pediacute

Management of Common Pediatric Emergencies & Urgent Medical Presentations in the Office : 

Management of Common Pediatric Emergencies & Urgent Medical Presentations in the Office N5305 Child Health II, Summer 2007 Priscilla Rieves, MS, RN, CPNP

Pediatric Trauma : 

Pediatric Trauma Children= developmental risk for injury Natural risk due to curiosity Impulsiveness Impatience Driven to test and master new skills Limited understanding of fear

Pediatric Trauma : 

Pediatric Trauma Populations at higher risk for injury: Males 2:1 Minorities Low economic resources Single parent households

Anaphylaxis : 

Anaphylaxis Acute reaction when antigen introduced systemically into an individual who has preexisting IgE antibodies Clinical findings Difficulty breathing – constriction of major airways Shock – hypotension caused by histamine release

Anaphylaxis : 

Anaphylaxis Usual Causes Food Eggs, fish, milk, peanuts, shellfish, soybeans, tree nuts Insect stings Medications (PCN) Radiocontrast media Latex Antitoxins to tetanus Mannitol, radiocontrast material, opiates and vancomycin may degranulate mast cells and cause a reaction that resembles anaphylaxis

Anaphylaxis : 

Anaphylaxis History Usually starts within hour of exposure, but can occur over seconds to hours Starts with face flush, palms and soles, pruritis on head, palms and soles May see angioedema in lips and eyes Pruritis and watery discharge from nose and eyes Crampy abdominal pain

Anaphylaxis – HX cont : 

Anaphylaxis – HX cont Impaired airway (breathing) from swollen lips, tongue, larynx, epiglottis and surrounding tissues Bronchospasm – chest tight, sob, cough and wheeze Cardiovascular- mild hypotension to cardiovascular collapse with hypotensive shock

Anaphylaxis : 

Anaphylaxis Patients at higher risk Asthmatics because they are already hyperactive and have compromised airways Prevention: Avoid cause if at all possible Use injectable epinephrine when symptoms start to escalate

Treatment of Acute Anaphylaxis : 

Treatment of Acute Anaphylaxis Epinephrine 1:1000 dilution (1 mg/ml) injected at 10 – 20 minute intervals at 0.01 ml/kg SQ per dose, max dose of 0.3 per dose Oxygen Albuterol Administration of diphenhydramine and corticosteroids

What to tell parents : 

What to tell parents Parents should seek medical attention if child has any of following symptoms after exposure to allergen (new food, inhaling something, getting a shot, insect sting) Tingling or numbness around mouth Difficulty breathing Coughing or wheezing (high pitched sounds from lungs) Swelling of hands and face Tightness to chest or throat Difficulty breathing or feels anxious Stomach cramps, vomiting and diarrhea Pounding heart fainting

What to do? : 

What to do? Make sure if see child with reaction that they have an epi pen at home and instruct how/when to use Allergy testing Immunocap for food and environment to identify source if unknown Proper instruction re: insect repellent, layered clothing Teach children (if age appropriate) when to notify their parent if feeling “funny”.

Respiratory Distress : 

Respiratory Distress Unique anatomic airway considerations in children: Upper airway small/ prone to obstruction Large head and prominent occiput/ head and chin tilt toward chest when supine Narrowest part of airway at cricoid ring in subglottic space/ easily obstructed when soft tissue inflamed

Respiratory Distress : 

Respiratory Distress Risk Factors Family or child hx of anaphylaxis, allergies, eczema, asthma, urticaria Previous history of food intolerance Residence in area with high levels pollution or naturally occurring respiratory irritants Exposure to allergens in the home

Respiratory Distress : 

Respiratory Distress Assessment: Grunting Nasal flaring Chest wall retractions Use of accessary muscles Cyanosis (severe hypoxemia) Percussion Hyperresonant (hyperinflation) Dullness (atalectasis, pulmonary consolidation, or pleural effusion)

Respiratory Distress : 

Respiratory Distress Auscultation Crackles (rales): intermittant, low or higher pitched, generally inspiratory, produced by opening airways, closed during previous expiration. Wheezes: continuous, high-pitched, rumbling or sonorous Stridor: type of wheeze, harsh, predominately inspiration, localized over the central trachea and bronchi

Respiratory Distress : 

Respiratory Distress Management based on cause: Take pulse oximetry reading for baseline Take reading after treatment If sats not coming up place on O2 Recheck pulse oximetry once on O2 O2 masks Must have holes or one way valves in place to allow patient to blow off CO2

Respiratory DistressCommon Pulmonary Emergencies : 

Respiratory DistressCommon Pulmonary Emergencies Status Asthmaticus Asthma exacerbation- smooth muscle spasm, mucosal edema & mucous plugging Leads to airflow obstruction with air trapping Mismatch in ventilation-perfusion r’ships Status asthmaticus occurs when pt doesn’t respond to initial doses of bronchodilators

Respiratory Distress : 

Respiratory Distress Status Asthmaticus- Presentation Wheezing and coughing child Signs anxiety re: ↑ WOB PASS score (Gorelick) used in ER Pediatric Asthma Severity Score

Respiratory Distress : 

Respiratory Distress Status Asthmaticus- Treatment Continuously monitor cardiorespiratory status B-agonists Albuterol levabuteral (used with albuterol prevented hosp) Terbutaline epinephrine

Respiratory distress : 

Respiratory distress Corticosteroids (Nat’l Asthma Education and Prevention Program Guidelines) Use if don’t respond to inhaled B-agonists Oral is effective as parenteral during asthma exacerbation Will decrease chance of hospitalization 1-2 mg/kg/day (max 60) in 2 divided doses/day Length single day to up to 7

Sudden Infant Death Syndrome : 

Sudden Infant Death Syndrome Sudden death of an infant under 1 year of age which remains unexplained after thorough case investigation, including performance of complete autopsy, examination of death scene, and review of clinical history Is most common cause of infant death under 6 months of age and remains diagnosis of exclusion

Sudden Infant Death Syndrome : 

Sudden Infant Death Syndrome Poorly understood disorder Postmortum exam important feature # deaths peaks at 2 months or age Age range- few weeks- 6 months Increase deaths during respiratory virus season

Sudden Infant Death Syndrome : 

Sudden Infant Death Syndrome Deaths occur between midnight and 0800 More common among minorities and socioeconomically disadvantaged populations 3:2 male predominance

Sudden Infant Death SyndromeManagement : 

Sudden Infant Death SyndromeManagement Obtain thorough history looking at circumstances around death rather than wrongdoing of parents Reassure parents they aren’t to blame Offer support to parents/ support groups Support siblings and help parents support them and understand reactions

Sudden Infant Death Syndrome : 

Sudden Infant Death Syndrome Provide follow-up at key times (birthdays, holidays) for first year Evaluate need for monitoring of succeeding children Prevention Back to sleep Firm mattress/no pillow or stuffed animals Avoid overheating (espec. Environment) Avoid smoking Avoid drugs/alcohol during pregnancy and lactation

Shock : 

Shock Common causes in child: Anaphylaxis Anaphylactoid reaction Spinal cord injury/ spinal shock Head injury Sepsis Drug intoxication: barbiturates, Phenothiazine, antihypertensive agents Arrythmias, congenital and acquired heart disease Thyrotoxicosis

Shock : 

Shock Initial Assessment Vital signs (hypotension, tachycardia, tachypnea) Auscultate chest for cardiopulmonary functioning Evaluate peripheral perfusion Evaluate skin temp and diaphoresis Evaluate for hypothermia and decreased urine output Assess liver size Obtain enough history to attempt to determine etilogy of the disturbance

Shock : 

Shock Management Transfer child ASAP to medical facility Position child in recumbent or trendelenburg’s position Administer O2 judiciously Evaluate and provide early intervention for cause (hemorrhage, treat anapylaxis-etc) Fluid resuscitation with NS or LR if available

Head Injury : 

Head Injury Common cause of injury in child since head large in proportion to body. If child hit by car most common injuries lower chest abdomen, head and neck Note time of event- several days ago and have HA or just happened LOC/change in behavior Seizure Vomiting (especially if projectile) Concurrent injury such as cervical

Head Injury : 

Head Injury Physical Assessment Scalp for laceration, swelling, hematoma Drainage from ears and nose Neuro Assessment LOC Orientation- age appropriate, for infants, would be VERY irritable Pupillary responses- size, reactivity, speed Movement– symmetrical, strength in extremities DTR’s Infants- assess fontanels

Concussion : 

Concussion Clinical features: Amnesia, brief unconsciousness Dizziness Headache Vomiting Management: Acetaminophen- stronger meds can mask problems Close observation at home if uncomplicated Wake child every 2 hrs for first 24 (child should awaken easily and be able to stay awake few minutes)

Concussion - Management: : 

Concussion - Management: Teaching: Take to ER IF: Unusual irritability or behavioral change Increased drowsiness or unconsciousness Vomiting more than 1-2 times Neck pain Bloody or watery discharge from ear or nose Seizure or fainting HA that gets worse or lasts > one day Unequal pupils Trouble with vision, hearing or speech Difficulty walking or muscle weakness

Concussion : 

Concussion Complicated: Loss of consciousness > 5 minutes Persistent symptoms Inadequate home observation Would proceed with CT scan and possible hospitalization

Skull Fracture : 

Skull Fracture Linear fractures – disruption in integrity of skull occurring at point of impact. Accounts for 75% of pediatric head injuries Basilar Skull Fracture – linear skull fracture at the base of the skull Can cause tears in sack compartments that hold the brain Often leads to CSF leaks

Basilar Skull Fracture : 

Basilar Skull Fracture Clinical findings History of trauma Facial muscle weakness Problems with facial sensation May complain of “smelling difficulties” CSF leak- clear or serosanguenous may leak from nose or ears Battle sign- peri-auricular ecchymosis (blood in ear canals) Raccoon Eyes- periorbital swelling and ecchymosis (usually after 12 hours)

Basilar Skull Fracture : 

Basilar Skull Fracture Treatment- transport to ER Elevate Head Do not pack nose or ears if CSF leakage suspected (place gauze over them) Fluid restriction CT scan Lab testing of drainage from nose or ears to determine if CSF May require lumbar subarachnoid drainage of excess fluid Prophylactic antibiotics sometimes given – high chance of meningitis due to direct contact of bacteria in paranasal sinuses, nasopharynx and middle ear. IF have CSF leakage = higher risk. May need surgical repair

Eye Trauma : 

Eye Trauma History of Eye injury Visual status of child prior to injury Visual acuity Use of corrective lenses Inability to open eye Check Visual Fields for deficits Palpate the orbital rim Examine pupils, note size and reaction Examine cornea and conjunctive If extreme swelling, suspect orbital fracture or any difficulty with movements should be referred to opthamologist

Eyelid lacerations : 

Eyelid lacerations History always want to ask about mechanism of injury to determine presence of contaminants Cleanse the wound Wound closure- see Page 1134-1135 of Burns book) Some offices have glue (dermabond) can be tricky on eye- steri strips if superficial Give tetanus booster as appropriate See back for follow-up Refer to opthamology if any concern about: Disruption of lacrimal system (can’t produce tears) Foreign bodies- that can’t remove Occult perforations of the globe Note: Barbara covered corneal abrasions in eye lecture

Other Eye Injuries : 

Other Eye Injuries Penetrating Foreign Body Immobilize the patient and protect eye Elevate HOB 30 degrees to decrease IO pressure Transfer to emergency facility Chemical Burn Alkali substance more damaging, deeper penetration, greater risk for loss of vision Acids more superficial, slower penetration Household cleaning agents common cause Eye should be flushed immediately Child needs to go to ER Can result in loss of vision or loss of eye

Abrasions : 

Abrasions Clean wound and apply antibiotic ointment Cover with dressing until eschar forms Deep or extensive abrasion with embedded material- Topical anesthesia and aggressive cleaning Teach family about wound care

Lacerations : 

Lacerations Management (general considerations) Deeper the wound, more difficult to close Goal is to preserve function and promote cosmetic integrity with minimal scarring Wounds should be closed within 12-24 hours (golden window 8-12 hr) Check wounds within 48-72 hours for signs infection Consider splinting

Lacerations : 

Lacerations Consult specialist Lacerations to face, lips hands genitalia, mouth or periorbital area Bite wounds are not sutured Longer sutures left in, greater the scarring and potential for infection

Suturing : 

Suturing Adequate restraint as appropriate Local anesthesia- can use lidocaine with epi (buffered) inject around circumference of wound Cannot use buffered lidocaine on fingers, toes, ears or penis (straight lidocaine only). Can apply topical as well Never shave the eyebrow (will need to suture right through it) Control bleeding sites Debride prior to suturing

Suturing : 

Suturing Parent instructions How to clean and dress wound Suture removal Face 4-5 days Scalp 5-7 days Palms, hands, arms, trunk 7-10 days Legs 10-14 days Will have entire lab and lecture on suturing during preceptorship semester!

Cat and Dog bites : 

Cat and Dog bites Dog bites= 89-90% of animal bites Infection develops in 20% Cat bites = 15% of animal bites Usually present as puncture wounds 30-40% become infected Due to razor sharp small teeth that penetrate deeply into soft tissue

Cat and Dog bites : 

Cat and Dog bites History- Circumstances of Injury Provoked animal Animal’s immunization status Tetanus immunization status of child Current medications Wound measurement Photographs

Cat and Dog bites : 

Cat and Dog bites Bite wounds polymicrobial contamination Pastuerella Multocida (gram negative anaerobe) present in oropharynx of dogs and cats Found in 20-30% of dog bite wounds and > 50% of cat bites

Cat and Dog bites/ Management : 

Cat and Dog bites/ Management Cleanse wound irrigate with normal saline with a use 22 gauge IV catheter if possible on a 30-60 cc syringe (No betadine directly in wound) Debride devitalized or crushed tissue Deep puncture wounds that are seen > 24 hours after injury are considered clinically infected Bites of hand should not be closed primarily

Cat and Dog bites/ Management : 

Cat and Dog bites/ Management Low risk- wounds seen within first 24 hours after injury (these may be sutured) Uninfected high risk- wounds seen 72 hours later and may need to undergo delayed primary closure

High Risk Wounds requiring prophylactic antibiotics : 

High Risk Wounds requiring prophylactic antibiotics Full thickness puncture wounds- severe crush and/or edema present with wounds or wounds requiring debridement Bite wounds of hand, foot or face, bone, joint, tendon or ligament or wound adjacent to a prosthetic joing Underlying diabetes, liver or pulmonary disease, history of spleenectomy, malignancy, HIV or other immunocompromising condition Prophylactic antibiotcs used for 3-7 days

Infected Wounds/Treatment : 

Infected Wounds/Treatment Usually Augmentin Treat cellulitis for 10-14 days Culture wound AFTER DEBRIDING, if MRSA will need Bactrim or Clindamycin

Evaluation of Pediatric Burns : 

Evaluation of Pediatric Burns Types 1st degree- superficial, characterized by redness and pain 2nd degree- involves epidermis and varying thickness of dermal layer, skin is red and develops painful blisters 3rd degree- destroys both layers of skin, skin is whitish, charred and leathery Need to calculate percentage of total body area involved Rule of nines- adults Berkow chart- children

Evaluation of Pediatric Burns : 

Evaluation of Pediatric Burns Management Initially- Stop burning process must remove clothing or irritant over the burn area ABC’s Get history of how happened, including potential for inhalation injury

Evaluation of Pediatric Burns : 

Evaluation of Pediatric Burns Management Ongoing 1st degree- symptomatic pain relief (analgesics, creams/lotions) Small 2nd and 3rd degree Analgesics/conscious sedation Wound debridement- cleaning, removal of devitalized tissue but do NOT break blisters Topical antibiotics- silvadene to penetrate burn eschar and establish antibacterial layer (applied BID) keep in frig at home and office

Evaluation of Pediatric Burns : 

Evaluation of Pediatric Burns Management Ongoing (small 2nd and 3rd degree_ Cleanse with warm saline or mild soap and water Be sure to leave blisters intact Daily follow up Medicate with Ibuprofen, tylenol or tylenol with codiene if appropriate Cleanse wound twice daily Apply topical antibacterial such as Silvadene and Bacitracin Keep Silvadene in Fridge

Evaluation of Pediatric Burns : 

Evaluation of Pediatric Burns Management Ongoing more extensive Refer to ER IV access with 2 large bore IV’s Fluid resuscitation (2-4 ml RL x %TBSA , ½ first 8 hours, remainder next 16 hours) Maintain body temperature Monitor urine output Cover wounds and pain management Check immunizations

Evaluation of Pediatric Burns : 

Evaluation of Pediatric Burns Burn referral Criteria- per American Burn Association 2nd and 3rd degree burns > 10% TBSA in patients < 10 years of age 2nd and 3rd degree burns to perineum, genitalia, extremities, face and major joints 3rd degree burns > 5% TBSA ANY AGE Electrical burns Chemical burns Associated inhalation injury Circumferential burns of extremities/chest Any burn injury with serious pre-existing medical condition Severe/extensive burns require aggressive resuscitation and transfer to burn center

Electrical burns : 

Electrical burns Minor Common electrical cord across mouth Clean wound Allow to heal, may need appliance to keep corners of mouth from adhering Warn parents that common complication is erosion of labial artery to the lip- can occur week after the burn

Chemical Burns : 

Chemical Burns Treatment in Clinical site Lavage area with water immediately to return skin to normal pH Evaluate for chemical inhalation Manage burn as you would others

Emergencies in Adolescents: : 

Emergencies in Adolescents: 15 year old girl presents after 2 weeks of heavy menses (10-12 tampons/day) complaining of pallor, lightheadedness and fatigue. She has fallen once or twice but has no abdominal or pelvic pain. PE: HR 105, BP 110/76. Remainder of vital signs within normal limits

Acute Menorrhagia : 

Acute Menorrhagia Common problem in adolescent females Anovulatin is cause 80% of time Results in lack of progesterone to stabilize endometrium from unopposed estrogen stimulation, leaving thick, fragile and vascular endometrium Progesterone aids in vasospasm and clotting so menstruation is heavy when it occurs Can constitute emergency if severe

Acute Menorrhagia : 

Acute Menorrhagia Management Need to quantify menstrual blood loss Menorrhagia- menstrual blood loss of 80 ml or more during cycle There are pictoral blood loss charts that can be used based on amount of pads used. If lose > 80 ml blood with cycles, will be anemic so can do H&H, along with retic and ferritin. Always consider possibility of spontaneous abortion

Acute Menorrhagia : 

Acute Menorrhagia Other things to consider- Cervicitis- can present with irregular menstrual periods as first sign May need to check for chalmydia and gonorrhea (by urine or cervical swab) Tests are indicated EVEN if teen denies sexual activity Consider evaluation for coagulopathy (19% of teens hospitalized for menorrhagia were found to have clotting disorder) Do coag panel with platelet count, And von Willebrand’s disease workup

Acute Menorrhagia : 

Acute Menorrhagia Other Causes of Menorrhagia in Teen: Malignancy Polyps Endometriosis PCOS (polycystic ovarian syndrome) Endometriosis Fibroids May do Pelvic US Thyroid Panel!!!! 17-hydroxyprogesterone, androstenedione and DHEA levels

Acute Menorrhagia : 

Acute Menorrhagia Work up of this case reveals: Hgb 8.3%, HCT 25%, retic 1.2%, normal platelets and negative pregnancy test Teen transported to hospital for severe anemia Crystalloid bolus given PRBC transfusion IV conjugated estrogen every 4-6 hours until bleeding stops Antiemetics as estrogen causes nausea High dose progesterone to stabilize fragile endometrium

Acute Menorrhagia : 

Acute Menorrhagia After stabilization in hospital: Oral contraceptives- to stabilize the endometrium and allow for rebuilding of iron stores

Case Emergency in Teen Girl # 2 : 

Case Emergency in Teen Girl # 2 16 year old presents to clinic with mother and they ask for referral for counseling. Her mother reports her daughter has been acting sad since they moved to the area 2 months ago. The day before she had left a note saying she needed to talk to someone. A referral for counseling is made but what else needs to be done at this visit?

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Suicide third leading cause of death in girls ages 10-24 Counseling and SSRI’s seem to be effective in treating adolescents New concerns about suicide on SSRI’s Fewer than 1/3 of suicidal adolescents access counseling Adults often view depression as normal part of adolescence

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Need to assess her risk for suicide (complete assessment) Acutely suicidal referral to counselor in future may be too late Study looked at group of suicidal teens who were discharged from ER and referred to counselor and 42-77% of them did not keep appts.

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Suicide is a deficiency disease Deficiency of social connections Teen has no one with whom they are able or willing to talk to are at greater risk Safety plan needed to have that person they contact when they have harmful thoughts

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Alcohol and substance abuse Risk factor as escape from their problems or solution for depression Access to lethal means is often overlooked Lock up firearms, medications and other harmful substances May see history of parental alcohol or legal troubles

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Teens with sexual identity issues are at higher risk for depression and suicidal ideation. Worse when teen not ready to discuss identity issues with others Gay, lesbian, bisexual and questioning youth who are open but experiencing harassment from others including friends or family members are at increased risk.

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen If depressed teen is not suicidal at time of assessment, could become suicidal if stressful trigger occurs. Need to review possible triggers with parents Remind them to increase vigilence if trigger occurs

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Assessment HEADSSS can assess all pertinent areas of teens life Format helps to develop good rapport before asking about sensitive topics Straight forward questions may need to be used if don’t have time for formal assessment such as: “Do you ever get so sad that you think about hurting yourself?” Follow up questions: “What makes you feel sad?” “What do you do when you get sad or down about something?”

Depressed/ Suicidal Teen : 

Depressed/ Suicidal Teen Remember Not all suicidal teens will identify themselves as depressed Can ask about equivalents such as boredom and irritability (increases screening sensitivity) Formulate a signed safety contract – teen promises to contact someone before doing something harmful and identifying that person IF teen with suicidal ideation refuses to sign safety contract, needs immediate referral to mental health professional. Frequent follow-ups