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 | |||||||||||||||||||||||||||
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COMA
History: trauma, ingestion, infection, fasting, diabetes, drug use, seizure
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