Chapter 35: Pediatric Emergencies

The Infant | Growth and Development

0 to 2 Months

• Spend most of their time sleeping or eating

• Unable to tell the difference between strangers and caregivers

• Sucking reflux

2 to 6 Months

• More active

• Increased awareness

• Persistent crying and irritability are signs of illness

6 to 12 Months

• Babbling and walking

• Separation anxiety

Assessment

• Allow the patient to be near parents, give sensory comfort

• Do painful or uncomfortable procedures at the end

The Toddler | Growth and Development

12 to 18 Months

• Begin to walk and explore their environments, and begin to imitate behaviors

18 to 24 Months

• The mind of the toddler develops rapidly

Assessment

• Separation anxiety still persists; demonstrate procedures on a doll

• Trouble localizing pain

• Distract patients

• Painful experiences have lasting impressions

The Preschool-Age Child | Growth and Development

• Rapid increase in language learning

• Rich imaginations

• Learning which behaviors are good and which are bad

• Risk of foreign body obstructions

Assessment

• Describe sensations

• Tell the child what you are going to do

• Easily distracted

• Never lie to not losing trust

• Begin assessment from toes to head

• Modesty is developing

School-Age Years | Growth and Development

• Act more like adults

• Popularity, self-esteem, self-awareness, and understanding death

Assessment

• Talk to the child like an adult, and start from the head to the toes

• Ask questions that you can control

• Understand the difference between emotional and physical pain

• Distract with conversations and reward with toys

Adolescents | Growth and Development

• Participate in decision-making

• Incorporate morals and beliefs

• Depends more on friends than family

• Puberty

• Risk-taking behaviors

Assessment

• Understands complex concepts and treatment options

• Respect modesty, be honest, and allow the adolescent to speak openly

• Risk-taking behaviors from influenced

• Possibility of pregnancy

• Clear understanding of the purpose and meaning of pain—distract them with interests

The Respiratory System | Anatomy and Physiology

• Smaller in diameter and length

• The vocal cords are higher and forward

• The neck appears to be nonexistent

• A larger, rounder occiput

• A larger tongue

• A long, floppy, U-shaped epiglottis at a 45° angle

• Less developed rings of cartilage

• A narrowing funnel-shaped airway

• Infants are nose breathers because of their straw-like airways

• Faster respiration rates decrease as lungs grow and develop

• Muscle fatigue in the diaphragm and intercostal muscles occurs because they aren’t developed

• Pressure on the abdomen blocks the movement of the diaphragm

• Breath sounds are easier to hear

The Circulatory System | Anatomy and Physiology

• Pulse rates decrease as an infant grows older

• Constriction of blood vessels can be so profound

The Nervous System | Anatomy and Physiology

• Immature, underdeveloped, and not well protected

• The occiput is large, so the child is more susceptible to injury and has increased momentum when falling

• Brain hemorrhaging is common

• Requires a greater blood flow, O₂, and glucose

• Spinal cord injuries are less likely

The Gastrointestinal System | Anatomy and Physiology

Abdominal muscle structures are not developed, so children are susceptible to trauma, internal bleeding, and organ damage.

The Musculoskeletal System | Anatomy and Physiology

• Children’s bones are softer and more flexible, making children more susceptible to fractures

• Fontanelles, soft spots, close and become skull bones

• Bulging indicates increased ICP

• Sunken indicates dehydration

• The thoracic cage is small and flexible → the organs are less protected

The Integumentary System | Anatomy and Physiology

Thinner, burns easily, and larger body surface area—significant loss of fluids and heat losses.

Pediatric Assessment Triangle | Primary Assessment

• Allows you to form a rapid general impression of a child in less than 30 seconds

• Appearance, work of breathing, and circulation to the skin

• Use PAT or AVPU for LOC

• TICLS: Tone, Interactiveness, Consolability, Look or gaze, and Speech or cry to assess if the patient is sick

• Increased work of breathing:

  • Grunting/wheezing, accessory muscle use, retractions, head bobbing, nasal flaring, tachypnea, and tripod position

• Mottling is the constriction of peripheral blood vessels

Hands-on XABCs | Primary Assessment

• XABCDE

• Always position the airway in a neutral sniffing position

• Place folded 1-inch-thick towels underneath patients

• Place both hands on the patient’s chest

• In infants, palpate the brachial or femoral pulse

• In children older than 1, palpate the carotid pulse

• Bradycardia is when the respiratory rate is less than 80 beats/min in children and less than 100 beats/min in newborns

• Wong-Baker FACES pain scale in patients 3 or older

• Infants younger than 6 months lack the ability to shiver

• Keep warm

Transport Decision | Primary Assessment

• Children under 40 pounds should be transported in a car seat

  • Place the head of the stretcher in an upright position

  • Children younger than 2 years must be placed in the rear-facing position

• Immobilize patients with spinal injuries on long backboards

• Use the ambulance car seat

Secondary Assessment | Patient Assessment

• BP is not checked on patients younger than 3 years old

• Use pressure cuffs that cover two-thirds of the patient’s arm

• 70 + (2 × Child’s age in years) = Lowest expected systolic BP

• For patients younger than 3 years, look at chest rise and fall for 1 minute

Respiratory Emergencies and Management

• Respiratory problems are the leading cause of cardiopulmonary arrest

• Early stages show anxiety, restlessness, and combativeness

• Efforts to breathe decrease in respiratory failure

• Changes in behavior occur until a patient demonstrates an altered level of consciousness

• Respiratory failure does not always indicate airway obstructions

• BVM and 100% O₂ for patients experiencing respiratory failure

• Allow patients to remain in a comfortable position

Airway Obstruction | Respiratory Emergencies and Management

• Can be caused by foreign objects

• Can be caused by infections

  • Pneumonia, croup, epiglottitis, and bacterial tracheitis

• Stridor in the upper airway and wheezing in the lower airway

• Provide O₂ for mild airway obstructions

• Provide 5 back blows for infants and flip

• Patients older than 1 year use the Heimlich maneuver

• Chest compressions relieve severe airway obstructions

Asthma | Respiratory Emergencies and Management

• The bronchioles are inflamed and swollen

• Expiratory wheezing

• Allow children to assume a position of comfort

• MDI and nebulizer

• Use slow and gentle breaths for ventilation

• Status asthmaticus is a true emergency: O₂, ventilate, and transport

• The patient may become exhausted from breathing

Pneumonia | Respiratory Emergencies and Management

• Leading cause of death for children

• Infection of the lungs

• A secondary infection

• Tachypnea, grunting, or wheezing sounds

• Unilateral sounds or crackling

• Monitor the airway and administer O₂

• Use a bronchodilator if there’s wheezing

Croup | Respiratory Emergencies and Management

• Laryngotracheobronchitis

• 6 months–3 years

• Stridor and seal-bark cough

• Humidified O₂, don’t use bronchodilators

Epiglottis | Respiratory Emergencies and Management

Tripod position and drooling.

Bronchiolitis | Respiratory Emergencies and Management

• Often caused by RSV

• Spread through droplets

• Infants with RSV refuse liquids

• Look for signs of dehydration

Pertussis | Respiratory Emergencies and Management

• Whooping cough

• Keep the airway open and transport

• Spread through the respiratory droplets

Airway Adjuncts | Respiratory Emergencies and Management

Oropharyngeal Airways

• Keeps the tongue from blocking the airway

• Length-based resuscitation tape (Broselow tape)

Nasopharyngeal Airways

Oxygen Delivery Devices | Respiratory Emergencies and Management

• Blow-by technique

• Use NRB, nasal cannula, or a simple face mask for patients with adequate respirations or chest volume

Nasal Cannula

Nonrebreathing Mask

Bag-Mask Device

One-Person Bag-Mask Ventilation on a Pediatric Patient

• 1 breath every 2–3 seconds

Two-Person Back-Mask Ventilation on a Pediatric Patient

Cardiopulmonary Arrest | Respiratory Emergencies and Management

• Children become more hypoxic, and their hearts become more and more bradycardic until no pulse is felt

• Ventilate with O₂ before cardiac arrest occurs

Shock | Circulation Emergencies

• The most common causes of shock in pediatric patients:

  • Traumatic injury with blood loss

  • Dehydration

  • Severe infection

  • Neurologic injury

  • Allergic reaction

  • Diseases of the heart

  • Tension pneumothorax

  • Cardiac tamponade

• In infants:

  • Tachycardia

  • Poor cap refill

  • Mental status changes

• BP is most difficult

• Decrease in urine input

• Absence of tears

• A sunken fontanelle

• Changes in LOC

Anaphylaxis

• Vasodilation and bronchoconstriction

• Administer 0.15 mg of epinephrine

Bleeding Disorders | Circulation Emergencies

• Hemophilia

• Common in the male population

• Decreases blood clotting factor

Altered Mental Status | Neurologic Emergencies and Management

• If a child is not behaving in a developmentally appropriate manner, then this could indicate an altered mental status

• AEIOU-TIPS

• Confusion to coma

• ABCs and transport

Seizures | Neurologic Emergencies and Management

• Subtle in infants

• Obvious in older children

• ABCs

• Recovery position

• Rectal dose of diazepam (Diastat)

Meningitis | Neurologic Emergencies and Management

• Inflammation of the meninges

• Some are at greater risk:

  • Males

  • Newborn infants

  • Children with compromised immune systems

  • Children who have any history of brain, spinal cord, or back surgery

  • Children who have had head trauma

  • Children with shunts, pins, or other foreign bodies within their brain or spinal cord

• Shunts drain fluid from the brain to the abdomen

• Vary depending on age

• Stiff neck in children

• Bulging fontanelle

• Neisseria meningitidis causes a rapid onset of meningitis symptoms

  • Small, pinpoint, cherry-red eyes

Gastrointestinal Emergencies and Management

• Liver and splenic injuries are common

• Ingestion of unknown substances

• Appendicitis

• Susceptible to fluid loss

Poisoning Emergencies and Management | Gastrointestinal Emergencies and Management

• Common among children

• Signs and symptoms depend on the substance, age, and weight of the patient

• Contact the national Poison Control hotline for assistance in identifying poisons

• Perform decontamination and assess ABCs

• Activated charcoal

  • Not indicated for children who have ingested an acid, alkali, or petroleum product

Dehydration Emergencies and Management | Gastrointestinal Emergencies and Management

• Vomiting and diarrhea

• Lips and gums are dry

• Loose skin

• Shunting to compensate

• Normal BP while in shock because of the compensatory phase

• ABCs or IV via ALS backup

Fever Emergencies and Management

• 100.4°F or higher is considered abnormal

• Common causes of fever:

  • Infection

  • Status epilepticus

  • Cancer

  • Drug ingestion

  • Arthritis and systemic lupus erythematosus

  • High environmental temperature

• Rectal temperatures are most accurate for infants

• A thermometer under the tongue or under the arm for older children

• Respiratory distress, shock, stiff neck, rash, hot skin, cheeks, seizure, and bulging fontanelles

• ABCs

Febrile Seizures | Fever Emergencies and Management

• Common in children between 6 months–6 years

• Characterized by generalized (tonic-clonic) seizure activity

• Last less than 15 minutes with a short postictal phase or none

• ABCs and use tepid water

Drowning Emergencies and Management

• The second most common death

• Lack of O₂

• Ice water leads to hypothermia

• Request ALS for these called

• Assess ABCs

Pediatric Trauma Emergencies and Management

• Unintentional injuries are the number one killer

• Flexible bones are more susceptible to trauma

• A fracture in the femur is a major source of blood loss

Physical Differences | Pediatric Trauma Emergencies and Management

• Due to size, traumatic injuries may differ

• Head and neck injuries are common

Psychological Differences | Pediatric Trauma Emergencies and Management

Less mature psychologically and have a lack of judgement and experience.

Injury Patterns | Pediatric Trauma Emergencies and Management

Vehicle Collisions

• Injuries depend on the height of a child

• Bumpers dip before impact

Sports Activities

• Head and neck injuries

Injuries to Specific Body Systems | Pediatric Trauma Emergencies and Management

Head Injuries

• Proportionately larger heads

• Nausea and vomiting after a traumatic injury suggest a serious injury

• Children younger than 8–10 years require padding

Chest Injuries

• Soft, flexible ribs

Abdominal Injuries

• Can compensate for shock better than adults

• Managed in the same way as adults

Burns | Pediatric Trauma Emergencies and Management

• Do not tolerate burns as well as adults do

• Exposure to hot substances or objects

• Infections following burns are common

• Greater than 25% blood loss → shock

• Adults: greater than 30–40% blood loss → shock

Injuries of the Extremities | Pediatric Trauma Emergencies and Management

Bones bend more easily.

Pain Management | Pediatric Trauma Emergencies and Management

• Use the Wong-Baker FACES scale

• Limited to:

  • Positioning

  • Ice packs

  • Extremity elevation

• Provide emotional support

Disaster Management

The JumpSTART triage system.

Signs of Abuse | Child Abuse and Neglect

• CHILD ABUSE mnemonic

Bruises

• Bruises to the back, buttocks, ears, or face are suspicious

Burns

• Penis, testicles, vagina, or buttocks

• Burns that encircle a hand or foot

• Cigarette burns or grid pattern burns

Fractures

• Femur or complete fracture of a bone

Shaken Baby Syndrome

• Bleeding within the head and damage to the cervical spine as a result of being shaken

• Increase in ICP

Neglect

• Failure to provide life necessities to children

• Dirty, thin, or developmentally delayed

Symptoms and Other Indicators of Abuse | Child Abuse and Neglect

• Withdrawn, fearful, or hostile

• Report all cases of suspected abuse

Sexual Abuse | Child Abuse and Neglect

• Sometimes beaten

• Encourage the child not to wash

• Maintain a professional composure

Sudden Unexpected Infant Death and Sudden Infant Death Syndrome

• A case is unknown until an investigation is conducted

• Suffocation, infection, poisoning, cardiac problems, and trauma

• SIDS cannot be explained by another cause

• Risk factors:

  • Mothers younger than 20

  • Mother smoked during pregnancy

  • Mother used alcohol

  • Low birth weight

• Usually discovered in the morning

Patient Assessment and Management | Sudden Unexpected Infant Death and Sudden Infant Death Syndrome

• Overwhelming infection

• Child abuse

• Airway obstruction

• Meningitis

• Accidental or intentional poisoning

• Hypoglycemia

• Congenital metabolic effects

• XABCs

• Begin CPR if there are no signs of postmortem changes

Scene Assessment | Sudden Unexpected Infant Death and Sudden Infant Death Syndrome

• Signs of illness

• The general condition of the house

• Signs of poor hygiene

• Family interaction

• The site where the infant was discovered

Communication and Support of the Family After the Death of a Child | Sudden Unexpected Infant Death and Sudden Infant Death Syndrome

• Provide emotional support

• Begin CPR on an infant if the family demands it

• Ask about the child’s date of birth and medical history

• Use the word dead or died

• Acknowledge feelings

• Offer to call other family members

• Keep instructions short

• Ask each family member individually if they want to hold the child

• Wrap the dead child in a blanket

• Individuals grieve in different ways

Apparent Life-Threatening Event | Sudden Unexpected Infant Death and Sudden Infant Death Syndrome

• Near-miss SIDS

• Infants with cyanosis and apnea when found by parents who resume breathing and color with stimulation

Brief Resolved Unexplained Event

Pediatric cardiac arrest; however, the infant appears normal