Emergencies

Kate Kernan

Robert M. (Bo) Kennedy

Emergency department (ED) visits are stressful for both children and parents. During a busy day in the ED, waits are often long and patients and parents have no awareness of the many demands upon you and other staff. This often causes already stressed patients and parents to become impatient and restless. The following helps to optimize interactions with families:

Cleansing your hands with alcohol hand sanitizer as you come into the room indicates your respect for the health of the patient.
Introduce yourself, and explain your role in the ED assessment.
Obtain a brief relevant history to enable prompt and appropriate therapy. A more detailed history can be obtained after initial intervention.
Consciously perform a rapid cardiopulmonary assessment as you walk into the room. Note the patient’s color, mental status, and work of breathing. If any of these are abnormal, proceed to auscultation of the lungs noting degree of air exchange, wheezes, rales, etc. Concurrently, note the rate and character of the pulse and capillary refill. This rapid assessment enables you to determine whether you need to immediately support ventilation or emergently seek vascular access to rapidly administer fluids. Otherwise, you can generally proceed to obtain a history and perform a typical physical exam.
For routine exams, perform the auscultation portion of the examination first (lungs, heart, and abdomen) and the more invasive parts later (ears and throat). If possible, keep toddlers on a parent’s lap (or very close by) during the physical examination. You may use the parents’ help during the examination (e.g., let a parent position the stethoscope on the chest).
Keep the parents informed about their child’s clinical progress. Give them an expectation of time frame, for example, that results of lab tests such as a CBC will be available in about 2 hours. The more informed about process and time course parents are, the more patient they will be. Explain what to expect in the course of illness and give return parameters that require urgent reevaluation.

CARDIOPULMONARY RESUSCITATION

Most commonly in pediatrics, hypoxia from respiratory failure causes bradycardia, followed by cardiac arrest.
Patients who receive delayed resuscitation or who present in asystole have a poor prognosis.
All resuscitation begins with support of ventilation and circulation. Check the blood sugar in any patient with a decreased mental status or seizure. Identify the cause early. Reversible causes must be addressed to successfully achieve return of spontaneous circulation. While providing resuscitation, a designated team member should obtain a rapid, focused history that can further guide resuscitation efforts.

Etiology

Most common causes:
- Trauma: motor vehicle crashes, burns, child abuse, firearms
- Pulmonary: foreign body aspiration, smoke inhalation, drowning, respiratory failure
- Infectious: sepsis, meningitis
- Central nervous system: head trauma, seizures
- Cardiac: congenital heart disease, myocarditis
- Others: sudden infant death syndrome (SIDS), poisoning, suicide, dehydration, congenital anomalies
Reversible causes (Hs and Ts): Hypovolemia, hypoxia, hypoglycemia, hypo-/hyperkalemia, hydrogen ion (acidosis), hypothermia, Tension pneumothorax, tamponade, toxins, and thrombosis (pulmonary and coronary)

Treatment (Basic Life Support; Table 4-1)

Focus on hard, rapid compressions with minimal pauses. Target between 100 and 120 compressions/min, at a depth of 1/3 to 1/2 the AP diameter of the chest (˜ 1.5 inches in infants, 2 inches in children, and at least 2 inches in teens and adults).
The goal is to optimize flow of oxygenated blood through the coronary arteries to the myocardium to enable resumption of spontaneous depolarization and pumping of the heart. Effective cardiac compressions also deliver oxygenated blood to the brain and other essential organs. Minimize interruption of compressions; each time compressions are stopped, blood flow through the coronary arteries stops, and the initial compressions on resumption are ineffective. Since cardiac output during compressions is only 25%-33% of normal, ventilations should also be only 25%-33% of normal; positive pressure ventilations impede blood return to the heart, and thus, overventilation compromises cardiac output.

TABLE 4-1 Basic Techniques of Pediatric Life Support

Not breathing or only gasping
No pulse palpated within 10 sec (carotid in adults, brachial or femoral in children)
Call for help, AED
Compressions	Lower half of the sternum in child and adult One finger width below the mammary line in infants Two hands in adults, heel of one hand in child Two thumbs encircling the chest in infant with 2 rescuers Depth at least 2 inches or 1/3 to 1/2 the AP diameter in adult, about 1.5 inches in child, or 1/3 to 1/2 the AP diameter in infant Rate: 100-120 compressions/min
Airway	Head tilt-chin lift
Breathing (after first 30 compressions)	2 breaths at 1 sec/breath
Compression/ventilation ratio	No advanced airway: Single rescuer 30:2 Two rescuers: 15:2 up to puberty then 30:2 After intubation: ˜8-10 breaths/min, 1 breath every 6-8 sec, asynchronous with compressions
*Foreign body aspiration*	Abdominal thrusts/Heimlich maneuver	Back blows and chest thrusts if < 1 year of age
American Heart Association, Guidelines Pediatric Advanced Life Support, 2011.