Treating Pediatric Summertime Emergencies ORLANDO FIRE DEPARTMENT EMS Division August 2015
Transcript
1. ORLANDO FIRE DEPARTMENT EMS Division August 2015
2. OBJECTIVES Review Bites & Stings Review Drowning Review
Heat Exposure Spectrum Understand common pediatric summertime
emergencies and their pathophysiology. Know the treatment methods
for each emergency. Review initial stabilization and safe transport
for each specific emergency.
3. Key Terms Anaphylaxis: An exaggerated, life- threatening
hypersensitivity reaction to a previously encountered antigen.
Drowning: Death by asphyxia after submersion. Heat stroke:
Life-threatening failure of the body's temperature- regulating
mechanisms after exposure to high or prolonged heat stress.
Laryngospasm: A sudden, temporary closure of the larynx.
4. Treating Pediatric Summertime Emergencies EMS is called to a
daycare for a 4-year-old child with difficulty breathing. On
arrival, they find a 33-lb child in moderate distress with
inspiratory and expiratory wheezing. A quick history reveals that a
bee stung the patient 15 minutes prior to arrival. Ten minutes
later, the patient vomited and started wheezing.
5. Treating Pediatric Summertime Emergencies The patient is
quickly placed on a monitor and vital signs show a heart rate of
160, respiratory rate of 40, oxygen saturation of 88% and a blood
pressure of 80/40. His physical exam reveals a patient in obvious
distress, moist mucous membranes and normal oropharynx without
tongue swelling.
6. Treating Pediatric Summertime Emergencies His heart is
tachycardic with a regular rhythm. Auscultation of the chest shows
the patient is tachypneic with inspiratory and expiratory wheezing
coupled with intercostal and substernal retractions. His abdomen is
soft, non- tender and non- distended. An examination of the skin
show a blanching, raised, erythematous rash around the sting site
on his leg that has spread to his trunk. The patient is quickly
placed on oxygen. The steps that are taken next save this patient's
life.
7. Deadly Season Summer, a much-anticipated season of the year
for both adults and children, is unfortunately a time for
significant unintentional injury and death to kids. This is
secondary to a combination of children being out of school and
spending more time outdoors, coupled with decreased adult
supervision. Statistics from the National SAFE Kid Campaign Study
reveal that nearly half of the unintentional deaths of children
under 14 years of age occur between May and August, with a peak
occurring in July.
8. Deadly Season During these summer months approximately 9
million children are seen in EDs across the country and over 9,000
children will die as a result of these injuries.1 Through proper
assessments and symptom identification, first responders can
provide key initial stabilization for common summertime emergencies
and prevent further mortality.
9. Deadly Season Children are at higher risk for traumatic
injuries based on anatomy alone. A smaller body size can lead to
multiple injuries from just a single impact. Children also have a
decreased circulating blood volume indicating that hypovolemic
shock can result from a relatively small blood loss. A relatively
cartilaginous skeleton can lead to visceral and brain injuries that
are common in the absence of bony injuries.
10. Bites & Stings Reactions to insect stings are seen
commonly in pediatric practice, ranging from simple local reactions
to systemic anaphylaxis. Both warmer weather and spending more time
outdoors are risk factors. Though a rare occurrence from a sting,
one has to be prepared for anaphylaxis when transporting these
patients. Stinging insects include honeybees, bumblebees, wasps,
yellow jackets, hornets, harvester ants and fire ants. Biting
insects include mosquitoes, fleas, horseflies, ticks and
chiggers.
11. Bites & Stings - anaphylaxis How it occurs: Immediately
after contact with the insect, a local reaction occurs at that site
with associated edema and pruritic local erythema. Irritant
substances concentrated in insect saliva cause these local
reactions in an insect bite. In insect stings, the female insect
has a barbed stinging apparatus that becomes lodged in the skin and
rips away, along with the venom sac, from the insect's body
following a sting event.
12. Bites & Stings - anaphylaxis Treatment: These local
reactions usually last several hours and respond to the application
of cool compresses. Antihistamines such as diphenhydramine
(Benadryl) and analgesics may also be helpful. Stingers should be
removed as rapidly as possible using something stiff--such as thick
paper or a credit card--because venom can continue to be released
for several seconds.
13. Bites & Stings - anaphylaxis Treatment (continued): The
area should then be washed with soap and water and elevated if on
an extremity. Larger local reactions can also occur, involving
areas of approximately 510 cm in diameter that are adjacent to the
site of the sting. The swelling generally peaks in 2448 hours, but
the reactions can last up to 10 days. Steroids are usually not
indicated for insect stings unless there's anaphylaxis.
14. Bites & Stings - anaphylaxis Severe cases: Although
systemic reactions to insect stings and bites are the exception
with less than 1% of children experiencing them, they can be life-
threatening.2 Anaphylaxis is a serious allergic or hypersensitivity
reaction that's rapid in onset and may cause death secondary to
rapid mast cell degranulation. In order to have an anaphylactic
reaction, one must have had a previous sting. Higher-risk patients
are immunocompromised patients (e.g. AIDS, cancer, medically
fragile) or patients with known anaphylaxis or severe
allergies.
15. Bites & Stings - anaphylaxis Severe cases: Per the
latest guidelines from the American Academy of Allergy, Asthma, and
Immunology, there are different ways to diagnose anaphylaxis but
the important points are that it can be an abrupt or delayed onset
and usually two of the following criteria have to be met: Skin or
mucosal involvement; Respiratory compromise such as wheezing or
persistent cough; Hypotension; Persistent vomiting or diarrhea; or
End organ dysfunction.
16. Bites & Stings - anaphylaxis Severe cases: The
immediate initial therapy for anaphylaxis is epinephrine (1:1,000)
0.01 mg/kg, with max of 0.3 mg intramuscularly in the anterolateral
thigh. Please note that this is a change from the past when
epinephrine was given subcutaneously. Giving it intramuscularly
provides more rapid absorption.
17. Bites & Stings - anaphylaxis Severe cases: In patients
with true anaphylaxis, intramuscular epinephrine should be given
first before IV access is obtained. Epinephrine can be repeated if
needed. Once IV access is established, an antihistamine such as
diphenhydramine should be administered. A normal saline bolus
should be considered if the patient has decreased capillary refill
or is hypotensive.
18. Bites & Stings - anaphylaxis Severe cases: Nebulized
albuterol can be used if the patient is wheezing or in respiratory
distress. If EMS protocol allows, a corticosteroid such as
solumedrol at a dose of 2 mg/kg should be given to a maximum dose
of 60 mg.
19. Bites & Stings - anaphylaxis Severe cases: Patients who
meet criteria for anaphylaxis should never been left on the scene
and should always be transported to the nearest appropriate ED,
even if there's dramatic improvement or complete resolution of
symptoms after epinephrine. This is because there's a rebound
phenomenon that can occur approximately 46 hours after the initial
exposure.
20. Drowning
21. Drowning Drowning is the second leading cause of injury
related death in children less than 15 years old.1 Recent studies
conducted by the CDC reveal that the rates of drowning deaths in
children less than 19 years of age have decreased in the past 10
years, but drowning still remains the number one cause of
unintentional injury leading to death in boys ages 1--4. Between
the months of May and August, two thirds of all deaths from
drowning occur, with most of them occurring on the weekends.
22. Drowning Statistics for nonfatal drowning are even more
difficult to obtain, but nonfatal drowning events may occur several
hundred times as frequently as reported drowning deaths.
23. Drowning Risk factors: Risk factors for drowning include
inability to swim, as well as risk-taking behaviors, particularly
in adolescents. There's a bimodal age distribution, which includes
children less than 5 years of age and those 15--19 years of age who
are more likely to drown.
24. Drowning Risk factors (continued): The location of the
drowning accident is also age dependent; children less than 1 year
of age drown most frequently in the bathtub, children ages 14 drown
in swimming pools, and adolescents and teens are most likely to
drown in natural bodies of water.
25. Drowning Risk factors (continued): Children of low-to-
middle income background account for 90% of all drownings,
indicating that children of lower economic status are at higher
risk.1 Various primary medical conditions preclude some children to
drowning accidents such as children with seizures, who are 4 times
more likely to drown. Likewise, children with a primary cardiac
arrhythmia are at high risk, particularly if it is a cold- water
drowning or a significant amount of exercise is involved.
26. Drowning Pathophysiology: Both fatal and non- fatal
drownings begin with a period of panic. Contrary to popular belief,
the victim won't wave his or her arms and call for help. With
panic, there will be a loss of the normal breathing pattern, air
hunger and periods of breath holding.
27. Drowning Pathophysiology (continued): The patient will be
holding himself upright with arms extended laterally to assist with
posture and lung expansion, and may be mistaken for playing or
splashing as they struggle to stay above water. The struggle for
children to remain above water may only last for 10 seconds, while
adults may struggle for 60 seconds.
28. Drowning Pathophysiology (continued): In 20% of cases,
reflexive laryngospasm occurs and water isn't aspirated into the
lungs.3 The combination of hypoxia, hypercarbia and acidosis can
decrease myocardial contractility, elevate pulmonary artery and
systemic vascular resistance, and produce cardiac arrhythmias,
seizures and death.
29. Drowning Initial assessment and transport: The initial
presentation of a victim of a submersion injury is quite varied,
depending on initial submersion time and resulting hypoxemia. Signs
and symptoms may include loss of consciousness, apnea, dyspnea,
tachypnea, tachycardia, altered mental status, seizures, coughing
or decreased breath sounds on exam.
30. Drowning Initial assessment and transport (continued):
Initial treatment of the potential drowning child includes
supporting the ABC's (airway, breathing and circulation) by
providing high-quality CPR. If the patient doesn't have an adequate
respiratory effort, it's acceptable to provide bag-mask ventilation
if good chest rise is noted and transport time is short.
31. Drowning Initial assessment and transport (continued): If
the patient aspirated a significant amount of water, they may
require a slightly higher pressure (positive end-expiratory
pressure) to bag. Should the patient be difficult to bag or there
will be a prolonged transport time, intubation should be
considered.
32. Drowning Initial assessment and transport (continued): If
intubation isn't necessary, the patient should be placed on a
non-rebreather mask with 100% oxygen to help correct hypoxia.
33. Drowning Initial assessment and transport (continued): One
should avoid the Heimlich or other techniques to remove water as
they haven't proven to demonstrate any benefit. Correction of the
hypoxia is the key to a positive patient outcome.
34. Drowning Initial assessment and transport (continued):
Near-drowning patients should always be transported to the nearest
appropriate ED given the risk of rapid decompensation. Even the
asymptomatic near-drowning victim requires observation of at least
four hours.
35. Heat Exposure Spectrum Heat illnesses occur along a
spectrum of very minor (heat rash, cramps) to life-threatening
conditions such as heat stroke. Most episodes of heat illness occur
during times of increased environmental heat as well as increased
exposure to heat. The heat exposure spectrum includes heat rash
(miliaria), heat cramps, heat edema, heat syncope, heat exhaustion
and heat stroke.
36. Heat Exposure Spectrum Pathophysiology: A normal body
temperature of 98.6 degrees F is maintained within a narrow range
by balancing heat load and dissipation. As the body's core
temperature rises from hot weather or exercise, heated blood is
transferred to the skin surface if it's cooler.
37. Heat Exposure Spectrum Pathophysiology (continued): In an
effort to more rapidly dissipate heat, the body dilates blood
vessels and pores and evaporates sweat to help with cooling.
Unfortunately, this mechanism becomes ineffective once the relative
humidity is over 75%. With heavy work, the body may lose 1--2
liters of fluid.
38. Heat Exposure Spectrum Pathophysiology (continued): After
several hours of fluid loss, a person may start to become
symptomatic with loss of endurance, increased thirst and becoming
uncomfortable. After 35 hours, the body has decreased blood to
circulate to the rest of the body, which may lead to decreased
alertness, nausea, muscle cramps, headache and/or loss of
strength.
39. Heat Exposure Spectrum Pathophysiology (continued): If not
treated with fluid resuscitation, this may lead to heat stroke.
Heatstroke by definition is a core temperature greater than 105
degrees F, decreased level of consciousness and an environment
consistent with heat stroke.
40. Heat Exposure Spectrum Initial assessment and transport:
The key to treating heat exposure spectrum is to identify
approximately where the patient is on the spectrum. Heat rash
presents with a possibly pruritic maculopapular rash treated by
cool baths, loose clothing and removing the patient from the
environment.
41. Heat Exposure Spectrum Initial assessment and transport
(continued): Heat cramps present as brief, intermittent muscular
cramps that are relieved by increased salt intake. If they're more
severe they may require IV fluids.
42. Heat Exposure Spectrum Initial assessment and transport
(continued): Heat syncope is a temporary loss of consciousness
associated with vasodilation and venous pooling. It occurs usually
after standing a long time or a quick adjustment in position. These
patients usually have a normal core temperature and mental status
will quickly improve once supine and IV fluids are
administered.
43. Heat Exposure Spectrum Initial assessment and transport
(continued): The definition of heat exhaustion involves a known
heat exposure and core temperature between 37--40 degrees C. These
patients present with evidence of mild tomoderate volume depletion,
variable nonspecific symptoms including nausea, fatigue, confusion,
headache and tachycardia. Treatment consists of removal from the
heat to a cool environment, removal of excessive clothing, chilled
oral rehydration with salt containing fluids or IV hydration.
44. Heat Exposure Spectrum Initial assessment and transport
(continued): Central nervous system dysfunction is the hallmark for
heat stroke. When first assessing these patients, the ABCs are
paramount as these patients may need an airway intervention. Wet
sheets without air movement tend to increase the core temperature
and should be avoided.
45. Heat Exposure Spectrum Initial assessment and transport
(continued): When treating these patients, it's helpful to recall
the treatment mantra of Corey Slovis, MD, chairman of emergency
medicine at Vanderbilt Medical Center: "Wet and windy." Use ice
packs on the groin and the axilla, fans to help with convection
cooling, and IV fluids as needed for hydration. Those patients with
altered mental status, vital sign changes or evidence of
dehydration should be transferred to the nearest hospital for
observation and further treatment.
46. Conclusion In the medical community, summertime involves a
unique set of medical issues along with an increase in trauma
patients. First responders must be prepared to treat these patients
quickly and efficiently so that morbidity and mortality can be
minimized. Lauren Mutter, MD, is a pediatric emergency medicine
fellow at Le Bonheur Children's Hospital. Mark Meredith, MD, is
associate professor of pediatric emergency medicine at Le Bonheur
Children's Hospital.
47. References Unintentional Drowning: Get the facts. (Oct. 24,
2014.) Centers for Disease Control and Prevention. Retrieved May 4,
2015, from
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2000;21(8):256. Salomez F, Vincent JL. Drowning: A review of
epidemiology, pathophysiology, treatment and prevention.
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Nicklas RA. Et al. Emergency department diagnosis and treatment of
anaphylaxis: A practice parameter. Ann Allergy Asthma Immunol
2014;113(6):599608. Jardine DS. Heat illness and heat stroke.
Pediatr Rev. 2007;28(7):249258.