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Pediatric Emergencies and Resuscitation
Injuries are the leading cause of death in American children and young adults and account for more childhood deaths than all other causes combined (see Chapter 13 ). Rapid, effective bystander cardiopulmonary resuscitation (CPR) for children is associated with survival rates as high as 70%, with good neurologic outcome. However, bystander CPR is still provided for <50% of children who experience cardiac arrest outside medical settings. This failing has led to long-term survival rates of <40%, often with a poor neurologic outcome.
Approach to the Emergency Evaluation of a Child
The first response to a pediatric emergency of any cause is a systematic, rapid general assessment of the scene and the child to identify immediate threats to the child, care providers, or others. If an emergency is identified, the emergency response system (emergency medical services, EMS) should be activated immediately. Care providers should then proceed through primary , secondary , and tertiary assessments as allowed by the child's condition, safety of the scene, and resources available. This standardized approach provides organization to what might otherwise be a confusing or chaotic situation and reinforces an organized thought process for care providers. If at any point in these assessments the caregiver identifies a life-threatening problem, the assessment is halted and lifesaving interventions are initiated. Further assessment and intervention should be delayed until other caregivers arrive or the condition is successfully treated or stabilized.
General Assessment
On arrival at the scene of a compromised child, a caregiver's first task is a quick survey of the scene itself. Is the rescuer or child in imminent danger because of circumstances at the scene (e.g., fire, high-voltage electricity)? If so, can the child be safely extricated to a safe location for assessment and treatment? Can the child be safely moved with the appropriate precautions (i.e., cervical spine protection), if indicated? A rescuer is expected to proceed only if these important safety conditions have been met.
Once the caregiver and patient's safety has been ensured, the caregiver performs a rapid visual survey of the child, assessing the child's general appearance and cardiopulmonary function . This action should be only a few seconds and include assessment of (1) general appearance, determining color, tone, alertness, and responsiveness; (2) adequacy of breathing, distinguishing between normal, comfortable respirations and respiratory distress or apnea; and (3) adequacy of circulation, identifying cyanosis, pallor, or mottling. A child found unresponsive from an unwitnessed collapse should be approached with a gentle touch and the verbal question, “Are you OK?” If there is no response, the caregiver should immediately shout for help and send someone to activate the emergency response system and locate an automated external defibrillator (AED) . Figs. 81.1 and 81.2 present basic life support (BLS) pediatric cardiac arrest algorithms for 1 rescuer and 2 or more rescuers, respectively. The provider should then determine whether the child is breathing and, if not, provide 2 rescue breaths. If the child is breathing adequately, the circulation is quickly assessed. Any child with heart rate <60 beats/min or without a pulse requires immediate CPR. If the caregiver witnesses the sudden collapse of a child, the caregiver should have a higher suspicion for a sudden cardiac event. In this case, rapid deployment of an AED is crucial. Any interruptions in care of the child to activate EMS and locate the nearest AED should be very brief. If >1 caregiver is present, someone should always remain with the child and provide initial care or stabilization (see Fig. 81.2 ).
Primary Assessment
Once the emergency response system has been activated and the child is determined not to need CPR, the caregiver should proceed with a primary assessment that includes a brief, hands-on assessment of cardiopulmonary and neurologic function and stability. This assessment includes a limited physical examination, evaluation of vital signs, and measurement of pulse oximetry if available. The American Heart Association, in its Pediatric Advanced Life Support (PALS) curriculum, supports the structured format of airway, breathing, circulation, disability, exposure (ABCDE) . The goal of the primary assessment is to obtain a focused, systems-based assessment of the child's injuries or abnormalities, so that resuscitative efforts can be directed to these areas; if the caregiver identifies a life-threatening abnormality, further evaluation is postponed until appropriate corrective action has been taken.
The exam and vital sign data can be interpreted only if the caregiver has a thorough understanding of normal values. In pediatrics, normal respiratory rate, heart rate, and blood pressure have age-specific norms ( Table 81.1 ). These ranges can be difficult to remember, especially if used infrequently. However, several standard principals apply: (1) a child's respiratory rate should not be >60 breaths/min for a sustained period; (2) normal heart rate is 2-3 times normal respiratory rate for age; and (3) a simple guide for pediatric blood pressure is that the lower limit of systolic blood pressure should be ≥60 mm Hg for neonates; ≥70 mm Hg for 1 mo-1 yr olds; ≥70 mm Hg + (2 × age) for 1-10 yr olds; and ≥90 mm Hg for any child older than 10 yr.
Table 81.1
Normal Vital Signs According to Age
| AGE | HEART RATE (beats/min) | BLOOD PRESSURE (mm Hg) | RESPIRATORY RATE (breaths/min) |
|---|---|---|---|
| Premature | 120-170 * | 55-75/35-45 † | 40-70 ‡ |
| 0-3 mo | 100-150 * | 65-85/45-55 | 35-55 |
| 3-6 mo | 90-120 | 70-90/50-65 | 30-45 |
| 6-12 mo | 80-120 | 80-100/55-65 | 25-40 |
| 1-3 yr | 70-110 | 90-105/55-70 | 20-30 |
| 3-6 yr | 65-110 | 95-110/60-75 | 20-25 |
| 6-12 yr | 60-95 | 100-120/60-75 | 14-22 |
| 12+ yr | 55-85 | 110-135/65-85 | 12-18 |
* In sleep, infant heart rates may drop significantly lower, but if perfusion is maintained, no intervention is required.
† A blood pressure cuff should cover approximately two thirds of the arm; too small a cuff yields spuriously high pressure readings, and too large a cuff yields spuriously low pressure readings. Values are systolic/diastolic.
‡ Many premature infants require mechanical ventilatory support, making their spontaneous respiratory rate less relevant.
Airway and Breathing
The most common precipitating event for cardiac instability in infants and children is respiratory insufficiency . Therefore, rapid assessment of respiratory failure and immediate restoration of adequate ventilation and oxygenation remain the first priority in the resuscitation of a child. Using a systematic approach, the caregiver should first assess whether the child's airway is patent and maintainable. A healthy, patent airway is unobstructed, allowing normal respiration without noise or effort. A maintainable airway is one that is either already patent or can be made patent with a simple maneuver. To assess airway patency, the provider should look for breathing movements in the child's chest and abdomen, listen for breath sounds, and feel the movement of air at the child's mouth and nose. Abnormal breathing sounds (e.g., snoring or stridor), increased work of breathing, and apnea are all findings potentially consistent with airway obstruction. If there is evidence of airway obstruction, maneuvers to relieve the obstruction should be instituted before the caregiver proceeds to evaluate the child's breathing.
Assessment of breathing includes evaluation of the child's respiratory rate, respiratory effort, abnormal sounds, and pulse oximetry. Normal breathing appears comfortable, is quiet, and occurs at an age-appropriate rate. Abnormal respiratory rates include apnea and rates that are either too slow (bradypnea) or too fast (tachypnea). Bradypnea and irregular respiratory patterns require urgent attention because they are often signs of impending respiratory failure and/or apnea. Signs of increased respiratory effort include nasal flaring, grunting, chest or neck muscle retractions, head bobbing, and seesaw respirations. Hemoglobin oxygen desaturation, as measured by pulse oximetry, often accompanies parenchymal lung disease apnea or airway obstruction. However, providers should keep in mind that adequate perfusion is required to produce a reliable oxygen saturation (S o 2 ) measurement. A child with low S o 2 is a child in distress. Central cyanosis is a sign of severe hypoxia and indicates an emergent need for oxygen supplementation and respiratory support.
Circulation
Cardiovascular function is assessed by evaluation of skin color and temperature, heart rate, heart rhythm, pulses, capillary refill time, and blood pressure. In nonhospital settings, much of the important information can be obtained without measuring the blood pressure; lack of blood pressure data should not prevent the provider for determining adequacy of circulation or implementing a lifesaving response. Mottling, pallor, delayed capillary refill, cyanosis, poor pulses, and cool extremities are all signs of diminished perfusion and compromised cardiac output. Tachycardia is the earliest and most reliable sign of shock but is itself fairly nonspecific and should be correlated with other components of the exam, such as weakness, threadiness, and absence of pulses. An age-specific approach to pulse assessment will yield best results.
Disability
In the setting of a pediatric emergency, disability refers to a child's neurologic function in terms of the level of consciousness and cortical function. Standard evaluation of a child's neurologic condition can be done quickly with an assessment of pupillary response to light (if one is available) and use of either of the standard scores used in pediatrics: the Alert, Verbal, Pain, Unresponsive (AVPU) Pediatric Response Scale and the Glasgow Coma Scale (GCS). The causes of decreased level of consciousness in children are numerous and include conditions as diverse as respiratory failure with hypoxia or hypercarbia, hypoglycemia, poisonings or drug overdose, trauma, seizures, infection, and shock. Most often, an ill or injured child has an altered level of consciousness because of respiratory compromise, circulatory compromise, or both. Any child with a depressed level of consciousness should be immediately assessed for abnormalities in cardiorespiratory status.
Alert, Verbal, Pain, Unresponsive Pediatric Response Scale
The AVPU scoring system is used to determine a child's level of consciousness and cerebral cortex function ( Table 81.2 ). Unlike the GCS, the AVPU scale is not developmentally dependent—a child does not have to understand spoken language or follow commands, merely respond to a stimulus. The child is scored according to the amount of stimulus required to obtain a response, from alert (no stimulus, the child is already awake and interactive) to unresponsive (child does not respond to any stimulus).
Table 81.2
AVPU Neurologic Assessment
From Ralston M, Hazinski MF, Zaritsky AL, et al, editors: Pediatric advanced life support course guide and PALS provider manual: provider manual, Dallas, 2007, American Heart Association.
| A | The child is awake, alert, and interactive with parents and care providers. |
| V | The child responds only if the care provider or parents call the child's name or speak loudly. |
| P | The child responds only to painful stimuli, such as pinching the nail bed of a toe or finger. |
| U | The child is unresponsive to all stimuli. |
A, Alert; V, verbal, P, pain, U, unresponsive.
Glasgow Coma Scale
Although it has not been systematically validated as a prognostic scoring system for infants and young children as it has in adults, GCS is frequently used in the assessment of pediatric patients with an altered level of consciousness. The GCS is the most widely used method of evaluating a child's neurologic function and has 3 components. Individual scores for eye opening, verbal response, and motor response are added together, with a maximum of 15 points ( Table 81.3 ). Patients with a GCS score ≤8 require aggressive management, generally including stabilization of the airway and breathing with endotracheal intubation and mechanical ventilation, respectively, and if indicated, placement of an intracranial pressure monitoring device. The Full Outline of Unresponsiveness (FOUR) score is another useful assessment and monitoring tool (see Table 85.1 ).
Table 81.3
Glasgow Coma Scale
Adapted from Teasdale G, Jennett B: Assessment of coma and impaired consciousness: a practical scale, Lancet 2:81–84, 1974.
| EYE OPENING (TOTAL POSSIBLE POINTS 4) | |||
| Spontaneous | 4 | ||
| To voice | 3 | ||
| To pain | 2 | ||
| None | 1 | ||
| VERBAL RESPONSE (TOTAL POSSIBLE POINTS 5) | |||
| Older Children | Infants and Young Children | ||
| Oriented | 5 | Appropriate words; smiles, fixes, and follows | 5 |
| Confused | 4 | Consolable crying | 4 |
| Inappropriate | 3 | Persistently irritable | 3 |
| Incomprehensible | 2 | Restless, agitated | 2 |
| None | 1 | None | 1 |
| MOTOR RESPONSE (TOTAL POSSIBLE POINTS 6) | |||
| Obeys | 6 | ||
| Localizes pain | 5 | ||
| Withdraws | 4 | ||
| Flexion | 3 | ||
| Extension | 2 | ||
| None | 1 | ||
Exposure
Exposure is the final component of the pediatric primary assessment. This component of the exam is reached only after the child's airway, breathing, and circulation have been assessed and determined to be stable or have been stabilized through simple interventions. In this setting, exposure stands for the dual responsibility of the provider to both expose the child to assess for previously unidentified injures and consider prolonged exposure in a cold environment as a possible cause of hypothermia and cardiopulmonary instability. The provider should undress the child (as is feasible and reasonable) to perform a focused physical exam, assessing for burns, bruising, bleeding, joint laxity, and fractures. If possible, the provider should assess the child's temperature. All maneuvers should be performed with careful maintenance of cervical spine precautions.
Secondary Assessment
For healthcare providers in community or outpatient settings, transfer of care of a child to emergency or hospital personnel may occur before a full secondary assessment is possible. However, before the child is removed from the scene and separated from witnesses or family, a brief history should be obtained for medical providers at the accepting facility. The components of a secondary assessment include a focused history and focused physical examination.
The history should be targeted to information that could explain cardiorespiratory or neurologic dysfunction and should take the form of a SAMPLE history : signs/symptoms, allergies, medications, past medical history, timing of last meal, and events leading to this situation. Medical personnel not engaged in resuscitative efforts can be dispatched to elicit history from witnesses or relatives. The physical examination during the secondary assessment is a thorough head-to-toe exam, although the severity of the child's illness or injury could necessitate curtailing portions of the exam or postponing nonessential elements until a later time.
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