1. PEDIATRIC
EMERGENCIES
Dr Varsha Atul Shah

2. Pediatric Emergencies
 Basic
Approach to Pediatric
Emergencies
– Approaches to patient vary with age and
nature of incident
– Practice quick and specific questioning
of the child
– Key on your visual assessment
– Begin your exam without instruments
– Approach the child slowly and gently

3. Pediatric Emergencies
 Basic Approach (cont..)
– Do not separate the child from the
mother unnecessarily
– Be honest and allow the child to
determine the order of the exam
– Avoid touching painful areas until the
child’s confidence has been gained

4. Pediatric Emergencies
 Child’s response to emergencies
– Primary response is fear
 Fear of being separated from parents
 Fear of being removed from home
 Fear of being hurt
 Fear of mutilation
 Fear of the unknown
– Combat the fear with calm, honest
approach
 Be honest - tell them it will hurt if it will
 Use approach language

5. Development Stages -
Keys to Assessment
 Neonatal stage - birth to 1 month
– Congenital problems and other illnesses
often n noted
– Personality development begins
– Stares at faces and smiles
– Easily comforted by mother and
sometimes father
– Rarely febrile, but if so, be cautious of
meningitis

6. Development Stages -
Keys to Assessment
 Approach to Neonates
– Keep child warm
– Observe skin color, tone and respiratory
activity
– Absence of tears when crying indicates
dehydration
– Auscultate the lungs early when child is quiet
– Have the child suck on a pacifier
– Have child remain on the mother’s lap

7. Development Stages -
Keys to Assessment
 Ages 1-5 months - Characteristics
– Birth weight doubles
– Can follow movements with their eyes
– Muscle control develops
– History must be obtained from parents
 Approach
– Keep child warm and comfortable
– Have child remain in mother’s lap
– Use a pacifier or a bottle

8. Development Stages -
Keys to Assessment
 Ages1-5 months - Common
problems
– SIDS
– Vomiting and diarrhea/dehydration
– Meningitis
– Child abuse
– Household accidents

9. Development Stages -
Keys to Assessment
 Ages 6-2 months - Characteristics
– Ability to stand or walk with assistance
– Very active and explore the world with
their mouths
– Stranger anxiety
– Do not like lying supine
– Cling to their mothers

10. Development Stages -
Keys to Assessment
 Ages6-12 months - Common
problems
– Febrile seizures
– Vomiting and diarrhea/dehydration
– Bronchiolitis or croup
– Car accidents and falls
– Child abuse
– Ingestions and foreign body
obstructions
– Meningitis

11. Development Stages -
Keys to Assessment
 Ages 6-12 months - Approach
– Examine the child in the mothers lap
– Progress from toe to head
– Allow the child to get used to you

12. Development Stages -
Keys to Assessment
 Ages 1-3 years - Characteristics
– Motor development, always on the move
– Language development
– Child begins to stray from mother
– Child can be asked certain questions
– Accidents prevail

13. Development Stages -
Keys to Assessment
 Ages 1-3 yrs - Common problems
– Auto accidents
– Vomiting and diarrhea
– Febrile seizures
– Croup, meningitis
– Foreign body obstruction

14. Development Stages -
Keys to Assessment
 Ages 1-3 yrs - Approach
– Cautious approach to gain confidence
– Child may resist physical exam
– Avoid “no” answers
– Tell the child if something will hurt

15. Development Stages -
Keys to Assessment
 Ages 3-5 years - Characteristics
– Tremendous increase in motor
development
– Language is almost perfect but patients
may not wish to talk
– Afraid of monsters, strangers; fear of
mutilation
– Look to parent for comfort and
protection

16. Development Stages -
Keys to Assessment
 Ages 3-5 yrs - Common problems
– Croup, asthma, epiglottitis
– Ingestions, foreign bodies
– Auto accidents, burns
– Child abuse
– Drowning
– Meningitis, febrile seizures

17. Development Stages -
Keys to Assessment
 Ages 3-5 yrs - Approach
– Interview child first, have parents fill in
gaps
– Use doll or stuffed animal to assist in
assessment
– Allow child to hold & use equipment
– Allow them to sit on your lap
– Always explain what you are going to do

18. Development Stages -
Keys to Assessment
 Ages 6-12 years - Characteristics
– Active and carefree
– Great growth, clumsiness
– Personality changes
– Strive for their parent’s attention
 Common problems
– Drowning
– Auto accidents, bicycle accidents
– Fractures, falls, sporting injuries

19. Development Stages -
Keys to Assessment
 Age 6-12 yrs - approach
– Interview the child first
– Protect their privacy
– Be honest and tell them what is wrong
– They may cover up information if they
were disobeying

20. Development Stages -
Keys to Assessment
 Ages 12-15 - Characteristics
– Varied development
– Concerned with body image and very
independent
– Peers are highly important, as is interest
in opposite sex

21. Development Stages -
Keys to Assessment
 Ages 12-15 - Common problems
– Mononucleosis
– Auto accidents, sports injuries
– Asthma
– Drug and alcohol abuse
– Sexual abuse, pregnancy
– Suicide gestures

22. Development Stages -
Keys to Assessment
 Ages 12-15 - Approach
– Interview the child away from parent
– Pay attention to what they are not
saying

23. Development Stages -
Keys to Assessment
 Characteristics
of Parents response
to emergencies
– Expect a grief reaction
– Initial guilt, fear, anger, denial, shock
and loss of control
– Behavior likely to change during course
of emergency

24. Development Stages -
Keys to Assessment
 Parent Management
– Tell them your name and qualifications
– Acknowledge their fears and concerns
– Reassure them it is all right to feel as they do
– Redirect their energies - help you care for child
– Remain calm and in control
– Keep them informed as to what you are doing
– Don’t “talk down” to parents
– Assure parents that everything is being done

25. General Approach to
Pediatric Assessment
 History
– Be direct and specific with child
– Focus on observed behavior
– Focus on what child and parents say
– Approach child gently, encourage
cooperation
– Get down to visual level of child
– Use a soft voice and simple words

26. Physical Exam
 Avoid touching painful areas until
confidence has been gained
 Begin exam without instruments
 Allow child to determine order of
exam if practical
 Use the same format as adult
physical exam

27. General Approach to
Pediatric Assessment
 Physical Exam (cont.)
– Special concerns
 Fontanels should be inspected in infants
– Normal fontanels should be level with surface of
the skull or slightly sunken and it may pulsate
– Abnormal fontanels
 Tight and bulging (increased ICP from trauma
or meningitis)
 Diminished or absent pulsation
 Sunken if dehydrated

28. General Approach to
Pediatric Assessment
 Special concerns (cont..)
– GI Problems
 Disturbancesare common
 Determine number of episodes of vomiting,
amount and color of emesis

29. Pediatric Vital Signs
 Blood Pressure
– Use right size cuff, one that is two-
thirds the width of the upper arm
 Pulse
– Brachial, carotid or radial depending on
child
– Monitor for 30 seconds

30. Pediatric Vital Signs
 Respirations
– Observe the rate before the child
starts to cry
– Upper limit is 40 minus child’s age
– Identify respiratory pattern
– Look for retractions, nasal flaring,
paradoxical chest movement
 Level of consciousness
– Observe and record

31. Noninvasive Monitoring
 Prepare the child before using
devices
– Explain the device
– Show the display and lights
– Let child hear noises if devices makes
them
 Pulseoximetry-particularly useful
since so many childhood
emergencies are respiratory

32. Pediatric Trauma
 Basics
– Trauma is leading cause of death in children
– Most common mechanisms-MVA, burns,
drowning, falls, and firearms
– Most commonly injured body areas-head,
trunk, extremities
– Steps much like those in adult trauma
 Complete ABCDE’s of primary
assessment
 Correct life threatening conditions
 Proceed to secondary assessment

33. Causes of Death
 National  Oklahoma
– MVA 43% – MVA 35%
– Burns 14.9% – Drowning 14.5%
– Drowning 14.6% – Burns 14.0%
– Aspiration 3.4% – Firearms
– Firearms 9.9%
3.0% – Aspiration 5.7%
– Falls 2.0% – Stab/cut ?

34. Frequency of Injured Body Parts
 Head 48%
 Extremities 32%
 Abdomen 11%
 Chest 9%

35. Pediatric Trauma
 Head, face, and neck injuries
– Children prone to head injuries
– Be alert for signs of child abuse
– Facial injuries common secondary to
falls
– Always assume a spinal injury with head
injury

36. Pediatric Trauma
 Chest and abdominal injuries
– Second most common cause of pediatric
trauma deaths
– Most result from blunt trauma
– Spleen is most commonly injured organ
– Treat aggressively for shock in blunt
abdominal injury

37. Pediatric Trauma
 Extremity injuries
– Usually limited to fractures and
lacerations
– Most fractures are incomplete - bend,
buckle,, and greenstick fractures
– Watch for growth plate injuries

38. Pediatric Trauma
 Burns
– Second leading cause of pediatric deaths
– Scald burns are most common
– Rule of nine is different for children
 Eachleg worth 13.5%
 Head worth 18%

39. Pediatric Trauma
 Child abuse and neglect - Basics
– Suspect if injuries inconsistent with
history
– Children at greater risk often seen as
“special” and different
 Premature or twins
 Handicapped
 Uncommunicative (autistic)
 Boys or child of the “wrong” sex

40. Pediatric Trauma
 Child
abuse and neglect - The child
abuser
– Usually a parent or someone in the role
of parent
– Usually spends much time with child
– Usually abused as a child

41. Pediatric Trauma
 Sexual Abuse - Basics
– Can occur at any age
– Abuser is usually someone in family
– Can be someone the child trusts
– Stepchildren or adopted children at higher
risk
 Paramedic actions
– Examine genitalia for serious injury only
– Avoid touching the child or disturbing
clothing
– Provide caring support

42. Pediatric Trauma
 Triggers to high index of suspicion
for child neglect
– Extreme malnutrition
– Multiple insect bites
– Long-standing skin infections
– Extreme lack of cleanliness

43. Pediatric Trauma
 Triggers to high index of suspicion
for child abuse
– Obvious fracture in child under 2 yrs
old
– Injuries in various stages of healing
– More injuries than usually seen in
children of same age
– Injuries scattered on many areas of
body
– Bruises that suggest intentional

44. Pediatric Trauma
 Triggers to high index of suspicion for
child abuse (cont.)
– Suspected intra-abdominal trauma in child
– Injuries inconsistent with history
– Parent’s account vague or changes during
interview
– Accusations that child injured himself
intentionally
– Delay in seeking help
– Child dresses inappropriately for situation

45. Pediatric Trauma
 Management of potentially abused child
– Treat all injuries appropriately
– Protect the child from further abuse
– Notify the proper authorities
– Be objective while gaining information
– Be supportive and nonjudgmental of
parents
– Don’t allow abuser to transport child to
hospital
– Inform ED staff of suspicions of child abuse
– Document completely and thoroughly

46. Pediatric Medical Emergencies -
Neurological
 Pediatric seizures - Common causes
– Fever, infections
– Hypoxia
– Idiopathic epilepsy
– Electrolyte disturbances
– Head trauma
– Hypoglycemia
– Toxic ingestion or exposure
– Tumors or CNS malformations

47. Pediatric Medical Emergencies -
Neurological
 Febrile Seizures
– Result from a sudden increase in body
temperature
– Most common between 6 months and 6 years
– Related to rate of increase, not degree of fever
– Recent onset of cold or fever often reported
– Patients must be transported to hospital

48. Pediatric Medical Emergencies -
Neurological
 Assessment
– Temperature - suspect febrile seizure if temp
over 103 degrees F
– History of seizure
– Description of seizure activity
– Position and condition of child when found
– Head injury, Respirations
– History of diabetes, family history
– Signs of dehydration

49. Pediatric Medical Emergencies -
Neurological
 Management - Basic Steps
– Protect seizing child
– Manage the ABC’s, provide
supplemental oxygen
– Remove excess layers of clothing
– IV of NS or LR TKO rate
– Transport all seizure patients, support
the parents

50. Pediatric Medical Emergencies -
Neurological
 Management - If status epilepticus
– IV of NS or LR TKO rate
– Perform a Dextrostix <80 mg/dl give
D25 2 ml/kg IV/IO if child is less than
12
– 12 or older give D50 1ml/kg IV
– Contact Medical Control if long transport

51. Pediatric Medical Emergencies -
Neurological
 Meningitis - Basics
– Infection of the meninges
– Can result from virus or bacteria
– More common in children than in adults
– Infection can be fatal if unrecognized
and untreated

52. Meningitis
 Assessment
– History of recent illness
– Headache, stiff neck
– Child appears very ill
– Bulging fontanelles in infants
– Extreme discomfort in movement

53. Meningitis
 Management
– Monitor ABC’s and vital signs
– High flow O2, prepare to assist with
ventilations
– IV/IO of LR or NS
– Fluid bolus of 20 ml/kg IV/IO push
 Repeat if no improvement
– Orotracheal intubation if child's
condition warrants

54. Pediatric Medical Emergencies -
Neurological
 Reye’s syndrome - Basics
– “New” disease - Correlated with ASA use
– Peak incident in patients between 5-15
years
– Frequency higher in winter
– Higher frequency in suburban and rural
population
– No single etiology identified
 Possibly toxic or metabolic problem
 Tends to occur during influenza B outbreaks
 Associated with chicken pox virus
 Correlation with use of aspirin use in children

55. Pediatric Medical Emergencies -
Neurological
 Reye’s syndrome - Complications
– Respiratory failure
– Cardiac arrhythmias
– Acute pancreatitis

56. Pediatric Medical Emergencies -
Neurological
 Assessment - Reyes Syndrome
– Severe nausea & vomiting
– Hyperactivity or combative behavior
– Personality changes, irrational behavior
– Progression of restlessness, stupor, convulsions, coma
– Recent history of chicken pox in 10-20% of cases
– Recent upper respiratory infections or gastroenteritis
– Rapid deep respirations, may be irregular
– Pupils dilated & sluggish
– Signs of increased ICP

57. Pediatric Medical Emergencies -
Neurological
 Reye’s syndrome - Management
– General and supportive
– Maintain ABC’s
– Administer supplemental oxygen
– Rapid transport

58. Child’s Airway vs.. Adults
 Smaller septum & nasal bridge is flat and flexible
 Vocal cords located at C3-4 versus C5-6 in adults
– Contributes to aspiration if neck is
hyperextended
 Narrowest at cricoid ring instead of vocal cords
 Airway diameter is 4 mm vs.. 20 mm in adult
 Tracheal rings more elastic & cartilaginous, can
easily crimp off trachea
 More smooth muscle , makes airway more
reactive or sensitive to foreign substances

59. 5 Most Common Respiratory
Emergencies
 Asthma
 Bronchiolitis
 Croup
 Epiglotitis
 Foreign bodies

60. Asthma
 Pathophysiology
– Chronic recurrent lower airway disease with
episodic attacks of bronchial constriction
 Precipitating factors include exercise, psychological
stress, respiratory infections, and changes in weather
& temperature
 Occurs commonly during preschool years, but also
presents as young as 1 year of age
– Decrease size of child’s airway due to edema &
mucus leads to further compromise

61. Asthma
 Assessment
– History
 When was last attack & how severe was it
 Fever
 Medications, treatments administered
– Physical Exam
 SOB, shallow, irregular respirations, increased or
decreased respiratory rate
 Pale, mottled, cyanotic, cherry red lips
 Restless & scared
 Inspiratory & expiratory wheezing, rhonchi
 Tripod position

62. Asthma
 Management
– Assess & monitor ABC’s
– Big O’s (Humidified if possible)
– IV of LR or NS at a TKO rate
– Assist with prescribed medications
– Prepare for vomiting
– Pulse oximeter
– Intubate if airway management becomes
difficult or fails

63. Bronchiolitis
 Basics
– Respiratory infection of the bronchioles
– Occurs in early childhood (younger than 1
yr)
– Caused by viral infection
 Assessment/History
– Length of illness or fever
– has infant been seen by a doctor
– Taking any medications
– Any previous asthma attacks or other
allergy problems

64. Bronchiolitis
 Signs & symptoms
– Acute respiratory distress
– Tachypnea
– May have intercostal and suprasternal
retractions
– Cyanosis
– Fever & dry cough
– May have wheezes - inspiratory & expiratory
– Confused & anxious mental status
– Possible dehydration

65. Bronchiolitis
 Management
– Assess & maintain airway
– When appropriate let child pick POC
– Clear nasal passages if necessary
– Prepare to assist with ventilations
– IV LR or NS TKO rate
– Intubate if airway management
becomes difficult or fails

66. Croup
 Basics
– Upper respiratory viral infection
– Occurs mostly among ages 6 months to 3
years
– More prevalent in fall and spring
– Edema develops, narrowing the airway lumen
– Severe cases may result in complete
obstruction

67. Croup
 Assessment/History
– What treatment or meds have been given?
– How effective?
– Any difficulty swallowing?
– Drooling present?
– Has the child been ill?
– What symptoms are present & how have they
changed?

68. Croup
 Physical exam
– Tachycardia, tachypnea
– Skin color - pale, cyanotic, mottled
– Decrease in activity or LOC
– Fever
– Breath sounds - wheezing, diminished breath
sounds
– Stridor, barking cough, hoarse cry or voice

69. Croup
 Management
– Assess & monitor ABC’s
– High flow humidified O2; blow by if child won’t
tolerate mask
– Limit exam/handling to avoid agitation
– Be prepared for respiratory arrest, assist
ventilations and perform CPR as needed
– Do not place instruments in mouth or throat
– Rapid transport

70. Epiglotitis
 Basics
– Bacterial infection and inflammation of the
epiglottis
– Usually occurs in children 3-6 years of age
– Can occur in infants, older children, & adults
– Swelling may cause complete airway
obstruction
– True medical emergency

71. Epiglotitis
 Assessment/History
– When did child become ill?
– Has it suddenly worsened after a couple of
days or hours?
– Sore throat?
– Will child swallow liquids or saliva?
– Is drooling present?
– High fever (102-103 degrees F)
– Onset is usually sudden

72. Epiglotitis
 Signs & Symptoms
– May be sitting in Tripod position
– May be holding mouth open, with tongue protruding
– Muffled or hoarse cry
– Inspiratory stridor
– Tachycardia, tachypnea
– Pale, mottled, cyanotic skin
– Anxious, focused on breathing, lethargic
– Very sore throat
– Nasal flaring
– Look very sick with high fever

73. Epiglotitis
 Management
– Assess & monitor ABC’s
– Do not make child lie down
– Do not manipulate airway
– High flow humidified O2; blow by if child won’t
tolerate mask
– Limit exam/handling to avoid agitation
– Be prepared for respiratory arrest, assist
ventilations and perform CPR as needed
– Contact medical control

74. Aspirated Foreign Body
 Basics
– Common among the 1-3 age group who
like to put everything in their mouths
– Running or falling with objects in mouth
– Inadequate chewing capabilities
– Common items - gum, hot dogs, grapes
and peanuts

75. Aspirated Foreign Body
 Assessment
– Complete obstruction will present as
apnea
– Partial obstruction may present as
labored breathing, retractions, and
cyanosis
– Objects can lodge in the lower or upper
airways depending on size
– Object may act as one-way valve
allowing air in, but not out

76. Aspirated Foreign Body
 Management - Complete Obstruction
– Attempt to clear using BLS techniques
– Attempt removal with direct
laryngoscopy and Magill forceps
– Cricothyrotomy may be indicated

77. Aspirated Foreign Body
 Management - Partial obstruction
– Make child comfortable
– Administer humidified oxygen
– Encourage child to cough
– Have intubation equipment available
– Transport to hospital for removal with
bronchoscope

78. Mild, Moderate, & Severe Dehydration
 History
– Previous seizures, when it began, how long
– Reason for seizure
– When were fluids last taken, how much, is it
usual for the child
– Current fever or medical illness
– Behavior during seizure
– Last wet diaper
– Any vomiting or diarrhea
– Other medical problems

79. Mild, Moderate, & Severe Dehydration
 Physical Assessment/Signs & symptoms
– Onset very abrupt
– Sudden jerking of entire body, tenseness, then
relaxation
– LOC or confusion
– Sudden jerking of one body part
– Lip smacking, eye blinking, staring
– Sleeping following seizure

80. Mild, Moderate, & Severe Dehydration
 Physical Assessment/ Vital signs
– Capillary refill
– Skin color
– Alertness, activity level

81. Mild, Moderate, & Severe Dehydration
 Mild dehydration
– Infants lose up to 5% of their body
weight
– Child lose up to 3-4% of their body
weight
– Physical signs of dehydration are barely
visable

82. Mild, Moderate, & Severe Dehydration
 Moderate Dehydration
– Infants lose up to 10% of their body
weight
– Children lose up to 6-8% of their body
weight
– Poor skin color & turgor, dry mucous
membranes, decreased urine output &
increased thirst, no tears

83. Mild, Moderate, & Severe Dehydration
 Severe Dehydration
– Infants lose up to 15% of their body
weight
– Child lose up to 10-13% of their body
weight
– Danger of life-threatening hypovolemic
shock

84. Mild, Moderate, & Severe Dehydration
 Management
– If mild or moderate
 Givefluids orally if there is no abdominal
pain, vomiting or diarrhea and is alert
– Severe
 High flow O2
 IV/IO with NS or LR
 Fluid bolus of 20 ml/kg IV/IO push
 Repeat fluid bolus if no improvement

85. Congenital Heart Disease
 Blood is permitted to mix in the 2
circulatory pathways
– Primary cause of heart disease in
children
– Various structures may be defective
– Hypoxemia usually results

86. Congenital Heart Disease
 History
– Name of defect to share with medical control
– Any meds taken routinely, were they taken
today
– Any other home therapies (O2, feeding
devices)
– Any recent illness or stress
– Child's color
– What kind of spell, how long did it last
– Ant treatment given

87. Congenital Heart Disease
 Signs & symptoms
– Intercostal retractions, difficulty breathing,
tachypnea, crackles or wheezing on
auscultation
– Tachycardia, cyanosis with some defects
– Altered LOC, limpness of extremities,
drowsiness
– Cool moist skin, cyanosis, pallor
– Tires easily, irritable if disturbed,
underdeveloped for age
– Uncontrollable crying, irritability
– Severe breathing difficulty, progressive

88. Congenital Heart Disease
 Management
– Monitor ABC’s & vitals
– Maintain airway/administer high flow O2
– Assist ventilations as needed, intubate if
needed
– Cyanotic spell, place in knee chest position
– Prepare to perform CPR
– Establish IV TKO if lengthy transport time is
anticipated

89. Home High Technology Equipment
 Chronic & terminal illness
– Respiratory & cardiac
 Premature infants
 Cystic Fibrosis
 Heart defects & post transplant patients

90. Home High Technology Equipment
 Ventilators
 Suction
 Oxygen
 Tracheostomy
 IVpumps
 Feeding pumps

91. Home High Technology Equipment
 Management
– Support efforts of parents
– Home equipment malfunction, attach
child to yours
– Monitor ABC’s & treat as patient’s
condition warrants
– Have hospital notify child’s physician if
possible