Pediatric Emergencies Flashcards
How does pediatric resuscitation differ from adults?
- Unknown whether it makes a difference of starting with ventilations (ABC) or with chest compressions (CAB)
- Asphyxial cardiac arrest MC in kids (as opposed to VF) so ventilations are extremely important for pediatric CPR
- However, CAB is recommended for children in order to simplify training
What type of cardiac arrest is MC in infants and children?
Asphyxial (as opposed to VF) so ventilations are extremely important for pediatric CPR
Define secondary survey
SAMPLE
- Symptoms
- Allergies
- Meds
- Past med hx
- Last meal time
- Events and environment
How does a child’s anatomy differ from an adult’s?
- Smaller airways
- Less blood volume
- Bigger heads
- Vulnerable internal organs
- High surface area to body mass
Describe a child’s airway
- Large tongue
- Smaller tracheal diameter
- Narrowest point is at cricoid cartilage (NOT glottis)
- Trachea is collapsible
- Back of head is rounder (requires careful positioning to keep airway open)
Narrowest point of child’s airway?
Cricoid cartilage (NOT glottis)
Describe the blood volume of a child
- LESS than adults
- Approx 70 cc of blood for every 1 kg of body weight
Describe the head of a child
- Relatively bigger heads than adults
- Prone to falling because they are top heavy
Describe the internal organs of a child
- Soft bones/cartilage and lack of fat in ribcage make internal organs susceptible to significant internal injuries
- Injuries can occur with much less force or obvious signs
How to assess pediatric emergency?
- Appearance
- Work of breathing
- Circulation to the skin
(assesses CV, respiratory, and neuro systems)
Describe ATLEs
- Apparent life threatening events
- Apnea, color change, hypotonia, choking/gagging
- 50% remain unexplained
- Apnea monitoring is INEFFECTIVE in reducing SIDS
Signs of asthma severity?
- Hypoxemia (pO2 under 91%)
- Hypercapnia (CO2 mid 40s or higher)
- Pulsus paradoxus (10-25 mmHg in moderate, 20-40 in severe)
CXR evaluation of asthma
NOT routinely indicated but may show hyperinflation, peribronchial cuffing, patchy atelectasis
Describe FB aspiration in children
- RARELY witnessed event
- Onset is abrupt w/cough, choking, wheezing
What ages MC at risk for FB aspiration?
6 months to 4 years old
How does clinical presentation of FB aspiration vary between upper and lower airway?
- Upper: sudden onset cough, dysphonia
- Lower: persistent cough/wheeze, fever, unilateral findings
Treatment of FB in upper airway?
If it doesn’t clear spontaneously, back blows per CPR recommended (NO finger sweeps)
When is removal of a FB in the GI tract recommended?
- Button batteries in esophagus (can be observed if in stomach)
- Open safety pin in stomach
- More than 1 magnet (mucosal entrapment)
- Objects over 5 cm (ligament of Treitz)
- Wooden toothpicks (mouth flora)
What causes croup?
Parainfluenza
Clinical presentation of croup
- Subglottic edema w/upper airway obstruction
- Barking cough
- Inspiratory stridor
Treatment of croup
- Cool, moist air (usually good enough on its own)
- O2
- Racemic epinephrine via nebulizer
- Dexamethasone
Clinical presentation of epiglottitis
- Toxic appearance
- Drooling, dysphagia
- Muffled voice
- Tripod position
Cause of epiglottitis?
HIB (now only unimmunized)
Treatment of epiglottitis?
- Immediate ET intubation
- IV abx after cultures
- Sedation while intubated can be a problem
Risk factors for pediatric sepsis/bacteremia
- Infant younger than 2 mo
- Immunocompromised
- Unvaccinated
Describe pediatric febrile seizures
- 2-5% of children 6 months to 5 yo
- Males slightly MC
- 75% are simple febrile seizures
- 25% are complex
Describe simple febrile seizures in kids
- Fever
- Single generalized motor seizures (NOT FOCAL)
- Lasts less than 15 mins
- Neurologically healthy
- 1/3 recurrence risk
Describe complex febrile seizures in kids
- 25% of cases
- Focal seizure
- Prolonged (over 15 mins)
Describe symptomatic febrile seizures in kids
- Least common type (approx 5%)
- Preexisting neuro abnormality
What is the most important aspect of evaluating febrile seizures in kids?
Differentiate simple from complex!
Workup of possible pediatric febrile seizures?
Consider LP if under 12-18 months OR if signs of meningitis at any age
Risk factors for pediatric meningitis
- Visit to healthcare setting within past 48 hrs
- Seizure activity at time of arrival
- Focal seizure
- Abnormal neuro findings
Treatment for prolonged pediatric febrile seizure?
Rectal BZD
Antipyretic treatment of pediatric febrile seizure
NOT effective in reducing recurrence (use as needed for other symptoms)
Describe SIRS
- Sepsis or systemic inflamm response from an insult AND the host response that follows
- Early recognition and intervention clearly improves outcomes
What has radically decreased the number of pediatric patients presenting with sepsis/SIRS?
Vaccination
Risk factors for pediatric sepsis/SIRS?
- AIDS
- Hgb SS
- Congenital heart disease
- GU anomalies
- Burns
- Splenic dysfunction
- Malignancies
- NICU/PICU patients
- Indwelling devices
Clinical presentation of pediatric sepsis/SIRS
- May have normal BP initially (compensated shock)
- Hypotension: SBP under 70 in 0-12 mo infants, under 90 in 10 yo or older
- Capillary refill over 2 secs
Treatment of pediatric sepsis/SIRS
- Respiratory assessment
- Fluids: boluses of crystalloid 20 mL/kg
- Vasopressors (if continued signs of volume depletion after 3 boluses)
- Abx (empiric)
Abx for BIRTH-8 weeks old sepsis/SIRS
Ampicillin/gentamicin OR ampicillin/cefotaxime OR ampicillin/ceftriaxone
Abx for over 8 weeks old sepsis/SIRS
3rd generation cephalosporin/ampicillin/sulbactam
Abx for pediatric sepsis/SIRS with indwelling catheters or MRSA risk:
Vancomycin
When should abx be given with pediatric sepsis/SIRS patients?
ASAP
Risk groups for HIB transmission
- Infants and young children (from household contacts or daycare classmates)
- American Indian/Alaska Native populations
What is the 2nd MC cause of vaccine-preventable death in the US?
Pneumococcal disease (after influenza)
Major clinical syndromes of pneumococcal disease
- Pneumonia
- Bacteremia
- Meningitis
MC clinical presentation of pneumococcal disease in children?
Bacteremia W/O known site of infection
What is the leading cause of bacterial meningitis among children younger than 5 yo?
S pneumo
What young adults are most at risk for meningococcal disease?
College freshmen in a dorm
Describe meningococcal disease
- Nasopharynx colonization
- Organism invades bloodstream in some people
- Antecedent URI may be contributing factor
- Fatality rate 9-12% (up to 40% in meningococcemia)
Clinical findings of meningococcal meningitis
Fever
HA
Stiff neck
Treatment of DKA in children?
- Rehydration
- Correction of acidosis, electrolyte disturbances
What causes mortality in DKA cases?
The precipitating underlying cause AND cerebral edema during rehydration
Describe volume resuscitation in DKA
- Less aggressive: 10 mL/kg x 2 boluses
- 2 or more boluses ONLY if hemodynamically unstable
Treatment of DKA after 1st hour
- Slow correction of hyperglycemia, ketosis, met acidosis
- Controlled decrease in serum osmolarity
- Hydrate w/0.9% or 0.45% NaCl
- Add KCl based on serum K
Insulin treatment in DKA
Do NOT give until severe hypokalemia resolves
MC cause of severe diarrhea in pediatrics?
Rotovirus
nearly universal infection by 5 yo
Bilious vomiting in a newborn:
ALWAYS surgical emergency
Double bubble is a finding of what condition?
Intestinal malrotation
MC cause of intestinal obstruction in first 2 years of life?
Intussusception (males 3:1)
Clinical presentation of intussusception
3-12 mo thriving with paroxysms of abd pain, then vomiting/diarrhea, within 12 hrs currant-jelly stool
Currant jelly stools?
Intussusception
Treatment of intussusception
Barium and air enemas are diagnostic/therapeutic
Describe anaphylaxis
- Multisystemic reaction from rapid release of inflamm mediators
- Both IgE and non-IgE activation of mast cells and basophils
What causes IgE mediated anaphylaxis?
Foods, preservatives, meds, insect venom (bees)
What causes non-IgE anaphylaxis?
Infection, opiates, radiocontrast dye, exercise
Who is MC affected by anaphylaxis
Males MC before 15 yo
Females MC through adulthood
Primary clinical diagnostic criteria of anaphylaxis
- Acute onset of skin and/or mucosal symptoms
- Respiratory compromise AND/OR
- Reduced BP or associated symptoms of end organ dysfunction
Observation vs. inpatient monitoring of anaphylaxis
- Mild symptoms should be observed at least 4-8 hrs
- Hospitalize if fluid resuscitation, multiple doses of epi or bronchodilator
- Children needing vasopressors or glucagon should go to PICU
How to evaluate airway in anaphylaxis patients?
ABG (to evaluate oxygenation/ventilation)
Treatment of anaphylaxis
- Epi 1:1000 IM into thigh (SC NOT recommended)
- Epi 1:10000 IV/IO is reserved for uncompensated shock (risk of lethal dysrhythmias)
- Nebulized albuterol (if not responsive to epi)
- Nebulized epi (for stridor secondary to laryngeal edema)
How does compensated shock present in children?
Normal BP but tachy and other signs of hypoperfusion
What is considered hypotension in children 1-12 months old?
SBP under 70 mm Hg
What is considered hypotension in children 1-10 years old?
SBP under 70 plus (2*age)
What is considered hypotension in children over 10 yo?
SBP under 90 mm Hg
Leading cause of death among children older than 1 year?
Injury
MVAs, homicide/suicide, drowning
Red flags for child abuse
- Changing history or no explanation offered
- Delay in seeking care
- Inappropriate affect
How do bruises present on abused children?
PATTERN and DISTRIBUTION
Should you suspect abuse if told that child fell off bed/couch?
Rolling off bed/couch does NOT cause skull or long bone fractures in children so suspect abuse
Treatment of child abuse
- Mandatory reporting for suspected abuse (no matter how uncertain)
- Separate child from suspected perpetrator
- Document findings with photos
- Skeletal survey, coag studies, or other potential alternative explanation
How do most cases of sexual abuse in children present?
NONSPECIFIC findings
Describe neglect in children
- Difficult to document
- Failure to gain weight may be the only sign
- Child with birth defect/disease at higher risk
Describe Munchausen by proxy
- Symptoms often reported by perpetrator only
- Perpetrator often has some medical training
- Perpetrator usually cooperative until challenged
Describe the perpetrator of Munchausen by proxy
- Often has some medical training
- Is usually cooperative until challenged
What is the leading cause of death among injured children?
CNS trauma - diffuse edema (axonal injury) rather than focal space occupying lesions (early CT may not be sensitive)
MC cause of serious head injury in pts under 3 yo?
Physical abuse
MC cause of serious head injury in pts over 3 yo?
Falls, MVA, bicycle, pedestrian accidents
How long can postconcussion syndrome last?
Up to months after the injury (but rarely extends past 3 months)
When can someone resume activity at increased levels post-concussion?
As long as symptoms do not recur at each activity level
Indication for CT scans with head trauma?
Associated risk factors for traumatic brain injury:
- Skull fracture
- Focal neuro signs
- GCS less than 15
- LOC
When is hyperventilation therapy indicated in severe head injury?
Only briefly indicated for acute herniation
Describe SCIWORA syndrome
- Spinal cord injury w/o radiologic abnormality
- Unique to pediatrics (10-20% of children with SCI)
- Incompletely calcified vertebral column
Hallmark of SCIWORA syndrome?
Documented neuro deficit that may have changed or resolved by the time the child has arrived in the emergency department
What causes most thoracic injuries in pediatrics?
Blunt trauma (MVAs)
Describe the pediatric thorax
Greater cartilage content and incomplete ossification of ribs (allows for significant injury)
What is seat belt syndrome?
Concurrent findings of abd wall bruising, intra-abd injury and vertebral fracture
Why are children more susceptible to abdominal trauma?
Small, pliable rib cage and undeveloped abd muscles provide little protection to major organs
What is the MC intra-abd injury a/w abd wall bruising in kids?
Hollow viscus rupture
What causes 80% of fire related deaths?
Inhalation of toxic combustion products (NOT burns)
What puts someone at risk for inhalation injury?
History of closed-space exposure, facial burns, carbonaceous debris in mouth/pharynx/sputum
Treatment of inhalation injury
- 100% oxygen
- Airway maintenance is critical (early intubation if evidence of upper airway edema)
Leading cause of unintentional death in children?
Burns
Why are burns concerning in kids?
Body surface area is disproportionately higher relative to their weight
Describe differences in thermoregulation among pediatric patients
- Under 6 months: nonshivering thermogenesis, brown fat catabolism requiring large amounts of O2
- Over 6 months: able to shiver, greater evaporative water loss relative to weight, more prone to hypothermia
Describe differences in renal function of pediatric patients compared to adults
- GFR does not reach adult levels until age 9-12 mo
- Fluid overloading is a risk (esp infants)
When does a child’s GFR reach adult levels?
9-12 months old
Antimicrobial creams in pediatric burns?
May delay transfer - remove these agents once pt arrives at burn center
Burn center referral criteria
- Any partial thickness larger than 20% TBSA (or 10% in children)
- 3rd degree covering more than 5% TBSA
- 2nd or 3rd degree involving critical areas
- Burns a/w inhalation injury
- Electrical or lightning burns
- Coexisting trauma
What is the 2nd leading cause of unintentional death in children?
Drowning/submersion injury
What level of hypothermia mimics death?
Temp under 28 C (typical postmortem changes)
What HR may provide adequate perfusion in hypothermia?
As low as 4-6/min may be enough
Treatment of hypothermia in pediatrics
- Rewarm to 32-34 C
- Supportive (hypothermic myocardium is prone to VF)
- Defib and cardiac meds may not be effective until core temp 28-30 C
Levels of hyperthermia
- Heat cramps (mild)
- Heat exhaustion
- Heat stroke (thermoregulation failure)
How do dog bites occur in different ages of children?
- Head/neck in young children
- Upper extremities in school aged children
How do dog and cat bites occur by gender?
- Dog MC in boys
- Cat MC in girls
Treatment of bites in pediatric patients
- Irrigation and debridement
- Suture only facial/cosmetic lesions
- Pencillin/cephalexin OR amox/clavulanic acid
- Rabies and Td status
Poison control number?
1-800-222-1222
Describe poisoning in pediatrics
- Blood brain barrier may be more permeable until around 4 months old
- Children reside lower to the ground (higher risk for ingesting compounds)
- Inability to avoid hazards (cannot read warning labels)
What agents MC cause poisoning in under 6 yo?
Medications
analgesics cause fatal poisoning
