CHAPTER 7: Emergency Medicine

INITIAL APPROACH TO THE SICK CHILD

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.

AIRWAY AND CERVICAL SPINE STABILIZATION

• 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

BREATHING/VENTILATION

• Assess breath sounds, chest rise, and respiratory rate

CIRCULATION

• 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

DISABILITY (RAPID NEUROLOGIC EVALUATION) AND DEXTROSE

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

EXPOSURE/DECONTAMINATION

• Fully undress patient to evaluate for hidden injury

• Maintain normothermia to decrease metabolic needs

OBTAIN BRIEF HISTORY

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

BURNS

DEFINITION

• Acute injury due to transfer of thermal energy

EPIDEMIOLOGY

• 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

PATHOPHYSIOLOGY

• 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

DIAGNOSIS

• Always evaluate airway patency/inhalational injury

  • ✓ Look for soot in nares ...