ failure, particularly cardiovascular and respiratory failure, systemic thrombosis and adrenal dysfunction.
assessment findings
Assessment Findings
  • History or infection
  • History of poor feeding
  • Physical findings
    • Tachycardia: HR > 2 standard deviations above normal for age
    • Fever: > 38.5 or < 36 (neonate may be hypothermic)
    • Tachypnea: RR > 2 standard deviations above normal for age
    • Altered mental status - lethargy
    • Petechiae / or purpura
    • Poor peripheral perfusion (capillary refill less than 2 seconds)
    • Hypotension – late sign
laboratory values
Laboratory Values
  • WBC
    • Greater than 12,000
    • Lower than 4,000 or more than 10% immature neutrophils
  • Platelets in the acute phase may be elevated due to inflammation.
  • Platelets may decrease in the case of DIC
interdisciplinary interventions1
Interdisciplinary Interventions
  • Isolate if indicated
  • IV fluids (crystalloid solution) to restore circulating volume
  • Inotropic agents as needed
    • Norepinephrine – alpha receptor agonist causes peripheral arterial vasoconstriction
    • Dopamine – beta receptor agonist to increase cardiac output
  • Cultures: blood, spinal fluid, urine
  • Broad spectrum antibiotics: MRSA
  • If hypoglycemic – IV glucose
sepsis with ards
Sepsis with ARDS
  • Acute respiratory distress syndrome
    • Mechanical ventilation
    • Aggressive antibiotics to treat bacterial infection
    • Methylprednisone – anti-inflammatory
anaphylactic shock
Anaphylactic Shock
  • Results from a severe reaction to a drug, vaccine, food toxin, plant, venom or other antigen.
  • It is characterized by venodilation, systemic vasodilation, and increased capillary permeability combined with pulmonary vasoconstriction.
  • Vasoconstriction increased right heart work and may add to hypotension by reducing the delivery of blood from the right ventricle to the left ventricle
assessment findings1
Assessment Findings
  • Anxiety or agitation
  • Nausea and vomiting
  • Urticaria (hives)
  • Angioedema (swelling of face, lips and tongue)
  • Respiratory distress with stridor or wheezing
  • Hypotension
  • Tachycardia
  • What is first drug of choice?
poisoning
Poisoning
  • The fifth leading cause of death in children younger than 5 years
  • Overdose in infants are often the result of therapeutic overdosing
  • Children younger than 6 years
    • Cleaning substances, analgesics, topical agents, cough and cold preparations
  • Adolescents drug experimentation and suicide attempts

Questions: Why is OD on Tylenol (acetaminophen) a problem?

poisoning1
Poisoning
  • Over a million children are poisoned annually.
  • Ages of risk are 2 to 4 years and adolescents.
  • Common poisons ingested:
    • Iron, lead, acetaminophen, hydrocarbons, liquid Drano, and plants.
assessment1
Assessment
  • #1 Look at the child
  • May present with no symptoms to coma
focus history
Focus History
  • What was ingested?
  • How much was ingested?
  • When did it occur?
  • What therapy was initiated before arrival in the ED?
aap recommendations
AAP Recommendations
  • AAP – American Academy of Pediatrics
  • Syrup of Ipecac no longer be used routinely in the home to induce vomiting.
  • Research has failed to show benefit for children who were treated with Ipecac.
  • Prevention is the best defense against unintentional poisoning
parent teaching
Parent Teaching
  • Post the universal phone number for poison control center near the telephone
  • 1-800-222-1222
  • Call 911 in the case of convulsions, cessation of breathing or unconsciousness
  • Do not make your child vomit
emergency treatment
Emergency Treatment
  • Always assess the child to determine the care: airway, breathing, LOC
  • History of what substance was swallowed
  • Ask parent to bring in container or sample of substance swallowed
  • Activated charcoal may be given to help absorb substance ingested
lead poisoning
Lead Poisoning
  • There are about 1.7 million children with elevated lead levels.
  • A large proportion are poor, African-American, Mexican-American, and living in urban areas.
  • Children are more susceptible because they absorb and retain lead.
lead poisoning1
Lead Poisoning
  • Lead interferes with normal cell function, and adversely affects the metabolism of vitamin D and calcium.
  • Clinical manifestations depend on degree of toxicity.
  • Neurologic effects include decreased IQ scores, cognitive deficits, impaired hearing, and growth delays.
lead poisoning2
Lead Poisoning
  • Sources of lead:
    • Lead based paint
    • Soil and dust
    • Drinking water from lead lined pipes
    • Food growth in contaminated fields
    • Contamination from occupations or hobbies
lead levels
Lead Levels
  • Blood lead levels between 10 and 19 ug/dL are typically asymptomatic
    • Teaching about hazards of lead
  • Blood levels between 20 to 44 ug/dL may present with increase motor impairment and lethargy (poor school performance)
    • Home assessment
    • Chelation therapy may be indicated
  • Levels greater than 70 ug/dL are considered an emergency
prevention of lead poisoning
Prevention of Lead Poisoning
  • Washing hands and toys
  • Low-fat diet
  • Check home for lead hazards
  • Regularly clean home
  • Take precautions when remodeling or working on old cars, furniture, or pottery.
  • Call 1-800-424-lead for guidelines