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Course: Pediatric Nursing

Topic: Nursing Management during Pediatric Emergency

The Nurses International Community

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Module Goals

Learners will be able to:

Identify common pediatric emergencies
Discuss evidence-based management of pediatric emergencies
Discuss the role of the nurse during pediatric emergencies

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Pediatric Emergencies: Choking

Caused when airway is obstructed by foreign body/object
Can lead to cardiac arrest if not managed appropriately
Management depends on the severity of the obstruction
Severity of Choking:

Partial/mild choking

Child is coughing, making sound

Complete/severe choking

Child unable to cough or make sound

Skellett, 2021

Topjian, 2020

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Partial/Mild Choking

Signs/symptoms:

Crying or verbal response to questions
Loud cough
Able to take a breath before coughing
Fully responsive

Management:

Sit the child in upright position, per comfort
Speak to the child in calm reassuring manner
Allow spontaneous coughing

Do not attempt to manually remove the obstruction

Remain with child and observe for signs of complete/severe choking

Topjian, 2020

Skellett, 2021

Save a Life Certifications by NHCPS, n.d.

Contact info: info@nursesinternational.org

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Complete/Severe Choking

Signs/symptoms:

Unable to vocalise
Quiet or silent cough
Unable to breathe
Cyanosis
Decreasing level of consciousness

Immediate intervention is necessary

To remove foreign body obstruction from the airway
To prevent cardiac arrest

Topjian, 2020

Skellett, 2021

Save a Life Certifications by NHCPS, n.d.

Contact info: info@nursesinternational.org

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Severe Airway Obstruction but Conscious:

Management in Infants

Back Blows:

Support infant’s head and neck with one hand avoiding pressure on their throat.
Place Infant in prone position with head lower than the body.
With heel of free hand, provide back blow on the back between the shoulder blades for 5 times.

Aim is to clear obstruction with each blow

If unsuccessful after 5 back blows, give chest thrusts

Topjian, 2020

Skellett, 2021

Perth Children’s Hospital, 2021

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Severe Airway Obstruction but Conscious:

Management in Infants (Continued)

Chest thrusts

Place infant in head-downwards supine position, supported along the back and head.
Provide 5 chest thrusts (similar to chest compression of cardiopulmonary resuscitation for infant).

Chest thrusts if unsuccessful, alternate with 5 back slaps.

Cycles of back slaps and chest thrusts repeated until obstruction is cleared or infant becomes unconscious.

Topjian, 2020

Skellett, 2021

Perth Children’s Hospital, 2021

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Choking in Infants

Topjian, 2020

Skellett, 2021

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Severe Airway Obstruction and Conscious:

Management in Children Over 1 Year

Topjian, 2020

Skellett, 2021

Back slaps:

Back blows are effective if child is positioned head down.
Small child may be positioned along the rescuers lap as with infant.
5 back slaps provided on the back between shoulder blades.

If 5 back slaps unsuccessful, provide abdominal thrusts.

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Severe Airway Obstruction and Conscious:

Management in Children Over 1 Year

Abdominal thrusts

Standing/kneeling behind the child, wrap arms around their waist under their ribcage.
Clench fist and place it just above umbilicus.
Grasping fist with other hand, pull sharply inwards and upwards.
Avoid pressure on xiphoid process or rib cage.
Repeat until obstruction is cleared.

Alternate between back slaps and abdominal thrusts until obstruction is cleared or child become unresponsive.

Topjian, 2020

Skellett, 2021

Contact info: info@nursesinternational.org

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Severe Choking and Unresponsive Children Management

Alert emergency medical service (EMS)

Out of hospital: Call if phone available.
In-hospital: Alert code for emergency management team.

Immediately initiate cardiopulmonary resuscitation (CPR) as per pediatric basic life support protocol.
Remove visible foreign body when opening airway for rescue breaths.
Continue pediatric basic life support until help arrives.

Topjian, 2020

Skellett, 2021

Dodson & Cook, 2022

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Severe Choking and Unresponsive Children Management

In hospital, if all attempts fail then trained specialist may perform:

Laryngoscopy to remove object with forceps/suction.
Or, cricothyrotomy with transtracheal ventilation if object is above the level of the vocal chord.

Child should be examined by ENT (ear, nose, throat) specialist after stabilization.

Topjian, 2020

Skellett, 2021

Dodson & Cook, 2022

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What Would the Nurse Do?

A 2 year old is choking on a toy in a shopping mall. The child is is responsive and taking breaths between coughing fits. His father is panicking and trying to take the toy out of his mouth manually.

What should the nurse do if present?

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The nurse understands that it is partial choking. The nurse should instruct the father not to attempt to manually remove the obstruction as it may dislodge the toy and fully obstruct the airway. The nurse should then encourage the parent to stay calm and position the child in an upright position, as per their comfort. The nurse should speak to the child in a calm reassuring manner and allow spontaneous coughing. The should stay close and observe for signs of complete/severe choking and wait for help to arrive. If the choking advances to complete/severe, then the nurse should start back blows. If 5 back blows are unsuccessful, chest thrust should be started. For this, the nurse should place the infant in head-downwards supine position, supported along the back and head, provide 5 chest thrusts (similar to chest compression of cardiopulmonary resuscitation for infant), Alternate cycles of 5 back slaps and chest thrusts until obstruction is cleared or infant becomes unconscious.

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Drowning

Experience respiratory impairment from submersion/immersion in liquid.
Drowning injuries may cause morbidity or death.
Hypoxia may cause irreversible neurological injury within 4-10 minutes.
Most long-term sequelae are neurological.

World Health Organization, n.d.

Children’s Health Queensland Hospital and Health Service, 2019

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Drowning: Initial Management

Remove the child from the water and to dry land if self safety is not at risk

Assess child’s breathing

If breathing normally:

Consider recovery position
Dry and warm child’s body if the water temperature was low
Transport child to hospital

Global First Aid Reference Center, 2021

Children’s Health Queensland Hospital and Health Service, 2019

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Drowning: Initial Management

If not breathing

Call EMS on phone, or send for EMS and automated external defibrillator if other person present
Open airway, remove foreign object, give 2 rescue breaths
If still not breathing, immediately start CPR cycles as per pediatric basic life support guidelines
If alone, activate EMS after 2 minute of CPR

Turn child to side-lying position with head facing down if vomiting

Global First Aid Reference Center, 2021

Children’s Health Queensland Hospital and Health Service, 2019

Contact info: info@nursesinternational.org

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Drowning: Further In-Hospital Management

Investigations:

Adequate oxygenation, prevention of aspiration
Hypothermia treated with warmed IV fluids, humidified oxygen delivery, forced air warming blankets
Antibiotics if signs of infection

Children’s Health Queensland Hospital and Health Service, 2019

The Royal Children’s Hospital Melbourne, 2020

ECG for suspected cardiac dysrhythmias CXR Head CT imaging for suspected trauma injuries	Potassium, creatinine Renal and haematologic function tests Sputum culture (‘dirty’ water drowning)

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Critical Thinking Question/

A 13 years old child who is rescued from drowning has blue (cyanotic) lips and feet. After gaining consciousness, the child is unable to answer orientation questions.

How would the nurse interpret this finding?

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Shock

Shock is failure of oxygen delivery to meet tissue metabolic demands
Is life threatening
Types of shock in children:

Hypovolemic shock (most common)
Distributive shock
Cardiogenic shock
Obstructive shock

Multiple types of shock can occur simultaneously

Topjian et al., 2020

Contact info: info@nursesinternational.org

Hypovolemic shock: inadequate perfusion of vital organs because of reduction in circulating blood volume (hemorrhage, trauma, fluid loss from diarrhea and vomiting, inadequate fluid intake)
Cardiogenic shock: due to the inability of the heart to pump blood to tissues (decreased cardiac output), as in congestive heart failure; rare in children (hypoxia, arrhythmias, congenital heart)
Distributive shock: due to massive vasodilatation from interference with sympathetic nervous system or effects of histamine or toxins, such as in anaphylaxis, septic shock, neurologic injury, spinal cord injury, intoxication with some drugs (e.g., tricyclic antidepressants, iron)
Obstructive (mechanical) shock: obstruction of cardiac filling such as that caused by pericardial tamponade or tension pneumothorax, coarctation of the aorta

(Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care: Chapter 20

General Emergencies and Major Trauma, 2009)

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Shock: Signs/Symptoms

Infant:

Irritability initially, then lethargic
Poor feeding
Decreased responsiveness to parents or caregivers
Trauma,
Fever, cough indicating pneumonia
Decreased urine output

Older child:

Nausea
Lightheadedness, faintness
Thirst
Altered level of consciousness
Trauma

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care: Chapter 20

General Emergencies and Major Trauma, 2009

Contact info: info@nursesinternational.org

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Shock: Clinical Features

Moves from compensated state to decompensated state
Compensatory mechanisms help maintain cardiac output and end-organ perfusion

Tachycardia
Increased systemic vascular resistance (Vasoconstriction)
May cause tachypnea, cool clammy skin

When compensatory mechanisms fail, following occur:

Hypotension, tachypnea or bradypnea
Inadequate end-organ perfusion: depressed mental status, decreased urine output, lactic acidosis, weak central pulses

Topjian et al., 2020

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Shock: Assessment and Management

Breathing and perfusion reliable indicators of shock in children

Persistent tachycardia, cool extremities, capillary refill > 2 seconds

Where shock is suspected, immediate assessment and management of ABCs (airway, breathing, circulation) is priority
Goals of treatment:

Restore circulating blood volume
Improve oxygenation of vital tissues
Prevent ongoing volume losses

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care: Chapter 20 General Emergencies and Major Trauma, 2009

Contact info: info@nursesinternational.org

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Shock: Management (Continue)

Priority: Airway patency, adequate ventilation
Direct pressure to control bleeding from external wounds if present
Positioning in Trendelenburg's position
Intravenous (IV) fluid resuscitation

Failed IV access for three attempts or within 60-90 minutes, require intraosseous access
20 ml/Kg IV bolus of normal saline or Ringer’s Lactate
IV bolus repeated until perfusion improve or signs of fluid overload

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care: Chapter 20 General Emergencies and Major Trauma, 2009; Martin & Weiss, 2015; Topjian et al., 2020

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Shock: Management (Continued)

After initial management, investigation is performed to identify the cause and is managed accordingly

Septic shock:

Life-threatening hypotension due to body’s reaction to infection
Investigation: Lactate level, mean arterial pressure, creatinine, urine output, platelets, glasgow coma scale, blood pressure, blood culture
Management: Parenteral fluids and antibiotics, vasoactive drug

Standl et al., 2018

Martin & Weiss, 2015

Topjian et al., 2020

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Shock: Management (Continued)

Anaphylactic shock:

Generalized immune system reaction to antigen causing itchy skin, edema, collapsed blood vessels, difficulty breathing, fainting, or even death
Management:

Management of airway obstruction, adequate ventilation
Immediate intramuscular epinephrine shot
Fluid resuscitation
Antihistamines, Beta agonists, corticosteroids may be prescribed

Standl et al., 2018

National Cancer Institute, n.d.; The Royal Children’s Hospital Melbourne, 2021

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Nurse’s Role in Management of Pediatric Emergencies

Able to assess and identify pediatric emergencies
Provide basic life support
Be familiar with agency protocols regarding management of different pediatric emergencies
Support family :

Communicate the child’s health condition, management
Ensure family’s concerns are addressed in timely and appropriate manner
Assist family in caring for their child where possible

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Case Study

A nurse is taking care of a 6-month-old who presents with vomiting and diarrhea for 4 days. Upon assessment the nurse notes that the infant is lethargic with capillary refill of 5 seconds, heart rate of 173, blood pressure of 69/40, and weak brachial pulses. The family states the infant has not had a wet diaper in the last 12 hrs.

What kind of shock should the nurse suspect?
Is it compensated or decompensated shock?
What should the nurse do next?

Contact info: info@nursesinternational.org

The nurse should suspect hypovolemic shock due to the vomiting and diarrhea
This is decompensated shock (hypotension, changes in mental status from decreased perfusion, delayed capillary refill, decreased urine output)
Where shock is suspected, the immediate assessment and management of ABCs (airway, breathing, circulation) is priority. The goals of treatment are:

Restore circulating blood volume
Improve oxygenation of vital tissues
Prevent ongoing volume losses

So in this situation, after making sure airway and breathing are okay, the nurse should focus on circulation as it is impaired (delayed capillary refill and hypotension). The nurse should immediately establish IV access or verifiy patency of an existing IV and then administer a 20 mL/kg fluid bolus per policy or after checking with the physician.

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Red Flags

Community or private child play areas are not well supervised or not constructed for maximum safety.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

Children’s Health Queensland Hospital and Health Service. (2019). Queensland Pediatric Guideline , Emergency: Drowning- Emergency management in children. https://www.childrens.health.qld.gov.au/guideline-drowning-emergency-management-in-children/

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care: Chapter 20 General Emergencies and Major Trauma. (2009). https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care/chapter-20-general-emergencies-major-trauma.html#a24

Dodson, H., & Cook, J. (2022, May 2). Foreign Body Airway Obstruction. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553186/

Contact info: info@nursesinternational.org

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References:

Global First Aid Reference Center. (2021, February 15). Drowning. International Federation of Red Cross. https://www.globalfirstaidcentre.org/drowning/

Martin, K., & Weiss, S. L. (2015). Initial resuscitation and management of pediatric septic shock. Minerva pediatrica, 67(2), 141–158. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395852/#:~:text=Current%20pediatric%20guidelines%20recommend%20starting,%E2%80%9Ccold%20shock%E2%80%9D%20in%20children.&text=However%2C%20in%20children%20with%20%E2%80%9Cwarm,more%20appropriate%20to%20increase%20SVR

National Cancer Institute. (n.d.). anaphylactic shock. U.S. Department of Health and Human Services, National Institute of Health. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/anaphylactic-shock

Perth Children’s Hospital. (2021, August). Choking. Government of Western Australia, Child and Adolescent Health Services. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Choking

Contact info: info@nursesinternational.org

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References:

Save a Life Certifications by NHCPS. (n.d.). Relief of Choking For Adults, Children, & Infants. https://nhcps.com/lesson/relief-of-choking-for-adults-children-infants/

Skellett, S., Maconochie, I., Bingham , B., Worrall, M., Scholefield, B.R., Johnson, M., Page, M., Andre, A., Bower, E., Wyllie, J., Lockey, A., Hampshire, S. (2021, May). Paediatric basic life support Guidelines. Resuscitation Council UK. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-basic-life-support-guidelines#:~:text=In%20the%20paediatric%20basic%20life,rescue%20breaths%20have%20been%20delivered

Standl, T., Annecke, T., Cascorbi, I., Heller, A. R., Sabashnikov, A., & Teske, W. (2018). The Nomenclature, Definition and Distinction of Types of Shock. Deutsches Arzteblatt international, 115(45), 757–768. https://doi.org/10.3238/arztebl.2018.0757

The Royal Children’s Hospital Melbourne. (2020, June). Drowning https://www.rch.org.au/clinicalguide/guideline_index/Drowning/

Contact info: info@nursesinternational.org

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References:

The Royal Children’s Hospital Melbourne. (2021, January). Anaphylaxis. https://www.rch.org.au/clinicalguide/guideline_index/Anaphylaxis/

Topjian, A. A., Raymond, T.T., Atkins, D., Chan, M., Duff, J.P., Joyner Jr, B.L., Lasa, J.J., Lavonas, E.J., Levy, A., Mahgoub, M., Meckler, G.D., Roberts, K.E., Sutton, R.M., & Schexnayder, S.M. (2020). Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation,142:S469–S523. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901

World Health Organization. (n.d.). Drowning. https://www.who.int/health-topics/drowning#tab=tab_1

Contact info: info@nursesinternational.org

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