Pediatric Medical Emergencies

1
Pediatric Medical Emergencies
2
Fever

• Not a disease, its a sign of disease
• Severity is not indication of severity of
  underlying disease
• Usually good

3
Fever

• Treat child, not thermometer
• How do you know he has a fever?
• How sick does he look?
• How long has he been listless, weak?
• Will he tolerate being held on moms shoulder?
• Does he cry even when consoled?

4
Fever

• Educate parents
• Tempra, Tylenol
• Avoid aspirin
• Sponge with water at 96 - 970F
• Do not say tepid, lukewarm
• Do not leave kid unattended

5
Fever

• Educate parents
• Do not
• Use ice water
• Bundle
• Use alcohol rubs
• Use tap water enemas

6
Fever

• Emergency if
• gt1040F in any child
• gt1010F in infant lt 3months old

7
Septic Shock

• Peripheral hypoperfusion due to septicemia (blood
  infection)
• Most common in young infants, debilitated children

8
Septic Shock

• Pathophysiology
• Severe peripheral vasodilation
• Fluid loss from vessels to interstitial space

9
Septic Shock

• Signs/Symptoms
• Warm shock
• Tachycardia, full pulses
• Slow capillary refill
• Fever
• Flushed skin

10
Septic Shock

• Signs/Symptoms
• Cold shock
• Tachycardia, weak pulses
• Slow capillary refill
• Cool, pale, mottled skin

Cold shock has 90 mortality
11
Febrile infant Wont tolerate being held to
shoulder Septic Shock
12
Septic Shock

• Management
• 100 oxygen
• LR in 20cc/kg boluses
• Fill dilated vascular space
• Prevent onset of cold shock

13
Meningitis

• Inflammation of meninges
• Increased CSF production
• Cerebral /meningeal edema
• Increased intracranial pressure

14
Meningitis

• Signs/Symptoms Older Children
• Fever
• Headache
• Stiff neck (cant touch chin to chest)
• Decreased LOC
• Seizures

15
Meningitis

• Signs/Symptoms Infants
• Difficulty feeding
• Irritability
• High-pitched cry
• Bulging fontanelle
• Classic meningeal signs possibly absent

16
Meningitis

• Meningococcemia
• Petechial rash
• Septic shock
• DIC

17
Reyes Syndrome

• Non-communicable
• Affects ages 2 -19
• Mostly toddlers, pre-schoolers

18
Reyes Syndrome

• Pathophysiology
• Dysfunction of hepatic urea cycle enzymes
• Increased protein breakdown leading to rise in
  blood ammonia levels
• Diffuse cerebral edema

19
Reyes Syndrome

• History
• Previously healthy child
• Recovering from viral illness
• Frequently chicken pox or influenza
• Frequently received aspirin during illness

20
Reyes Syndrome

• Signs/Symptoms
• Prolonged, violent vomiting
• Varying degrees of personality change
• Unusual behavior
• Irritability, drowsiness

21
History of vomiting Altered LOC Recovering
from virus Reyes Syndrome
22
Crankiness in infant Recovering from virus
Reyes Syndrome
23
Reyes Syndrome

• Management
• Avoid overstimulation
• IVs at tko
• Decrease ICP by controlled hyperventilation

24
Seizures

• Second most common pediatric complaint after
  fever
• Can result from same causes as adult seizures

25
Seizures

• Pedi seizures can also result from fever
• Most common from 6 months to 3 years
• Caused by rapid rise in body temperature
• Short-lived
• Does not recur during that illness

26
Seizures

• Potential dangers
• Aspiration
• Trauma
• Missed diagnosis

27
Seizures

• Febrile seizure diagnosis risky in field

28
Seizures

• History
• Previous seizures?
• Previous febrile seizures?
• Number of seizures this episode?
• What did seizure look like?

29
Seizures

• History
• Remote, recent head trauma?
• Diabetes?
• Headache, stiff neck?
• Petechial rash?

30
Seizures

• History
• Possible ingestion?
• Medications?

31
Seizures

• Physical exam
• ABCs
• Neurological exam
• Signs of injury?
• Signs of dehydration?
• Rash, stiff neck?
• Bulging, depressed anterior fontanelle?

32
Seizures

• Management--if actively seizing
• Place on floor away from furniture
• Position on side
• Prevent injury
• Do not restrain
• Do not force anything between teeth

33
Seizures

• Management--following seizure
• Check ABCs, suction prn
• Assure good oxygenation, ventilation
• Vascular access
• Check blood glucose, if lt 70, give D25W
• If febrile, remove excess clothing, sponge with
  water to cool patient.

34
Status Epilepticus

• Diazepam
• 0.3 mg/kg to 5mg if lt 5 years old
• 0.3 mg/kg to 10mg if gt 5 years old

35
Status Epilepticus

• Administer diazepam slowly
• Anticipate respiratory arrest, hypotension
• Rectal route is alternative when vascular access
  cannot be obtained

36
Most Common Cause of Seizure Deaths
Anoxia
37
Hypoglycemia

• More common than in adults, especially in
  newborns
• Signs/symptoms may mimic hypoxia

38
Hypoglycemia

• Check blood glucose in any child with
• Seizures
• Decreased LOC
• Severe dehydration
• Known hypoglycemia or diabetes
• Pallor, sweating, tachycardia, tremors

39
Hypoglycemia

• Management
• Oral sugar if tolerated
• 2cc/kg D25W, if oral sugar not possible
• ? Glucagon 1 mg IV or IM
• Reassess every 20 - 30 minutes

40
Diabetes Mellitus

• Typically insulin-dependent
• Complications
• Hypoglycemia
• Hyperglycemia, DKA

41
Diabetes Mellitus

• DKA therapy same as for severe dehydration
• Not every diabetic is known diabetic
• Every diabetic must have first hyperglycemic
  episode

42
Coma

• Disturbance in consciousness patient
  unresponsive to stimuli
• Causes
• Metabolic
• Structural

43
Coma

• Metabolic causes
• Anoxia Drug Toxicity
• Hypoglycemia Epilepsy
• DKA Reyes Syndrome
• Infections
• Increased ICP (Edema)

44
Coma

• Structural causes
• Trauma
• Tumor
• CVA

45
Coma Control ABCs before worrying about cause!!
46
Coma

• Airway/Breathing
• All patients with decreased LOC receive oxygen!!
• Evaluate for ineffective breathing patterns
• Controlled hyperventilation if increased ICP
  suspected

47
Coma

• Circulation
• Control bleeding
• Give fluid boluses for hypovolemia
• Disability
• AVPU, pupils
• Check blood glucose

48
Coma

• Management
• Support ABCs
• 2 cc/kg D25W glucose lt 70 mg
• Narcan 0.1 mg/kg IV/IM/SQ/ET
• Elevate head 300 if C-spine injury not suspected
  and patient not in shock
• Rapid transport
• Reassess, Reassess, Reassess

49
Poisoning

• Incidence
• Accidental 75 children lt 5 years old
• Overdose School-age, adolescents

50
Poisoning

• Assessment
• Remove to safe environment
• Control airway
• Support breathing 100 O2
• Circulation - vasodilation, decreasing myocardial
  tone, hypoxia
• Blood glucose

51
Poisoning

• History
• What?
• When?
• How much?
• Vomiting? Coughing? Seizures? Altered LOC?
• Ipecac?

52
Poisoning

• Management
• Support ABCs
• Consider D25W, Narcan
• Ipecac?/Charcoal?
• Transport samples
• Consult poison control
• Treat patient, not poison!!

53
Near-Drowning

• A leading cause of childhood death
• Two major groups
• Toddlers
• Adolescents

54
Near-Drowning

• Pathophysiology
• Hypoxia
• Acidosis
• Hypothermia
• Aspiration, pulmonary edema, atelectasis

55
Near-Drowning

• Management
• Protect rescuers
• Assume C-spine injury
• 100 oxygen
• Decompress stomach early with gastric tube

56
Near-Drowning

• Management
• Remember mammalian diving reflex!!
• Think about underlying causes-- ? Child
  abuse
• All near-drownings are transported regardless of
  how good they look!!