SUBJECT: PEDIATRICS 3

TOPIC:PEDIATRIC EMERGENCIES
SEMESTER: 2 (MIDTERM COVERAGE): DR MARRIANE CEREDENO, MD, DPPS
o TRANSCRIBED BY: GOWDA, SHABARESH K.M
o Shabareshk7@gmail.com
o Reference: Dr Ceredeno’s PPT + Nelson Textbook of Pediatrics 21st edition 2020.

the caregiver should have higher suspicion for a

PEDIATRIC EMERGENCIES sudden cardiac event
• Injuries are the leading cause of death.
o Children are particularly vulnerable. Why?
§ Small size
§ Relative physical incoordination
§ Limited ability to predict danger
§ Immature bones and muscles
§ Thin body walls
§ Heads > Total Body Surface Area
• Rapid, effective, bystander CPR for children is
associated with 70% survival rate, with good neurologic
outcomes.
• Most common cause of unintentional injury and death?
o Motor vehicle related injuries
• Second leading cause of death in children <5 y/o?
o Drowning

APPROACH TO THE MERGENCY EVALUATION OF A CHILD

The first response to a pediatric emergency of any cause is a
systematic, rapid general assessment of the scene and the child
to identify immediate threats to the child, providers or others.
Note:
If at any point in these assessments the caregiver identifies a life-
threatening problem, the assessment is halted, and lifesaving
interventions are begun.

GENERAL ASSESSMENT
Survey the scene itself!
Þ Identify imminent danger
o Fire, high voltage, electricity
Þ Can the child be safely moved with appropriate
precautions?
o Cervical spine protection
PRIMARY ASSESSMENT
Þ Rapid visual survey of the child
Hands on assessment of a CP, Neurologic function & stability:
o General appearance and CP function
1. Limited PE
2. Evaluation of Vital signs
SHOULD BE DONE IN A FEW SECONDS
3. Measurement of pulse oximetry
1. General appearance A standardized approach is the best
a. Tone, color, alertness, responsiveness
2. Adequacy of breathing
a. Respiratory distress, apnea
3. Adequacy of circulation
a. Cyanosis, mottling, pallor
(Mnemonic: ABCà Appearance, Breathing, Circulation)

Apnea: “an unexplained episode of cessation of breathing for

20 seconds or longer, or a shorter respiratory pause associated
with bradycardia, cyanosis, pallor, and/or marked hypotonia.”

IF UNRESPONSIVE
1. A child should be approached with a gentle touch and
the verbal question “Are you ok?”
2. If no response, the caregiver should ask for help and
send someone to activate the emergency response
system and locate an automated external defibrillator
(AED)
3. Any child with a HR <60 bpm or without a pulse requires
immediate CPR
4. If the caregiver witnesses the sudden collapse of a child
Read the table: IMPORTANT
1
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, the love of what you are doing.”
à Dr Ceredeno’s PPT à Nelson’s Textbook à Other References à Mnemonics à Important questions for the exam
 SUBJECT: PEDIATRICS 3
TOPIC:PEDIATRIC EMERGENCIES
SEMESTER: 2 (MIDTERM COVERAGE): DR MARRIANE CEREDENO, MD, DPPS
o TRANSCRIBED BY: GOWDA, SHABARESH K.M
o Shabareshk7@gmail.com
o Reference: Dr Ceredeno’s PPT + Nelson Textbook of Pediatrics 21st edition 2020.

ABCDE CIRCULATION
Þ Airway Evaluation of skin, color, temperature, HR, heart rhythm,
Þ Breathing capillary refill time and BP
Þ Circulation
Þ Disability Signs of diminished perfusion & compromised cardiac output:
Þ Exposure Þ Mottling
Þ Delayed capillary refill
GENERALITIES Þ Cyanosis
Þ No RR should be > 60 for sustained period Þ Poor pulses
Þ HR is 2-3x normal RR Þ Cool extremities
Þ BP: Lower limit of systolic BP should be (mm/Hg)
o Neonates >/= 60 Tachycardia is the earliest and most reliable sign of shock
o 1m – 1y/o >/= 70 Þ Non specific
o 1-10 y/o >/= 70 + (2 x age) Þ Corelate with other components
§ Example: o Weakness, threadiness, absence of pulse
• Age of the child = 3 years DISABILITY
• 70 + (2 x 3) A child neurologic function in term of the level of consciousness
• 76 and cortical function
o >10 y/o >/= 90 Þ Pupillary response to light
Þ Alert, verbal, pain, unresponsive (AVPU)
AIRWAY AND BREATHING Þ Pediatric Response Scale
The most common precipitating event for cardiac instability in Þ Glasgow Coma Scale (GCS)
infants and children is respiratory insufficiency
Rapid assessment of respiratory failure and immediate
restoration of adequation ventilation and oxygenation remain
the first priority in the resuscitation of a child
Using a systematic approach , assess if:
Þ Patent airway
o If healthyà open and unobstructed
o Without noise or effort
Þ Maintainable airway
o Already patent
o Or can be made patent with simple maneuver

To determine patency:
1. Breathing movements of the air at the child’s mouth
and nose
2. Breathing movements in child’s chest and abdomen
3. Listen for breath sounds

If obstructed: Findings à
Þ Snoring or stridor (Abnormal breathing sounds)
Þ Increased work of breathing
Þ Apnea

ASSESSMENT OF BREATHING
Þ Respiratory rate
Þ Respiratory effort
Þ Abnormal sounds
Þ Pulse oximetry

Þ Bradypnea and irregular respiratory patients require

urgent attention because they are often signs of
impending respiratory failure and/or apnea

Þ Central cyanosis: Severe hypoxia

o Emergent need for O2 supplementation and
respiratory support

2
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, the love of what you are doing.”
à Dr Ceredeno’s PPT à Nelson’s Textbook à Other References à Mnemonics à Important questions for the exam
 SUBJECT: PEDIATRICS 3
TOPIC:PEDIATRIC EMERGENCIES
SEMESTER: 2 (MIDTERM COVERAGE): DR MARRIANE CEREDENO, MD, DPPS
o TRANSCRIBED BY: GOWDA, SHABARESH K.M
o Shabareshk7@gmail.com
o Reference: Dr Ceredeno’s PPT + Nelson Textbook of Pediatrics 21st edition 2020.

MC CAUSES OF DECREASED LEVEL OF CONSCIOUSNESS TERTIARY ASSESSMENT

Þ RF with hypoxia or hypercarbia Ancillary laboratory procedures and radiographic assessments
Þ Hypoglycemia Þ CBC with PC
Þ Poisonings Þ PT, PTT
Þ Drug overdose Þ ABG
Þ Trauma Þ BUN, creatinine
Þ Seizures
Þ Infection FOREIGN BODY ASPIRATION
Þ Shock

Most often, an ill or injured child has an altered level of

consciousness because of respiratory compromise, circulatory
compromise, or both

NOTE
GCS <8 requires aggressive management including intubation
and mechanical ventilation respectively

EXPOSURE
Dual responsibility of the provider to both expose the child to
assess for previously unidentified injuries and consider prolonged
exposure in a cold environment as a possible cause of
hypothermia and cardiopulmonary instability
Þ Undress the child (If feasible and reasonable)
o Focused PE
o Assess for burns, bruising, bleeding and
fractures

IMPORTANT: Rule of 9’s

SECONDARY ASSESSMENT
Þ Focused history and PE
o SAMPLE History
§ Signs/Symptoms
§ Allergies
§ Medications
§ Pat medical history
§ Last meal
§ Events leading to the situation

3
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, the love of what you are doing.”
à Dr Ceredeno’s PPT à Nelson’s Textbook à Other References à Mnemonics à Important questions for the exam
 SUBJECT: PEDIATRICS 3
TOPIC:PEDIATRIC EMERGENCIES
SEMESTER: 2 (MIDTERM COVERAGE): DR MARRIANE CEREDENO, MD, DPPS
o TRANSCRIBED BY: GOWDA, SHABARESH K.M
o Shabareshk7@gmail.com
o Reference: Dr Ceredeno’s PPT + Nelson Textbook of Pediatrics 21st edition 2020.

INTUBATION
Indications
Þ Unable to maintain airway
Þ Unable to maintain oxygenation
Þ Unable to control CO2 levels
Þ Sedation or paralysis
Þ Anticipation of deterioration that will lead to the first 4
mentioned above

PRE-PROCEDURAL PREPARATION
Þ Suction
Þ Oxygen
Þ Airway
Þ People
Þ Monitor
Þ Medications

RAPID SEQUENCE INTUBATION

Þ Induce anesthesia and paralysis to complete,
intubation quickly

Þ Sellick maneuver à Downward pressure on the cricoid

cartilage to compress the esophagus against the
vertebral column

4
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, the love of what you are doing.”
à Dr Ceredeno’s PPT à Nelson’s Textbook à Other References à Mnemonics à Important questions for the exam
 SUBJECT: PEDIATRICS 3
TOPIC:PEDIATRIC EMERGENCIES
SEMESTER: 2 (MIDTERM COVERAGE): DR MARRIANE CEREDENO, MD, DPPS
o TRANSCRIBED BY: GOWDA, SHABARESH K.M
o Shabareshk7@gmail.com
o Reference: Dr Ceredeno’s PPT + Nelson Textbook of Pediatrics 21st edition 2020.

SHOCK 5. Initial management

Þ Oxygen and nutrient delivery to the tissues is a. O2 support
inadequate to meet metabolic demands b. HR< 60 bpm with poor perfusion is an
Þ Does not begin when BP drops; it merely worsens and indication to begin chest compressions
become more difficult (refractory) to treat once blood
pressure is abnormal 6Hs
Þ Compensated shock à Oxygen delivery is mostly 1. Hypoxia
preserved through compensatory mechanism: Normal 2. Hypovolemia
BP 3. Hydrogen ions (acidosis)
Þ Decompensated shock à Hypotension and organ 4. Hypokalemia/ hyperkalemia
dysfunction 5. Hypoglycemia
Þ Irreversible shock à Organ failure progresses, and 6. Hypothermia
death ensues
5Ts
HYPOVOLEMIC SHOCK 1. Toxins
1. Most common type of shock 2. Tamponade
2. Related to fluid losses from severe diarrhea 3. Tension pneumothorax
4. Thrombosis
DISTRIBUTIVE SHOCK 5. Trauma
Hypovolemia occurs because of third spacing of intravascular
fluids into the extravascular compartment
Eg: Sepsis, anaphylaxis and burn injuries

CARDIOGENIC SHOCK
Profound myocardial dysfunction leading to tissue
hypoperfusion
Eg: Myocarditis, cardiomyopathy

OBSTRUCTIVE SHOCK
Cardiac output is lowered by obstruction impeded the blood
flow in the body
Eg: Tension, pneumothorax, massive pulmonary embolism,
pericardial tamponade

The treatment of shock focuses on the modifiable determinants

of oxygen delivery while reducing the imbalance oxygen supply
and demand

NOTE
1. Oxygen administration by nasal cannula or face mask
2. Aggressive volume resuscitation for hypovolemic or
distributive shock
3. Relief of obstruction
a. Eg: Ductus arteriosus can be reopened by
prostaglandin administration

RECOGNITION OF BRADYARRYTHMIAS & TACHYARRHYTHMIAS

In ALS, arrhythmias are most usefully classified according to the
observed HR (slow/fast) and its effect on perfusion (adequate or
poor)

BRADYARRHYTHMIAS TACHYARRYTHMIAS
1. HR is slower than the normal range for age 1. Rhythm disturbances of atrial and ventricular origin
2. May be an incidental finding 2. In pathologic states such as hypovolemia, anemia,
3. Relative bradycardia occurs when the HR is too slow for pain, anxiety and metabolic stress
child’s activity level or metabolic needs 3. Narrow complex rhythms à doesn’t originate from the
4. Significant if with signs of systemic hypoperfusion sinus node
(pallor, altered mental status, hypotension and 4. Wide complex rhythms
acidosis) a. Eg: Vtach

5
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, the love of what you are doing.”
à Dr Ceredeno’s PPT à Nelson’s Textbook à Other References à Mnemonics à Important questions for the exam
 SUBJECT: PEDIATRICS 3
TOPIC:PEDIATRIC EMERGENCIES
SEMESTER: 2 (MIDTERM COVERAGE): DR MARRIANE CEREDENO, MD, DPPS
o TRANSCRIBED BY: GOWDA, SHABARESH K.M
o Shabareshk7@gmail.com
o Reference: Dr Ceredeno’s PPT + Nelson Textbook of Pediatrics 21st edition 2020.

RECOGNITION & MANAGEMENT OF CARDIAC ARREST

1. When the heart fails as an effective pump and blood
flow ceases
2. Unresponsive and apneic with no palpable pulse
3. Leads to progressive deterioration in heart, brain and
other organ function
4. Most often the result of progressive organ and tissue --------------------------------------------------------------------------------------------------------
ischemia
5. The most important treatment of cardiac arrest is
anticipation and prevention.
6. Intervening when a child manifests RD or early stages of
shock can prevent deterioration to full arrest.

POST RESUSCITATION CARE

1. Close observation in an ICU
2. Good post resuscitation care includes supportive
services for the parents, siblings, family and friends.
3. HYPERTHERMIA must be avoided
4. Hypoxic Ischemic encephalopathy with
a. subsequent development seizures,
b. intellectual impairment and
c. spasticity
is a serious and common complication of cardiac arrest

In cases in which the child is critically ill but stable, the family
should be brought to the bedside as soon as the healthcare
team deems it safe and appropriate.
6
“Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, the love of what you are doing.”
à Dr Ceredeno’s PPT à Nelson’s Textbook à Other References à Mnemonics à Important questions for the exam