Pediatric Emergencies

Stages if Development:

• Infancy: First year of life

• Toddler: 1-3 years

• Preschool: 3-6 years

• School age: 6-12 years

• Adolescent: 12-18

Infant:

• First month after birth is neonatal or newborn period.

• 0-2 months

  • An inconsolable infant could be a sign of significant illness

  • Predisposed to hypothermia

• 2-6 months

  • Persistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development

• 6-12 months

  • May cry if separated from parents/caregivers

  • Persistent crying or irritability can be symptom of serious illness

• Assessment

  • Observe from distance

  • Provide sensory comfort; warm hands and end of stethoscope

  • Do painful procedures at end of assessment

Toddler:

• After infancy until 3 years of age

• 12-18 months

  • Lack of molars increase risk of choking

• Assessment:

  • Stronger anxiety, resist separation from caregiver

  • Begin assessment at the feet

  • Persistent crying symptom of serious illness or injury

Preschool-Age Child:

• Age 3-6 years

• Rich imagination and fearful about pain. Foreign body aspiration airway obstruction continues to be a high risk

• Assessment

  • Can understand directions and be specific in description

  • Communicate simply and directly

  • Appeal to their imagination

  • Never lie to patient

  • Begin at feet moving to head

  • Keep child as covered as possible

School-Age Years:

• 6-12 years; beginning to act more like adults

• Assessment

  • Assessment begins to be more like adults

  • Gain trust, talk to child not just caregiver

  • Start with head move to feet

  • Do not bargain or debate with the patient

  • Ask only the type of questions that let you control the answer

  • Allow child to listen to his or her heartbeat through the stethoscope

  • Provide simple explanation for pain and what will be done

Adolescents:

• 13-18; physically similarly to adults

• Assessment

  • Allow them to be involved in their own care by providing choices while lending guidance.

  • EMT of same gender should do physical examination, if possible.

  • Allow them to speak opening and ask questions

  • Risk-taking behaviors are common

  • Female patients may be pregnant, can interview without caregiver present.

Respiratory System:

• Pediatric airway is smaller in diameter and shorted in length, lungs are smaller, heart is higher.

• Glottic opening is higher and positioned more anteriorly, and neck appears to be nonexistent.

• As child develops, neck becomes proportionally longer as vocal cords and epiglottis achieve anatomically correct adult position

• Larger tongue; long, floppy U shaped epiglottis.

• Diameter of trachea in infants is about same as drinking straw

• RR of 20-60 is normal for newborn

• Children have an oxygen demand twice that of an adult, increases risk of hypoxia

• Careful when immobilizing spine, can compromise respiratory

• Gastric distension can interfere with diaphragm movement and lead to hypoventilation

• Breath sounds are more easily heard in children because of their thinner chest walls

Circulatory System:

• Infants heart can be 160 bpm or more

• Children are able to compensate for decreased perfusion by constricting the vessels in the skin

• Signs of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet

Nervous System:

• Head to body ratio is larger

• Occipital region of head is larger

• Subarachnoid space is relatively smaller, leaving less cushioning for brain

• Brain tissue/cerebral vasculature are fragile and prone to bleeding from shearing forces

• Pediatric brain requires higher cerebral blood flow, oxygen, and glucose

  • At risk for secondary brain damage

• Spinal cord injuries less common, but if injured, it is more likely to be an injury to the ligaments because of a fall. Follow local protocols or manual in-line stabilization

Gastrointestinal System:

• Have less protection from trauma, and liver/spleen/kidneys are proportionally larger and situated more anteriorly and close to one another. Prone to bleeding and injury, higher risk of multiple organ injury.

Musculoskeletal System:

• Open growth plates allow bones to grow.

• Bone length discrepancies can occur if injury to growth plate occurs. Immobilize all strains and sprains

• Bones on head are flexible and soft

• Thoracic cage is highly elastic and pliable

Integumentary System:

• Pediatric system differs in a few ways, thinner skin and less subcutaneous fat, composition of skin is thinner and tens to burn more deeply and easily, higher ratio of body surface area to body mass leads to larger fluid and heat loss

Assessment:

• Appearance:

  • LOC, interactiveness, and muscle tone

  • Use AVPU, modified for age

  • TICLS mnemonic helps determine if patient sick or not sick: Tone, Interactiveness, Consolability, Look or gaze, Speech or cry

• Work of Breathing:

  • Increases as body attempts to compensate

  • Can manifest as airway noise, accessory muscle use, retractions, head bobbing, nasal flaring, tachypnea, tripod

• Circulation to the Skin:

  • Pallor of skin and mucous membranes may be seen in compensated shock

  • Mottling is sign of poor perfusion

  • Cyanosis reflects decreased level of oxygen

• Transport Decision:

  • If less than 40lbs, transport in car seat and mount it to a stretcher

Respiratory Emergencies and Management:

• Leading cause of cardiopulmonary arrest in pediatric population are respiratory problems.

• S/S of increased work of breathing:

  • Nasal flaring, abnormal breath sounds, accessory muscle use, tripod position

• As it progresses to respiratory failure:

  • Efforts to breathe decrease, chest rises less with inspiration, body has used up all available energy stores and cannot continue to support extra work of breathing

  • Changes in behavior and eventually, altered level of consciousness. Patient may experience periods of apnea. Heart muscle becomes hypoxic, and heart rate slows

  • Respiratory failure doesn’t always mean airway obstruction

  • Condition can progress from respiratory distress to failure at any time, reassess frequently

  • A child or infant needs supplemental oxygen

  • Assist ventilation with a bag-mask device and 100% oxygen, allow patient to remain in a comfortable position

Airway Obstruction:

• Children can obstruct airway with any object they can fit into their mouth, in cases of trauma teeth may have been dislodged into the airway

• Infections can also cause obstruction; signs of this are congestion, fever, drooling, and cold symptoms

• S/S of partial upper obstruction: Decreased breath sounds and stridor

• S/S of lower airway obstruction: Wheezing and/or crackles

• Clear airway if no sound or unconscious

Asthma:

• Pretty standard. Contact ALS

Pneumonia:

• Presentation:

  • Unusual rapid breathing, sometimes with grunting or wheezing sounds. Nasal flaring, tachypnea, hypothermia or fever, unilateral diminished breath sounds or crackles over the infected lung segments.

• Supportive treatment, monitor airway/breathing, give oxygen if needed, administer bronchodilator if permitted.

Croup:

• Typically between 6 months - 3 years

• Hallmark are stridor and seal-bark cough

• Treatment

  • Croup often responds well to the administration of humidified oxygen, bronchodilators NOT indicated and can make it worse.

Epiglottitis:

• Bacterial infection of the soft tissue in the area above the vocal cords, incidence decreased since development of vaccine.

• Epiglottis can swell 2-3 times normal size.

• Children look ill, very sore throat, high fever, tripod position and drooling.

Bronchiolitis:

• Often caused by RSV.

• Most common in premature infants and results in copious secretion, occurs during first 2 years of life and more common in males.

• Look for dehydration, SOB, and fever

• Treatment

  • Be calm, position of comfort, treat airway/breathing, humidified oxygen helpful, consider ALS.

Pertussis:

• Bacterial, whooping cough. Very contagious

Airway Adjuncts:

• Blow-by technique at 6 L/min provides more than 21% oxygen concentration.

• Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration.

• Nonrebreathing mask at 10 to 15 L/min provides up to 95% oxygen concentration.

• Bag-mask device at 10 to 15 L/min provides nearly 100% oxygen concentration.

Meningitis:

• Infants younger than 2-3 months can have apnea, cyanosis, fever, distinct high-pitched cry, or hypothermia. Increasing irritability and bulging fontanelle without crying.

Gastrointestinal Emergencies and Management:

• Appendicitis is common, lower right quadrant. Rebound tenderness common sign. Can lead to peritonitis or shock if untreated.

Poisoning:

• Usual poison procedure, but ask a lot of questions from caregiver in primary assessment, and alert for abuse signs.

Fever Emergencies and Management:

• 100.4 F (38 C) or higher is abnormal

• Caused by: Infection, status epilepticus, cancer, drug ingestion (aspirin)

• Rectal temperature is most accurate for infants and toddlers, under tongue or arm will work for older children.

• Transport and manage ABCs

Febrile Seizures:

• Common between 6 months and 6 years

• Caused by fever alone, typically occur on first day of febrile illness.

• Characterized by tonic-clonic activity

• Last less than 15 minutes with little or no postictal state

• May be a sign of more serious problem

• Assess ABCs, provide cooling measures with tepid water, and provide prompt transport

Sudden Unexpected Infant Death:

• SUID refers to sudden and unexpected death where the cause is not known until an investigation is conducted.

  • One cause of SUID is SIDS, which results in death that can’t be explained.

• 3,500 infants die of SIDS annually.

SIDS:

• 3 tasks: Assessment of scene, assessment and management of patient, communication and support of the family.

Apparent Life-Threatening Event (ALTE):

• Infants who are not breathing, cyanotic, and unresponsive sometimes resume breathing and color with stimulation.