PAEDIATRIC EMERGENCIES

HARI KRISHNA G L
ASST PROFESSOR
Govt. Nursing College,TVPM
 SCOPE OF SESSION
• Introduction and assessment
• Motor vehicle accidents
• Drowning
• Poisoning
• Bites and stings
CASE PRESENTATION

Ms. X, 2 year & 7 months old toddler, hailing in a

metropolitan city. Parents are in abroad & baby is
being taken care of well; pet & pampered by
grandparents. On a sunny afternoon grandfather
went to market; grandmother & child was alone at
home
Suddenly it started raining. Grandma went up the
terrace to take the dried clothes; came back. After
some time she realized that grand daughter is
missing. Searched everywhere. After an hour
found child inside the washing machine ……
DIED due to suffocation (?head injury)
 REACTION OF CHILD’S FAMILY

 Disbelief…. anger ……

 Guilt …..fear…..

 Anxiety……frustration…..

 Depression…
CAN IT BE PREVENTED ???????
CHILDREN ARE

Curious by nature
Mobile
Inadequate depth perception
Explore the environment
Inability to distinguish between good & harmful.
Imitate the behavior of others
CAUTION !!!! GREAT MIND AT WORK
 INTRODUCTION

• Major public health concern

• Outrank all childhood diseases as a cause of death
• Injuries cause widespread mortality & morbidity.
• Levels of prevention
• Four “Es” approach – Education, enforcement,
environmental modification, engineering
 ASSESSMENT
A.Initial Assessment:-

 Pediatric assessment triangle

 Primary survey (ABCDE)
 Secondary survey
• Vital sign
• Focused history
• Physical examination

B.Ongoing Assessment
PEDIATRIC ASSESSMENT TRIANGLE
 Assessment of a sick child
Check for general danger signs; needs urgent attention
• Altered sensorium
• Persistent vomiting
• Feeding difficulty
• Stridor/cyanosis
• Bleeding tendency
• Seizures
• Decreased urine output
• Looks pale
ASSESSMENT AREAS
 Airway
• Look whether airway is clear.
• If there are secretions suction it
• If child is unconscious, head tilt and chin lift
• If not able to maintain airway still, ET
intubation may be needed.
 WORK OF BREATHING
 Reflects adequacy of airway, oxygenation and
ventilation
 Assessment areas:-
• Body position
• Visible movement (chest/abdomen)
• Respiratory rate
• Respiratory effort
• Audible airway sounds
• Normal findings: Quiet, non labored
respiration, equal chest rise and fall,
respiratory rate within normal range.

• Abnormal findings: Nasal flaring,

chest retractions, muffled or hoarse
speech, stridor, grunting, gasping,
wheezing, use of accessory muscle,
abnormal body position
• Sniffing position:

• Tripod position
• Grunting – short, low pitched sound heard at the
end of exhalation that represents an attempt to
generate PEEP by exhaling against a closed glottis

• Gasping – Inhaling & exhaling with quick difficult

sound

• Gurgling – Abnormal respiratory sound associated

with collection of liquid or semisolid material in the
patients airway.
 CIRCULATION

 Reflects the cardiac output and perfusion of vital

organs
 Assessment area – skin color
• Normal findings:- Color appear normal for child’s
ethnic group
• Abnormal findings :- Pallor, mottling, cyanosis
 DISABILITY(MENTAL STATUS)

• A – Alert
• V – Responds to verbal stimuli
• P – Responds to painful stimuli
• U - Unresponsive
 RESPIRATORY PROBLEMS CARDIOVASCULAR PROBLEMS

• Upper airway obstruction

• Shock
• Bronchiolitis
• Arrhythmias
• Acute severe asthma
• Cyanotic spells
• Acute Respiratory Distress
Syndrome
• Empyema
 CNS GASTROINTESTINAL SYSTEM

• Increased ICP
• GI bleeds
• Trauma
• Acute liver failure
• Status epilepticus
• Severe acute pancreatitis
• Head injury
• Diarrhea and dehydration
 OTHERS
• Acute renal failure
• Electrolyte imbalances
• Drowning
• Poisoning
• Stings and bites
• Burns
 TRIAGING PROTOCOL USED IN CMC
PEDIATRIC EMERGENCY SERVICES

PRIORITY I
 Impending cardiac arrest/ gasping
 GCS <8. (only on painful stimuli)
 active seizures
 Respiratory distress with
 RR > 60 < 2 months
> 50 2 months to 1 yr
> 40 > 1 yr
 SpO2 < 94% in RA
 intercostal or subcostal retractions
 Subcutaneous emphysema
 Grunting/ stridor/ audible wheeze
 signs of shock
 tachycardia/ bradycardia
 CRT > 3 secs
 cold peripheries
 Altered mentation- drowsy or irritable
 Urine output
 Systolic BP
< 60 mm of hg - newborn
< 70 mm of hg - infants
< 70 + (age * 2) - > 1 yr
 Severe dehydration
 Sunken eyeballs
 Depressed anterior fontanel
 Dry tongue
 Loss of skin turgor
 Unknown bite/ snake bite/ scorpion sting
 Poisoning
 Any active bleed
 Temp > 102oF in young infant
 Any hemat-oncology patient
 PRIORITY II
 Irritable crying infant
 GCS < 12+ ; ABC not compromised
 h/o convulsions
 Tachypnea
 Abdominal pain
 Asthma
 h/o foreign body ingestion
 AGE with some dehydration- dry tongue and moderately sunken
eyeballs
 Neurological patients
 Non active bleed
 h/o hemoptysis/ hematemesis
 Skin rashes/ infections
 Fever with neck stiffness
 PRIORITY III
Temp < 100oF
Cold and cough symptoms only
AGE with no dehydration
Throat pain
Joint pains
All elective procedures
 Cardiovascular emergencies
• Shock
• Cyanotic spells
• Arrhythmias
1. SHOCK
 Definition
• Shock is a syndrome of cardiovascular
dysfunction characterized by the inability of
the circulatory system to provide adequate
oxygen and nutrients to meet the metabolic
demands of vital organs.
 Stages of compensated shock
• Tachycardia
• Cool extremities
• Prolonged capillary refill
• Weak peripheral pulses
• Bounding pulse
• Normal BP- due to compensatory mechanisms
 Stages of shock
I. COMPENSATORY STAGE

II. PROGRESSSIVE STAGE

III. IRREVERSIBLE STAGE

 HYPOVOLEMIC SHOCK
• GI loss, hemorrhage, diuresis
• Tachypnea
• Tachycardia
• Hypotension
• Variable pulse volume – depending on severity
• Delayed capillary refill
• Oliguria, cold clammy skin and altered mental status
 SEPTIC SHOCK
• Suspected infection manifested by hypo or
hyperthermia
• Signs of decreased perfusion:
 Altered mental status
 Prolonged capillary refill
 Diminished or bounding peripheral pulses
 Mottled cold extremities
 Decreased urine output
 ANAPHYLACTIC SHOCK
• Caused by a severe allergic reaction when a
patient who has already produced antibodies to
an antigen develops a systemic antigen antibody
reaction.
• Antigen- antibody reaction provokes mast cells to
release vasoactive substances- histamine,
bradykinin- vasodilation and capillary permeabilty.
• Rash, urticaria, angioedema, bronchospasm,
nausea, vomiting
 CARDIOGENIC SHOCK
• Heart’s ability to pump blood is impaired and
the supply of oxygen to myocardial tissue is
inadequate.
• Causes can be congenital heart disease,
myocarditis, cardiomyopathy, arrhythmias,
drug toxicity, prolonged shock with poor
myocardial perfusion.
 NEUROGENIC SHOCK
• Due to loss of sympathetic tone – vasodilation
occurs
• Caused by spinal cord injury, spinal anesthesia,
nervous system damage.
• Bradycardia
• Hypotension with bounding pulse
• Dry, warm skin
 Monitoring
• Continuous monitoring pulse
• BP
• CFT
• RR
• Urine output
• ECG
• Neurological status
 ASSESSMENT
• Airway
• Breathing
• Circulation
 MANAGEMENT
• Stabilize the airway and breathing:
• Establish IV access- 2 IV lines preferred
• Correct hypovolemia
• Administer antibiotics in suspected septic
shocks
• Administer inotropes
 How much fluid to be administered?

• Hypovolemic shock:
Fluids and inotropic agents should not be used
• Septic shock:
Here fluid requirement will be quite large, up to
80-200ml/kg in the initial phase. Dopamine is
ideally started after 60ml/kg of crystalloid
Correction of metabolic abnormalities

• Glucose is given in hypoglycemia.

• Calcium given in documented hypocalcemia
either as calcium gluconate or calcium
chloride
• Inotropic agents
• Steroids
• Antibiotics
 2. Cyanotic spells
• Cyanotic spell occurs in TOF and TOF like
situations.
• It is characterised by progressive cyanosis,
extreme irritability and rapid and deep breathing.
• The baby will be hypoxic, hypoxemic and acidotic.
• ABG- PO2 low, SAo2 low, pH low, PCO2 low
• Usual age group is between 3 and 9 months
 Initial identify
Resuscitation
a. Oxygen by mask(100% O2)
b. Knee chest position
c. IM or slow IV (over 10 mts) of morphine
0.05mg/kg immediately on arrival
Establish an IV line
a. Infuse NS bolus, 20ml/kg/in one hour and
maintain dextrose saline infusion
• Give IV morphine 0.05 mg/kg once more
• IV sodium bicarbonate 1ml/kg immediately
and 8 hourly
• Vasodilators
• Plan emergency BT shunt
• Abdominal aortic compression could be
helpful
• Ketamine is an alternative to morphine
 Post spell situation
• Oral Propranolol to prevent recurrence with
iron supplement.
 3. Arrhythmias
• Childhood arrhythmias can be
a. Tachy arrhythmia – SVT, AFL, AF
b. Brady arrhythmia- CHB, sinus node dysfunction,
sino atrial block

SVT: It is the most common symptomatic

arrhythmia of childhood at any age. It is a
narrow QRS tachycardia with a rate of more
than 220/mt with an absent P wave.
• The drug of choice is IV Adenosine –bolus dose.
Each bolus has to be given as rapid IV push through
a large, proximal vein, flushed immediately with
saline, at intervals of 2- 4 mts.
• Note:
- Use largest available vein
- Do not aspirate blood into syringe before push
- Keep IV atropine and Aminophylline ready
- Defibrillator should be available
 Ventricular Tachycardia
• It is a wide QRS, regular tachycardia with a
rate lower than SVT.
• IV Lidocaine 1mg/kg bolus followed by
infusion at rate of 20-50 mcgm/kg/mt, can be
given.
• Amiodarone IV can also be given
• In pulseless VT, the most important treatment
is immediate defibrillation.
MOTOR VEHICLE ACCIDENTS
• Most common cause of death from trauma among children 5 –
9 years of age.
• Type of impact:-
 Head on(frontal)
 Rotational
 Lateral
 Roll over
 Rear end
 Mechanism

Vehicle strikes an object

The occupant collide with the
interior of the vehicle
Internal organs collide with other
organs like muscle, bone, supporting
structure inside the body
If loose objects in the vehicle
become projectile - severe
 IMPACT OF MVC

Initial impact:-
• Child is small, initial impact on child higher on the
body than adults; Bumper strikes on child’s pelvis/
legs; predictable injuries to chest, abdomen, pelvis,
femur
Second impact:-
• Front of vehicle’s hood continues forward and
strike child’s thorax; child thrown backward forcing
head and neck to flex forward; Coup counter coup
injuries
• Third impact:-
Child is thrown to ground; fall under vehicle and can
be trapped and dragged for some distance; fall to side
of vehicle; child’s lower limbs run over by front
wheel
 ASSESSMENT & MANAGEMENT

• Airway & cervical spine protection

Assess spinal injury, altered mental
status, back pain, numbness,
tingling sensation.
Cervical-spinal stabilization (?injury)
Don’t apply traction to neck (exacerbate injury)
Perform tracheal intubation if needed
 Breathing:-
• Expose child’s chest & abdomen
• Look at rate & depth of respiration
• Breathing adequate provide supplemental
oxygen
• Clear airway of blood, vomitus; foreign material.
• If open pneumothorax - cover wound with sterile
occlusive dressing.
 CIRCULATION:-

• Assess child for signs of internal hemorrhage

(shock)
• Control major bleeding – apply pressure;
elevate extremity; Quality of pulse (thready,
bounding, weak)
• If pulse is absent – chest compression
• If signs of shock – IV access; fluid resuscitation
with 20ml/kg of isotonic crystalloid solution
(NS/RL)
• DISABILITY:-
GCS – assessment of neurologic status
• EXPOSE/ENVIRONMENT:-
Privacy, consent, maintain body temperature
• TRANSPORT:-
 Cervical collar
 Contraindications:-
 Penetrating foreign body to neck with hemorrhage
 Presence of tracheal stoma that is vital
 Inspect & palpate each of the major areas for
DCAP – BLS – TIC

D – Deformities
C – Contusions
A – Abrasions
P – Penetrations
B – Burns
L - Lacerations
S – Swelling/edema
T – Tenderness
I – Instability
C - Crepitus
DROWNING, SUBMERSION & INJURY
• Drowning :- Death from suffocation in a liquid.
• Near drowning :- Survival at least 24hrs after an
episode of submersion.
• Secondary drowning :- Death occurs longer than
24hrs after submersion secondary to respiratory
decompression.
• Immersion syndrome:- Death following submersion
in extremely cool water
PATHOPHYSIOLOGY
CLINICAL FINDINGS SEVERITY MORTALITY

1. Normal lung auscultation with coughing 1 0

2. Abnormal lung auscultation with crackles 2 0.6

3. Abnormal lung auscultation without 3 5.2

crackles in all areas with out AHTN

4. Stage 3 + with AHTN 4 19.4

5. Isolated respiratory arrest 5 44

6. Isolated cardiopulmonary arrest 6 93

 MANAGEMENT

• Assess & Maintain airway – cervical spine

• Support cardio respiratory function
• Administer IV fluids
• Observe for neurologic status
• Prevention of hypothermia
• Active rewarming measures – gastric lavage,
peritoneal lavage, warm IV fluids
• NG tube – gastric decompression
• Continuous bladder drainage
TOXICOLOGICAL EMERGENCIES (POISONING)

• Poison is a substance that on ingestion, inhalation,

absorption, application, injection or development
with in the body in relatively small amounts may
cause structural or functional disturbance.
• Most common – ingestion; Carbon monoxide is the
most common inhaled poison.
• Poisoning – intentional, unintentional
 Forms of poisons

• Solid poison:- Medicines, plants, powders

• Liquid poison:-Lotions, furniture, polish, syrup
• Spray form:- Pesticides, spray paints
• Gas/vapor:- CO from exhaust fumes, furnaces

 POISONING AGENTS:-
• Kerosene oil; Barbiturates; Organophosphate
compounds; Corrosives
• 90% exposure occurs at home
 TOXIDROME
1.ORGANOPHOSPHEROUS POISIONING

• May be acute or chronic

• Chronic exposure may be dietary
• Cholinergic
• Children are at risk
 SIGNS & SYMPTOMS

• S – Salivation •D – Diarrhea
• L – Lacrimation •U – Urination
•M – Miosis
• U – Urination
•B – Bronchospasm
• D – Defecation •L – Lacrimation
• G - GI distress •E – Emesis
• E – Emesis •S - Salivation
 FIRST AID
- Terminate exposure
– Empty mouth of poison/agent
– Remove contaminated clothes
– Flush eyes continuously with NS or tap water at
home for 15 to 20 mins.
– Flush skin and wash with soap and a soft cloth
– Bring victim into fresh air
– Give a sip of water to dilute ingested poison
– Identify the poison.
 MANAGEMENT
• Assess the victim- ABC, need for CPR
• Watch out for seizures
• Reduction of dermal contact and gastric emptying
• Activated charcoal- 1-2g/kg
• ANTIDOTE:- Atropine sulphate- 0.03-0.04mg/kg
IV, repeated after 15 minutes and then every hour
until atropinization (maximum 1mg/kg in 24 hr)
 2. KEROSENE POISONING
Clinical Manifestations:-
 Restlessness
 Fever
 Abdominal distension
 Convulsions and coma
 Symptomatic treatment
 Gastric lavage is contraindicated; Chemical
pneumonitis
 3. LEAD POISONING

• Lead is present in lead based paints, food cans,

dyes, toys, pottery, ceramic ware, cosmetics and
even in water.
• 15-18 million children in developing countries
have permanent brain damage due to lead
poisoning [WHO]
• A child absorbs approx 50% of exposed lead
whereas an adult absorbs only 10%. [Children’s
bodies are much more receptive to lead.]
 PATHOPHYSIOLOGY

Increased lead
absorption

Neurologic
Hematologic Renal system system
system

Damages cells of
proximal tubules Increases
Interferes with
membrane
synthesis of heme
permeability;
increased ICP, tissue
GLYCOSURIA,
ischemia, and
PROTEINURIA,
ANEMIA atrophy
KETONURIA
 CLINICAL MANIFESTATIONS
• Behavioral effects
Neurocognitive effects:-
• Aggression •Developmental delays
• Hyperactivity •Lowered IQ scores
• Impulsiveness •Speech problems
• Delinquency •Reading skill deficits
• Disinterest •Visual-spatial problems
•Visual motor problems
• Withdrawal
•Learning disabilities
•Lower academic success
 DIAGNOSTIC EVALUATION

A finger stick blood specimen screening test

Blood lead level (BLL) test

Acceptable serum value- <10mcg/dl.

Erythrocyte proto porphyrin (EP) test

 MANAGEMENT

• A BLL greater than 20mcg/dl requires management.

• Environmental investigation.
• Maintain adequate hydration
• Periodic monitoring of LFT and KFT
• CHELATING AGENTS:-
• British ant lewisite (BAL) or dimercapol
• Calcium di sodium edetate (EDTA)
• Succimer or DMSA
• Health education
Harmful effects
Sources
Importance of wet cleaning
Good nutrition
Follow up
BITES & STINGS
 SNAKE BITE
• More people in India die of snake bite than the rest
of the world put together.(50,000/year!)
• Common poisonous snakes are- cobra, vipers, sea
snake, krait
• Hematotoxic
• Neurotoxic
• Myotoxic
 CLINICAL MANIFESTATION
Local tissue destruction
Soft pitting edema that generally develops over 6-
12 hours but may start within 5 minutes
Bullae
Streaking
Erythema or discoloration
Contusions
• Systemic toxicity
 Hypotension
 Petechiae, epistaxis, hemoptysis
 Paresthesias - Forewarn neuromuscular blockade
and respiratory distress (more common with coral
snakes)
 INVESTIGATIONS
• Complete blood count
• Urinalysis
• Platelets
• Creatinine
• Prothrombin time
• Blood urea nitrogen
 FIRST AID
Keep the person calm, reassuring them that bites
can be effectively treated in an emergency room.
Restrict movement, and keep the affected area below
heart level to reduce the flow of venom.
Remove any rings or constricting items because the
affected area may swell.
Create a loose splint to help restrict movement of the
area.
 If the area of the bite begins to swell and change
color, the snake was probably poisonous.
Restrict activity and immobilize the affected area
(commonly an extremity); keep walking to a
minimum.
Negative-pressure suctioning devices offer some
benefit if used within several minutes of
envenomation.
Monitor the person's vital signs; If there are signs of
shock (such as paleness), lay the person flat, raise the
feet about a foot, and cover the person with a blanket.
Bring in the dead snake only if this can be done
safely.
Do not give antivenin in the field.
Immediately transfer to definitive care.
 DONT’S

• Make an incision over the bite,

• Mouth suctioning,
• Tourniquet use,
• Ice packs,
• Electric shock
 MANAGEMENT
Reassure the patient during the implementation of
ABCs.
Monitor vital signs and establish at least one large-
bore IV and initiate crystalloid infusion.
Administer oxygen therapy.
Keep a close watch on the airway at all times in case
intubation becomes necessary.
 ANTI - VENOM
First 10-20 minutes…
5 vials in 250ml of NS (125ml for infants weighing
<10kgs)
Administer slowly (1-2ml/hr)
If no adverse reaction…
Complete total volume in 2 hours
Continue to administer 5 vial aliquots until there is no
further progression of swelling.
Pain medication

Antibiotics

Tetanus toxoid
Wound debridement
 SCORPION BITE

• Scorpions usually hide during the day and are

active at night.
• Not all scorpion bites are lethal.
• Most sting in self defense
• Only one considered lethal- centruroides
sculpturatus
 CLINICAL MANIFESTATION
• A stinging or burning sensation at the injection site
(very little swelling or inflammation)
• Positive "tap test" (i.e., extreme pain when the sting
site is tapped with a finger)
• Restlessness
• Convulsions
• Roving eyes
• Staggering gait
• Thick tongue sensation
• Slurred speech
• Drooling
• Muscle twitches
• Abdominal pain and cramps
• Respiratory depression
 MANAGEMENT

• Symptomatic treatment
• Tetanus prophylaxis
• Scorpion sting antivenom if available.
 DOG BITES

• 80-90% of reported animal bites

• Boys most often the victim
• The dog is known to the victim in 90% of cases
• Extremities are the most frequent sites
• Head and neck bites are most common in children
 FIRST AID
• Wash the wound with soap & water
• Apply a clean dressing over the wound
• Seek medical help.
• Anti rabies serum to be infiltrated if wound is <24
hours old (20IU/kg)
• Tetanus Toxoid
• Active immunization by rabies vaccine
– Cell derived
– Nerve cell tissue origin- not used now a days as it
is less potent and increase adverse effect
 ANTI RABIES

Pre exposure prophylaxis-

3 doses (0.1ml on day 0,7, & 28 IM or ID
Booster doses every 5 years
Post exposure treatment-
5 doses on day 0,3,7,14, & 28 IM or,
2 doses on day 0 followed by 1 dose on day 7 & 21
(4 doses)
If immunized-
2 doses separated by 3 days (IM or ID)
 PALS
• A
• B
• C
• D
 NURSING DIAGNOSIS
• Airway
• Breathing
• Circulation
• Fluid Volume
• Pain
• Coping
• Situational crisis
• Anticipatory grieving
• Altered parenting
“LIFE IS A GIFT OF GOD; SAVE
IT”
THANK YOU