peds emergencies

Pediatric Emergencies

NUR 306

Emergency Assessment

  • Ventilation, Oxygenation, and Perfusion: Assess ventilation, oxygenation, and perfusion as the first step.
  • Establish Patent Airway: Ensure the airway is unobstructed and adequate breathing is present.
  • Rapid Cardiopulmonary Assessments: Conduct quick evaluations of the heart and lungs.
  • Initial Assessment Steps:
      - Evaluate safety of the scene.
      - Determine the need for cardiopulmonary resuscitation (CPR).
      - Limit central pulse assessment to less than 10 seconds.
      - Use head-tilt/chin-lift or jaw thrust maneuvers to assess the airway.
      - Monitor chest rise and respiration rates.
      - Assess capillary refill, bleeding and blood loss, peripheral pulses, and blood pressure.
      - Conduct a neurological assessment, including Glasgow Coma Scale (GCS) scoring.

General Nursing Interventions for Emergencies

  • Provide CPR:
      - Be self-aware of personal feelings during the process.
      - Participate in debriefing after life-threatening events.
  • Administer Medications and Fluids:
      - Administer medications based on weight-based dosing.
      - Use normal saline or lactated ringers for volume expansion.
      - Apply the push-pull technique for rapid administration of fluid boluses.
  • Emotional and Psychological Support:
      - Acknowledge that caregivers may experience feelings of sadness, fear, guilt, or anger.
      - Provide current information and communicate openly and honestly.
      - Exhibit empathy and ongoing emotional support.
      - Collaborate with social workers and chaplains as necessary.

Respiratory Emergencies

  • Sequential Impact: Remember the progression: Respiratory distress → respiratory failure → cardiac arrest.
  • Time is Tissue: The importance of prompt action cannot be overstated.
  • Signs and Symptoms: Look for changes in respiratory rate (RR), chest rise and fall, level of consciousness (LOC), cyanosis, etc.

Respiratory Arrest

  • Definition: A cessation of breathing or severe respiratory dysfunction leading to inadequate ventilation and oxygenation.
  • Preceding Condition: Usually occurs after a state of respiratory distress.
  • Consequences: Leads to cardiopulmonary arrest if untreated.
  • Intervention Priority: Quickly determine the cause to pinpoint appropriate interventions.
  • Do Not Leave Patient Unattended: Never leave a patient in respiratory arrest while seeking help.
  • Emergency Equipment: Keep emergency equipment near the bedside.
  • Observed Clinical Manifestations: Possible changes include:
      - Tachypnea, apnea, or bradypnea
      - Shallow chest rise
      - Altered mental status
      - Cyanosis

Causes of Respiratory Arrest

  • Upper Airway Disorders: Conditions include croup, epiglottitis, strangulation, and tracheal stenosis.
  • Lower Airway Disorders: Issues such as asthma, bronchitis, pertussis, pneumothorax, and pneumonia.
  • Neurological Disorders: Include seizures, spinal cord trauma, and sudden infant death syndrome (SIDS).
  • Cardiac Disorders: Conditions like arrhythmias, acquired heart problems, and congenital defects.
  • Traumatic Injuries: May involve burns, foreign body aspiration, child abuse, drowning, electrocution, gunshot wounds, or motor vehicle accidents.
  • Other Causes: Shock, cystic fibrosis, diabetic ketoacidosis, and reflux.

Interventions for Respiratory Arrest

  • Airway Management: Open the airway and assist with breathing to maintain oxygenation.
  • Techniques for Opening Airway: Head tilt/chin lift or jaw thrust as appropriate.
  • Using a Bag-Valve Mask (BVM): Utilize a BVM to deliver breaths until endotracheal intubation or a Laryngeal Mask Airway (LMA) is established.
  • Emergency Equipment at Bedside: Ensure availability of a mask/bag, code sheet, suction device, trach board, or ETT.
  • Parental Involvement: Encourage presence of parents during resuscitation when a code occurs.
  • Mechanical Ventilation: Implement mechanical ventilation to replace spontaneous breathing following intubation.
  • Contact Respiratory Therapist (RT): Engage RT as soon as possible.

Drowning (Submersion Injuries)

  • Definition: Trauma caused by near drowning or survival after asphyxia and respiratory impairment due to submerging in a liquid medium.
  • Asphyxiation Process:
      - Sequence involves submersion, breath holding, panic, swallowing of water, aspiration, and laryngospasm.
      - This leads to hypoxia (oxygen deprivation) and hypercapnia (carbon dioxide retention) resulting in unconsciousness.
  • Categorization: Include drowning, near drowning, and dry drowning.
  • Prevention Focus: Education and supervision are paramount, emphasizing risk factors like lack of swimming ability, inadequate physical barriers to water, and insufficient monitoring.
  • Manifestations to Observe: Tachypnea, labored breathing, wheezing, shortness of breath (SOB), and hypoxemia.

Long-Term Consequences of Drowning

  • Effects of Resuscitation: Even with resuscitation, there may be long-term consequences including brain damage due to prolonged hypoxia, acute respiratory distress syndrome, and lung infections.
  • High-Risk Concerns: Increased likelihood of pulmonary edema and neurologic injury should be monitored closely.
  • Assessment Considerations: Assess for respiratory distress and signs of cerebral edema, changes in LOC, and Cushing's triad.
  • Spinal or Neurogenic Shock Assessment:
      - Symptoms often associated with spinal injury above T5.
      - Observed effects include low systemic vascular resistance (vasodilation), excessive parasympathetic activity causing additional vasodilation, and bradycardia impacting cardiac output.

Treatments for Drownings

  • Immediate Rescue: Rapid rescue from water is crucial.
  • Basic Life Support (BLS): Stabilize cardiopulmonary status through basic life support measures.
  • Oxygenation Focus: Treatments should be aimed at optimizing oxygenation, cardiac output, and controlling body temperature.
  • Oxygen Administration and Monitoring: Administer oxygen while monitoring levels closely.
  • Ventilatory Support: Use non-invasive or invasive ventilatory support to reduce carbon dioxide levels.
  • Temperature Management: Monitor for temperature changes and manage them appropriately.
  • Fluid Resuscitation: Provide fluid resuscitation and inotropic support to restore intravascular volume.
  • Pulmonary Edema Monitoring: Keep a close watch for signs of pulmonary edema.
  • Preventive Education: Encourage preventive measures including establishing physical barriers around pools and providing swimming lessons.

True or False About Submersion Injuries

  • Symptom Onset Timing: Symptoms of submersion injuries can indeed present up to 24 hours post-situation.
      - True: Symptoms such as pulmonary edema and laryngospasm may appear within this timeframe, thus necessitating at least 24 hours of observation following any submersion incident.

Shock

  • Definition: A condition marked by reduced tissue perfusion, leading to diminished oxygen delivery and inadequate removal of metabolic waste products.
  • Consequences: Prolonged oxygen deprivation results in cellular hypoxia and eventual cell death.
  • Shock Types: Classify shock by its cause, including:
      - Hypovolemic
      - Distributive (further categorized into neurogenic, septic, anaphylactic)
      - Obstructive
      - Cardiogenic
  • Stage Classification: Shock can be characterized into compensated (homeostatic mechanisms active), decompensated (presence of hypotension and rapid decline), and irreversible (imminent death likelihood).

Signs and Symptoms of Shock by Stage

  • Compensated Shock: Symptoms include tachycardia, tachypnea, and variations in skin temperature (warm or cool).
  • Decompensated Shock: Signs display as cool skin, decreased peripheral pulses, diminished urinary output, extreme tachycardia, altered neurological status, and hypotension.
  • Irreversible Shock: Manifestations consist of bradycardia, unresponsive hypotension to therapy, and evident end-organ damage.

Compensatory Mechanisms in Shock

Mechanisms to Maintain Cardiovascular Function
  • Heart: Increased heart rate and cardiac contractility.
  • Hypothalamus: Stimulation of thirst.
  • Blood Vessels: Vasoconstriction occurs in skin and non-vital organs.
  • Liver: Constriction of veins and sinusoids, facilitating mobilization of stored blood.
  • Kidneys: Adrenal cortex responds with aldosterone release, promoting sodium and water retention and decreased urine output.

Types of Shock

  • Hypovolemic Shock: Resulting from loss of plasma or blood from intravascular space (causes: fluid loss, dehydration, burns, hemorrhage).
  • Distributive Shock: Involves abnormal blood volume distribution due to vasodilation and altered capillary permeability (causes: sepsis, spinal cord injury, anaphylaxis).
  • Obstructive Shock: Mechanical blockage affecting blood flow to the heart and major vessels (causes: tension pneumothorax, pulmonary embolism).
  • Cardiogenic Shock: Occurs when the heart fails to maintain output and adequate tissue perfusion (causes: cardiomyopathy, myocarditis, congenital heart disease).

Treatments for Shock

  • Hypovolemic Shock:
      - Secure IV access, administer intravenous fluid (IVF) replacement to restore circulating volume.
      - Only bolus isotonic fluids are to be used; inotropes may be indicated if unresponsive to fluids.
  • Distributive Shock:
      - Manage anaphylaxis with fluids, epinephrine, antihistamines, and corticosteroids.
      - Sepsis requires fluids and antibiotics for treatment.
      - For autonomic dysreflexia, address the causative factors (i.e., empty bladder, eliminate impaction, regulate temperature).
  • Obstructive Shock:
      - Treat underlying causes, such as pericardial drainage for cardiac tamponade, chest tube insertion for pneumothorax, or anticoagulant use for embolism.
  • Cardiogenic Shock:
      - Initiate low IV fluid bolus, implement inotropes, utilize vasodilators, and correct any acid-base imbalances.

Poisoning

  • Impact of Ingestion: Outcomes largely depend on the child's age and weight, toxicity of the ingested substance, the response time, and treatment efficacy.
  • Common Manifestations: These vary based on the substance ingested, but may include:
      - Nausea, vomiting, anorexia, pallor, sweating, altered mental status, bradycardia, hypotension, tachypnea, and seizures.
  • Frequently Ingested Substances:
      - Comprise cosmetics, personal care products, analgesics, pesticides, household cleaners, alcohols, and medications.
  • Assessment of Substance Ingestion: Identify what was consumed and the quantity, noting that corrosives can lead to respiratory compromise and opioids may cause respiratory depression.
  • Interventions: Tailor responses based on the specific substance ingested and contact a poison control center for further guidance.

Poisoning/Overdosing Specifics

  • Acetaminophen (Tylenol): Progression from nausea/vomiting to improved symptoms, then severe right upper quadrant pain, confusion, jaundice, and possible mortality or recovery.
  • Aspirin: Acute presentations may include nausea/vomiting, tinnitus, disorientation, oliguria, and lightheadedness leading to seizures. Chronic ingestion presents more subtly but can still result in significant side effects like bleeding tendencies and dehydration that can lead to seizures.
  • Hydrocarbons: Signs may start with gagging/choking, followed by nausea/vomiting, weakness, tachypnea leading to cyanosis, grunting, and retractions.
  • Corrosives: Symptoms include pain and burning in the mouth, edema, whitish mucous membranes, severe vomiting (potentially bloody), and drooling leading to shock.
  • Lead Exposure:
      - Low exposure leads to impulsiveness, hyperactivity, and mild intellectual difficulty.
      - High exposure can trigger serious health issues including cognitive delays, blindness, paralysis, coma, seizures, or even death; can also involve kidney function and anemia complications.

Sudden Infant Death Syndrome (SIDS)

  • Definition: The unexplained death of an infant during sleep, typically one year or younger.
  • Etiology: Unknown; different factors around physical condition and sleep environment may contribute.
  • Modifiable Risk Factors:
      - Include sleep position, surface/environment, infant temperature, second and third-hand smoke exposure, and maternal behaviors.
      - Additional factors: inadequate prenatal care, substance abuse, breastfeeding, lack of immunizations, respiratory infections.
  • Unmodifiable Risk Factors:
      - Include sex (male), age, race (non-white), family history (siblings or cousins), prematurity or low birth weight, maternal age (<20 years), and brain defects.
  • Support for Families: Offer guidance and support to families affected by SIDS.

Prevention of SIDS

  • Guidelines:
      - Encourage the Back-to-Sleep position.
      - Use a firm mattress without any soft bedding or items in the crib.
      - Maintain normothermia (normal body temperature).
      - Advise parents to keep the baby in the same room until at least 6 months old.
      - No Co-sleeping: Advise against co-sleeping to minimize risks.
      - Breastfeeding: Recommended as a preventive measure.
      - Pacifiers: Offer pacifiers during sleep as a possible deterrent for SIDS.
      - Immunizations: Ensure that babies are up to date on their vaccines.

Medications Used in Pediatric Emergencies or Codes

  • Atropine: An anticholinergic agent utilized to elevate heart rate and cardiac output.
  • Dextrose: Administered to increase blood glucose levels.
  • Dobutamine: Used to enhance heart rate and myocardial contractility.
  • Dopamine: Functions to improve cardiac output and elevate blood pressure.
  • Epinephrine: Administered to raise heart rate and systemic vascular resistance.
  • Naloxone: Effective in reversing respiratory depression and hypotension due to narcotic effects.