poisoning, drowning

7/28/2019 Poisoning, Drowning

1/24

UNIT6 NURSINGCAREOFCHILDRENWITHPAEDIATRICEMERGENCIES

Structure

6.0 Objectives

6.1 Introduction

6.2 Cardiopulmonary Resuscitation (CPR) Paediatric Life Support

6.3 Management of Paediatric Emergencies

6.3.1 Drowning

6.3.2 Bums

~6.3.3 Falls and Injsries6.3.4 Ingestion ofForeign Bodies

6.3.5 Poisoning

6.3.6 Respiratory Distress Syndrome

6.4 1-et I!s Sum Up6.5 Answers to CheckYour Progress

6.6 Further Readings

6.0 OBJECTIVES

After completing this unit, you should be able to:

describe the procedure of Cardiopulmonary Resuscitation;

list and define common Paediatric Emergencies;explain the concept of Paediatric Emergencies;

describe the various Emergencies in children;

identify the goals and needs of the child in various Emergency Conditions;

discuss the nursing management of the Emergencies in Children; and

list the complication of the problems.

6.1 INTRODUCTION

The increase in population and change in life style have imposed stress amongpeople resulting in an increase in the morbidity and mortality. These are higheramong the children due to their inadequate organ responses and inability to

cope up especiaI1y during Emergencies. The nurse should be competent enoughto assess and take care of children who require Emergency care. In this unit

we shall focus on Cardiopulmonary Resuscitation or Paediatric life support. We

shall also focus on Paediatric Emergencies related to respiratory syndrome,

drowning, poisoning, bums, falls, injuries and ingestion of Foreign Bodies.

We shall begin with Cardiopulmonary Resuscitation.

6.2 CARDI0,PULMONARYRESUSCITATION (CPR)PAEDIATRIC LIFE SUPPORT

As a Nurse you must have come across children with life threatening

conditions deterioratingand going into a state of cardio-respiratory(CR) arrest.Cessation of cardiac activity is determined by inability to palpate a central


2/24

Nursing Care of Children pulse, unresponsiveness and Gnea . CPR consists of measures for establishingwith Medical andSurgical problems-II and maintaining airway, initiate breathing and providing adequate circulation for

tissue perfusion. Prompt resuscitative measures can save a life particularlywhen child is suffering from a salvageable condition. Failure of circulation for

more than 3-4 minutes can lead to irreversible cerebral damage, therefore CPR

must begin quickly. It is worthwhile to familiarize yourself with correct steps in

cardio-respiratory resuscitation.

Common causes of CR arrest include: (i) airway obstruction, (ii) lower

Respiratory Tract Infections, (iii) drowning, (iv) anaphylaxis, (v) seriousinfections, and (vi) cardiac conditions.

A quick assessment of an unresponsive child would include asking a few

questions to establish the etiology and evaluating the stability of the vital signs.

Evaluate the level of consciousness, state of airway, breathing, ventilation and

circulation.

Initiation ofCPR

A child who is unresponsive should be immediately placed in supine position.Put the ear in front of the mouth and nose of the child so that you can feel

the exhaled air, and the respiratory movement can be observed simultaneously.

Cardiac status can be assessed by palpating the central pulses like carotid or

brachial pulses. If ventilation alone is absent and pulses are of good volume,

started simultaneously. You should follow the step-wise approach as givenbelow in a child with cardio-respiratory arrest. .

Airway

Place the patient supine on a firm surface with his head at level or slightly

lower than the level of heart. Immediately, clear the airway and start rescue

I breathing. In an unconscious patient the base of the tongue falls back toobstruct the airways. For this, combination of head tilt and chin lift should beemployed to open the airways. In this method the flat of the hand is placed onthe forehead and pressure is applied to tip the patient's head maximallybackward. Chin can be lifted forward with the other hand placing the fingertipsI under the mandible near the protruberance of the chin, bringing the chinforward while supporting the jaw (Fig. 6.1). Oral cavity should be cleared of allsecretions.


3/24

Breathing

If after opening the airway child is still not breathing or having gasping

respiration, rescue breathing should be started. Place your mouth over the

mouth of the baby to make a tight seal. In infants, nose can also be includedwhile in the older children nose can be pinched. Two slow breaths are

delivered in succession each lasting for 1-1%second. This helps to check ifthere is any airway obstruction as well as helps in opening of collapsed alveoli.

Amount of air deliveted should cause adequate rise in chest wall. If chest wall

does not rise, airway obstruction due to inflammatory swelling, mucous plug or

foreign body should be suspected. In such a case, readjust at head tilt and

lifting of chin and repeat rescue breathing with greater pressure and volume; ifstill not successful, suspect foreign body. A self inflating bag and mask can beused for administering positive pressure ventilation, ifavailable (Fig. 6.2)

Nursing Care ofChildren with

Paedintric Emergencies

L

Valve assemt Safety valve

+Oxygen inlet+Air inlet

4Patientoutlet withmask

Fig. 6.2: Self-inflating bagandmask

Circulation

If central pulses (femoral in infants and carotid in chilcken) are not palpable,begin chest compression without losing any time. In young infants, encircle the

chest with both hands forming a rigid surface in the back and place the thumbs

at the level of mid sternum to compress the chest (Fig. 6.3). In toddlers, heelof one hand and in older children heel of both hands (one above the other) can

be placed on the mid sternum for compression. Elbows are then straightened

with shoulders directly over the hands so that thrust is directly down. In

Fig. 63: Chest ompression


4/24

Nursing care at child re^ cK11dren over 8 years you may use "adult" tw o hand ~ G ~ I I U UI chestwtthMedical andsurgical Problems-11

compression. The depth of compression should be % to 1" in inhnts, 1 to 1.5"in younger and 1.5 to 2" in older children (Fig. 6.3).

Synchronizing Chest Compression and Breathing: Th e rate of compressionshould be about 100 in infants and 80 in older children. After every 5

compressions one breath should be delivered during recovery phase of fifth

compression. Every few minutas the CPR can be stopped to see ifspontaneous pulse has returned.Other Measures

If facilities are available and rescuers are trained following measures should

also be undertaken:

i) Endotracheal intubation facilitates better ventilation and effective trachealsuction. Intubation protects airway from aspiration and enablesadministration of medication.

ii) Oxygenation is very essential to prevent hypoxia.iii) Establish an intravenous line immediately to give fluids and drugs.Metabolic acidosis is an important outcome of tissue hypoxia.

fCkar theAirway

HeadTZltandChin Lift+Look fosBmthingand Cireufation

J

*I Mouth toMouthRespiration IIorBag andMask Respiration I

Fig. 6.4:Algorithm forCardiopulmonary Resuscitation.


5/24

Sodabicarb 1 mlkg diluted in same amount of distilled water can be givenempirically i/v slow to treat acidosis. If the patient is hypotensive, normalsaline in a dose of 20 mlkg can be pushed to expand the intravascularvolume.

iv) Adrenaline is very useful. It helps by elevating the blood pressure and

thus improving the perfusion and often restores the spontaneous pulses.

Adrenaline 0.1 ml/kg of 1:10,000 solution should be given IV initially andCPR continued. The dose can be repeated after 5 minutes. Intracardiac

route for adrenaline should only be used if intravenous access has not

been made.

While doing CPR it is important to remember that the patient will require

further management in an Intensive Care Unit and these measures should be

continued while transporting the patient to a higher centre. Attention should also

be paid to preventing heat loss while doing CPR and during transportation.

Fig. 6.4 provides an algorithm for management of a child with cardiorespiratory

arrest.

6.3 MANAGEMENTOF PAEDIATRICEMERGENCIES

Let us first discuss why the children are more prone to come across

emergency situations.

Young children, because of their intense activity, insatiable curiosity and

immaturity have more accidents such as scalds and falls and poisoning

from medications or households solution than do adult. Lead poisoning from

ingestion of lead paint is more common in toddlers because of their desire

to bite on hard surface, such as painted crib rails.a The causes and types of injury are closely related to the child's level of

growth and development at the time of accident. The prevention of

Nursing Care of

Children withPaediatric Emergencies


6/24

Nursing Care of Children

with Medical andSurgical Problems-11accident therefore requires an understanding of this important area.Therefore Parents and care givers must constantly be alert to the potentialdangers that exist in the environment which include Falls, suffocation;aspiration or swallowing of foreign materials, drowning, burns, poisoningmotor vehicle accident, injuries to the body, etc.

Accident can be prevented by parents to a great extends. It is yourresponsibility as nurse to educate the parents individually or in groups aboutprevention of home accident.

6.3.1 Drowning

Drowning is a cause of accidental death in children Accidental drowning mayoccur because children do not have adequate protective supervision. It may bedefined as submersign incident leading to death within the first 24 hours.Near-Drowning: is a submersion incident in which the individual survives formore than 24 hours, irrespective of the eventual outcome.

Causes

These fatalities occur between the age of1 and 4 years and during 15-17

years especially in boys. Most childhood drowning occur in fresh water,bathtubs, swimming pools, ponds, large buckets, washing machine, toilets andtanks. In adolescents drowning occurs lake and rivers.

Reaction to Submersion

The first reaction of child is panic, frantic, struggling and an attempt to hold thebreath. Latter on gasping occurs and water is swallowed, child may vomit andaspirate vomitus. Laryngospasm may occur, leading to unconsciousness.Pathophysiology

Pathophysiological effects occur as a consequence of hypoxemia, aspiration andfailure of other organs. Death is either due to immediate asphyxia followinglaryngealspasm, aspiration of fluid or due to late complication. The clinicalchanges and complication are also influenced by the fact whether submersionoccurred in fresh water or seawater.

.

Causes of Hypoxemia in Drowning

a) Laryngeal spasm

b) Pulmonary shunting through non-ventilated alveoli

c) Collapse of alveoli

d) Fluid in alveoli and pulmonary edema (with sea-water)

e) Decreased lung compliance (with fresh and sea-water)

t) Complications like aspiration pneumonitis, altered alveolar capillarymembrane, formation of protein-rich exudates and infection.

Nursing Management

a) Emergency Care: Mouth to mouth ventilation should be startedimmediately. Half of the submersion victims vomit during ventilation.Oxygen should be given as soon as possible.

b) Cardiac Massage: Effective external cardiac massage 80-100compression/minute in children and 100- 120 compression.minute in infantshould be instituted if no pulse is felt. Maximum ventilatory and circulatory

support should be continued Transport the victim to the hospital if required.

Obtain information' about incident such as the type of water, length ofsubmersion, time of initiation ofCPR and duration of unconsciousness.


7/24

Management in the Hospital Nursing Care ofChildren with

After the airways is cleared warm humidified oxygen at the rate of 8-10 Paediatric EmergenciesIlmin should be given by mask or nasal cannula until evaluation iscompleted.

Provide mechanical ventilatory support if required.

The stomach contents should be aspirated as soon as possible to decreasethe possibility of vomiting and as spiration and improve respiration by

decreasing intra abdominal pressure.

Monitor the circulatory status with frequent blood pressure measurement.

Obtain blood sample for a complete blood count, electrolytes and otherstudies.

ABGS and PH are monitored frequently because they serve as a guide tooxygen, fluid and electrolyte therapies.

Insertion of a central various pressure line is important to obtaininformation about the status of the blood volume.

Keep 1.V line open.Administer drugs as per order.

Chest x-

ray should be done to determine the presence of aspirated foreignmaterial or other abnormality.

Insert Foley catheter so that precise output measurements can be obtainedsince metabolic acidosis may compromise kidney function.

Near drowning children admitted to the hospital should be kept underobservation and treated for at least 24 to 48 hours period which includes.

Bed rest

If there is loss of consciousness. Give care as an unconscious patientChange position frequently to prevent skin break down

Make Continuous observation and assessment of the child

Administer medication and treatment as per prescribed treatment

Provide emotional support to the child and parents.

As a Nurse you O b s e ~ a t i 0 ~and Assessment of the Child Includesa) Continuous observation and assessment of the circulatory, respiratory,

neurologic and renal function.

b) Observe childs progress and determine the complication.

c) Record T.P.R.and blood pressure frequently.

d) Record intake and output to check the response of kidneys.e) Prevent aspiration as it my cause abscess formation pneumonia,

bronchospasm, alveolar membrane damage, hyaline membrane disease andatelectasis. Prolonged anoxia can lead to irreversible CNS damage.

Supportive Treatment

Meticulous aseptic techniques be used to prevent infection. Medication is usedfor the correction of metabolic acidosis and electrolyte imbalance and thealleviation of bronchospasm. Administration of diuretics may help to mobilize

interstitial pulmonary edema and reduce intracranial pressure. The prophylactic1st of antibiotics or of

corticosteroids is controversial. Other supportivemeasures include.Quick and the administration of1.V fluids to maintain renaloutput.


8/24

Nursing Care of Children Treatment of comatose patient to prevent brain edema.with Medical andSurgical problems-I1 maintain a state of hypothermia (rectal or other core temperature must be

monitored constantly.)

Near drowning victims should have the head elevated to about 60 degree

and should be kept in a dark and quiet area, chilled by means of a cooling

blanket only until the rectal temperature is 36C to 37OC.Prevention

Characteristics of child is to explore the surrounding with great curiousty.Awareness of the danger and depth of water has no significance for children.

Parents and caretakers should never leave the child unattended. They should

supervise closely when near any source of water including buckets. Keepbathroom doors and lid on toilet closed. Have fence around swimming pool and

lock gate. Teach swimming and water safety measures. Training is necessary

in the art of basic life support and first aid are important.


9/24

through vital organs, muscle compartments, and nerve or vascular pathways.

Loss of limbs, cardiac fibrillation, respiratory collapse, and bums are common

sequelae following exposure to electrical energy.

Chemical Injury and contact injury-chemical bums are commonly seen in thepediatric population and cause extensive injury. The severity of injury is related

to the chemical agent and the duration of contact. Chemical injury in the

toddler ofien result from the ingestion of caustic household agent.Radiation injury' can occur during childhood and adolescence from

overexposure to ultraviolet rays from the sun. Severe and repeated bums ofthis type not only cause great discomfort but also may cause premature aging

of the skin. The battered child is often a victim of bum injury.

Pathophysiology of bums. The severity of the injury depends on the

temperature of the burning agent and the length of exposure. The effect ofburns cause problems in various functions of the body as given below.

Circulatory

Cardiac function is further compromised by the circulating plasma volume loss..Cardiac output may decrease to 20 per cent of normal, returning to preburn

level after approximately36hours. Cardiac function is supported by aggressive

fluid replacement. A frequent complication in small children during the phase of

aggressive fluid resuscitation is pulmonary edema and congestive heart failure.

Hernodynamics

Immediately after a bum injury occurs, tdere is an increase in capillarypermeability. Water, electrolytes, albumin and protein extravate into theinterstitial and intracellular compartments, forming edema. Up to 60 per cent of

the intravascular fluid volume is lost. In the first 4 day after the injury, two

times the normal albumin stores are lost from the intravascular compartment,one half through surface loss and one half in edema. There is 10 per centweight gain due to accumulation of fluid, Metabolic acidosis resulting from a

decrease in blood PH reflect impaired circulation and decreased perfusion inthe peripheral tissues.

Vascular volume depletion result in decreased blood pressure and blood flowand polycythemia due to hemoconcentration. Blood viscosity increase, leading toslugging in the vasculature. This process may continue for 18 to 36hours, but

the consensus is that capillary integrity is generally restored within 24 hours.

Renal Function

Inadequate cardiac output due to hypovolemia lead to diminished renal perfusionand reduced glomerular filtration rate. Early destruction of red cells maypresent as free hemoglobin in urine. In children with extensive bums, acute

tubular necrosis and renal shut down may occur. This retention may be present

for several weeks, although the evaporative water loss may balance excessive

retention.

Gastrointestinal Tract Function

As a result of burn injury acute gastric dilation occurs, creating abdominal

distention and regurgitations. Malabsorption occurs secondary to a decrease in

blood supply and motility of the G.I. tract. Ulceration appear on thegastroduodenal mucosa and a decrease in gastric mucus production is apparent.

Hyperacidity of gastric secretion with high level of hydrogen ion increase

susceptibility to curling ulcer.

Nursing Care ofChildrpn withPaediatric Emergencier

II


10/24

Nursing Care of Childrenwith Medical andSurgical Problems-11

Pulmonary Function

Hyperventilation, detectable around third day often rises to a maximum at aboutfive days after the bums and then gradually declines unless other complicationsupervene. Oxygen consumption shows a marked increase resulting indecreased arterial oxygen tension, Arterial Po, usually returns to the normallevel spontaneously by the end of first week.

Water Evaporation

Evaporation of water from the site of burn occurs due to exudation of plasmaon the surface during first 48 hours following bum. The amount of evaporativeloss may be as high as 6 to 18 litres per day in tropical condition.We have discussed the pathophysiology of burns now let us learn theclassification of bums.

Estimation of Depth of Burn Injury

A thermal injury is described as partial thickness or full thickness, depending onthe depth and severity of tissue damage.

. . .a) First Degree

Burns affecting the epidermal layer is characterized by erythema due tovascular response in the sub papillary vessels. Edema occurs in the basallayer irritating the nerve ending at this level and causing discomfort.

b) Second Degree

Bums which involve from one half to seven eights of the dermal layer. Itis subdivided into superficial partial thickness and deep partial thickness. Insuperficial partial thickness bum, the surface may be covered with blistersof varying size. The removal of blister reveals the skin beneath it which isweeping, glistering bright pink or red and exquisitely sensitive to touch,temperature and air flow. The deep partial thick-ness bum destroys the entire

thickness of the epidermis including dermal papillae leaving intact the sweatglands and hair follicles from which epithelial elements cover the wounds.

c) Third Degree

Full thickness injury involves all the epidermis and dermis. The burnt skin is

hard and dry, tan or fawn colored and after exposure to air it becomesparchment like and translucent with thrombosed vessels visible underneath.

Children less than 4 years of age have a higher mortality as compared toolder patients with similar injury. Their response to stress is limited andsmaller body mass equipped with low protein and fat stores is unable tocope with hypermetabolism.

Classification

The burns are classified on the basis of extent (size) and depth

a) Minor Burns

Second degree burns of less than 10 percent of body surface area or thirddegree bums of less than 2 percent of body surface area.

b) Moderate Burns

Second degree burns affecting 10-25 percent of body surface area or thirddegree bum of less than 10 percent of body surface area (except bums of

hand, face and feet)

c) Major Burns

Second degree bums exceeding 25 percent of body surface area or thirddegree bums of face, hands, feet or over 10 percent of other body surfacearea.


11/24

Estimation of Burn Area

The estimation of the extent of burn area expressed as the percentage of the

surface area of the skin burnt to the total body surface area (TBSA) is

important, not only for giving treatment but also as a prognostic indicator.

Rule of Nines

The conventional "Rule of Nines" first devised by pulaski and tennison andpopularised by wallace is applicable only to children above 10 years of age.The body surface is divided into areas representing 9 per cent or multiples of9 per cent. The head and neck constitutes 9 per cent; anterior trunk 2 x 9 or18 per cent; posterior trunk19 per cent; each lower extremity 18 per cent;each upper extremity 9 per cent; and the perineum 1 per cent.

Fig. 6.5: Estimation of burn area in children above 10 years Rule of9.

Rule ofFive

It is convenient, easy and quick method of estimation of surface area of burns

in young children as shown in fig. Scattered areas of damage can be calculated

using the knowledge that the palmer surface of one's own hand with fingers

and thumb by the side constitute approximately 1.0 percent of the body surface.

Infant child

Total105%(5%ma y be subtractedfrom the hunk)

Fig. 6.6: Estimation of burn area by Rule of Five (Lynch an$Blocker 1963)


Paediatric Emergencies


12/24

Nursing Care o f Children Nursing Managementwith Medical andSurgical Problems-I1

Emergency First Aid

Stopping the burning process, immediate transport of medical aid. Children

should be taught the "stop, drop and roll" technique for extinguishing flame.

Once the flame is extinguished, cool water should be poured over the

injured area. If heat is present, the burnt area should be cooled with wateras with flame injury. After 10 minutes, saturated clothing, towel, or blanketsshould be replaced with clean dry linen to prevent excessive heat loss.Chemical bums must be lavaged continuously for a minimum of 30 minutes

to adequately dilute and neutralize strong chemical compounds. Electricalshock or burn injury should be monitored for cardiac irregularities and

treated as patients with spinal cord injuries during transport and early

emergency care.

Protection of the Burn Area

Bum area should be covered with clean dry cloth or dressing to preventcontamination with infection agents and exposure to the air.

Transportation to a Medical Facility

Assessment should be done quickly and ensure the adequacy of the

airway, breathing, and circulation. Emergency resuscitation measure should

be instituted as indicated, and the victim should be trlrlsported to a medicalfacility.

Emotional Support to the Parents

Provide the reassurance and support to the caregivers, friends, and relatives

which helps to reduce anxiety and conserve energy after a traumatic injury.

a) Minor Burns: Partial thickness injuries less than 10-1 5 per cent bum inchildren It involves bum of face, feet, perineum or hands and can be

treated at home.

b) Major. Burns: 15 per cent in children, require admission.Assess the air way, breathing and the circulatory status and assess need

for resuscitation/tracheotomy.Administer 0, by mask for the 24 hours.Keep child nil by mouth.

Intravenous therapy is indicated (cut down). On the 4th day send cathetertip for culture.

Take blood for Hb, TLC, DLC, WBC, Serum Creatinine, RBCS, Sodium,Potassium Bicarbonate, Protein and albumin.Catheterise and record urine output hourly Adjust the rate of

IVinfusion toobtain a urine output of 1 to 2 mllkg per hour.

Pass a neasogastric tube and connect to drainage for aspiration of water.

Watch for gastric dilation.

Monitor vital signs.

Clean the burn area with betadine or antiseptic solution and apply silversulpha diazine (SSD). Blisters can be punctured with a sterile needle and

the skin left intact. Stop using SSD at the end of 1st week and start

furacin dressing.

Give Injection Tetanus Toxoid 0.5 ml I.M.Give Injection crystalline penicillin 50,000 unitfig body weight after testdose.

134Administer conservative dose of analgesics.

K

'-


13/24

0 Provide Local treatment (two methods have been used (closed method)and open (exposure) method.)

i) Exposure MethodThe principles of this method include dryness, coolness and exposure tolight of the burnt surface conditions which are unfavorable to the

growth of Pathogenic bacteria. Exposure method is especially useful forbums of face, buttocks and perineal regions.

iii Closed MethodIn this bums area are covered with dressing but local application ofvarious local antibacterial creams and solution for absorption of exudate

is done.

Nutrition

Due to bums there is rapid decrease in body weight. A diet rich in calories and

proteins is started gradually. Energy and protein requirements in children withbums are calculated by following formula. Calories-60 Kca lkg body weight +35 Kcal per 1.0 per cent of bum, proteins 3 9 k g body weight + 1.Og per 1.0per cent bum.

Brooke's Formulaa) Fluid requirement

b) Estimate the accurate/approximate weight of the patientc) First 24 hours

Colloids (blood, plasma, dextran) 0.5 mlkg/per cent bum physiological saline1.5mlkg/per cent bum. 5 per cent dextrose depending on age and size ofpatient.

d) Second 24 hours

Colloids (blood, plasma, dextran) 0.25ml I kg/per cent burn, physiologicalsaline 0.75 mlkglper cent bum. 5 per cent dextrose depending on age andsize of patient.

e) Ascorbic acid, vitamin B complex and folates are important for woundhealing. . .

Complication

a) Shock: It is corrected by early administration of fluid, plasma and plasmasubstitutes.

b) Respiratory tract injury: Mechanical airway obstruction may be noticed24 to 48\ hours after bums due to edema of head and neck when the faceis burnt.

c) Nosocomial infection: septicemia

Gastro duodenal hemorrhage: (curling's ulcer) bleeding may occur 7 to10 days after injury due to stress ulcers.

e) Bone and joint abnormalities: septic arthritis osteoporosis, pathologicalfractures and abnormalities of bone growth due to bum injury.

f) Thrombophebitis.Delayed Complication

Yost burn scarsb) Contractures

) Marjolin's ulcer (bum scar carcinoma)


Paediatrlc Emergencies


14/24


15/24

The school child can sustain major or minor injuries as a result of falls, motor

vehicle accident, and fire arms (e.g. cuts, contusions, multiple fractures, headand spinal injuries and trauma to soft tissue and organs).

Eye injuries account for about one third ofall blindness in children. Eye injuriesoccurs due to chemicals, playing with fire, arms, spots, chemicals burns in the

sclera and conjurlctiva may cause ulceration of the cornea. Contact sportscause black eyes (echymosis) and injuries of the orbit Treatment will depend on

injury and its severity. (Covering eyes, use of eye ointments and drops,

sedation and frequent eye examination.)

Prevention of Injury

During infancylearly childhoodlschoolage.Always raise crib rails to their f ~ l lheight when the child is unattended.Never leave an infant of any age on a raised surface that dose not have

protective siderails without someone nearby attending even when a

restraining device such as a belt is used.

Never carry an infant in an area where the floor is slippery or cluttered

with objects on which the adult could slide or trip.

Do not leave an infant unattended in a highchair even after protectiveharness has been applied.

Do not leave an infant unattended in a walker.'

Close off with a door or fence the top and bottom of any stairways to

which the mobile infant has access.

Keep stairs free of object to prevent falls when carrying an infant.Keep low windows securely screened and locked.

Educate child regarding proper use of seat belts while travelling in a

vehicle.

Maintain discipline while travelling in a vehicle.Emphasize safe Pedestrain behavior and supervise tricycle riding.

Insist on wearing safety apparel (e.g. helmet)Educate child for traffic rules, and traffic signal.

Supervise at playground. Select play areas with soft ground cover and safe

equipment.

6.3.4 Ingestion of Foreign Bodies

As we know that small children are curious and innocence children are

notorious for inserting various object into their orifices like mouth, nose, ears,

anus and vagina. Aspiration of foreign bodies can occur at any age but is mostcommon in older infants and children in the ages group of 1 to 3 years.

Severity is determined by the location, type of object aspirated, the extent of

obstruction. For example, peanuts, seeds, nuts,.popcorn, Bengalgram and othervegetable, small pieces, etc. are inserted.

A sharp or irritating object produces irritation and edema, latex balloonq(inflated, uninflated or broken pieces) are especially hazardous, object such as

safety pins, parts of broken toys, beads, button, and coin. An object of

sufficient size obstructing a passage can produce various changes including

atelectasis, emphysema, inflammation and abscess.'

Manifestation

Very small object may not cause respiratory obstruction, but later on an

obstructed object may produce atelectasis, bronchicetasis, pulmonary abscess


Paediatric Emergencies


16/24

Nursing Care of Childrewith Medical and

Surgical Problems-I1'n and emphysema, foreign body in the air passage produce choaking, gagging or

coughing. Laryngotracheal obstruction causes dyspnea, cough, stridor, cyanosisand hoarseness. Bronchial obstruction usually produce cough, wheezing,

asymmetric breath sound, decreased airway entry and dyspnea. Child become

unconscious and dies of asphyxia if the object is not removed.

Treatment

Laryngioscopic or bronchoscopic removal of foreign body. If the object is

lodged in the larynx, tracheostomy may be necessary to maintain

respiration until further treatment is given.0 After removing foreign body the child is placed in a high humidityatmosphere.

0 Antibiotics may be administered to prevent secondary infection.0 Observation of the child for further signs is necessary.

Nursing Management of Child with Ingestion of Foreign Body

a) Recognize the sign of foreign body aspiration and implement immediatemeasure to relieve the obstruction.b) Immediate removal of foreign body. Prevent local tissue inflammation.

c) Prevent secondary infection, and treat with appropriate antibiotics.d) Place child in an atmosphere of high humidity.

e) Educate Parents, baby care takers about emergency procedure.

Prevention

a) Keeping small objects such as toys with movable parts, safety pins, small

candies, nuts, marbles, out of reach of infants and young children.

b) Adults, should not set a negative example by putting pins, needle, common

pins and other small objects into their mouths as young children often

imitate their elders. Small children should not be allowed to play withballoons.

c) As a Nurse you can educate parents singly or in group about hazards ofaspiration.

d) As a Nurse you should also educate ancillary health personnel, day care

provider and baby care takers and baby sitters.

6.3.5 Poisoning

Poisoning is a common medical emergency in childhood. In children under 5

years of age essentially all poisoning are accidental. Nearly 75 per cent of allpoisoning episodes involve ingestion of substance which are nontoxic or havemild toxicity.


17/24

A poison is any substance that when ingested, inhaled or absorbed even in Nursing Care or

relatively small amounts can cause damage to a structure or disturbance of Children withPaediatric Emergenciesbody function by its chemical action.

Poisoning is definedasa morbid condition caused by the ingestion of a toxic substance.

Common Clinical Manifestation

Gastrointestinal Disturbances: Nausea, vomiting, anorexia, abdominalpain, and diarrhoea.

Respiratory and Circulatory Symptoms: possible unexplained cyanosis,shock, and collapse.

Central Nervous System: lethargy, sudden loss of consciousness andconvulsions, dizziness, stupor, coma.

Management for Poisoning and Overdose

The following data should be obtained at the time of initial contact.

Phone Number: getting the caller's telephone number is necessary incase he requires follow-up calls.

Address: This may be crucial if emergency equipment needs to bedispatched or if the person on the phone becomes hysterical or develops

lethargy, convulsions and so on.

Evaluation of Severity: Callers may begin with a description of symptomsor signs such as a convulsion. It is vital to evaluate the current status of

the patient in terms of immediate danger, potential danger and no danger.

Further history may be necessary to evaluate an asymptomatic patient.

Weight and Age: This helps to estimate the level of potential toxicity.

Time of Ingestion: This permits interpretation of onset of symptoms orsigns as well as well as evaluation of laboratory data and other prognostic I

information.

Past Medical History: To determine the usual health status of the patient

as a basis for interpreting signs. It will also suggest interaction of chronicmedications or allergies with the current ingestion.

Type of Exposure: Products, names and ingredients should be obtainedfrom labels or from the POISONINDEX system.

Amount of Exposure: How many tablets or how much fluid has beenconsumed should be estimated. Tablets or fluid remaining in the containershould be counted or measured.

Route of Exposure: To determine whether the exposure was byingestion, inhalation, local application to the eyes or skin or parenteral.

We have learnt that the data should be obtained for management let us discuss

the primary assessment and intervention.

Primary Assessment and Interventions

Maintain an open airway because some ingested substances may causesoft tissue swelling of the airway.Attain Control of the Airway, ventilation, and oxygenation. In theabsence of cerebral or renal damage, the patient's prognosis dependslargely 6n successful management and support ofvital functions.

Subsequent Assessment

Identify the poison.-

Try to determine the product taken: where, when, why, how much, who

witnessed the event, time since ingestion. 139

/'-


18/24

the poison control center in the area if an unknown toxic agentas been taken or if it is necessary to identify an antidote for a known

toxic agent.

Continue the focused assessment, observing any significant deviations from

normal. Different poisons will affect the body in different ways.

Obtain blood and urine tests for toxicology screening. Gastric contents may

also be sent for toxicology screening in serious ingestions.

Monitor neurologic status, incfuding mentation Monitor the vital signs and

neurologic status.

Monitor fluid and electrolyte imbalance.

General Interventions

A) Supportive Care

Initiate IV access.

Administer oxygen for respiratory depression.

Monitor and treat shock.

Prevent aspiration of gastric contents by positioning (on side with headdown), use of oropharyngeal airway and suctioning.

Give supportive care to maintain vital organ.

Insert an indwelling urinary catheter to monitor renal function.*

Support the patient having seizures. Many poisons excite the central

nervous system, or tbe patient may convulse from oxygen deprivation.Monitor and treat for complications; hypotension, coma, cardiac

dysrhythmias, and seizures.

Psychiatric evaluations may be done after the patient is stabilized.B) Minimizing Absorption

The primary method for preventing or minimizing absorption is to administer

Activated charcoal with a cathartic to hasten excretion. Newer superactivatedcharcoals can reduce absorption of a toxic substance by as much as 50 per

cent. Administering activated charcoal plus a cathartic is just as effective or

more effective than gastric lavage.

Administration of oral activated charcoal-absorbs the poison on the surface

of its particles and allows it to pass with the stool. Multiple doses may beadministered.

Activated charcoal is usually mixed in tap water to make a slurry.

The secondary method for preventing or minimizing absorption is induction of

emesis with syrup of ipecac. This procedure should be done only if the patientis conscious and has a good eye reflex. It is most effective within 30 minutes

of ingestion of poison.

Syrup of ipecac, 30 ml by.mouth followed by two glasses of water is theusual adult dose.

For children between age 1 and 12, give 15 ml followed by 8 to 16 ouncesof water.

Gasteric lavage for the obtunded patient. Save gastric aspirate for

toxicology screening.

Perform the Procedures to enchance the removal of the ingested substanceif the patient is deteriorating.- Forced diuresis with urine pH alteration-to enhance renal clearance.


19/24

- Hemoperfusion (process of blood through an extracorporeal circuit and - .a cartridge containing an adsorbent, such as charcoal, after which the Children with

Paediatric Emergenciesdetoxified blood is returned to patient). I- Hemodialysis-used in selected patients to purify blood and accelerate

the elimination for circulating toxins.w

- Repeated doses of charcoal-for binding nonabsorbed drugs/toxins.

Nursine Care of

- Gastric lavage may be used in conjunction with activated charcoal, and

a cathartic to maximize elimination of the substance.

C) Providing an Antidote IAn antidote is a chemical or physiologic antagonist that will neutralize the

poison.

Administer the specific antidote as early as possible to reverse or diminish

Ieffects of the toxin.

Outcome

Although all forms of childhood poisoning can be serious, most children recover

after prompt treatment and follow-up care.

PreventionProvide guidance for accident prevention to the parents.

Explain the ways to prevent poisoning by effective storage in a locked

cabinet and handling of potentially dangerous substance in the home.

Toxic substances should never be stored in food containers.

Any empty containers that contain toxic substances should be discarded

immediately and safely.

Advise parents to lable poisonous substances with stickers and teach

children their meaning to help them avoid touching the containers.

The nurse must emphasize that the best general preventive measures areparental vigilance and firm guiding discipline.

6.3.6 Respiratory Distress SyndromeRespiratory distress in a newborn is a challenging problem. It accounts for

significant morbidity and mortality. It occurs in 4 to 6 per cent of neonates. The

condition is preventable. Early recognition and prompt management are required.

A few may need ventilatory support, but this treatment is often not available

and when available may be expensive.

"Respiratory distress in newborn is defined as a respiratory rate over 601minand/or use of accessory muscles of respiration. This is often accompanied by

grunting, retraction of the intercostal muscles. Central cyanosis, lethargy and- . .. .L-,.-r

disease, aspiration syndromes, pneumcanomalies. Rapid breathing, may also uc arclL 11. ..-----cardiac failure, birth asphyxia and aciA-^'~


20/24

Nurcing Care of Children It is symptom complex that originates secondary to a deficiency of the quantitywith Medical andSurglcrl problems-Il or the quality of pulmonary surfactant superimposed on a structurally andfunctionally immature cardiopulmonary system. It is important to remember thatin addition to surfactant deficiency immaturity of cardio pulmonary systemsignificantly contributes to the syndrome of respiratory distress. The term"hyaline membrane disease" and R.D.S. are used synonymously used.

Causes

Airway Obstruction

a Nasal or nasopharyngeal: choanal atresia, nasal edemaa Oral cavity: macroglossia, micrognathiaa Neck: congenital goiter, cystic hygromaa Larynx: web, stenosis, cord paralysis, laryingomalacia

a Trachea: tracheamalacia, tracheo-esophageal fistula

Lung Parenchymal Disorders

Aspiration syndromes: Liquor, meconium, blood

Air leak: pnemothorax, pneumomedistinum

a PneumoniaPulmonary hemorrhage 1

a Transient techypnea of newborn.

Congenital Malformations

Diaphragmatic hernia

a Metabolic causes: acidosis, hypothermia, hypoglycemiaBirth asphyxia

Non Pulmonary Causes: Non respiratory problem can also manifest with

-respiratory distress. These include cardiac (congenital heart diseases,myocardial dysfuntion) neurologic (asphyxia, intracranial bleeding) andmetabolic hypoglycemia, acidosis hypothermia.

Respiratory Distress or Hyaline Membrane Disease (HMD) iscaused by deficiknt surfactant in the lungs. Hence it is seen

more often in premature babies. The respiratory distress starts at

birth.

Aspiration Syndrome: The commonest of these is the meconiumaspiration syndrome (MAS). Babies born through meconium stained liquorcould have MAS and aspiration may occur in utero, during delivery orimmediately after birth. Thick meconium could block air passages and

cause atelectasis and air leak syndromes. Postnatally milk can be aspiratedin babies with cleft palate and regurgitation problem.Pneumonia: (Congenital and postnatal pneumonia) In developing countries,

Pneumonias account for more than 50 percent cases of re~piratory~distressin new born. Primary pneumonia are more common among term or postterm infants because of higher incidence of prenatal aspiration due to fetalhypoxia as a result of placental dysfunction. Preterrn babies may developpneumonia as a consequence of septicemia, aspiration of feeds andrespiratory failure. Pneumonia may be due to aspiration (tracheoesophageal fistula) gestro-esophageal reflux or may be of bacterial or viraletiology. Bacterial organisms are usually gram-ve or staphylococci.

Pneumothorax: In neonates could be spontaneous but it is more often dueto MAS or staphylococcus pneumonia. Air leaks are seen more common in

babies or when aggressive rees&ation is dm for bah


21/24

asphyxia. The distress is usually sudden in onset and heart sound become Nursing Care of Iless distinct. Immediate management in hemodynamically unstable neonate

is by a needle aspiration and later chest drainage.

Children withPeediatric Emergencies I

Pulmonary Hemorrhage: Massive amount of bleeding from the lungssignifies this condition. It is common in babies who are growth retarded,

have cold injury, and have suffered from perinatal asphyxia or have severe

. hemolytic disease.

Assessment: Baby will have tachypnoea, laboured breathing with chest wallrecession and nasal flaring, expiratory grunting, tackycardia and cyanosis.

.

.

I

Scoring of respiratory distress.

A score of greater than 6 would indicate severe respiratory distress.

Pathophysiology

In Preterm basis there is deficiency of surfactant. Surfactant is needed to

increase surface tension. Absence or abnormal surfactant decrease surface

tension which is needed to keep alveoli patent. Due to a absence of surfactant

alveoli collapse during expiration and are difficult to inflate during inspiration.

This affects gas exchange and the baby goes into respiratory failure.

Investigation

a) Shaketest or Foam Stability test-negative shaketest ie no bubbles or bubbles

covering less than 113 of the rim indicates a high risk of RDS.b) Polymorph count

c) Sepsis screening

d) Chest x-ray

Nursing Management

Providing effective ventilation and oxygen therapy

Providing optimal environmental temperature

Providing adequate nutrition, correct the acid base balance, and maintaing

normal blood pressure and hematocrit

The baby should be protected from infection

Minimum handling of critically ill RDS babies is important. The baby's head

should be elevated to decrease pressure on the diaphragm

Change position to prevent skin irritation. If head is extended (or) flexed on

the chest, the infant's respiratory efforts will be less effective due to

narrowing of the tracheal diameter.

Monitoring is needed in all babies with*reipiratory distress. Emphasis is onclinical monitoring. - -All babies with significant distress should be kept on IV fluids, andk


22/24

Nursing Care of Children

with Medical andSurgical Problems-I1

pressure hematocrits and sugar should be monitored and maintained at

optimum level

Provide oxygen therapy ventilatory support or CPAP (continuous Positive

Airway Pressure) Majority of the babies with RDS will need VentilatorySupport.

6.4 LET US SUM UP

In this unit we have made an attempt to make you understand how to manage

pediatric emergencies. We have discussed C.P.R. We have covered theconcept of pediatric emergencies. Emergencies arises due to drowning, Bums,Falls and injuries, ingestion of foreign bodies, poisoning and respiratory distress

syndrome. We have discussed definition, causes, manifestation and management

of all these emergencies.

6.5 ANSWERS TO CHECK YOUR PROGRESSCheck Your Progress 1

1) By Palpating central pulses - fermal in infants and carotid in children.2) 5:l3) Adrenaline 0.1 m l k g of 1:10,000 solution intravenously elevates BP and

improve circulation. The dose can be repeated after 5 minutes.

Check Your Progress 2

1) Drowning: A submersion leading to death within the first 24 hours.Near Drowning: A submersion incident in which there is survival for thefirst 24 hours, irrespective of the eventual outcome.

2) i) 80-100 'ii) Cardio Pulmonary Resuscitationiii) 60

Check Your Progress 3

1) Scald injury from moist heatFlame injury

Electrical injury

Chemical injury

Radiation injury


23/24


24/24

(HMD) aspiration syndrome, due meunium aspiration Pneumonia,Pneurnothorax, Pulmonary hemorrhage.

Broadribb's Margaret G Marks, Introductory Pediatric Nursing. 4th ed. J.B.Lippincott CorflparyPhiladelphia: 262-265.

Donna L. Wang Nursing Care of Infants and Children. 6th St Louis Mosby.

Dorothy R Marlow; Barbara A Redding Textbook of Pediatric Nursing 6th ed.Philadelphia; W.B. saunders company.

Meharban Singh. Medical Emergencies in Children 2nd ed. New Delhi sagerpublications.

Sandra M Neltina. The Lippincott Manual of Nursing Practice. 6th ed,

Philadelphia; Lippincott 964-967.

poisoning, drowning

Documents