Oxtober 20101Confidential

Pediatric

Urgencies and Emergencies

Cheryl Cairns, DNP CPNPCommunity Pediatrics

Pediatric Institute

© Cleveland Clinic 2017

DOS Course 20171

• Participants will be able to identify urgent and emergent

issues in the pediatric primary care setting

• Participants will be able to discuss assessment and

interventions for common pediatric urgent issues

• Participants will be able to discuss recognition of Red

Flags and appropriate need for emergent intervention

Objectives

DOS Course 20172

• Choking = foreign object lodged in the throat

– Blocks the flow of air

• Universal sign

– Hands clutched to throat

• Other indications

– Inability to talk

– Difficulty breathing or noisy breathing

– High pitched weak cry

– Inability to cough forcefully

– Skin, lips and nails turning blue or dusky

– Loss of consciousness

Choking

DOS Course 20173

http://www.riskmanagement365.com/w

p-content/uploads/2012/12/choking-c

• Small round objects

– Coins

– Button-type batteries

– Buttons

– Balls, marbles

• Toys with small parts

• Balloons

• Hair bows, barrettes,

• Rubber bands

• Pen or pen caps

• Refrigerator magnets

• Pieces of dog food

Choking Hazards

DOS Course 20174

http://happyhealthychildren.info/wp-content/uploads/2014/01/choking.jpg

• Food accounts for 50% of choking episodes

• Keep the following foods away from children younger

than 4 years:

– Hot dogs

– Nuts and seeds

– Chunks of meat or cheese

– Whole grapes

– Hard or sticky candy

– Popcorn

– Chunks of peanut butter

– Chunks of raw vegetables

– Chewing gum

Choking Hazards

DOS Course 20175

• Assume a seated position

– hold the infant facedown on your forearm, which is resting on your

thigh

– Thump the infant five times on the middle of the back using the

heel of your hand

– Hold the infant face up on your forearm with the head lower than

the trunk if the above doesn't work

– Using two fingers placed at the center of the infant's breastbone,

give five quick chest compressions

• Repeat the back blows and chest thrusts if breathing

doesn't resume. Call for emergency medical help

• Begin infant CPR if one of these techniques opens the

airway but the infant doesn't resume breathing

Heimlich Maneuver Infant

DOS Course 20176

• Any injury to the brain which disrupts normal brain

function on a temporary or permanent basis.

• Concussions are typically caused by a blow or jolt to the

head

• Children and adolescents are more susceptible to the

effects of a concussion because their brains are still

developing

Concussion

DOS Course 20177

• Traumatic brain injury in kids

– ~ 500,000 emergency department visits in US annually

– 40% of sports-related concussions involved children between the

ages of 8 and 13 years

– 50% of "second impact syndrome" incidents–brain injury caused

from a premature return to activity after suffering initial

concussion–result in death.

– Football has the highest rate of concussion in sports.

– Girls have higher concussion rates than boys in similar sports up

to14 years

– Sports less commonly considered potential sources of head injury

include volleyball, soccer, and cheerleading.

Concussion

DOS Course 20178

• Headache

• Nausea or vomiting

• Dizziness or balance problems

• Double or blurry vision

• Sensitivity to light

• Sensitivity to noise

• Feeling dazed or stunned

• Sleeping more or less than usual

• Trouble falling asleep

Concussion Symptoms

DOS Course 20179

Concussion Symptoms

• Feeling mentally “foggy”

• Trouble concentrating

• Trouble remembering

• Confused or forgetful about recent events

• Slow to answer questions

• Changes in mood—irritable, sad, emotional, nervous

• Drowsiness

DOS Course 201710

• Rest

• Regular sleep routine

• Avoid high-risk/high-speed activities

• Limit activities that require concentration

• Return to their normal activities slowly, not all at once

• Follow up with provider

Concussion Treatment

DOS Course 201711

• Unequal Pupil Size

• Unable to arouse

• Headache worsening

• Weakness, numbness, decreased coordination

• Repeated vomiting or worsening nausea

• Slurred speech

• Seizure

• Increased confusion

• Loss of Consciousness

• Behavioral changes

• Neck pain

Concussion Red Flags

DOS Course 201712

• Most common metabolic/endocrine disorder of childhood.

• Evidence points to autoimmune destruction of pancreatic

beta cells in genetically predisposed individuals

• Prevalence 2 in 1000 school age children

• Symptoms of new onset diabetes manifest when insulin

secreting reserve diminished stores < 20 % of normal

• Symptoms: polyuria, polydipsia, weight loss, and fatigue

• New onset: 23% Dx - Diabetic ketoacidosis.

– 36 % of children under 5

– 16% of teens

• Rates are higher in developing countries

Diabetes Mellitus

DOS Course 201713

• Definition:

– Hyperglycemia glucose >200

– Metabolic acidosis-venous pH 7.3

– Bicarbonate concentration< 15meq/l

– Ketonemia

– Ketononuria

– Severity determined by the degree of acidosis

Diabetic Ketoacidosis (DKA)

DOS Course 201714

DOS Course 201715

• Prevalence in children with Type 1

1-10 per 100 person years

• Etiology

– Lack of insulin with > levels of counter regulatory hormones

– Manifests when >90% of pancreatic islet beta cells destroyed

– New diagnosed diabetes

–Delayed diagnosis

– Established diabetes

–Lack of insulin-missed doses

–Discontinuation of insulin injections/pump delivery

Causes DKA

DOS Course 201716

• Nausea

• Vomiting

• Lethargy

• Tachycardia

• Tachypnea

• Kussmaul respirations

• Abdominal pain

• Fruity breath

DKA Symptoms

DOS Course 201717

• Vital Signs

• Weight / Height

– Determine surface area

– Should be used for calculations and not the weight from a

previous office visit or hospital record

• Glasgow Coma Scale scores

• Hydration status

– 5% Reduced skin turgor, dry mucous membranes,

tachycardia

– 10% Capillary refill ≥3 s, sunken eyes

– >10% Weak or impalpable peripheral pulses, hypotension,

shock, oliguria

DKA Assessment

DOS Course 201718

Best eye response Best verbal responseBest verbal response

(nonverbal children)Best motor response

1. No eye opening

2. Eyes open to pain

3. Eyes open to verbal

command

4. Eyes open spontaneously

1. No verbal response

2. No words, only

incomprehensible sounds;

moaning and groaning

3. Words, but incoherent

4. Confused, disoriented

conversation

5. Orientated, normal

conversation

1. No response

2. Inconsolable, irritable,

restless, cries

3. Inconsistently consolable

and moans; makes vocal

sounds

4. Consolable when crying

and interacts

inappropriately

5. Smiles, oriented to sound,

follows objects and

interacts

1. No motor response

2. Extension to pain

(decerebrate posture)

3. Flexion to pain

(decorticate posture)

4. Withdrawal from pain

5. Localizes pain

6. Obeys commands

Glasgow Coma Scale

DOS Course 201719

• Labs

– CMP

– CBC

– Phosphate

– Calcium

– Magnesium

– Lactate

– HbA1c

– Venous ph

• ABG

• Urine

• EKG

DKA Testing

DOS Course 201720

• Fluid and Electrolyte replacement and stabilization

• Restore intravascular volume

• Improve glomerular filtration

• Replenish depleted electrolytes

DKA Treatment

http://medscape.com/news/2014/is_141113_iv_saline_bags_800x600.jpg

DOS Course 201721

• Complications

– Cerebral Edema

– Hypoglycemia

– Hypokalemia

– Cardiac Dysrhythmia

– Pulmonary edema

– Pancreatitis

– Rhabdomylosis

– Thromboembolism

– Renal Failure

– Coma

– Death

DKA Complications

DOS Course 201722

DKA FOLLOW UP

http://www.bing.com/images/search?q=Diabetes+Education&view=detailv2&adlt

Case presentation: 7 year old female

low grade fever, vomiting, and abdominal pain

WHAT QUESTIONS SHOULD YOU ASK ???

DOS Course 201723

• Definition

– Blood glucose < 70 mg/dL

• Causes

– Increased insulin

– Diarrhea

– Vomiting

– Injury

– Illness

– Infection

– Emotional stress

– Celiac disease

– Adrenal disorders

– Pituitary disorders

HYPOGLYCEMIA

DOS Course 201724

• Shakiness

• Dizziness

• Sweating

• Hunger

• Headache

• Pale skin color

• Difficulty paying attention

• Clumsiness

• Sudden moodiness or confusion

• Tingling sensations around the mouth

• Loss of consciousness

Hypoglycemia Symptoms

DOS Course 201725

• 15-15 Rule

– It’s easy to remember how to treat hypoglycemia with the 15-15

rule. 15 grams of carbohydrates, wait 15 minutes, and then test

again to see if normal blood glucose level. If not, give second dose

of 15 grams and test again

• Goal is to reach 100 mg/dL

• Fifteen grams of carbohydrates should bring up your

glucose by about 50 mg/dL

• Fifteen grams of carbohydrates

– 5 - 6 hard candies

– 3 - 4 glucose tablets

– ½ cup juice

Hypoglycemia Treatment

DOS Course 201726

• Severe hypoglycemia - Intravenous glucose

• If unable to use parenteral glucose -dissolve Glucagon

– For adults and for pediatric patients weighing more than 44 lb (20

kg), give 1 mg (1 unit) by subcutaneous, intramuscular, or

intravenous injection.

– For pediatric patients weighing less than 44 lb (20 kg), give 0.5 mg

(0.5 unit) or a dose equivalent to 20 to 30 μg/kg.2-6

– Discard any unused portion.

• Follow up

– supplemental carbohydrate to restore liver glycogen and to

prevent secondary hypoglycemia

– Contact Emergency Services

Treatment of Severe Hypoglycemia

DOS Course 201727

Dehydration

DOS Course 201728

Clinical Dehydration Scale

Characteristic Score of 0 Score of 1 Score of 2

General appearance Normal Thirsty, restless or lethargic but irritable when touched

Drowsy, limp, cold, sweaty, comatose or not

Eyes Normal Slightly sunken Very sunken

Mucous Membranes Moist Sticky Dry

Tears Tears Decreased tears Absent tears

Dehydration Score

0-1 No dehydration

2-3 Mild dehydration

4 Severe dehydration

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-

Disasters/Documents/MANUAL-06-internacional-2011.pdf

• Treatment

– Supportive measures for no or mild dehydration, providing oral

rehydration therapy (ORT) and an unrestricted diet.

– Mild to moderate dehydration, referral to the primary care office,

urgent care visit or emergency department will be require

– Severe dehydration requires prompt emergent care

• Refer

– Bloody diarrhea,

– Refusal to eat or drink for hours

– Moderate to severe dehydration

– Intermittent abdominal pain

– Severe abdominal pain

– Behavior changes including lethargy/decreased responsiveness.

Dehydration

DOS Course 201729

• Vomiting

– Frequent small feedings (every 10-60 minutes) of oral rehydration

solutions or tolerated foods.

– Children weighing < 10 kg should receive 60-120ml (2-4 ounces)

of ORT per episode of vomiting or diarrheal stool

– > 10 kg should receive 120-240 (4-8 ounces).

– ORT should be continued for 4-6 hours if tolerated or until

adequate rehydration is achieved.

– Frequent telephone follow up or referral for direct supervision in

the office, urgent care may be necessary

– It is not necessary to avoid milk products

– Complex carbohydrates are recommended and

– Avoid high fat foods and high sugar beverages

•

Dehydration

DOS Course 201730

• No antiviral agents are available

• Antimicrobial agents should not be used unless treatable

bacteria or parasite is the cause

• Routine use of antimicrobial agents may lead to

increased antimicrobial resistance

• Ondansetron- Zofran (not recommend for routine gastroenteritis)

– IV: Infants and Children ≥1 month: 0.15 or 0.3 mg/kg/dose once;

maximum dose: 16 mg/dose (DeCamp, 2008)

– Oral: Infants and Children 6 months to 10 years, ≥8 kg (Freedman,

2006)

– 8 to 15 kg: 2 mg/dose once

– >15 to 30 kg: 4 mg/dose once

– >30 kg: 8 mg/dose once

Dehydration

DOS Course 201731

Rehydration

DOS Course 201732

http://www.bing.com/images/search?q=dehydration+scale+for+children&view

• Fever

– Not an illness

– physiologic mechanism that has beneficial effects in fighting

infection

– slows the reproduction of bacteria and viruses, enhances

neutrophil production and T-lymphocyte proliferation, and aids in

the body's acute-phase reaction

– 38°C (100.4°F)

• Degree of fever does not = severity of illness

• One of the most common clinical symptoms managed by

pediatricians and other health care providers

• Estimates one-third of all presenting conditions in children

Febrile Illness

DOS Course 201733

• Benefits of fever reduction

– Relief of patient discomfort

– Reduction of insensible water loss-decrease the occurrence of

dehydration.

• Risks of lowering fever

– Include delayed identification of diagnosis

– Initiation of appropriate treatment

– Drug toxicity

Febrile illness

DOS Course 201734

• 100˚ - 102˚F Low grade : Beneficial range

• 102˚ - 104˚F Mild : Still Beneficial

• Over 104˚F Moderate : Causes discomfort /harmless

• Over 105˚F High : Maybe higher risk of bacterial infections

• Over 106˚F Very high : Important to bring it down

• Over 108˚F Dangerous : Hyperthermia ( heat stroke)

Fever Classifications

DOS Course 201735

• Rectal– Standard for Infants

– Lubricate, ½ inch or just past anal sphincter

– Point toward umbilicus, do not leave child unattended

• Temporal– Place on hairline toward the top of the ear

– Make sure it is touching the skin

• Oral– Place the tip under child’s tongue toward the back of mouth

• Axillary– Under the arm, least reliable

• Tympanic– May be difficult to place

– Not reliable under 6 months

– Cerumen may cause incorrect reading

Methods of Obtaining Temperature

DOS Course 201736

http://pediatrics.aappublications.org/content/127/3/580.full#T1

Alternating combined antipyretics may be more effective

than monotherapy for reducing temperature

Fever Symptom Treatment

DOS Course 201737

• History

– Under 2 months of age

– Unimmunized

– Previous hospitalization

– Prolonged ICU stay

– Prematurity

– Immunocompromised disease

• Assessment

– Cyanosis

– Dehydration

– Petechial rash

– Inconsolable

– Mental status changes

Febrile Illness Red Flags

DOS Course 201738

• Definition: Clinical syndrome of upper respiratory symptoms of

cough and congestion accompanied by lower respiratory infection

• Etiology

– Respiratory Syncytial Virus RSV.

– Rhinoviruses,

– Human Metapneumovirus,

– Influenza,

– Adenovirus

• Incidence

– Most common under 2

– 3 months – 3 years

– Winter

Bronchiolitis

DOS Course 201739

http://dxline.info/img/new_ail/rsv-infection.jpg

• Incubation

– 2-8 days ( usually 4-6);

– Respiratory droplets

– Stable 6 hours on hard surfaces

– Stable on hands for 30 minutes

– Contagious for 3-4 weeks

• Symptoms

– Wheezing

– Rhinorrhea

– Cough

– Fever may be present

Bronchiolitis

DOS Course 201740

• Exclusive breastfeeding for the first 6 months

• Avoid exposure to tobacco smoke

• Good hand hygiene

– Scrub for 30 Seconds

– Hand sanitizer

http://visualjournalism.com/wp-content/uploads/2009/11/8_steps_hands.jpg

Bronchiolitis Prevention

DOS Course 201741

• Hydration

• Aspirators

– Bulb Syringe

– Parent Powered

– Electric

http://hubpages.com/family/best-baby-nasal-aspirator-for-your-infant

Bronchiolitis Treatment Supportive

DOS Course 201742

RED FLAGS

Retractions Cyanosis Tachypnea Grunting Dehydration

http://classconnection.s3.amazonaws.com/576/flashcards/2053576/png/rsv1367434389844.png

http://

Bronchiolitis

DOS Course 201743

• Asthma is a significant health problem worldwide

• One of the most common chronic diseases of childhood

Asthma

DOS Course 201744

http://www.newtoasthma.com/wp-content/uploads/2014/05/Asthma-problem.jpg

• Genetic and environmental factors

• An inherited tendency to develop allergies

• Parents who have asthma

• Certain respiratory infections during childhood

• Allergens or exposure to viral infections in in early

childhood when the immune system is developing

• Young children who often wheeze and have respiratory

infections—as well as certain other risk factors—are at

highest risk of developing asthma that continues beyond

6 years of age

Asthma Causes

DOS Course 201745

• One Major Decisive Factor

– Parent with asthma

– Diagnosis of eczema

– Environmental allergies

• Two Minor Decisive Factors

– Food allergies

– Greater than 4% blood eosinophil

– Wheezing apart from colds

Asthma Predictive Index

DOS Course 201746

• Symptoms

– Cough- worse at night

– Wheezing

– Chest tightness

– Shortness of Breath

• Triggers

– Allergens such as dust, animal fur, cockroaches, mold, pollen, grass

– Irritants such as smoke, air pollution, chemicals

– Upper respiratory infections

– Exercise

Asthma is Individualized

Asthma

DOS Course 201747

Asthma Action Plan

DOS Course 201748

https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf

• Avoid triggers

• Short acting bronchodilator – Albuterol

– 2 puffs every 4 - 6 hours prn

• Inhaled corticosteroids (always rinse mouth)

• Long - acting Beta 2 agonist

• Leukotriene modifier

• Oral Steroid

Asthma Treatment

DOS Course 201749

https://www.nhlbi.nih.gov/files/docs/public/lung/SoYouHaveAsthma_PRINT-reduced-filesize.pdf

• Use of spacer

– Ensure that medication

is inhaled properly to

improve lung function

• RED FLAGS

– Shortness of breath at rest

– No improvement in cough

– SOB with use of albuterol

– Increased work of breathing

– Use of accessory muscles

Asthma

http://www.bing.com/images/search?q=picture+of+inhaler+with+spacer&viewd

DOS Course 201750

• 5 year old female

• History of repeated URI

• Mom states “ they last all winter”

• Dad has allergy to pollen

• Cough mostly at night

• Started kindergarten this year

Case Study

DOS Course 201751

• Epilepsy

– Recurrent unprovoked seizures

• Etiology

– Genetic

– Metabolic

– Infection

– Trauma

– Developmental brain disorder

Seizures

DOS Course 201752

• Seizure accompanied by fever

– Temperature > 100.4 F or 38C

– Without central nervous system infection

– 6 - 60 months of age

• Simple

– Generalized < 15 minutes and did not recur within 24 hours

• Complex

– Focal > 15 minutes and recurrent within 24 hours

• Simple febrile seizures

– No evidence of increased mortality, hemiplegia, or mental

retardation

– Recurrence in one-third of the children

Febrile Seizure

DOS Course 201753

• Identify cause

• Differential diagnosis

• Immunization status

• Symptomatic treatment

• Meningitis considered in the differential diagnosis

– lumbar puncture should be performed if the child is ill-appearing or

if there are clinical signs of concern

• Simple febrile seizure does not usually require further

evaluation

– Specifically EEGs, blood studies or neuroimaging

Febrile Seizure Treatment

DOS Course 201754

• Definition

– Radial head subluxation

– Annular ligament displacement

• Epidemiology

– One and four years (2-3)

– Girls > boys

– Left > right

• Mechanism

– Axial traction on a pronated forearm in extension

– Sudden traction on the distal radius

– Portion of the annular ligament slips over the head of the radius

and slides into the radiohumeral joint

– Becomes trapped

Nursemaid’s Elbow

DOS Course 201755

• History

– Forearm was pulled while it was pronated and elbow was extended

– Parent pulls child’s arm

– 50 percent of cases

– Younger than six months of age typically involves rolling over in bed

• Exam

– Hold the affected arm close to the body

– Elbow either fully extended or slightly flexed and the forearm pronated

– Distress with attempts to move the elbow

– Mild tenderness over the anterolateral aspect of the radial head

– The distal humerus and ulna are typically nontender

Nursemaid’s Elbow

DOS Course 201756

• Support the child's arm at the elbow

• Exert moderate pressure on the radial head with the thumb or one finger

• With the other hand, the examiner holds the child's distal forearm, pulls with

gentle traction

• While maintaining traction, fully supinates the child's forearm and then fully

flexes the elbow in one smooth motion

• Click may be felt by the finger over the radial head as it is reduced

Supination / Flexion Technique

DOS Course 201757

©2017 UpToDate

• Support the child's arm at the elbow

• Place moderate pressure on the radial head with one

finger

• Grip the child's distal forearm with the other hand and

hyperpronate the forearm

• Click may be felt by the finger over the radial head

when the subluxation is reduced

Hyperpronation

DOS Course 201758

©2017 UpToDate

• Radiographs are not needed

• Postreduction

– Successful reduction, there is immediate pain relief

– Confirmed when the child moves the affected arm

– Occurs within 5 to 10 minutes

– Recurrence rates range from 27 to 39 percent

– No long term sequelea

– Indications for referral

– After several failed attempts at reduction, radiographs of the arm

should be obtained to evaluate for fractures of the radius or ulna

– Child with normal radiographs who refuses to use the arm should

be referred to a (pediatric) orthopedic surgeon

– Affected arm should be placed in a sling

– Spontaneous reduction may occur

Nursemaid’s Elbow

DOS Course 201759

• Definition

– SCFE - slipped upper femoral epiphysis

– Displacement of the capital femoral epiphysis from the femoral

neck through the physeal plate

• Incidence

– Approximately 1 per 1,000 to 10,000 children and young

adolescents

– Male - has not yet reached the fourth Tanner stage / 13.5 years

– Female - premenarche / 12 years

– Male - to – female ratio is 1.5 : 1

– Obese

Slipped Capital Femoral Epiphysis

DOS Course 201760

• Klein line is drawn along the superior border of the

femoral neck that would normally pass through a portion

of the femoral head.

• If not, slipped capital femoral epiphysis is diagnosed

Slipped Capital Femoral Epiphysis

DOS Course 201761

• Preslip

– Pain but no discernible displacement of the epiphysis

• Acute

– Symptoms of less than three weeks duration

– Joint effusion is present

– No metaphyseal remodeling

– 10 to 15 percent of patients

– Associated with major trauma

• Acute-on-chronic

– History of symptoms and signs of chronic with an acute increase

in pain and loss of motion of the affected hip

Classification

DOS Course 201762

• Chronic

– Most common pattern of presentation

– Characterized by vague, intermittent symptoms

– Longer than three weeks

– Metaphyseal remodeling is present

– No effusion

• Diagnosis

– Plain radiographs reveal an apparent posterior displacement of

the femoral epiphysis

• Treatment

– Operative stabilization

Classification – Diagnosis – Treatment

DOS Course 201763

• 13 year old male

• BMI 92%ile on growth charts

• Pain in knee after gym class

Case Presentation

DOS Course 201764

Questions ?

Thank You For Making

a Difference in the Life

of a Child

Conclusion

DOS Course 201765

https://www.cdc.gov/headsup/pdfs/providers/ace_v2-a.pdf

https://www.ncbi.nlm.nih.gov/pubmed/25236310

http://pediatrics.aappublications.org/content/127/2/389

https://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-

report

Diabetic Ketoacidosis in Infants, Children, and Adolescents A consensus

statement from the American Diabetes Association: Joseph Wolfsdorf, MB

Nicole Glaser,Mark A. Sperling, Diabetes Care 2006 May; 29(5): 1150-1159.

https://doi.org/10.2337/dc06-9909

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-

and-Disasters/Documents/MANUAL-06-internacional-2011.pdf

References

DOS Course 201766

DOS Course 201767