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.

EMERGENT AIRWAY AND CERVICAL SPINE STABILIZATION

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

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

• Immobilize cervical spine with collar (with attention to proper pediatric sizing).

• Establish airway (apply oxygen, assist ventilation, place advanced airway if needed for airway protection or for apnea).

BREATHING/VENTILATION

• Assess breath sounds, chest rise, and respiratory rate.

• Assess need for needle decompression or chest-tube placement (e.g., absent breath sounds in one lung).

CIRCULATION

• Establish IV access with a maximum of three IV placement attempts in emergency evaluation then consider intraosseous access (if <8 years old) or central venous access.

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

• Initiate chest compressions if patient is in cardiopulmonary arrest.

DISABILITY (RAPID NEUROLOGIC EVALUATION) AND DEXTROSE

• Assess mental status via Glasgow Coma Scale score (Table 7-1) or classify as AVPU: alert, responds to verbal stimuli, responds to painful stimuli, or unresponsive.

• Obtain bedside dextrose sample, replace dextrose if indicated.

EXPOSURE/DECONTAMINATION

• Fully undress patient to evaluate for hidden injury with attention to possible contamination and safety of patient and staff.

• Maintain normothermia to decrease metabolic needs.