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