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Pediatric Medical

Emergencies

Structured approach to
the seriously ill infant & child

Assessment & resuscitation occur at


the same time

Order of assessment & resuscitation


enables identification of immediately
life threatening problems,
which are treated as they are found

Respiratory
Obstructio
n

Foreign
body
Asthma
Croup

Respirato
ry
Depressio
n

Fluid loss

Fluid
Maldistribu
tion

Convulsion
s
Poisoning
Raised ICP

Blood Loss
Burns
Vomit/Diarrh
oea

Sepsis
Anaphylaxi
s
Cardiac
Failure

Respiratory
Failure

Circulatory
Failure

CARDIAC
ARREST

Key

differences in children

Weight
Anatomical - size & shape
Physiological cardiovascular, respiratory,

immune function
Psychological intellectual ability & emotional
response

Treatment must be catered for the


various differences

Airway
Breathing

Primary assessment
with Resuscitation

Circulation

Secondary assessment
identification of key
features

Disability

Emergency treatment

Exposure

Stabilisation
Transfer to definitive care

Vocalisations : crying or talking,

-indicate ventilation & some degree of airway patency

Assess patency by
-Looking for chest and/or abdominal movement
- Listening for breath sounds
- Feeling for expired air

Stridor

: suggest upper airway obstruction

Reassess after airway opening


manoeuvres
( head tilt/chin lift; jaw thrust)

Oxygen

Potential

respiratory failure

Potential

circulatory failure

Potential

central neurological failure

Effort of breathing

Recession

intercostal, sub-costal or sternal recession


(particularly in infants with more compliant chest

walls)

degree of recession indicates severity of


respiratory
difficulty
- patient with exhaustion, chest movement &
recession will decrease

Respiratory
Accessory

rate

muscle use

Flaring

of the nostrils

Child's

position

Age (yrs)

Respiratory rate
( breaths/min)

<1

30 -40

1-2

25-35

2-5

25-30

5-12

20-25

>12

15-20

WHO definitions of Fast Breathing


are:

< 2 months is 60 breaths per minute

2 12 months is 50 breaths per minute

12 months to 5 years is 40 breaths per


minute

Inspiratory

stridor

- upper airway pathology

Expiratory

wheeze

- lower airways pathology

Grunting
- stiff lungs to prevent airway collapse
(represents closure of the larynx
during expiration)

1. Exhaustion
2. Central
respiratory
depression
3. Neuromuscular
disease

1.

Exhaustion

2. Central
respiratory
depression
3. Neuromuscular
disease

Effort of breathing

Efficacy of breathing

Chest expansion

- reduced or absent
- symmetrical or asymmetrical

Breath sounds

- reduced or absent
- symmetrical or asymmetrical

Pulse oximetry

Normal oxygen saturation (SaO2)


is 95 100% in room air

A Silent Chest is a Pre- Terminal sign

Effort of breathing

Efficacy of breathing

Effects of Respiratory Inadequacy

Heart
rate

-increased by hypoxia, fever


-Bradycardia with hypoxia is a sign of
impending cardio-respiratory arrest

Skin
colour

- Hypoxia first causes vasoconstriction &


pallor
-Cyanosis is late sign & may indicate
impending
cardio-respiratory arrest

Mental
status

- Hypoxic child : agitated first,


then drowsy unconscious
-Pulse oximetry may be difficult to
measure in
agitated patient

SaO2

< 85% in room air is a Preterminal sign

Cyanosis

is Pre- terminal sign


( except cyanotic heart disease )

Infant 12 months old


Birth weight - doubles by 5 months
- triples by 1 year
- quadruples by 2 years

After 12 months,
Weight (Kg) = 2 x (age in years + 4)
the formula can be applied, but needs to be modified according
to whether the child is small or large compared with the average

Cardiovascular signs

Heart rate

-increases in shock
- Bradycardia may be a sign
of
imminent cardiorespiratory
arrest

Pulse volume

Absent peripheral pulses or


reduced central pulses can
indicate shock

Capillary refill

mostly in dehydrated children


and not as a sole sign of
circulatory failure)

Blood

Pressure

Age (yrs)

Systolic blood pressure


( mmHg)

<1

70-90

1-2

80-90

2-5

80-95

5-12

90-110

>12

100-120

Systolic BP = 80 + ( age in years X 2)

Cardiovascular signs

Effects of Circulatory inadequacy

Respiratory rate

tachypnoea &
hyperventilation
occurs with acidosis eg. poor
tissue
perfusion

Skin
temperature/colour

poor perfusion

Mental status

agitation, then drowsiness,


unconsciousness

Urine ouput

<2ml/kg/hour in infants
<1ml/kg/hour in a child
indicates inadequate renal

Cyanosis despite O2 ( cyanotic heart disease )

Marked tachycardia
Raised jugular venous pressure
Gallop rhythm / murmur
Enlarged liver
Absent femoral pulses

Conscious level

AVPU
Alert
Responds

to Voice

Responds

only to Pain

Unresponsive

to all stimuli

Conscious level

Posture

assess with painful


stimulus

decorticate

decerebrate

Conscious level

Posture

Pupillary signs

Airway and Breathing

Effort
Efficacy
Effects

Circulation

Heart rate
Capillary refill time
Blood pressure
Skin temperature

Disability

Conscious level
Posture
Pupils
Glucose

Values in children