FERNANDO GONZALEZ, DO, FACOP

SHANNON CLINIC
PEDIATRICS
SAN ANGELO, TEXAS
 I HAVE NO DISCLOSURES TO MAKE
 TOPIC OBJECTIVES
 TO LEARN THE BASIC PATHOPHYSIOLOGY &
EMERGENCY RESPONSE FOR
 RESPIRATORY DISTRESS
 SHOCK
 BURNS
 BITES & STINGS &
 HEAT ILLNESS IN CHILDREN
 The primary mission in a pediatric emergency
is the resuscitation & stabilization of the
patient.
 Trauma is the #1 cause of death in children in the US
after the first year.
 Pediatric arrest is usually respiratory in origin.
 Prolonged deterioration
 Associated with severe hypoxia and acidosis
 Outcomes are dismal
 Early intervention and action is critical
 HISTORY
 A focused medical history
 S- SIGNS & SYMPTOMS
 A- ALLERGIES & IMMUNIZATIONS
 M- MEDICATIONS
 P- PAST MEDICAL HISTORY & ILLNESS
 L- LAST MEAL
 When & what
 E- EVENTS PRECEDING ILLNESS OR INJURY
 Timing, duration, fever, treatments
 Hazards at scene
 EXAMINATION: ABCDE
 A focused physical exam which includes vital signs
and pulse oximetry
 A- AIRWAY ASSESSMENT
 Look for chest wall movement, signs of obstruction, level
of consciousness
 Listen for abnormal breath sounds
 Feel for air movement
 EXAMINATION
 AIRWAY INTERVENTIONS
 If no trauma, head tilt
 Place oropharyngeal airway if needed
 Immobilize spine if trauma is present
 Suction naso-oropharynx
 Visualize for foreign bodies & remove
 Intubate if necessary
 Perform cricothyroidotomy
 EXAMINATION
 B- BREATHING ASSESSMENT
 Look for signs of respiratory distress (a clinical state
characterized by abnormal respiratory rate or effort)
 Tachypnea
 Bradypnea (an omnious sign)
 Apnea
 Retractions, flaring, grunting
 Cough, stridor, gurgling
 Chest wall motion
 Altered mental status (hypoxia)
 Cyanosis
 EXAMINATION
 BREATHING ASSESSMENT
 Listen for breath sounds
 Rales/crackles
 Wheezes/rhonchi
 Asymmetric breath sounds
 EXAMINATION
 BREATHING ASSESSMENT
 Feel for
 Crepitus
 Trachael deviation
 EXAMINATION
 BREATHING INTERVENTIONS
 Oxygen administration
 Ventilatory support
 Bag-mask ventilation
 Intubation & ventilator support
 Vapo-therm
 CPAP
 IMV
 Needle thoracotomy/Chest tube
 RESPIRATORY PROBLEMS
 RESPIRATORY FAILURE
 A clinical state of inadequate oxygenation or ventilation
or both
 Requires intervention to avoid deterioration to cardiac
arrest
 Causes
 Upper airway obstruction
 Lower airway obstruction
 Lung tissue disease
 Disordered control of breathing
 RESPIRATORY PROBLEMS
 UPPER AIRWAY OBSTRUCTION
 Foreign body aspiration
 Airway swelling (anaphylaxis, croup, epiglotittis)
 Mass (Peritonsillar abcess, tumor)
 Congenital airway abnormality (choanal
stenosis/atresia or subglottic stenosis)
 Signs generally occur in inspiration
 RESPIRATORY PROBLEMS
 LOWER AIRWAY OBSTRUCTION
 Obstruction of lower trachea, bronchi & bronchioles
 Asthma, bronchiolitis
 Signs generally occur in exhalation
 RESPIRATORY PROBLEMS
 LUNG TISSUE DISEASE
 A heterogeneous group of clinical conditions affecting
the lung at the alveolar level
 Characterized by small airway collapse & alveolar
congestion
 Pneumonia, pulmonary edema (CHF, ARDS), aspiration
pneumonitis, trauma, allergic reaction, toxins, vasculitis
 RESPIRATORY PROBLEMS
 DISORDERED CONTROL OF BREATHING
 An abnormal breathing pattern with signs of
inadequate respiratory rate, effort or both
 Neurologic disorders (seizures, meningitis, head injury,
brain tumor, neuromuscular disease)
 Altered mental status is typical
 “Breathing funny”
 EXAMINATION
 C- CIRCULATION ASSESSMENT
 Shock
 A critical condition resulting from inadequate oxygen &
nutrient delivery to tissues
 Characterized by inadequate peripheral and end organ
perfusion (Usually)
 Usually associated with low cardiac output
 EXAMINATION
 C- CIRCULATION ASSESSMENT
 Shock
 Tachycardia or bradycardia (most common cause is
hypoxia)
 Delayed capillary refill time (< 2 seconds is normal)
 Cool extremities
 Pulses (Normal, bounding, weak or absent)
 Skin color (pallor, mottling, cyanosis)
 EXAMINATION
 C- CIRCULATION ASSESSMENT
 Shock
 Hypotension
 A late finding indicating impending arrest
 Results from failure of compensatory mechanisms
 Minimum systolic blood pressure:
 Newborn: > 60
 Infants: > 70
 1-10 years of age: (2 x age in years) + 70
 Over 10 years: > 90
 EXAMINATION
 C- CIRCULATION
 Shock
 Types
 Hypovolemic: Results from volume loss
 Most common type of shock in children
 V/D, hemorrhage, DKA, 3rd space loss, burns
 Distributive: Inadequate distribution of blood volume
 Vasodilation, increased capillary permeability
 Sepsis, anaphylaxis, neurogenic (head/spinal injury)
 Cardiogenic: Inadequate perfusion d/t cardiac dysfunction
 CHD, myocarditis, cardiomyopathy, trauma
 Obstructive: Impaired cardiac flow
 Tamponade, tension pneumothorax
 EXAMINATION
 C- CIRULATION INTERVENTIONS
 Shock
 Early intervention reduces morbidity and mortality
 Goals:
 Optimize oxygen content of blood
 Improve volume & distribution of cardiac output
 Reduce oxygen demand
 Correct metabolic derangements
 EXAMINATION
 C- CIRCULATION INTERVENTIONS
 Shock
 Intravenous access: Peripheral IV, IO
 Fluid resuscitation
 20 ml/Kg NS/LR over 5-10 min, repeat prn
 Administer oxygen
 Medications
 Vasoactive agents (Central line)
 Antibiotics
 Epinephrine
 EXAMINATION
 D- DISABILITY
 A rapid evaluation of neurologic function
 Important indicators of cerebral function
 Decreased level of consciousness
 A: Alert, Active, Awake
 V: Voice
 P: Painful
 U: Unresponsive
 Glasgow Coma Scale (Head injury)
 Loss of muscular tone
 Seizures
 Pupil dilation
 EXAMINATION
 E- EXPOSURE
 Undress the patient
 Check for signs of trauma
 Bruising, bleeding, burns, deformity
 Check the core temperature
 Hypothermia
 Fever
 BURNS
 CLASSIFICATION
 Superficial (1st degree)
 Dry, warm, painful
 Partial thickness (2nd degree)
 Superficial dermis: Red, very painful, blistered
 Deep dermis: Dry, white, hyposensitive
 Full thickness (3rd degree)
 Anesthetic, dry, white, leathery
 BURNS
 MANAGEMENT
 Superficial: Heal in 10-14 days
 Analgesia, cool compresses
 Leave open
 Partial thickness: Heal in 2-3 weeks
 Debride, clean, dress daily, Silvadene/bacitracin ointment
 Leave blisters intact
 Accuzyme ointment
 Serial exams: refer for disfigurement/contractures
 Analgesics especially before dressing changes
 BURNS
 MANAGEMENT
 Full thickness
 ABCDE in severe injury
 Consultation with/transfer to PICU, Burn unit
 Fluids
 Volume replacement:
 4 ml/Kg/%BSA burned for 1st 24 hrs (Parkland)
 Give ½ in 1st 8 hrs plus maintenance volume & remaining ½
over next 16 hours
 BURNS
 DISPOSITION
 Outpatient therapy for superficial & partial thickness
burns
 Admission for major burns
 > 10% BSA with partial thickness burns
 > 2% BSA with full thickness burns
 Severe burns involving eyes, ears, face, hand/feet, or with
associated fractures
 High voltage electrical burns
 Child abuse/ neglect
 Associated smoke inhalation
 BITES & STINGS
 ANIMAL BITES
 General
 Irrigate & debride if possible.
 Do not suture unless necessary for cosmetic reasons (face).
 X-ray head and hand bites (fractures, puncture skull).
 Surgical consultation if bite involves tendons, joints, deep
fascial layers, major vasculature.
 Serious or infected wounds should be irrigated, debrided,
explored and closed, if indicated, in OR.
 Consider most wild carnivores as rabid unless proven
negative by brain fluorescein antibody test (skunk, raccoon,
bat, fox)
 Remember tetanus vaccination if not up to date.
 Follow up in 24-48 hours.
 BITES & STINGS
 DOG BITES
 Most frequent cause of fatality from animal bites in
children.
 Tearing/crushing type injuries
 Consider admission for cranial bites by a large animal.
 Prophylactic antibiotics do not improve outcomes in
uncomplicated bites not involving the hands/feet.
 Culture if infected or if > 12 hrs since bite occurred.
 Staph aureus: trimethoprim/sulfamethoxazole
 Pasturella multocida: amoxicillin/clavulanic acid,
45 mg/Kg/day in 3 doses
 BITES & STINGS
 CATS
 Puncture type wounds
 Frequently infected
 Pasturella
 Amoxicillin/clavulanic acid prophylaxis
 BITES & STINGS
 HUMAN
 Frequently infected
 Staph, Strep, anaerobes, Eikenella
 Amoxicillin/clavulanic acid x 5-10 days
 Consider possible child abuse
 Evaluate risk of transmission of HBV, HIV, HSV
 BITES & STINGS
 RABIES PROPHYLAXIS
 Dogs, cats, ferrets
 If animal available & healthy, observe for 10 days
 No prophylaxis unless animal develops symptoms
 If rabid or suspected, euthanize and test brain
 Immediate immunization and rabies immunoglobulin
 Unknown
 Consult public health department
 Wild carnivores (Bat, fox, raccoon, skunk)
 Regard as rabid unless brain is tested and negative on
fluorescein antibody test
 Immediate immunization and RIG
 BITES & STINGS
 RABIES PROPHYLAXIS
 Rabies Immunoglobulin (RIG)
 20 IU/Kg
 Infiltrate wound(s) with RIG. May dilute 2-3 times to
infiltrate all wound areas.
 Give remainder IM.
 May give at same time with vaccine but at different sites.
 It is preferred to begin RIG within 7 days of starting
vaccine but, if indicated, use both regardless of interval
between exposure and initiation of treatment.
 BITES & STINGS
 RABIES PROPHYLAXIS
 Immunization
 Vaccine reactions are rare in children.
 3 vaccines available in US
 1 ml IM on day 1, 3, 7, 14, 28 for 5 doses
 May discontinue if brain test is negative
 BITES & STINGS
 INSECTS
 Bees, wasps, fire ants, stinging caterpillars usually
 General measures
 Clean area
 Remove stinger if present
 Cool compresses, elevate
 Mild analgesics
 Oral antihistamines
 Consider corticosteroids for severe local reactions, severe
swelling
 Check tetanus status
 BITES & STINGS
 INSECTS
 Anaphylaxis
 The most serious concern
 Symptoms
 Chest/neck tightness
 Dizziness/syncope
 Disorientation
 Swelling
 Upper airway obstruction
 Wheezing/Respiratory distress
 Urticaria
 Hypotension
 BITES & STINGS
 INSECTS
 Anaphylaxis
 Treatment
 ABCDE
 Administer oxygen
 Administer epinephrine
 1:1,000; 0.01 mg/Kg SQ q 15 min prn or
 1:10,000: 0.01 mg/Kg IV/IO q 3-5 minutes to max 1 mg if
hypotensive for age.
 If patient remains hypotensive, give by continuous infusion, 0.1-1
umg/Kg/minute.
 Prescribe IM autoinjector (0.3 mg > 30 KG; 0.15 mg 10-30 Kg)
 Albuterol by nebulization for wheezing/respiratory distress.
 HEAT ILLNESS
 HYPOTHERMIA
 Definition: A core temperature of < 35 C (95 F)
 Causes
 Submersion accidents
 Septic shock
 Encephalopathy
 Accidental ingestions
 Metabolic disorders
 HEAT ILLNESS
 HYPOTHERMIA
 Peripheral vasoconstriction leads to increased muscle
tone, increased metabolism & shivering.
 At < 28 C (82.4 F), pupils are fixed & dilated. There is no
pulse or spontaneous respirations and the patient is rigid.
 Death cannot be declared until the patient is re-warmed
to at least 30 C (86 F) and resuscitated. Patients can
survive submersion times of up to 40 minutes and
prolonged CPR of > 2 hrs.
 Re-warm with passive techniques, body cavity irrigation,
ECMO (best) or cardiopulmonary bypass.
 HEAT ILLNESS
 HEAT STROKE
 Heat exposure resulting in a core temperature of > 40
C (104 F) with associated neurologic signs.
 Combative
 Disoriented
 If severe
 nuchal rigidity
 seizures
 posturing
 coma
 HEAT ILLNESS
 HEAT STROKE
 Complications
 Rhabdomyolysis
 Acute tubular necrosis
 DIC
 Hepatic degeneration
 Electrolyte derangements
 ARDS
 HEAT ILLNESS
 Heat Stroke
 Treatment
 ABCDE
 Cool patient (Cooling blankets, ice)
 IV fluids/fluid resuscitation
 Monitors
 Labs
 Admit
 HEAT ILLNESS
 HEAT CRAMPS
 Occurs during exercise with heat exposure
 Self limited
 Painful
 Temperature normal or only slightly elevated
 Rehydrate
 Occasionally requires IV fluids
 HEAT ILLNESS
 HEAT EXHAUSTION
 Temperature normal or only slightly elevated
 Symptoms
 Weakness
 Disorientation
 Nausea/vomiting
 Headache
 Increased thirst
 Muscle cramps
 No major CNS symptoms
 HEAT ILLNESS
 HEAT EXHAUSTION
 Treatment
 Fluid replacement
 Often requires IV access
 RESOURCES
 Pediatric Advanced Life Support, AHA/AAP,
Provider Manual, 2011
 The Harriet Lane Handbook, The Johns Hopkins
Hospital, 18th edition
 American Academy of Pediatrics, Red Book, 27th
edition
 Nelson’s Pocket Book of Pediatric Antimicrobial
Therapy, 16th edition