Paediatric Emergencies.

Kane GuthrieSt John Ambulance AustraliaState Retrieval Team.

Objectives

To gain an understanding of the differences between children and adults.

To understand difference’s in management between adults and children.

To understand different illnesses that affect children.

Introduction to the sick kid!! Sick children present

unique challenges to health care professionals.

Assessment and treatment of sick children are unique because children’s perceptions may be radically different from those of adults.

Adults Vs Kids The Difference

Children differ from adults: Size Developmentally Anatomically Physiologically.

Adults Vs Kids cont. The child’s airway is smaller than an adults

and can obstruct a lot more easily. Children have a smaller circulating blood

volume than an adult. An infants head is larger in proportion to

the rest of the body than an adults. (Heat Loss)!

Solid abdominal organs are relatively larger in children compared with adults, there is an increased risk of direct organ injury following blunt or penetrating forces.

Adults Vs Kids cont. The bones in a growing

child are stronger, thicker compared with adult’s decreasing there risk of an open fracture.

Children have a larger ratio of body surface area to weight, which makes them susceptible to convective and conductive heat loss.

Approach to the Paediatric Patient

Gaining Rapport: Builds confidence, and helps with assessing the child.

Age Appropriate: approach the child at an age appropriate level.

Development Appropriate: Younger child generally benefit from being examined while their parents are holding them.

Parental Involvement: in order to provide emotional support, parents should be encouraged to remain close to their child during procedures or examination.

Parental Issues

PARENTS KNOW THEIR CHILD BETTER THAN YOU!!! LISTEN TO THEM!!!!

Parents who often accompany their child are very anxious and concerned about their child's condition.

Listening to and addressing the parents concern’s in a sympathetic and unhurried fashion is the main therapeutic strategy to reassure the parent’s that a child with a minor illness will be ok.

Acknowledged the parents concerns and anxieties in an empathetic manner.

Assessment of the Sick Child

A: Alertness/activity B: Breathing C: Circulation Fluids in Fluids out

Vital signs It is necessary to

interpret the vital signs according to the age of a particular child.

A good rule to remember is any child with a persistent RR > 60 or a HR > 160 is abnormal.

Vital Signs cont.

Age Weight (kg)

RR (min) HR (min) BP(systolic)

Birth 3.5 40-60 100-170 50

1 year 10 30-40 100-170 65

4 years 15 20 80-130 70

8 years 25 16 70-110 80

12 years 40 16 60-100 90

Warning Signs in Sick Children! The pale, pasty child. The floppy child. The child who appears drowsy. Alterations in vital signs. Early signs of compensated shock. The tiring child with respiratory

distress. The child who looks sicker than the

child with the same disease.

Remember The Rule’s. A quite kid is a sick kid. Initial impressions are usually far

more important than any vital signs.

Paediatric Resuscitation The majority of cardiac arrest in

children/infants is caused by hypoxaemia or hypotension or both.

Causes can be: SIDS, trauma, drowning, septicaemia, asthma, or congenital abnormalities.

The initial ECG rhythm is usually bradycardia or asystole.

Remember 30:2

Shock

Shock results from an acute failure of circulatory function.

Inadequate amounts of nutrients, especially oxygen, are delivered to body tissues and there is inadequate removal of tissue waste products.

Causes of Shock Vomiting &/or

Diarrhoea Fever/rash

(septicaemia) Anaphylaxis Major trauma

(hypovolaemia) Sick cell disease DKA Drug ingestion

Shock The child may present primarily with: Pale, mottled skin Tachycardia > bradycardia Changes in mental status Tachypnoea Decreased peripheral pulses Decreased urine output Hypotension Hypoglycaemia (ABC Don’t Ever Forget

Glucose).

Shock Management D.R.A.B.C.D.E. A.V.P.U. O.P.R. (very

important) Vital signs Secondary

assessment. Ambulance

Trauma

Trauma is the prime cause of death and serious injury throughout childhood.

Children have the ability to compensate for an extended period of time due to small body area, and maintain adequate vital signs

Continuous monitoring is paramount in ongoing care of the paediatric trauma patient.

Assessing the Trauma Patient. D.R.A.B.C.D.E. O.P.R. A.V.P.U. History: A.M.P.L.E. Secondary

assessment.

Ongoing care of the trauma patient.

1. Early pain relief. 2. Continuous monitoring. 3. Support of family members.

Respiratory Emergencies

Most children with breathing difficulties will have an upper or lower respiratory tract illness.

Most respiratory illnesses are self-limiting minor infections, but a few present as potentially life threatening.

Respiratory Assessment Infants are nose

breather’s, nasal congestion can severely impair an infant respiratory status.

Feeding difficulties could mean respiratory problems.

Respiratory Assessment Cont! Recession: Sternal Respiratory rate:

Hypoventilation suggest exhaustion, hyperventilation suggest compensation.

Grunting/Stridor: high pitched noisy resp, sign of upper airway obstruction.

Accessory muscle use: neck or chest muscles

Flare of the alae nasi: Heart rate: brady =

exhaustion, tachy = compensating.

Skin colour: Central or peripheral cyanosis.

Mental Status: Confused = ?Hypoxia, hypoglycaemiaWheeze: suggest lower airway pathology.

Partial or complete obstruction:Foreign Body! Foreign body aspiration usually occurs in children less than 3 years old. The foreign body can lodge at any place along the airway. Hx:1. Coughing and choking episode 2. Cyanosis 3. Persistent cough after chocking episode. Manage as per choking guidelines!

Croup Croup is defined as a

syndrome with inspiratory stridor, a barking cough, hoarseness and variable degrees of respiratory distress.

Generally of viral origin (parainfluenza).

May have mild fever. Symptoms generally

worse at night. Tx: steroids

Epiglottitis

Share’s similar feature’s to croup.

Infection causes swelling of the epiglottis, surrounding tissues, & obstruction of the larynx.

Presents febrile, soft inspiratory stridor, and respiratory difficulty.

Epiglottis Cont. Typically the child sits

immobile, with a slightly raised chin with mouth open, drooling saliva.

Because the throat is so painful, the child is reluctant to talk or swallow drinks or saliva.

Attempts to examine the throat can result in total obstruction and death.

Leave child sitting in position they are comfortable, transport to hospital immediately.

Asthma

Asthma is recurrent episodes of cough, wheeze and breathlessness.

Life threatening asthma is characterised by silent chest, cyanosis, poor respiratory effort, exhaustion and altered mental state.

PMHX can tells us the clinical significance of a persons asthma.

Remember the Mag7 Use spacer to administer

ventolin.

Bronchiolitis

A viral infection commonly found in infants younger than 18months.

An inflammatory process causes edema in the bronchial mucosa with expiratory obstruction and air trapping.

•Dyspnea can last up to 5 days.•Hx typically includes a cold, cough, coryza (runny nose), before onset of dyspnea.

Cardiovascular Disorders:

Heart disease in children is generally caused by congenital abnormalities.

Children can suffer from heart murmurs, fast and slow heart rates, and structural defects in the hearts anatomy.

The main priority with management of these children is the ABC.

Head Injuries in Children. Head injury is the

most common single cause of trauma death in children aged 1-15 years.

It accounts for 40% of injuries.

Factors indicating a potentially serious head injury.

Hx of substantial trauma such as MVA, Fall from height.

A Hx of LOC. Children who are not fully conscious

and responsive. Any child with obvious neuro S&S

such as headache, convulsion/s, or limb weakness.

Evidence of penetrating injury.

Assessment of Concussion Concussion is a temporal loss of brain

function after a head injury. Generally caused by direct blow.Assess:1. Confusion: (Unsure of time and/or

place)2. Amnesia: (a loss of memory of the

injury)3. Loss of consciousness (even briefly)

Myths About Head Injuries

1. Paracetamol can be given to relieve discomfort and will not cause harm.

2. Children can sleep post head injury.3. Cold pack can be applied to head

injury to minimise swelling or stop bleeding.

Management of Head injury:

D.R.A.B.C.D.E Remember C spine: A.V.P.U. O.P.R. Secondary assessment BSL:? Why?

Burns & Scalds 2 main factors

determine severity of burns & scalds- these are temperature & the duration of contact.

Assess:1. Surface area: %BSA.2. Depth:3. Special areas.4. Airway:

Febrile Convulsion Are not epilepsy!! Typically occur in children between

6months - 6years. Caused by underlying fever can be bacterial

or viral related. Febrile convulsion is the bodies natural

response to fever. Not necessarily how high the fever is but how quick the fever rises, that cause the convulsion.

Febrile Convulsion Management!

D.R.A.B.C.D.E. O.P.R Remove clothing Do not over cool

child. Monitor vitals signs

(Temp) Paracetamol

(check dose!!!)

Gastroenteritis

Gastroenteritis (gastro) is a bowel infection that is common in young infants and children.

Viruses are the most common cause of gastro. (rotavirus)

Dehydration cause the most serious complications of gastro and fluid replacement is essential in preventing this.

Meningitis

Bacterial meningitis is a medical emergency requiring rapid diagnosis and prompt treatment.

Meningitis is the inflammation of the meninges that surround the brain.

Septicaemia is infection of the blood. Can present with both!!!

Clinical presentation in infants and toddlers.

Signs and symptoms of serious infection within this age group are often non specific:

1. Fever, irritability, vomiting.2. Drowsiness3. Neck stiffness or a bulging fontanelle. Both neck stiffness and bulging

fontanelle may be absent, especially during infancy and early in the illness.

Clinical presentation in children over the age of 3.

The signs of meningitis are more obvious.

1. Fever, severe headache, vomiting, photophobia (light sensitivity).

2. Neck stiffness.3.Delirium or deteriorating consciousness. A rash may be evident in some case’s

but is a late sign of the disease.

The Poisoned Child

D.R.A.B.C.D.E O.P.R Do not induce vomiting Try to find out what was taken, How much was taken When was it taken.

Drowning

Two major consequences occur from drowning:

1. Hypoxia2. Asphyxiation Generally related to amount of liquid

aspirated into lungs. No clinical difference between salt

water and fresh water drowning.

Tetanus! Always check with

parents if there immunised.

The End!