PEDIATRICS

PEDIATRIC EMERGENCIES 3.1.1

Dr. Marrianne Cerdeño | January 15, 2020

OUTLINE • Is the rescuer or child in imminent danger because of

circumstances at the scene (e.g., fire, high-voltage
I. APPROACH TO EMERGENCY electricity)?
EVALUATION OF A CHILD o If so, can the child be safely extricated to a
II. GENERAL ASSESSMENT safe location for assessment and treatment?
III. PRIMARY ASSESSMENT o Can the child be safely moved with the
IV. AIRWAY AND BREATHING appropriate precautions (i.e., cervical spine
V. CIRCULATION protection), if indicated?
VI. DISABILITY • A rescuer is expected to proceed only if these
VII. EXPOSURE important safety conditions have been met
VIII. SECONDARY ASSESSMENT • Once the caregiver and patient’s safety has been
ensured, the caregiver performs a rapid visual
IX. TERTIARY ASSESSMENT
survey of the child, assessing the child’s general
X. INTUBATION appearance and cardiopulmonary function
XI. PRE-PROCEDURAL PREPARATION • This action should be only a few seconds and
XII. SHOCK include assessment of
XIII. BRADYARRHYTMIAS o (1) general appearance, determining color,
XIV. TACHYARRHYTMIAS tone, alertness, and responsiveness;
XV. RECOGNITION AND MANAGEMENT o (2) adequacy of breathing, distinguishing
OF CARDIAC ARREST between normal, comfortable respirations
XVI. POSTRESUSCITATION CARE and respiratory distress or apnea; and
o (3) adequacy of circulation, identifying
cyanosis, pallor, or mottling
PEDIATRIC EMERGENCIES AND RESUSCITATION • A child found unresponsive from an unwitnessed
• Injuries are the leading cause of death in American collapse should be approached with a gentle touch
children and young adults and account for more and the verbal question, “Are you OK?”
childhood deaths than all other causes combined o If there is no response, the caregiver should
• Rapid, effective bystander cardiopulmonary immediately shout for help and send
resuscitation (CPR) for children is associated with someone to activate the emergency
survival rates as high as 70%, with good neurologic response system and
outcome o locate an automated external defibrillator
(AED)
• bystander CPR is still provided for <50% of children • The provider should then determine whether the child
who experience cardiac arrest outside medical is breathing and, if not, provide 2 rescue breaths.
settings. o If the child is breathing adequately, the
o This failing has led to long-term survival rates circulation is quickly assessed.
of <40%, often with a poor neurologic • Any child with heart rate <60 beats/ min or without a
outcome. pulse requires immediate CPR.
• If the caregiver witnesses the sudden collapse of a
APPROACH TO THE EMERGENCY EVALUATION OF A
child, the caregiver should have a higher suspicion for
CHILD a sudden cardiac event.
• The first response to a pediatric emergency of any
• In this case, rapid deployment of an AED is crucial.
cause is a systematic, rapid general assessment of
o Any interruptions in care of the child to
the scene and the child to identify immediate threats activate EMS and locate the nearest AED
to the child, care providers, or others. should be very brief. If >1 caregiver is
• If an emergency is identified, the emergency response present, someone should always remain with
system (emergency medical services, EMS) should be the child and provide initial care or
activated immediately. stabilization
• Care providers should then proceed through primary,
secondary, and tertiary assessments as allowed by
the child’s condition, safety of the scene, and resources
available
• If at any point in these assessments the caregiver
identifies a life-threatening problem, the assessment is BLS Healthcare provider; Pediatric Arrest Algorithm for
halted and lifesaving interventions are initiated. Single Rescuer
• Further assessment and intervention should be
delayed until other caregivers arrive or the condition is
successfully treated or stabilized.

GENERAL ASSESSMENT
• On arrival at the scene of a compromised child, a
caregiver’s first task is a quick survey of the scene
itself

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3.1.1 PEDIATRIC EMERGENCIES
• goal of the primary assessment: is to obtain a
focused, systems-based assessment of the child’s
injuries or abnormalities, so that resuscitative efforts
can be directed to these areas;
o if the caregiver identifies a life-threatening
abnormality, further evaluation is postponed
until appropriate corrective action has been
taken.
• normal respiratory rate, heart rate, and blood pressure
have age-specific norms.
• These ranges can be difficult to remember, especially
if used infrequently.
• several standard principals apply:
o (1) a child’s respiratory rate should not be
>_60 breaths/min for a sustained period;
o (2) normal heart rate is 2-3 times normal
respiratory rate for age; and
o (3) a simple guide for pediatric blood pressure
is that the lower limit of systolic blood
BLS Healthcare provider; Pediatric Arrest Algorithm for 2 pressure should be
or more Rescuer § ≥60 mm Hg for neonates;
§ ≥70 mm Hg for 1 mo-1 yr olds;
§ ≥70 mm Hg +(2 × _age) for 1-10 yr
olds; and ≥90 mm Hg for any child
older than 10 yr.

NORMAL VITAL SIGNS ACCORDING TO AGE

AGE HEART BLOOD RESPIRATORY
RATE PRESSURE RATE
(beats/min) (mmHg) (breaths/min)
Premature 120-170 55-75/35-45 40-70
0-3 mo 100-150 65-85/45-55 35-55
3-6 mo 90-120 70-90/50-65 30-45
6-12 mo 80-120 80-100/55- 25-40
65
1-3 yr 70-110 90-105/55- 20-30
70
3-6 yr 65-110 95-110/60- 20-25
75
6-12 60-95 100-120/60- 14-22
75
12+ yr 55-85 110-135/65- 12-18
85
*In sleep, infant heart rates may drop significantly lower, but if perfusion is
maintained, no intervention is required.
†A blood pressure cuff should cover approximately two thirds of the arm; too

small a cuff yields spuriously high pressure readings, and too large a cuff yields
spuriously low pressure readings. Values are systolic/diastolic.
‡Many premature infants require mechanical ventilatory support, making their
spontaneous respiratory rate less relevant.
PRIMARY ASSESSMENT
• Once the emergency response system has been • No Respiratory Rate should be more than 60
activated and the child is determined not to need CPR, for sustained period
the caregiver should proceed with a primary • Heart Rate is 2-3x normal Respiratory rate
assessment that includes a brief, hands-on • BP
assessment of cardiopulmonary and neurologic • Neonates >/= 60
function and stability • 1mo to 1yo >/= 70
o includes a limited physical examination, • 1- 10yo >/= 70 + (2xage)
evaluation of vital signs, and measurement of • >10yo >/= 90
pulse oximetry if available
• (ABCDE)
o airway, AIRWAY AND BREATHING
o breathing, • The most common precipitating event for cardiac
o circulation, instability in infants and children is respiratory
o disability, insufficiency
o exposure

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o rapid assessment of respiratory failure and • Tachycardia is the earliest and most reliable sign of
immediate restoration of adequate ventilation shock
and oxygenation remain the first priority in the o but is itself fairly nonspecific and should be
resuscitation of a child correlated with other components of the
o caregiver should first assess whether the exam, such as weakness, threadiness, and
child’s airway is patent and maintainable absence of pulses.
• A healthy, patent airway is unobstructed, allowing • An age-specific approach to pulse assessment will
normal respiration without noise or effort yield best results.
• A maintainable airway is one that is either already
patent or can be made patent with a simple maneuver. DISABILITY
• To assess airway patency, the provider should look for: • refers to a child’s neurologic function in terms of the
o breathing movements in the child’s chest and level of consciousness and cortical function.
abdomen, • Standard evaluation of a child’s neurologic condition
o listen for breath sounds, and can be done quickly with an assessment of pupillary
o feel the movement of air at the child’s mouth response to light (if one is available) and use of either
and nose. of the standard scores used in pediatrics:
• Findings potentially consistent with airway obstruction: o Alert, Verbal, Pain, Unresponsive (AVPU)
o abnormal breathing sounds (ex snoring or Pediatric Response Scale and
stridor) o Glasgow Coma Scale (GCS).
o increased work of breathing, and • The causes of decreased level of consciousness in
o apnea children are numerous and include conditions as
• If there is evidence of airway obstruction, maneuvers diverse as
to relieve the obstruction should be instituted before the o respiratory failure with hypoxia or
caregiver proceeds to evaluate the child’s breathing hypercarbia,
• Assessment of breathing includes evaluation of the o hypoglycemia,
child’s: o poisonings or drug overdose,
o respiratory rate, respiratory effort, abnormal o trauma,
sounds, and pulse oximetry. o seizures,
• Normal breathing appears comfortable, is quiet, and o infection, and
occurs at an age-appropriate rate. o shock.
• Abnormal respiratory rates include apnea and rates • Most often, an ill or injured child has an altered level of
that are either too slow (bradypnea) or too fast consciousness because of respiratory compromise,
(tachypnea). circulatory compromise, or both.
• Bradypnea and irregular respiratory patterns require • Any child with a depressed level of consciousness
urgent attention because they are often signs of should be immediately assessed for abnormalities in
impending respiratory failure and/or apnea. cardiorespiratory status.
• Signs of increased respiratory effort include:
o nasal flaring, • Alert, Verbal, Pain, Unresponsive Pediatric Response
o grunting, Scale
o chest or neck muscle retractions, o used to determine a child’s level of
o head bobbing, and consciousness and cerebral cortex function
o seesaw respirations.
• Hemoglobin oxygen desaturation often accompanies AVPU Neurologic Assessment
parenchymal lung disease apnea or airway A The child is awake, alert, and interactive with
obstruction. parents and care providers.
o providers should keep in mind that adequate V The child responds only if the care provider
perfusion is required to produce a reliable or parents call the child’s name or speak
oxygen saturation (SO2) measurement. loudly.
o A child with low SO2 is a child in distress. P The child responds only to painful stimuli,
• Central cyanosis is a sign of severe hypoxia and such as pinching the nail bed of a toe or
indicates an emergent need for oxygen finger.
supplementation and respiratory support. U The child is unresponsive to all stimuli.
A, Alert; V, verbal, P, pain, U, unresponsive.
CIRCULATION
• Cardiovascular function is assessed by evaluation of:
o skin color and temperature,
o heart rate,
o heart rhythm,
o pulses,
o capillary refill time, and
o blood pressure.
• Signs of diminished perfusion and compromised
cardiac output:
o mottling, pallor, delayed capillary refill,
cyanosis, poor pulses, and cool extremities
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Glasgow Coma Scale
EYE OPENING (TOTAL POSSIBLE POINTS 4)
Spontaneous 4
To voice 3
To pain 2
None 1
VERBAL RESPONSE (TOTAL POSSIBLE POINTS 5)
OLDER CHILDREN INFANTS AND YOUNG
CHILDREN
Oriented 5 Appropriate words, smiled 5
Fixes and follows
Confused 4 Consolable crying 4
Inappropriate 3 Persistently irritable 3
Incomprehensible 1 Restless, agitated 2
None 1 None 1
MOTOR RESPONSE (TOTAL POSSIBLE POINTS 6)

• 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
• Undress the child (if feasible and reasonable)
• Focused PE
• Assess for burns, bruising, bleeding and fractures
• With cervical spine precautions

SECONDARY ASSESSMENT
• Focused history and physical examination
• SAMPLE history:
• Signs/symptoms INTUBATION
• Allergies • Indications
• Medications • unable to maintain airway
• Past medical history • unable to maintain oxygenation
• Last meal • unable to control CO2 levels
• Events leading to the situation • sedation or paralysis
• anticipation of deterioration that will lead to
TERTIARY ASSESSMENT the first 4 mentioned above
• Ancillary laboratory procedures and Radiographic
assessments
• CBC with PC
• PT, PTT
• ABG
• Bun, Creatinine

PRE-PROCEDURAL PREPARATION
• Suction
• Oxygen
• Airway
• People

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3.1.1 PEDIATRIC EMERGENCIES
• Monitor • Significant if with signs of sytemic hypoperfusion
• Medications (pallor, altered mental status, hypotension, acidosis)
• Initial management: Oxygen support
RAPID SEQUENCE INTUBATION • HR < 60 beats/min with poor perfusion is an indication
• Induce anesthesia and paralysis to complete intubation to begin chest compressions
quickly
• Sellick maneuver – downward pressure on the cricoid • 6Hs
cartilage to compress the esophagus against the • Hypoxia
vertebral column • Hypovolemia
• Hydrogen ions (acidosis)
SHOCK • Hypokalemia or hyperkalemia
• Oxygen and nutrient delivery to the tissues is • Hypoglycemia
inadequate to meet metabolic demands • Hypothermia
• Does not begin when BP drops; it merely worsens and
become more difficult (refractory) to treat once blood • 5Ts
pressure is abnormal • Toxins
• Compensated shock – oxygen delivery is mostly • Tamponade
preserved through compensatory mechanisms: normal • Tension pneumothorax
BP • Thrombosis
• Decompensated shock - hypotension and organ • Trauma
dysfunction
• Irreversible shock – organ failure progresses and
death ensues
• Hypovolemic shock
• Most common type of shock
• Related to fluid losses from severe diarrhea
• Distributive shock – hypovolemia occurs because of
third spacing of intravascular fluids into the
extravascular compartment e.g. 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 impedes the blood flow in the body eg.
tension pneumothorax, massive pulmonary embolism,
pericardial tamponade

TREATMENT
• The treatment of shock focuses on the modifiable
determinants of oxygen delivery while reducing the
imbalance between oxygen supply and demand.
• Optimize the arterial content of blood
• Improve the volume and distribution of
cardiac output
• Correcting metabolic derangements
• Reducing oxygen demand
• Oxygen administration by nasal cannula or face mask
• Aggressive volume resuscitation for hypovolemic or
distributive shock
• Relief of obstruction eg. ductus arteriosus can be
reopened by prostaglandin administration

RECOGNITION OF BRADYARRHYTMIAS AND

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

BRADYARRHTHMIAS
• Heart rate is slower than the normal range for age
• May be an incidental finding
• Relative bradycardia occurs when the heart rate is too
slow for a child’s activity level or metabolic needs

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TACHYARRHTHMIAS

• Rhythm disturbances of atrial and ventricular origin

• In pathologic states such as hypovolemia, anemia,
pain, anxiety and metabolic stress
• Narrow complex rhythms – does not originate from the
sinus node
• Wide complex rhythms e.g. Vtach

RECOGNITION AND MANAGEMENT OF CARDIAC ARREST

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

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POST RESUSCITATION CARE

• Close observation in an ICU
• Good post resuscitation care includes supportive
services for the parents, siblings, family and friends
• HYPERTHERMIA must be avoided

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