Children with Pediatric Emergencies

Respt Arrest: greater risk in children because they have smaller airways and
underdeveloped immune systems resulting in diminished ability to combat serious
illness.
- Can choke on foods and small objects leading to cardiopulmonary arrest.
Assessment
- Always ask when the sx began and when do they occur, were they suddenly onset,
how have the sx progressed, what is the characteristic of the cough, is there any
stridor or wheezing, what makes the sx better, is the child taking any meds and is
there family hx of asthma or respt illness, are the immunizations up to date, are
they a preme child, and when did the child lasst eat.
- Observe the child when speaking. While in distress they may speak in short
sentences with gasping between words.
Exam
- Limited to inspection, observation, and auscultation.
- Establish if airway is patent (breathing w/out signs of obstruction),
maintainable(patent independently by the child or w interventions), or unable to
be maintained (not patent unless w an aggressive intervention)
- Children often appear anxious. Note nasal flaring or mouth breathing. Observe
for head bobbing and audible expiratory grunting or inspiratory stridor.
- Look for color: pale, mottled(d/t poor O2, hypothermia, stress), dusky(severe
compromise), cyanotic (late sign; central associated w respt or cardiac
compromise and peripheral associated with circulatory alteration).
- Tachypnea in respt distress. Seriously ill children grunt and can experience
hypoventilation (decrease in depth and RR).
- Periodic breathing: children <2mo old can experience reg breathing w occasional
short pauses. After apneic pause the infant will breathe rapidly for a short period
and then resume normal breathing.
- When auscultating: don’t let the child breathe more rapidly than normal (to
prevent hyperventilation) and to avoid making noises with the mouth.
- Note decreased or absent breath sounds which can be d/t bronchial obstruction
(mucus infection) or air trapping (asthma). Unilateral absent breath sounds
associated w foreign body aspiration and pneumothorax. Minimal or no air
movement requires immediate intervention
- Note any crackles wheezes or rhonchi and presence of pleural friction rub (low
pitched grating sound d/t inflammation of pleura)
- Assess for tactile fremitus and increased vibration is associated with
consolidating conditions like pneumonia.
 - Percussion: air filed lungs reveals resonant sounds. Hyperresonance assoc with
pneumothorax or asthma. Dull sounds over lungs consolidated with fluid
associated with pneumonia.
Labs
- O2 sat <95% = no good.
- ABGs: hypoxemia, hypercarbia, altered pH.
- Chest x ray: normal or lung expansion, pneumonia, tumor, foreign body.
Management
- Maintaining a patent airway, providing supplemental O2, monitoring for changes
in status, and maybe assisting with ventilation.
- For patent airway: decide if the child is safe to stay with the parent or whether
they must be placed on an exam table or bed. Many children are most comfy
sitting upright. Children unconscious may need to be placed supine to facilitate
positioning of airway.
- Infant: benefit from a small towel folded under the shoulders or neck. Dont do
neck flexion or hyperextension which can completely occlude the airway.
- Children >1yr old: hyperextend the neck via head tilt and chin lift. If the child has
neck trauma: use the jaw thrust maneuver by placing three fingers under the
child's lower jaw and lifting the jaw upward and outward.
- Some children who can’t maintain airway independently but can do so w some
assistance. Sometimes opening the airway and moving the tongue can help. Some
require nasopharyngeal or oropharyngeal airways.
Ventilation with Bag-Valve Mask
- Used for children who can’t ventilate by themselves. More efficient than only
using supplemental O2 and used in CPR for higher O2 concentrations.
- Choose a face mask that properly fits the child’s face and provides a seal over the
nose and mouth. Face masks should be clear so you can see the child’s lip color
and observe any emesis during resuscitation.
- When doing CPR: set O2 rate to 10L/min. Adolescent adult sized: set rate
15L/min. Make sure the oxygen is flowing through the tubing to the bag by
checking over the tail for oxygen flow to the bag (contain a plastic tail that allows
the O2 to freely flow and the person needs to manually pump the bag).
- Must seal the mask over the childs face and pump with the other. Left thumb and
index finger to hold the mask. Use upward pressure on the jaw angle while
pressing downward on the mask below the childs mouth to keep the mouth open.
- Rescue breaths should not over inflate the lungs (see proper rise and fall) and be
delivered over 1 second. After the first 2 rescue ventilations, perform the
breathing at a rate of one breath q 3-5 seconds, or about 12-20 breaths per
minute.
- Work with the child’s breathing of spontaneous effort. If they’re breathing out
dont attempt to force air in at the same time
 - Effectiveness: adequacy of chest rise, absence of abdominal distension, improved
HR and pulse ox reading, improved color, cap refill <3 seconds w strengthening
pulses. If they become pulseless: need to start CPR
Assisting with Tracheal Intubation
- Prep equipment and draw up meds. Turn up volume on cardiac monitor so you
can hear the QRS indication of HR and note any bradycardia
- Turn on suction nd make sure it’s working by placing your hand over the tubing
before attaching suction catheter. Continue to ventilate the child.
- Children >2: place a small pillow under head to facilitate opening of the airway.
When intubating, stand by the side to suction and provide BVM and assist w
securing the tube w tape.
- After each attempt: provide several breaths from the BVM
- Administer premeds and sedatives and paralyzing medications (reduces pain and
anxiety, minimizes effect of passing the ET tube down the airway, prevent
hypoxia, decreased ICP, prevents airway trauma and aspiration of stomach
contents)
- Attempts to insert tube should last no >20-30 seconds and after each attempt
need a BVM.
- Equipment: laryngoscope blades (straight blades or Miller should be used for
infants and young children and curved or Macs for older children), ET tubes
(estimated size, a size smaller and a size larger, stylet used to guide tube thru
vocal cords that is removed after), O2, suction, monitors (pulse ox cardiac), NG
tube, PPE, tape
Correct tube placement
- Apply end tidal Co2 monitor and observe for symmetric chest rise and auscultate
over lung fields for equal breath sounds.
- ET tube with water vapor means it’s in the trachea. Auscultate the abdomen for
absent breath sounds and note improvement in pulse ox.
- Once placed mark tube w pen at the level of the child's lip and secure w tip. Doc
the number and obtain a chest x-ray
- Exhaled CO2 should register yellow.
- ET taped securely and make sure to use soft wrist restraints to prevent child from
removing the tube, provide sedative, and use caution when moving child for
procedures.
Monitoring
- Make sure to frequently monitor the child and if they begin to exhibit signs of
deterioration, you need to assess.
- D: displacement. ET tube is displaced from trachea. Remove the tube and begin
BVM
- O:obstruction: ET obstructed with something like a mucous plug. Suction the
tube
 - P:pneumothorax: decreased breath sounds and chest expansion on the side
affected with subq emphysema. Tension pneumothorax=sudden drop in HR and
BP. prepare to assist w needle thoracotomy
- E:equipment failure: disconnected O2 supply or leak in the ventilator circuit.
Make sure all equipment is properly attached.
Shock
- Inability for blood flow and O2 delivery to meet demands of the tissues.
- Compensated shock: poor perfusion exists w out a drop in BP
- Decompensated shock: inadequate perfusion exists w a drop in BP. once child is
hypotensive organ perfusion is impaired.
- Shock= result of dramatic respt or hemodynamic response. In cases of circulatory
compromise and compensated shock, the HR increased but in neonates it may
decrease.
- Compensatory mechanisms are activated in response to decreased blood flow.
Blood is redirected away from less important body systems to vital organs like the
heart and brain.
- During compensated shock; can maintain level of blood flow to the organs via
peripheral vasoconstriction that becomes activated when the body has
diminished blood flow. As shock continues, capillary beds become obstructed w
debris, platelets, WBC causing endothelial damage. This damage then causes
poor blood flow to the capillaries, anerobic metabolism and lactic acid formation.
- With capillaries obstructed and blood flow impaired, tissue ischemia results and
will lead to altered perfusion to vital organs (ex: neuro changes with lack of blood
to the brain, oliguria w lack of blood to kidneys)
Types of Shock
- Hypovolemic shock: as a result of fluid losses like gastroenteritis, heat stroke,
blood loss, vomiting and diarrhea. Most common and occurs when systemic
perfusion decreases as a result of inadequate vascular volume.
- Septic shock: warm shock happens when there’s increased cardiac output with a
low afterload. In children, cold shock is more common when there’s a decrease in
cardiac output with an increase in afterload.
- Cardiogenic shock: ineffective pump of the heart that results in decreased stroke
volume.
- Distributive shock: loss in afterload that results in relative hypovolemia. Vascular
compartment expands d/t vasodilation and results in vasculature requiring more
fluid to maintain cardiac output despite no loss of fluid.
Assessment
- Cluster care when assessing. Determine when child became ill and tx that were
given and for sources of volume loss like vomiting, diarrhea, decreased oral
intake, and blood loss.
 - Ask when the child last urinated and investigate for other sx like lethargy and
AMS. ask about ingestion of meds and determine hx of allergies or congenital
heart defects.
- Key to successful management is early recognition of s/s. Obtain VS and note any
alterations. BP is not a reliable indicator.
- Bradycardia is a serious sign in neonates and can occur w respt compromise,
circulatory compromise, or overwhelming sepsis.
- Determine presence of a central pulse and if not present begin CPR. child in
shock will display respt distress (grunting, gasping, nasal flaring) and auscultate
breath sounds.
- Assess skin color and palapte skin temp to determine quality of pulses. Child will
have darker and cooler extremities with delayed capillary refills. Note line of
demarcation if present (where cool temp begins). (In distributive shock: full and
bounding pulses and warm, erythemic skin. Distal pulses will be weaker than
central pulses)
- Decreased elasticity is associated w hypovolemic states (late sign)
- Compensated shock: awake but obtunded and demonstrate signs of distress.
Decompensated shock: eyes closed and may be responsive only to stim or voices
- Always look for any external or internal injuries that can lead them to bleed.
Labs
- No tests should replace the priority of ABCs (respt support, vascular access, fluid
administration)
- Blood glucose, electrolytes, CBC, blood culture, CRP, ABGs, toxicology panel,
lumbar puncture, urinalysis, urine culture, x-rays.
Managing Child’s ABC
- Evaulate and manage airway and breathing and check for pulses. Initiate CPR if
the child is pulseless.
- All children w s/s of shock: receive 100% O2 via mask. If the child has poor respt
effort/apneic: admin 100% O2 via BVM or ET.
- Institute cardiac and apnea monitoring and assess O2 levels freq
Vascular Access
- Once airway and breathing is assessed: obtain vascular access and restore fluid
volume. Need a lot of isotonic fluid rapidly and access must be obtained using the
quickest route possible in children who have low conditions.
- Need LR or NS. 20mL/kg bolus infusion as rapidly as possible.
- Children in septic shock need larger amts of fluid. Children in shock d/t trauma
will receive a colloid like blood when there’s an inadequate response to isotonic
fluid.
- After each bolus: reassess the child for signs of positive response to fluid admin.
- Insert catheter for measurement of UO
 - Indications of improvement: improved CV status via central and peripheral pulse
stronger, line of demarcation is shorter, and capillary refill and BP improved.
Improved mental status (eyes open watching personnel). Improved UO:
1-2mL/kg/hr
- May need 100-200mL/kg of fluid during initial periods of shock and need
continuous assessment to determine if they’re having fluid volume overload.
- Don’t focus solely on circulatory status: can over look s/s of respt decline.
Meds
- Can help improve CO or increase/decrease afterload. Meds include: dobutamine
to improve cardiac contractility, epi for vasoconstriction, dopamine.
Cardiac Dysrhythmias
- Includes bradycardia (usually d/t vagal nerve stimulation). Infants exp poor
feeding and tachypnea, older children fatigue dizziness syncope.
- Tachycardia: fever, hypoxia and hypovolemia are usual reasons and tx involves
treating the underlying cause. SVT can also be seen in children w meds like
caffeine/theophylline and in children who have Wolff-Parkinson-White
syndrome.
- Asystole: hypoxemia, hypovolemia, hypothermia, electrolyte imbalance,
tamponade, toxic ingestion, tension pneumothorax, thromboembolism.
- Assessment: do this while instituting life saving methods. This includes asking of
cardiac problems, sx like syncope/palpitations/chest pain, activity intolerance,
precipitating factors like illness or meds, participation in sports before the event
occured, family hx of cardiac problems, tx performed at the scene
Physical exam
- Assess airway patency and WOB. assess color for pallor, mottling, duskiness,
cyanosis. Note bobbing, grunting, apnea. Inspect chest for barrel shape.
- Note diaphoresis, anxiety, and neck vein distension. Inspect fingertips for
clubbing.
- Auscultate for crackles and wheezing and the HR for pulse. If no pulse: initiate
CPR. listen for any extra sounds or murmurs (often systolic and can be benign)
and the quality, intensity and sound and location of them.
- Palpate PMI for thrills and note quality of pulses and evaluate each pulse
bilaterally and note their quality. Compare on each side upper and lowe and note
skin temp and cap refills. \
- Obtain ECG
TX
- Provide O2 at 100% and implement cardiac monitoring and assess O2 levels.
Obtain height for ET tube size and med doses. Remember ABC’s (respiratory
first)
- Pay attention to rhythm on the monitor but cont monitor the child’s pulse. If
child doesnt have a pulse or has a pulse <60bpm perform compressions
 - Bradycardia: find the underlying reason. If it persists administer atropine or epi
to increase the HR.
- SVT: uncompensated SVT needs adenosine w/ NS flush or cardioversion.
W/compensated SVT do a vagal maneuver.
- For collapsed rhythms: support ABCs: manage airway, provide O2, and give
fluids.
- Children need compressions for no pulse and do so before and after defib.
Administer meds like epi lidocaine or amiodarone. Defib them once and follow
with 5 cycles of CPR. (pulse v-tach= cardioversion, pulseless vtach and
vfib=defib, asystole meds only)
Submersion Injury
- Survival and neuro outcomes of drowning depends on early and app resuscitation
- Struggling to breathe followed by aspiration of water leading to poor O2, CO2
retention. Drowning depletes alveolar surfactant and pulmonary edema can
occur. Hypoxemia results in increased cap permeability and resultant
hypovolemia.
- Even aspirating small amts of water can lead to pulmonary edema 8 hrs after the
drowning episode. Can also be at risk for renal complications d/t altered renal
perfusion during the hypoxic state.
Assessment
- Obtain hx rapidly while implementing interventions: where did the incident
occur, did someone witness the childs entry, was it warm or cold water, salt or
fresh, is the water contaminated, any extenuating circumstances, what was the
length of time underwater, child conscious when reduced, what was done at the
scene and was there CPR, was an AED used, when did they last eat
- Evaluate airway patency and breathing. Auscultate for pulmonary edema
(hoarseness/crackles). Take VS and note perfusion. Note heart rhythm on the
monitor.
- Use penlight for pupillary reactions and pediatric coma scale for neuro status.
Can they speak/respond to stimuli
- Measure the child’s temp as hypothermia can happen w near drowning.
- Labs: ABGS for hypoxemia, acidosis, cardiac arrhythmias, chest xray for
pulmonary edema/infiltrates, electrolytes.
Management
- need s immediate airway interventions after getting the child from the water.
Interventions always focused on ABCs and most CPR has begun before the child
has entered the ED.
- If a cervical spine injury is suspected: stabilize manually or w cervical collar and
dont remove until it has been ruled out.
 - Suction airway for patency. Child may have aspirated particles from a
contaminated water source or emesis, relatively common comp of drowning.
Large bore suction catheter is needed.
- Administer O2 at 100%. Children w absent or poor respt effort will require
intubation.
- Insert orogastric or NG tube to decompress the stomach and prevent aspiration
of stomach contents. Chest compression for no pulse
- Some degree of hypothermia and need warming. Core body temp should be
raised slowly. Remove any wet clothing, dry the child, cover them with warmed
blankets and warm IV fluids.
Poisoning
- If a normally healthy child suddenly deteriorates without a known cause suspect
toxic ingestion.
- Obtain a rapid assessment: inquire abt time of poisoning and nature of toxin
(ingested, inhaled, applied to skin). What sx did they feel (N/V, abdominal pain,
neuro changes like disorientation, slurred speech, altered gait). Did they call
poision center and has any tx been given.
- In older children assess for r/f suicide.
Exam
- Ingestion of chemicals can cause many s/s. Perform thorough physical exam
noting alterations that can occur w ingestions like hyper/hypotension,
hyper/hypothermia, respt dep or ventilation, miosis (pupillary contraction) or
mydrasis.
- Pay attention to mental status, skin moisture/color, bowel sounds
- Labs include a chemistry panel for hypoglycemia or metabolic acidosis and for
renal function, ECG for arrhythmias, liver function tests, urine and blood
toxicology screens, and specific drug levels if the substance ingested is
known/suspected,
Management
- Give priority to ABCs. treat respt/cardiac alterations. Monitor VS frequently and
provide supportive care.
- Few specific antidotes are available for meds/toxins.
- Activated charcoal can be given to bind w the chemical substance in the bowel
- Whole bowel irrigation with polyethylene glycol electrolyte solutions may be
necessary.
- Dialysis may be required to lower the level of toxin in the blood.
- Intervention is based on the source of the toxin. Ex: charcoal is good for
absorpotion of meds but not effective in an iron OD
- Opioid ot narcotic ingestion: admin naloxone to reverse respt depression or
altered LOC. TX of seizures and thermoregulation.
- Specific tx of the poisoning will be determined when the toxin is identified and
poison control is inquired. Maintaining ongoing assessment of the poisoned child
is necessary bc many toxins exhibit late effects.