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INITIAL APPROACH TO THE SICK CHILD

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Emergency evaluation differs from a standard inpatient history and physical in that less background information is available about the child and evaluation and intervention steps often need to happen at the same time. Figure 7-1 outlines some of the early steps in the evaluation of the sick child, as well as interventions to consider at each stage.

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FIGURE 7-1

Emergency evaluation and interventions. Abbreviation: AMPLE: Allergies, Medications, Past medical history, Last meal, and Environments and events.

Graphic Jump Location
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AIRWAY AND CERVICAL SPINE STABILIZATION

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  • Open airway with head-tilt/jaw-thrust maneuver (use jaw thrust for trauma)

  • Clear debris using large bore (e.g., Yankauer) suction catheter

  • Cervical spine immobilization with collar

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BREATHING/VENTILATION

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  • Assess breath sounds, chest rise, and respiratory rate

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CIRCULATION

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  • Establish IV access within 90 seconds or three IV placement attempts then consider intraosseous access (if <8 years old) or central venous access

  • Consider 20 mL/kg of lactated ringers or normal saline administered as fast as possible (typically over 5 minutes) if signs of severe dehydration or shock

  • Consider chest compressions if cardiopulmonary arrest

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DISABILITY (RAPID NEUROLOGIC EVALUATION) AND DEXTROSE

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  • Assess mental status via Glasgow Coma Score or classify as AVPU: Alert, Responds to Verbal stimuli; Responds to Painful stimuli; or Unresponsive

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EXPOSURE/DECONTAMINATION

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  • Fully undress patient to evaluate for hidden injury

  • Maintain normothermia to decrease metabolic needs

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OBTAIN BRIEF HISTORY

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  • The initial history is brief, and can be recalled by the AMPLE pneumonic (Allergies, Medications, Past medical history, Last meal, Events prior to presentation)

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BURNS

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DEFINITION

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  • Acute injury due to transfer of thermal energy

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EPIDEMIOLOGY

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  • Death from fire and burns is the third leading cause of unintentional death in children <14 years in the United States

  • Mechanisms changes with age: Scalds, contact burns, fire, chemical, electrical radiation

    • Infants: Bathing-related scalds, abuse

    • Toddlers: Scalds by hot liquid spills

    • School-age: Fire (playing with matches)

    • Adolescents: Volatile agents and high-voltage electric lines

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PATHOPHYSIOLOGY

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  • First-degree: Redness and mild inflammatory response confined to epidermis; heals in 3–5 days without scarring

  • Second-degree: Destruction of the epidermis and portion of the dermis; blistering; pink-red color; many weeks to heal and may need skin grafts

  • Third-degree or full-thickness: Pale or charred color and leathery appearance; non-tender due to destruction of cutaneous nerves; most require skin grafting

  • Fourth-degree: Full-thickness involving underlying fascia, muscle, or bone

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DIAGNOSIS

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  • Always evaluate airway patency/inhalational injury

    • ✓ Look for soot in nares or throat

    • ✓ Low threshold to intubate as airway edema will likely get worse

  • Watch out for circumferential burns which may need fasciotomy

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