The Pediatric Emergency

When assessing an acutely ill child, always consider the similarities and differences between the pediatric age group and adult patients;approach the pediatric emergency as you would an emergency in an adult, but recognize the smaller size of the patient and the difference in the physiologic responses to acute illness and injury. The primary assessment of a child is the same as that of an adult.

The most dangerous life-threatening pediatric emergency is respiratory distress. Respiratory distress in a pediatric patient may arise from a variety of conditions that result from upper or lower airway disease. Common pediatric respiratory problems of the upper airway include croup (laryngotracheobronchitis), epiglottitis, foreign bodies, and bacterial tracheitis. Lower airway obstruction may result from asthma, pneumonia, bronchiolitis, and foreign bodies.

The hallmarks of respiratory distress are tachypnea, nasal flaring, retractions, stridor, cyanosis, head bobbing, prolonged expiration, and grunting. Children with upper airway disease almost always exhibit stridor. In a child with stridor, distinguish between croup and epiglottitis,^ child with epiglottitis may have a rapid progression to respiratory failure. Fortunately, the incidence of epiglottitis has decreased, presumably because of the Haemophilus influenzae type B (HIB) vaccine. If epiglottitis is suspected, do not examine the airway without being prepared to provide airway stabilization on an emergency basis. Manipulation of the child's airway can lead to complete airway obstruction. Table 26-2 compares some of the important differences between epiglottitis and croup.

The peak time for foreign body aspiration is 1 to 2 years of age. In a child, consider relief of airway obstruction in the following situations:

Choking is present The cough becomes ineffective Breathing becomes stridorous There is loss of consciousness The child becomes cyanotic

Table 26-2 Differentiation Between Epiglottitis and Croup

Characteristics Epiglottitis Croup

Cause

Age of child Clinical appearance Season Clinical onset

Upper respiratory tract infection Fever

Sore throat

Cough

Drooling

Stridor

Position

Epiglottis

Haemophilus influenzae type B

No seasonal predominance

Rapid

Rare

Not ''barking''; throughout the day

Prominent

On inspiration

Sitting forward with neck extended and mouth open Bright red

Viral, usually parainfluenza virus

3 months-3 years

Not extremely ill

Autumn and winter

Insidious

Common

Variable

''Barking''; during the night None

On inspiration and expiration

Variable

Normal

Immediately place the child face down, with the head lower than the torso, over your arm, which is placed on your thigh. Support the child's head by holding his or her jaw. Deliver five forceful back blows with the heel of your other hand between the child's scapulae. Turn the child onto the back while holding the child's head. Place two fingertips on the middle portion of the sternum, one fingerbreadth below the nipples. Depress the sternum 1 inch. Repeat this maneuver up to five times. Attempt to remove any visible material from the pharynx. Repeat the back blows and chest thrusts until the object is dislodged.

If the child becomes unconscious, check the mouth for a foreign body, and then perform mouth-to-mouth breathing. Gently tilt the child's head back while placing the other fingers under the jaw at the chin, and lift the chin upward. Seal the child's mouth and nose with your mouth. Deliver two breaths, watching the chest rise. Repeat the back blows and chest thrusts. Have someone call for help.

Dehydration is another important pediatric emergency. The most common causes are vomiting and diarrhea. In a child with mild dehydration (<5%), there may be only a slight decrease in mucous membrane moisture. In severe dehydration (15%), the following are commonly found:

Parched mucous membranes; no tears Markedly decreased skin turgor Sunken fontanelles Sunken eyeballs Tachypnea • Capillary refill* longer than 2 seconds Cool and clammy skin

Orthostatic hypotension: systolic pressure less than 80 mm Hg Tachycardia: faster than 130 beats per minute

Immediate intravenous infusion of isotonic fluids should be started in children with severe dehydration.

The secondary assessment outlined earlier and the AVPU mnemonic are just as important for children as for adults. Table 26-3 provides a useful reference for CPR.

*Capillary refill is an assessment of perfusion. It is the time required for a patient's skin color to return to normal after the nail bed has been pressed. The normal refill time is less than 2 seconds.

Table 26-3 Cardiopulmonary Action

If victim has a pulse, give one breath:

If victim has no pulse, locate compression landmark:

Compressions are performed with:

Rate of compressions per minute:

Compression depth:

Ratio of compressions to breaths with:

One rescuer

Two rescuers

Resuscitation Reference Chart Infant (<1 Year of Age)

Every 3 seconds

1 fingerbreadth below the nipple line

Two or three fingers on sternum

>100

1/3 to 1/2 depth of chest

Every 3 seconds

Same as in adult

Heel of hand on sternum

1/3 to 1/2 depth of chest

Adult

Every 5-6 seconds One finger on sternum

Two hands stacked, with heel of one hand on sternum

80-100

*3:1 in neonates.

Bibliography

Barkin RM, Rosen P (eds): Emergency Pediatrics: A Guide to Ambulatory Care, 5th ed. St. Louis, Mosby, 1999.

Capehorn DMW, Swain AH, Goldsworthy LL (eds): A Handbook of Paediatric Accident and Emergency

Medicine: A Symptom-Based Guide. Philadelphia, WB Saunders, 1998. Hazinski MF, Nadkarni VM, Hickey RW, et al: Major changes in the 2005 AHA guidelines for CPR and ECC:

Reaching the tipping point for change. Circulation 112(Suppl I):IV-206, 2005. Henry MC, Stapleton ER (eds): EMT Prehospital Care, 2nd ed. Philadelphia, WB Saunders, 1997. Howell JM, Altieri M, Jagoda AS, et al (eds): Emergency Medicine. Philadelphia, WB Saunders, 1997. McSwain NE, White RD, Paturas JL, et al: The Basic EMT: Comprehensive Prehospital Patient Care.

St. Louis, Mosby Lifeline, 1997. Revere C, Hasty R: Diagnostic and characteristic signs of illness and injury. J Emerg Nurs 19:2, 1993. Thomas H, O'Connor RE, Hoffmann GL, et al: Emergency Medicine: Self Assessment and Review, 4th ed. St. Louis, Mosby, 1999.

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