1. Pediatric Medical Emergencies

2. Fever l Not a disease, it’s a sign of disease l Severity is not indication of severity of underlying disease l Usually good

3. Fever l 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?

4. Fever l Educate parents Tempra, Tylenol Avoid aspirin Sponge with water at 96 - 97 0 F Do not say “tepid”, “lukewarm” Do not leave kid unattended

5. Fever l Educate parents Do not Use ice water “Bundle” Use alcohol rubs Use tap water enemas

6. Fever l Emergency if: >104 0 F in any child >101 0 F in infant < 3months old

7. Septic Shock l Peripheral hypoperfusion due to septicemia (blood infection) l Most common in young infants, debilitated children

8. Septic Shock l Pathophysiology Severe peripheral vasodilation Fluid loss from vessels to interstitial space

9. Septic Shock l Signs/Symptoms “Warm” shock Tachycardia, full pulses Slow capillary refill Fever Flushed skin

10. Septic Shock l Signs/Symptoms “Cold” shock Tachycardia, weak pulses Slow capillary refill Cool, pale, mottled skin “Cold” shock has 90% mortality

11. Febrile infant + Won’t tolerate being held to shoulder = Septic Shock

12. Septic Shock l Management 100% oxygen LR in 20cc/kg boluses Fill dilated vascular space Prevent onset of “cold” shock

13. Meningitis l Inflammation of meninges Increased CSF production Cerebral /meningeal edema Increased intracranial pressure

14. Meningitis l Signs/Symptoms: Older Children Fever Headache Stiff neck (can’t touch chin to chest) Decreased LOC Seizures

15. Meningitis l Signs/Symptoms: Infants Difficulty feeding Irritability High-pitched cry Bulging fontanelle Classic meningeal signs possibly absent

16. Meningitis l Meningococcemia Petechial rash Septic shock DIC

17. Reyes’ Syndrome l Non-communicable l Affects ages 2 -19 l Mostly toddlers, pre-schoolers

18. Reyes’ Syndrome l Pathophysiology Dysfunction of hepatic urea cycle enzymes Increased protein breakdown leading to rise in blood ammonia levels Diffuse cerebral edema

19. Reyes’ Syndrome l History Previously healthy child Recovering from viral illness Frequently chicken pox or influenza Frequently received aspirin during illness

20. Reyes’ Syndrome l Signs/Symptoms Prolonged, violent vomiting Varying degrees of personality change Unusual behavior Irritability, drowsiness

21. History of vomiting + Altered LOC + Recovering from virus = Reyes’ Syndrome

22. Crankiness in infant + Recovering from virus = Reye’s Syndrome

23. Reyes’ Syndrome l Management Avoid overstimulation IV’s at tko Decrease ICP by controlled hyperventilation

24. Seizures l Second most common pediatric complaint after fever l Can result from same causes as adult seizures

25. Seizures l 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

26. Seizures l Potential dangers Aspiration Trauma Missed diagnosis

27. Seizures “Febrile seizure” diagnosis risky in field

28. Seizures l History Previous seizures? Previous febrile seizures? Number of seizures this episode? What did seizure look like?

29. Seizures l History Remote, recent head trauma? Diabetes? Headache, stiff neck? Petechial rash?

30. Seizures l History Possible ingestion? Medications?

31. Seizures l Physical exam ABC’s Neurological exam Signs of injury? Signs of dehydration? Rash, stiff neck? Bulging, depressed anterior fontanelle?

32. Seizures l Management--if actively seizing: Place on floor away from furniture Position on side Prevent injury Do not restrain Do not force anything between teeth

33. Seizures l Management--following seizure Check ABC’s, suction prn Assure good oxygenation, ventilation Vascular access Check blood glucose, if < 70, give D 25 W If febrile, remove excess clothing, sponge with water to cool patient.

34. Status Epilepticus l Diazepam: 0.3 mg/kg to 5mg if < 5 years old 0.3 mg/kg to 10mg if > 5 years old

35. Status Epilepticus l Administer diazepam slowly l Anticipate respiratory arrest, hypotension l Rectal route is alternative when vascular access cannot be obtained

36. Most Common Cause of Seizure Deaths = Anoxia

37. Hypoglycemia l More common than in adults, especially in newborns l Signs/symptoms may mimic hypoxia

38. Hypoglycemia l Check blood glucose in any child with: Seizures Decreased LOC Severe dehydration Known hypoglycemia or diabetes Pallor, sweating, tachycardia, tremors

39. Hypoglycemia l Management Oral sugar if tolerated 2cc/kg D 25 W, if oral sugar not possible ? Glucagon 1 mg IV or IM l Reassess every 20 - 30 minutes

40. Diabetes Mellitus l Typically insulin-dependent l Complications Hypoglycemia Hyperglycemia, DKA

41. Diabetes Mellitus l DKA therapy same as for severe dehydration l Not every diabetic is known diabetic l Every diabetic must have first hyperglycemic episode

42. Coma l Disturbance in consciousness; patient unresponsive to stimuli l Causes Metabolic Structural

43. Coma l Metabolic causes: Anoxia Drug Toxicity Hypoglycemia Epilepsy DKA Reyes’ Syndrome Infections Increased ICP (Edema)

44. Coma l Structural causes: Trauma Tumor CVA

45. Coma Control ABC’s before worrying about cause!!

46. Coma l Airway/Breathing All patients with decreased LOC receive oxygen!! Evaluate for ineffective breathing patterns Controlled hyperventilation if increased ICP suspected

47. Coma l Circulation Control bleeding Give fluid boluses for hypovolemia l Disability AVPU, pupils Check blood glucose

48. Coma l 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

49. Poisoning l Incidence Accidental: 75% children < 5 years old Overdose: School-age, adolescents

50. Poisoning l Assessment Remove to safe environment Control airway Support breathing: 100% O2 Circulation - vasodilation, decreasing myocardial tone, hypoxia Blood glucose

51. Poisoning l History What? When? How much? Vomiting? Coughing? Seizures? Altered LOC? Ipecac?

52. Poisoning l Management Support ABC’s Consider D 25 W, Narcan Ipecac?/Charcoal? Transport samples Consult poison control Treat patient, not poison!!

53. Near-Drowning l A leading cause of childhood death l Two major groups Toddlers Adolescents

54. Near-Drowning l Pathophysiology Hypoxia Acidosis Hypothermia Aspiration, pulmonary edema, atelectasis

55. Near-Drowning l Management Protect rescuers Assume C-spine injury 100% oxygen Decompress stomach early with gastric tube

56. Near-Drowning l Management Remember mammalian diving reflex!! Think about underlying causes-- ? Child abuse All near-drownings are transported regardless of how good they look!!