Pediatric Emergencies

Sudden Infant Death Syndrome (SIDS)

  • Definition: A death occurring in a child under the age of 1 year without any known/identified cause after autopsy.

Safe Sleep Initiatives / Prevention

  • Guidelines:

    • Place infants back to sleep on a firm, empty surface (crib).

    • Maintain a minimalist crib with no pillows, blankets, or stuffed animals.

  • Effectiveness: These measures are effective for infants up to 12 months, which is the period of highest SIDS risk.

Anaphylaxis

  • Definition: An acute, Ig-E mediated response to an allergen that involves multiple organ systems and may be life-threatening.

  • Timing: Usually occurs 5-10 minutes after exposure/ingestion.

Management

  • Initial Actions: Assessment and support of airway, breathing, and circulation (ABCs).

  • Medications:

    • Oxygen (O2)

    • Epinephrine

    • Bronchodilators

    • Fluids

    • Antihistamines

    • Corticosteroids

  • Observation: Monitor for 4-6 hours for biphasic reactions, where symptoms return after initial resolution.

Discharge Planning

  • Key Components:

    • Identify allergens.

    • Teach the proper use of an epinephrine auto-injector (epi-pen).

    • Provide an epi-pen prescription and an allergy action plan for school.

    • Stress the importance of avoiding allergens and recognizing signs and symptoms.

Poisoning

  • Indication: Suspect toxic ingestion if a normally healthy child suddenly deteriorates.

History Assessment

  • Questions to Consider:

    • Time of poisoning?

    • Nature of the toxin?

    • Was it ingested, inhaled, or applied to the skin?

    • If it was a pill, do they have the bottle?

Signs and Symptoms (s/sx)

  • Nausea/vomiting (n/v)

  • Anorexia

  • Abdominal pain

  • Neuro changes, e.g., slurred speech, altered gait, change in level of consciousness (LOC).

  • For older children: inquire about depression or suicidal thoughts.

Physical Exam Findings

  • Vital Signs (VS): Hyper/hypotension, hyper/hypothermia.

  • Respiratory: Depression/hyperventilation.

  • Pupillary Response: Miosis (pupillary constriction) OR mydriasis (pupillary dilation).

Labs & Diagnostics

  • Chemistry panel

  • ECG

  • Liver Function Tests (LFTs)

  • Urine and blood toxicology

  • Specific drug levels if the substance is known or suspected.

Nursing Management

  • ABCs: Ensure airway, breathing, circulation are maintained.

  • Monitoring: Vital signs and obtaining necessary labs.

  • Medications:

    • Administer activated charcoal as ordered.

    • Use Polyethylene glycol solution for bowel irrigation.

    • Dialysis for removal of toxin from blood.

    • Administer naloxone if an opiate/narcotic is suspected.

    • Contact Poison Control!!

Prevention

  • Childproof cabinets containing cleaning products and medications.

  • Avoid referring to medication as candy.

  • Keep medical/cleaning products in original containers.

  • Educate caregivers on contacting poison control and emergency services.

  • High-risk age group: Toddlers and preschoolers.

Burns

  • Leading Cause: Hot liquids are the primary cause of burns in young children.

Prevention

  • Supervision: Essential during kitchen activities.

  • Childproofing: Implement safe kitchen practices.

  • Electrical Safety: Use outlet covers and keep cords out of reach.

  • Fire Safety: Keep matches and lighters out of reach, establish a family fire safety plan, teach “Stop, drop, and roll.”

  • Sun and Cold Exposure: Dress children appropriately and use sunscreen for prolonged sun exposure.

Drowning (Submersion Injury)

  • At-Risk Group: Children ages 1-4 are at greatest risk.

Pathophysiology

  • Aspiration leads to poor oxygenation with retention of CO2.

  • Alveolar surfactant depletion results in pulmonary edema and hypoxemia.

  • Risk of acute kidney injury (AKI) due to hypoxemia.

Detailed History of Incident

  • Where did it happen?

  • How long was the child submerged?

  • Were there witnesses?

  • Was the water cold or hot?

  • What were the extenuating circumstances?

  • Was the child conscious or unconscious when found?

  • Was CPR or Automated External Defibrillator (AED) used?

  • Was there a suspected cervical spine injury?

  • When was the last meal (important for intubation preparation)?

Assessments

  • Arterial Blood Gas (ABG)

  • ECG

  • Chest X-ray (CXR)

  • Serum electrolytes.

Nursing Management

  • ABCs: Ensure airway, breathing, circulation.

  • CPR: Administered on site.

  • Cervical Stabilization: If cervical spine injury is suspected.

  • Interventions:

    • Suction the airway.

    • Administer 100% O2.

    • Likely intubation needed.

    • Place nasal (NG) or orogastric (OG) tube for stomach decompression.

    • Provide chest compressions if pulseless.

    • Treat hypothermia with a blanket and warmed intravenous (IV) fluids; remove wet clothing.

Warming the Hypothermic Patient

  • Afterdrop: Core body temperature may paradoxically decrease upon warming as cold blood from extremities circulates back to the core for up to an hour.

  • Arrhythmias: Rapid warming can cause dangerous heart rhythms, potentially fatal.

  • Metabolic Issues: Extremely cold bodies may not process waste effectively, leading to organ failure.

  • Blood Clots: Rapid warming may dislodge clots, risking strokes or pulmonary embolism (PE).

  • Preferred Method: Gradual warming in a controlled environment, with temperature raised no more than 1-2 degrees Celsius per hour.

Pediatric Drowning Prevention

  • Supervision: Never leave a child alone near water (baths, toilets, buckets, pools, rivers, lakes, the ocean).

  • Pool Fencing: At least 5 feet tall with a self-closing/latching gate, and gate latch at least 55 inches high.

  • Education: Teach water safety rules early and provide age-appropriate swimming lessons, which can begin as early as 6 months for survival programs.

Choking

Signs/Symptoms of Choking

  • Wheezing or noisy breathing.

  • Clutching of the throat.

  • Cyanosis (usually on lips, face, and extremities).

  • Confusion or unexplained loss of consciousness (typically a late and severe sign).

  • Note: Choking can occur quickly and silently!

Prevention

  • Supervision: Always supervise meals and snacks, particularly for young children.

  • Food Risks: Monitor foods that increase choking risk, including grapes, hot dogs, nuts, raw vegetables, hard candy, and popcorn.

  • Safety Practices: Keep toys and small objects out of reach.

Injuries

Developmental Risk Factors for Injuries

  • Infants: Lower injury rates due to limited mobility and supervision, but risks include rolling off surfaces, falling from parents' arms, and choking.

  • Toddlers: Higher risk due to curiosity and impulsiveness, starting to walk and climb, leading to spills/touching hot objects, and falls from furniture.

  • Preschoolers: Highest frequency of injuries due to impulsivity and limited judgment, even with improved coordination; examples include running into the street for a ball and falling from playground equipment.

  • School-aged Children: Improved coordination yet engaging in risk-taking games and sports; injuries include bicycle and playground accidents, sports-related injuries, and pedestrian accidents.

  • Adolescents: High risk due to increasing risk-taking behavior, peer approval seeking; injuries often stem from motor vehicle accidents, sports trauma, and substance use.

Head Injury / Traumatic Brain Injury (TBI)

  • Common Causes: Falls, motor vehicle accidents (MVAs), pedestrian and bicycle accidents, and child abuse.

Physical Examination

  • Assess ABCs and neurological function (LOC, pupil response, seizures, gait, speech).

  • History: Document LOC, previous health status, and nature of the injury.

Labs & Diagnostics

  • X-ray of head and neck.

  • CT/MRI to evaluate brain injury.

  • Test clear liquid from ears or nose for glucose; positive indicates cerebrospinal fluid (CSF) leak.

Recovery Time

  • Variability: Recovery can range from days to months, depending on severity of the TBI.

    • Minor TBI: No LOC, no penetration, acting normally post-injury; monitored at home; must recognize symptoms for follow-up.

    • Severe TBI: Maintain airway and monitor breathing and circulation; assess for LOC and symptoms of increased intracranial pressure (ICP); administer mannitol as ordered; manage pain and sedation; monitor for complications like hemorrhage and infection.

Symptoms Requiring Follow-up

  • Constant headache.

  • Slurred speech.

  • Persistent dizziness.

  • Extreme irritability.

  • Vomiting more than twice.

  • Clumsiness or difficult walking.

  • Oozing blood or watery fluid from nose or ears.

  • Difficulty waking up.

  • Uneven pupils.

  • Unusual paleness.

  • Seizures.

  • Any signs/symptoms of increased ICP.

Prevention of TBI

  • Advise always using seatbelts in cars and using proper child car seats/booster seats.

  • Encourage wearing helmets when biking, skating, etc.

  • Ensure safety gates at stairs.

Concussion

  • Definition: A type of traumatic brain injury caused by a blow, jolt, or shaking, disrupting electrical activity of the brain.

Signs/Symptoms (s/sx)

  • Increased distractibility.

  • Difficulty concentrating.

  • Sleepiness.

  • Headache (HA).

  • Nausea/vomiting (n/v).

  • Confusion.

  • Change in LOC.

Nursing Considerations

  • Emphasize cognitive and physical rest.

  • Gradual return to activity.

  • Monitor for symptom exacerbation.

  • Symptom management as needed.

  • Advise against contact sports/activities with elevated risk of head injuries.

  • For persistent symptoms (>4 weeks), refer to neurology for consultation and possible rehabilitation.

Abuse & Neglect

Types of Child Abuse

  • Neglect, physical abuse, sexual abuse, and psychological/emotional maltreatment.

  • Most Vulnerable Group: Children under 1 year old, constituting a large portion of maltreatment cases with the highest fatality rates.

  • Neglect: The most common form of child maltreatment.

Identification: TEN-4-FACES

  • Areas of highly suspicious bruising:

    • Trunk.

    • Ears.

    • Neck.

    • Any bruising on infants < 4 months is suspicious.

    • Frenulum (inside the mouth).

    • Angle of the jaw.

    • Cheeks.

    • Eye area.

    • Sclera.

Red Flags

  • Bruising in TEN-4-FACES areas.

  • Unusual bruising or marks on the body.

  • Multiple injuries at various healing stages.

Normal Bruising

  • Accidental bruising typically occurs on bony prominences (knees, shins, elbows, foreheads).

Nursing Considerations

  • Documentation of bruising details.

  • Consider CT/MRI and X-ray imaging for further evaluation.

  • Mandatory reporting to child protective services (CPS).

  • Work in conjunction with child abuse pediatricians.

  • Offer support and counseling to affected families.

  • Record observations without making assumptions; document what is visible and what caregivers/children communicate.

Adolescent Safety Concerns

  • Developmental Behavior: Quest for independence and autonomy from parents.

    • Desire for peer approval and acceptance.

    • Risk-taking behavior arises from pre-frontal cortex immaturity versus limbic system reliability, leading to impulsivity and poor risk assessment.

    • Concerns regarding body image and self-esteem.

    • Increase in mental health issues, particularly suicidality—emphasize assessment during hospital stays and educate caregivers about warning signs.

  • Education: Teach adolescents to recognize risks to support peer protection.

Gun Violence

  • Nursing Role: Educate families on safety practices related to firearms, including:

    • Secure storage with gun locks and safes.

    • Store guns unloaded.

    • Keep ammunition stored separately from firearms.

    • Teaching young children gun safety: Stop, Don’t touch, Run away, Tell an adult.

    • Encourage open discussions about firearm safety within families.

    • Law: “Ethan’s Law,” requires proper storage of firearms to prevent access by individuals under the age of 18.