Children are not small adults!
Common Pediatric Emergencies
Maureen Novak, MD
Goals and Objectives
Recognize the acuity and implement
appropriate emergency management
Discuss the etiology and natural history of
common pediatric emergencies
Communicate effectively with patients,
families, nursing staff, EMS personnel, ancillary service personnel, referring physicians and consultants.
How are kids different?
Cardiac arrest is usually due to progressive
respiratory failure, shock or both
Once you have cardiac arrest-- Outcome is poor 5-12% survive to discharge In-hospital not much better with 27% survival
Yes! Then you make a difference!
Assess
Overall appearance
Work of breathing
Circulation Categorize Respiratory Circulatory
Assessment
Life threatening
Not life threatening
Dont forget to continually reassess
Decide
What can you do to help? Act Call 911 CPR Obtain code cart Monitor and saturation monitor Oxygen
Treatments
Airway Clear Maintainable simply Head tilt/chin lift (the so-called sniff position) Jaw thrust Oral and nasal airways Unmaintainable Removal of a foreign-body obstruction Endotracheal intubation Percutaneous needle cricothyrotomy
Breathing
Respiratory rate Effort Retractions Use of accessory muscles of respiration Nasal flaring Grunting Air entry/exchange Symmetric chest expansion Breath sounds Paradoxical breathing Stridor Wheezing
Circulation
Color Heart rate Blood pressure Quality/strength of
peripheral and central pulses Skin perfusion Capillary refill time Temperature Mottling
End-organ perfusion CNS Responsiveness
(awake, responds to voice, to pain, unresponsive) Recognize parents Muscle tone Pupillary reflexes Posturing Kidney perfusion
Urine output >1 mL per
kg per hour
Disability and Exposure
REALLY D IS FOR DA BRAIN!!!
Cortex Brainstem
Exposure Hypothermia Significant bleeding Petechiae/purpura consistent with septic shock Abdominal distension consistent with an acute abdomen
Respiratory distress
Asthma
Bronchiolitis
Pneumonia
Croup Foreign Body
Upper airway obstruction
Predominately during inspiration
Increased RR Change in voice
Hoarse Seal like cough
Stridor Poor chest rise
Poor air entry on auscultation
Foreign Bodies
Most common in children younger than 5 yo
Commonly aspirated objects include peanuts, grapes,
coins, small toys, jewelry, balloons and hot dogs
Suspect in any child presenting with the acute
respiratory distress with coughing, gagging and stridor especially when there is no history of prodromal illness
Where is the foreign body?
First child of the day
17mo presents with a one hour history Exam and abnormal of noisy
breathing after a choking episode
VS T36.8, P200(crying),RR
28, Oxygen sat 99% RA He was able to speak and drink fluids without difficulty Alert, with no signs of respiratory distress He was able to speak, had no cyanosis, no drollling, no dyspnea Lungs: mild wheezing with possible mild inspiratory stridor
Management
Remove obstructing object
Suction nose and mouth Reduce airway swelling
Position of comfort
Avoid unnecessary agitation Decision ?advanced airway Trach?
You are IT!
18 mo 2 d history of fever,
T39.1,P170, R28, BP 100/66.
Alert, awake; Prefers an upright or
noisy breathing, a harsh cough, and drooling. Cough was alarming to the parents. Tmax:39.5 degrees Drooling more than usual Her cry was more raspy Not taking solids well, but taking liquids well
a forward leaning position. Skin: warm & moist, no rash. No head or sinus tenderness. TMs normal. OP clear & mmm. No excessive drooling. Neck supple with shotty LN bilaterally. CV: regular without murmurs. Lungs clear when resting. With cry, mild inspiratory stridor, occasional barky cough
What is wrong here?
Croup
Mild
Moderate to severe Impending respiratory failure
Anaphylaxis
Add IM or IV epinepherine
Albuterol if wheezing Diphenhydramine and H2 Blocker Hypotension?
Trendelenberg IV crystalloid
Lower airway obstruction
Asthma
Bronchiolitis
Tachypnea
Expiratory wheezing
Prolonged expiratory Phase
Management: LRT
Bronchiolitis
Suctioning Ancillary testing
Asthma
Assess severity Oxygen Albuterol by MDI Corticosteroids
Management: LRT
Pneumonia
Viral
Assess severity
Oxygen
Ancillary testing
Antibiotics
Atypical
Bacterial
Fluids
Shock
Early recognition
Rapid treatment Categorize Type Severity Treat
Classification: Severity
Compensated
Increased HR Increased SVR
Increased Splanchnic Vascular resistance
Hypotensive (uncompensated)
Late finding usually
Irreversible organ injury or impending cardiac arrest <70mm Hg + (childs age in years x2)mmHg
Children 1-10
Warning signs:
Loss of peripheral pulses Deterioration in mental status Bradycardia and weak to absent central pulses: BAD
(impending arrest)
Classification: Type
Hypovolemic
Distributive
Septic
Anaphylactic
Hypovolemic
Most common
Fluid loss Diarrhea
Tachypnea (quiet)
Tachycardia Weak pulses Cool extremities Mental status
Oliguria
Distributive
Septic
Anaphylactic Neurogenic Head injury Spinal cord injury
Impaired level of consciousness Comfortable tachypnea Tachycardia Hypotension
Bounding pulses
Brisk or delayed cap refill Warm and flushed or pale
Petechial or purpura
Okso whats up here?
7 wk old term infant who presented in mid-November with wheezing, coughing, and two episodes of non-bilious emesis.
She was seen by her pediatrician, who suspected that she had bronchiolitis.
ED that night:
VS T37.2R, P168, R70, BP126/86, oxygen sat 96% RA. The infant was fussy, though consolable, with moderate respiratory distress. The anterior fontanelle:soft and flat. PERRL, mmm. Neck: supple. Lungs: diffuse wheezes and crackles bilaterally with intercostal retractions. Heart: difficult to auscultate due to the noisy breathing,
The abdomen was soft and nontender with active bowel sounds. The liver edge was palpated 3-4 cm below the right costal margin.
CR 3 seconds.
WHAT ARE YOU GOING TO DO??????
Thoughts?
Assess: life threatening or not?
What can you do to help? ABCDE
Airway? Breathing? Circulation?
Disability?
Exposure?
ALL THAT WHEEZES IS NOT BRONCHIOLITIS
http://www.scielo.br/img/revistas/abc/v87n2 http://www.hawaii.edu/medicine/pediatrics/ /en_a22fig01.gif pemxray/v2c06.html
Scared?CHF---scares me!
Tachypnea
May be the earliest sign
A complete history
The entire physical exam
OKAY, It is the last kiddo of the night---there cant be anymore??
9 mo arriving by EMS with a T40.2 and had a generalized seizure
Oops still seizing
T40.2, HR 180, RR 50, O2 sat 98% Now sleepy cries to stimulation, appears to recognize mother but is
increasingly irritable as she awakens HEENT: AF is full not pulsatile, PERRL, mmm, neck ?supple Lungs clear Cardiac: tachycardia, no murmurs Abdomen: soft, no HSM Skin: blanching macular rash on trunk, capillary refill >3s, warm Neuro: irritable, resists exam, but is strong! Will not interact.
Thoughts?
Assess: life threatening or not?
What can you do to help? ABCDE
Airway? Breathing? Circulation?
Disability?
Exposure?
I lied---time for one more
13 mo with vomiting for the Exam
Alert and active, appearing
past 12 hours: clear to yellow tinged fluid more than 10 times.
well T 37, P140, RR 20 Abdomen is soft, and nontender, nondistended. With no masses bulges, or HSM. His testes are descended and palpable bilaterally. Remainder of the exam is normal
So what are you going to do?
American Heart Association PALS
University of Hawaii Great library of radiographs AAP www.pedialink.org
