pediatric medical emergencies. fever l not a disease, it’s a sign of disease l severity is not...
TRANSCRIPT
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Pediatric Medical Emergencies
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Fever
Not a disease, it’s a sign of disease Severity is not indication of severity
of underlying disease Usually good
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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 mom’s shoulder?
• Does he cry even when consoled?
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Fever
Educate parents• Tempra, Tylenol
• Avoid aspirin
• Sponge with water at 96 - 970F• Do not say “tepid”, “lukewarm”• Do not leave kid unattended
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Fever
Educate parents• Do not• Use ice water• “Bundle”• Use alcohol rubs• Use tap water enemas
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Fever
Emergency if:• >1040F in any child
• >1010F in infant < 3months old
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Septic Shock
Peripheral hypoperfusion due to septicemia (blood infection)
Most common in young infants, debilitated children
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Septic Shock
Pathophysiology• Severe peripheral vasodilation
• Fluid loss from vessels to interstitial space
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Septic Shock
Signs/Symptoms• “Warm” shock• Tachycardia, full pulses• Slow capillary refill• Fever• Flushed skin
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Septic Shock
Signs/Symptoms• “Cold” shock• Tachycardia, weak pulses• Slow capillary refill• Cool, pale, mottled skin
“Cold” shock has 90% mortality
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Febrile infant + Won’t tolerate being held to shoulder =
Septic Shock
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Septic Shock
Management• 100% oxygen
• LR in 20cc/kg boluses• Fill dilated vascular space• Prevent onset of “cold” shock
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Meningitis
Inflammation of meninges• Increased CSF production
• Cerebral /meningeal edema
• Increased intracranial pressure
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Meningitis
Signs/Symptoms: Older Children• Fever• Headache• Stiff neck (can’t touch chin to chest)• Decreased LOC• Seizures
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Meningitis
Signs/Symptoms: Infants• Difficulty feeding• Irritability• High-pitched cry• Bulging fontanelle• Classic meningeal signs possibly absent
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Meningitis
Meningococcemia• Petechial rash
• Septic shock
• DIC
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Reyes’ Syndrome
Non-communicable Affects ages 2 -19 Mostly toddlers, pre-schoolers
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Reyes’ Syndrome
Pathophysiology• Dysfunction of hepatic urea cycle
enzymes
• Increased protein breakdown leading to rise in blood ammonia levels
• Diffuse cerebral edema
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Reyes’ Syndrome
History• Previously healthy child
• Recovering from viral illness
• Frequently chicken pox or influenza
• Frequently received aspirin during illness
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Reyes’ Syndrome
Signs/Symptoms• Prolonged, violent vomiting
• Varying degrees of personality change
• Unusual behavior
• Irritability, drowsiness
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History of vomiting + Altered LOC + Recovering from virus =
Reyes’ Syndrome
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Crankiness in infant + Recovering from virus =
Reye’s Syndrome
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Reyes’ Syndrome
Management• Avoid overstimulation
• IV’s at tko
• Decrease ICP by controlled hyperventilation
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Seizures
Second most common pediatric complaint after fever
Can result from same causes as adult seizures
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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
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Seizures
Potential dangers• Aspiration
• Trauma
• Missed diagnosis
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Seizures
“Febrile seizure” diagnosis risky in field
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Seizures
History• Previous seizures?
• Previous febrile seizures?
• Number of seizures this episode?
• What did seizure look like?
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Seizures
History • Remote, recent head trauma?
• Diabetes?
• Headache, stiff neck?
• Petechial rash?
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Seizures
History • Possible ingestion?
• Medications?
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Seizures
Physical exam• ABC’s• Neurological exam• Signs of injury?• Signs of dehydration?• Rash, stiff neck?• Bulging, depressed anterior fontanelle?
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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
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Seizures
Management--following seizure• Check ABC’s, suction prn• Assure good oxygenation, ventilation• Vascular access
• Check blood glucose, if < 70, give D25W
• If febrile, remove excess clothing, sponge with water to cool patient.
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Status Epilepticus
Diazepam:• 0.3 mg/kg to 5mg if < 5 years old
• 0.3 mg/kg to 10mg if > 5 years old
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Status Epilepticus
Administer diazepam slowly Anticipate respiratory arrest,
hypotension Rectal route is alternative when
vascular access cannot be obtained
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Most Common Cause of Seizure Deaths =
Anoxia
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Hypoglycemia
More common than in adults, especially in newborns
Signs/symptoms may mimic hypoxia
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Hypoglycemia
Check blood glucose in any child with:• Seizures• Decreased LOC• Severe dehydration• Known hypoglycemia or diabetes• Pallor, sweating, tachycardia, tremors
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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
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Diabetes Mellitus
Typically insulin-dependent Complications• Hypoglycemia
• Hyperglycemia, DKA
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Diabetes Mellitus
DKA therapy same as for severe dehydration
Not every diabetic is known diabetic Every diabetic must have first
hyperglycemic episode
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Coma
Disturbance in consciousness; patient unresponsive to stimuli
Causes• Metabolic
• Structural
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Coma
Metabolic causes:Anoxia Drug Toxicity
Hypoglycemia Epilepsy
DKA Reyes’ Syndrome
Infections
Increased ICP (Edema)
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Coma
Structural causes:• Trauma
• Tumor
• CVA
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Coma Control ABC’s before worrying about
cause!!
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Coma
Airway/Breathing• All patients with decreased LOC
receive oxygen!!
• Evaluate for ineffective breathing patterns
• Controlled hyperventilation if increased ICP suspected
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Coma
Circulation• Control bleeding
• Give fluid boluses for hypovolemia Disability• AVPU, pupils
• Check blood glucose
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Coma
Management• Support ABC’s• 2 cc/kg D25W glucose < 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
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Poisoning
Incidence• Accidental: 75% children < 5 years old
• Overdose: School-age, adolescents
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Poisoning
Assessment• Remove to safe environment
• Control airway
• Support breathing: 100% O2
• Circulation - vasodilation, decreasing myocardial tone, hypoxia
• Blood glucose
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Poisoning
History• What?
• When?
• How much?
• Vomiting? Coughing? Seizures? Altered LOC?
• Ipecac?
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Poisoning
Management• Support ABC’s
• Consider D25W, Narcan
• Ipecac?/Charcoal?
• Transport samples
• Consult poison control
• Treat patient, not poison!!
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Near-Drowning
A leading cause of childhood death Two major groups• Toddlers
• Adolescents
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Near-Drowning
Pathophysiology• Hypoxia
• Acidosis
• Hypothermia
• Aspiration, pulmonary edema, atelectasis
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Near-Drowning
Management• Protect rescuers
• Assume C-spine injury
• 100% oxygen
• Decompress stomach early with gastric tube
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Near-Drowning
Management• Remember mammalian diving reflex!!
• Think about underlying causes-- ? Child abuse
• All near-drownings are transported regardless of how good they look!!