Understanding Pediatric Emergencies: Management of Shock and Triage in Children

1. Pediatric Emergencies Jan Bazner-Chandler RN, MSN, CNS, CPNP

2. Developmental and Biologic Variances • Cricoid is the narrowest portion of the airway: no cuffed ET tubes in children under 8 years of age ET cuffed

3. Developmental and Biologic Variances • Total blood volume is smaller – small blood loss may led to hypovolemia and impaired profusion • Healthy children in shock will maintain blood pressure until more than 25% of blood volume is lost • Tachycardiaand delayed capillary refill are early signs of shock • Decreased blood pressure is late sign

4. Developmental and Biologic Differences • Respiratory arrest is more common in pediatric population • Respiratory rate below 10 or above 60 are sign that child may be headed for respiratory arrest without interventions

5. Triage • To “pick or sort”. • Goals of triage: • Rapidly identify seriously injured. • Prioritize all patients using the emergency department. • Initiate therapeutic measures.

6. Triage Classification • Resuscitation • Emergent- needs to be seen within 10 minutes • Urgent – need to be seen within 30 to 60 minutes • Semi-urgent – need to be seen within 1to 2 hours • Non-urgent – need to be seen within 2 to 3 hours

7. Assessment • Across-the-room assessment • Chief complaint • Brief history (AMPLE Mnemonic) • Allergies • Medications • Past medical history • Last meal • Events surrounding the incident

8. Focused Physical Assessment • Airway • Breathing • Circulation • Disability • Exposure • Full vital signs • Family presence • Give comfort • Head-to-toe assessment • Inspect • Isolate

9. Test and Procedures • CBC with differential: infection and lack of immune response • Type and cross match: blood type • Serum electrolytes: electrolyte imbalance • Radiographs: chest, abdomen, bones • Computed tomography – CT scan: detects bleeding or masses

10. Shock • Hypovolemic shock • Distributive • Cardiogenic • Obstructive Note: cardiogenic and obstructive more common in the adult

11. Shock • The earlier you can recognize shock, establish priorities, and start therapy, the better the child’s chance for a good outcome.

12. Hypovolemic Shock • Most common cause of shock in children • Fluid and electrolyte losses associated with fluid loss • Blood loss from trauma • Etiology: caused by inadequate volume relative to the vascular space

13. Hypovolemic Shock • Most common cause of shock in children worldwide • Fluid loss due to diarrhea is the leading cause • Other causes • Hemorrhage • Vomiting • Inadequate fluid intake • Osmotic diuresis (eg diabetic ketoacidosis • Third space losses (fluid leak into tissues • Burns • Sepsis

14. Physiology of Hypovolemic Shock • Characterized by decreased preload leading to reduced stroke volume and low cardiac output. • Compensatory mechanisms are tachycardia, increased contractility, and increased systemic vascular resistance.

15. Hypovolemic shock: Assessment • Cardiovascular • Tachycardia • Normal blood pressure or hypotension with a narrow pulse pressure • Prolonged capillary refill > than or equal to 2 seconds • Weak, thready or absent peripheral pulses • End-organ function • Cool to cold, pale diaphoretic skin • Changes in mental status • Oliguria

16. Interdisciplinary Interventions • IV fluids 20 mL/kg bolus of Crystalloid Solution • 0.9% normal saline • Ringer’s lactate • If signs of inadequate profusion after 2 or 3 boluses administer 10 mL / pg packed red blood cells • Control bleeding

17. Distributive Shock • Septic shock • Anaphylactic • Neurogenic shock (head injury, spinal injury)

18. Septic Shock • Most common form of distributive shock. • Caused by infectious organisms or their byproducts that stimulates the immune system and trigger release or activation of inflammatory mediators. • Uncontrolled activation of the inflammatory mediators can lead to organ failure, particularly cardiovascular and respiratory failure, systemic thrombosis and adrenal dysfunction.

19. Assessment Findings • History or infection • History of poor feeding • Physical findings • Tachycardia: HR > 2 standard deviations above normal for age • Fever: > 38.5 or < 36 (neonate may be hypothermic) • Tachypnea: RR > 2 standard deviations above normal for age • Altered mental status - lethargy • Petechiae / or purpura • Poor peripheral perfusion (capillary refill less than 2 seconds) • Hypotension – late sign

20. Laboratory Values • WBC • Greater than 12,000 • Lower than 4,000 or more than 10% immature neutrophils • Platelets in the acute phase may be elevated due to inflammation. • Platelets may decrease in the case of DIC

21. Interdisciplinary Interventions • Isolate if indicated • IV fluids (crystalloid solution) to restore circulating volume • Inotropic agents as needed • Norepinephrine – alpha receptor agonist causes peripheral arterial vasoconstriction • Dopamine – beta receptor agonist to increase cardiac output • Cultures: blood, spinal fluid, urine • Broad spectrum antibiotics: MRSA • If hypoglycemic – IV glucose

22. Sepsis with ARDS • Acute respiratory distress syndrome • Mechanical ventilation • Aggressive antibiotics to treat bacterial infection • Methylprednisone – anti-inflammatory

23. Anaphylactic Shock • Results from a severe reaction to a drug, vaccine, food toxin, plant, venom or other antigen. • It is characterized by venodilation, systemic vasodilation, and increased capillary permeability combined with pulmonary vasoconstriction. • Vasoconstriction increased right heart work and may add to hypotension by reducing the delivery of blood from the right ventricle to the left ventricle

24. Assessment Findings • Anxiety or agitation • Nausea and vomiting • Urticaria (hives) • Angioedema (swelling of face, lips and tongue) • Respiratory distress with stridor or wheezing • Hypotension • Tachycardia • What is first drug of choice?

25. Poisoning • The fifth leading cause of death in children younger than 5 years • Overdose in infants are often the result of therapeutic overdosing • Children younger than 6 years • Cleaning substances, analgesics, topical agents, cough and cold preparations • Adolescents drug experimentation and suicide attempts Questions: Why is OD on Tylenol (acetaminophen) a problem?

26. Poisoning • Over a million children are poisoned annually. • Ages of risk are 2 to 4 years and adolescents. • Common poisons ingested: • Iron, lead, acetaminophen, hydrocarbons, liquid Drano, and plants.

27. Assessment • #1 Look at the child • May present with no symptoms to coma

28. Focus History • What was ingested? • How much was ingested? • When did it occur? • What therapy was initiated before arrival in the ED?

29. AAP Recommendations • AAP – American Academy of Pediatrics • Syrup of Ipecac no longer be used routinely in the home to induce vomiting. • Research has failed to show benefit for children who were treated with Ipecac. • Prevention is the best defense against unintentional poisoning

30. Parent Teaching • Post the universal phone number for poison control center near the telephone • 1-800-222-1222 • Call 911 in the case of convulsions, cessation of breathing or unconsciousness • Do not make your child vomit

31. Emergency Treatment • Always assess the child to determine the care: airway, breathing, LOC • History of what substance was swallowed • Ask parent to bring in container or sample of substance swallowed • Activated charcoal may be given to help absorb substance ingested

32. Lead Poisoning • There are about 1.7 million children with elevated lead levels. • A large proportion are poor, African-American, Mexican-American, and living in urban areas. • Children are more susceptible because they absorb and retain lead.

33. Lead Poisoning • Lead interferes with normal cell function, and adversely affects the metabolism of vitamin D and calcium. • Clinical manifestations depend on degree of toxicity. • Neurologic effects include decreased IQ scores, cognitive deficits, impaired hearing, and growth delays.

34. Lead Poisoning • Sources of lead: • Lead based paint • Soil and dust • Drinking water from lead lined pipes • Food growth in contaminated fields • Contamination from occupations or hobbies

35. Lead Levels • Blood lead levels between 10 and 19 ug/dL are typically asymptomatic • Teaching about hazards of lead • Blood levels between 20 to 44 ug/dL may present with increase motor impairment and lethargy (poor school performance) • Home assessment • Chelation therapy may be indicated • Levels greater than 70 ug/dL are considered an emergency

36. Prevention of Lead Poisoning • Washing hands and toys • Low-fat diet • Check home for lead hazards • Regularly clean home • Take precautions when remodeling or working on old cars, furniture, or pottery. • Call 1-800-424-lead for guidelines