UNIT 6 NURSING CARE OF CHILDREN WITH PAEDIATRIC EMERGENCIES

Structure
6.0

6.1

6.2 6.3

Objectives Introduction Cardiopulmonary Resuscitation (CPR) Paediatric Life Support Management of Paediatric Emergencies 6.3.1 Drowning 6.3.2 Bums ~6.3.3 Falls and Injsries 6.3.4 Ingestion of Foreign Bodies 6.3.5 Poisoning 6.3.6 Respiratory Distress Syndrome 1-et I!s S u m Up Answers to Check Your Progress Further Readings

6.4

6.5 6.6

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 among people resulting in an increase in the morbidity and mortality. These are higher among the children due to their inadequate organ responses and inability to cope up especiaI1y during Emergencies. The nurse should be competent enough to 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,PULMONARY RESUSCITATION (CPR) PAEDIATRIC LIFE SUPPORT

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

conditions deteriorating and going into a state of cardio-respiratory (CR) arrest.

Cessation of cardiac activity is determined by inability to palpate a central

Nursing Care of Children with Medical and Surgical problems-II

pulse, unresponsiveness and Gnea. CPR consists of measures for establishing and maintaining airway, initiate breathing and providing adequate circulation for tissue perfusion. Prompt resuscitative measures can save a life particularly when 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) serious infections, 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 of CPR

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 given below 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 breathing. In an unconscious patient the base of the tongue falls back to obstruct the airways. For this, combination of head tilt and chin lift should be employed to open the airways. In this method the flat of the hand is placed on the forehead and pressure is applied to tip the patient's head maximally backward. Chin can be lifted forward with the other hand placing the fingertips under the mandible near the protruberance of the chin, bringing the chin forward while supporting the jaw (Fig. 6.1). Oral cavity should be cleared of all secretions.

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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 included while in the older children nose can be pinched. Two slow breaths are second. This helps to check if delivered in succession each lasting for 1-1% there 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; if still not successful, suspect foreign body. A self inflating bag and mask can be used for administering positive pressure ventilation, if available (Fig. 6.2)
L

Nursing Care of Children with Paedintric Emergencies

Valve assemt Safety valve

+Oxygen

inlet

+Air

inlet

Patient outlet with mask

Fig. 6.2: Self-inflating bag and mask

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, heel of 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

Nursing care at child wtth Medical and

re^

surgical Problems-11

cK11dren over 8 years you may use "adult" two hand ~ G ~ I I UOI U chest compression. The depth of compression should be % to 1"in inhnts, 1 to in younger and 1.5 to 2" in older children (Fig. 6.3).

1.5"

Synchronizing Chest Compression and Breathing: The rate of compression should 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 if spontaneous 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 tracheal suction. Intubation protects airway from aspiration and enables administration of medication. Oxygenation is very essential to prevent hypoxia. Establish an intravenous line immediately to give fluids and drugs. Metabolic acidosis is an important outcome of tissue hypoxia.

ii)

iii)

Ckar the Airway Head T Z l t and Chin Lift

Look fos Bmthing and Cireufation
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Mouth to Mouth Respiration or Bag and Mask Respiration

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Fig. 6.4: Algorithm for Cardiopulmonary Resuscitation

Sodabicarb 1 mlkg diluted in same amount of distilled water can be given empirically i/v slow to treat acidosis. If the patient is hypotensive, normal saline in a dose of 20 mlkg can be pushed to expand the intravascular volume. 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 and CPR continued. The dose can be repeated after 5 minutes. Intracardiac route for adrenaline should only be used if intravenous access has not been made.

Nursing Care of Children with Paediatric Emergencies

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 MANAGEMENT OF PAEDIATRIC EMERGENCIES

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 with Medical and Surgical Problems-11

accident therefore requires an understanding of this important area. Therefore Parents and care givers must constantly be alert to the potential dangers that exist in the environment which include Falls, suffocation; aspiration or swallowing of foreign materials, drowning, burns, poisoning motor vehicle accident, injuries to the body, etc. Accident can be prevented by parents to a great extends. It is your responsibility as nurse to educate the parents individually or in groups about prevention of home accident.

6.3.1 Drowning
Drowning is a cause of accidental death in children Accidental drowning may occur because children do not have adequate protective supervision. It may be defined as submersign incident leading to death within the first 24 hours. Near-Drowning: is a submersion incident in which the individual survives for more than 24 hours, irrespective of the eventual outcome. Causes These fatalities occur between the age of 1 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 and tanks. In adolescents drowning occurs lake and rivers. Reaction to Submersion The first reaction of child is panic, frantic, struggling and an attempt to hold the breath. Latter on gasping occurs and water is swallowed, child may vomit and aspirate vomitus. Laryngospasm may occur, leading to unconsciousness. Pathophysiology Pathophysiological effects occur as a consequence of hypoxemia, aspiration and failure of other organs. Death is either due to immediate asphyxia following laryngealspasm, aspiration of fluid or due to late complication. The clinical changes and complication are also influenced by the fact whether submersion occurred 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 capillary membrane, formation of protein-rich exudates and infection.

Nursing Management a) Emergency Care: Mouth to mouth ventilation should be started immediately. Half of the submersion victims vomit during ventilation. Oxygen should be given as soon as possible. b) Cardiac Massage: Effective external cardiac massage 80-100 compression/minutein children and 100-120 compression.minute in infant should 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 of submersion, time of initiation of CPR and duration of unconsciousness.

Management in the Hospital

After the airways is cleared warm humidified oxygen at the rate of 8-10 Ilmin should be given by mask or nasal cannula until evaluation is completed. Provide mechanical ventilatory support if required. The stomach contents should be aspirated as soon as possible to decrease the 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 other studies. ABGS and PH are monitored frequently because they serve as a guide to oxygen, fluid and electrolyte therapies. Insertion of a central various pressure line is important to obtain information 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 foreign material or other abnormality. Insert Foley catheter so that precise output measurements can be obtained since metabolic acidosis may compromise kidney function. Near drowning children admitted to the hospital should be kept under observation 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 patient Change 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 Includes

Nursing Care of Children with Paediatric Emergencies

a) 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 and atelectasis. Prolonged anoxia can lead to irreversible CNS damage.
Supportive Treatment

Meticulous aseptic techniques be used to prevent infection. Medication is used for the correction of metabolic acidosis and electrolyte imbalance and the alleviation of bronchospasm. Administration of diuretics may help to mobilize interstitial pulmonary edema and reduce intracranial pressure. The prophylactic 1st of antibiotics or of corticosteroids is controversial. Other supportive measures include.

Quick output.

and the administration of 1.V fluids to maintain renal

Nursing Care of Children with Medical and Surgical problems-I1

Treatment of comatose patient to prevent brain edema. 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. Keep bathroom 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.

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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.
Nursing Care of
Childrpn with Paediatric Emergencier

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Chemical Injury and contact injury-chemical bums are commonly seen in the pediatric 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 of this 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 of burns 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 approximately 36 hours. 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.
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Hernodynamics
Immediately after a bum injury occurs, tdere is an increase in capillary permeability. Water, electrolytes, albumin 'and protein extravate into the interstitial 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 cent weight gain due to accumulation of fluid, Metabolic acidosis resulting from a decrease in blood PH reflect impaired circulation and decreased perfusion in the peripheral tissues. Vascular volume depletion result in decreased blood pressure and blood flow and polycythemia due to hemoconcentration. Blood viscosity increase, leading to slugging in the vasculature. This process may continue for 18 to 36 hours, 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 perfusion and reduced glomerular filtration rate. Early destruction of red cells may present 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 the gastroduodenal 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 of Children with Medical and Surgical Problems-11

Pulmonary Function

Hyperventilation, detectable around third day often rises to a maximum at about five days after the bums and then gradually declines unless other complication supervene. Oxygen consumption shows a marked increase resulting in decreased arterial oxygen tension, Arterial Po, usually returns to the normal level spontaneously by the end of first week.
Water Evaporation

Evaporation of water from the site of burn occurs due to exudation of plasma on the surface during first 48 hours following bum. The amount of evaporative loss 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 the classification of bums.
Estimation of Depth of Burn Injury

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

a) First Degree Burns affecting the epidermal layer is characterized by erythema due to vascular response in the sub papillary vessels. Edema occurs in the basal layer 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. It is subdivided into superficial partial thickness and deep partial thickness. In superficial partial thickness bum, the surface may be covered with blisters of varying size. The removal of blister reveals the skin beneath it which is weeping, 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 sweat glands 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 becomes parchment like and translucent with thrombosed vessels visible underneath. Children less than 4 years of age have a higher mortality as compared to older patients with similar injury. Their response to stress is limited and smaller body mass equipped with low protein and fat stores is unable to cope 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 third degree 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 third degree 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 third degree bums of face, hands, feet or over 10 percent of other body surface area.

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.

Nursing Care of Children with Paediatric Emergencies

Rule of Nines
The conventional "Rule of Nines" first devised by pulaski and tennison and popularised 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 of 9 per cent. The head and neck constitutes 9 per cent; anterior trunk 2 x 9 or 18 per cent; posterior trunk 19 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 of 9.

Rule of Five
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

Total 105% (5%may be subtracted

from the hunk)

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

Nursing Care o f Children with Medical and Surgical Problems-I1

Nursing Management 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 water as with flame injury. After 10 minutes, saturated clothing, towel, or blankets should 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. Electrical shock 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 prevent contamination 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 medical facility. 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 10-15 per cent bum in children 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 catheter tip 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 IV infusion to obtain 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 silver sulpha 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 test dose.

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Administer conservative dose of analgesics.

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Provide Local treatment (two methods have been used (closed method) and open (exposure) method.) i) Exposure Method The principles of this method include dryness, coolness and exposure to light of the burnt surface conditions which are unfavorable to the growth of Pathogenic bacteria. Exposure method is especially useful for bums of face, buttocks and perineal regions.

Nursing Care of Children with Paediatrlc Emergencies

iii Closed Method

In this bums area are covered with dressing but local application of various 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 with bums are calculated by following formula. Calories-60 Kcalkg body weight + 35 Kcal per 1.0 per cent of bum, proteins 39kg body weight + 1.Og per 1.0 per cent bum. Brooke's Formula a) Fluid requirement b) Estimate the accurate/approximate weight of the patient c) First 24 hours Colloids (blood, plasma, dextran) 0.5 mlkg/per cent bum physiological saline 1.5mlkg/per cent bum. 5 per cent dextrose depending on age and size of patient. d) Second 24 hours Colloids (blood, plasma, dextran) 0.25ml I kg/per cent burn, physiological saline 0.75 mlkglper cent bum. 5 per cent dextrose depending on age and size of patient. e) Ascorbic acid, vitamin B complex and folates are important for wound .. healing. Complication a) Shock: It is corrected by early administration of fluid, plasma and plasma substitutes. b) Respiratory tract injury: Mechanical airway obstruction may be noticed 24 to 48\ hours after bums due to edema of head and neck when the face is burnt. c) Nosocomial infection: septicemia Gastro duodenal hemorrhage: (curling's ulcer) bleeding may occur 7 to 10 days after injury due to stress ulcers. e) Bone and joint abnormalities: septic arthritis osteoporosis, pathological fractures and abnormalities of bone growth due to bum injury.

f) Thrombophebitis.
Delayed Complication

Yost burn scars

b) Contractures
) Marjolin's ulcer (bum scar carcinoma)

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, head and spinal injuries and trauma to soft tissue and organs). Eye injuries account for about one third ofall blindness in children. Eye injuries occurs due to chemicals, playing with fire, arms, spots, chemicals burns in the sclera and conjurlctiva may cause ulceration of the cornea. Contact sports cause black eyes (echymosis) and injuries of the orbit Treatment will depend on tlie injury and its severity. (Covering eyes, use of eye ointments and drops, sedation and frequent eye examination.) Prevention of Injury During infancylearly childhoodlschool age. Always raise crib rails to their f ~ lheight l 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 protective harness has been applied. Do not leave an infant unattended in a walker.
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Nursing Care of Children with Paediatric Emergencies

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 most common 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 other vegetable, 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

Nursing Care of Childre'n with Medical and Surgical Problems-I1

and emphysema, foreign body in the air passage produce choaking, gagging or coughing. Laryngotracheal obstruction causes dyspnea, cough, stridor, cyanosis and 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. After removing foreign body the child is placed in a high humidity atmosphere. Antibiotics may be administered to prevent secondary infection. Observation of the child for further signs is necessary.

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Nursing Management of Child with Ingestion of Foreign Body

a) b) c) d) e) Recognize the sign of foreign body aspiration and implement immediate measure to relieve the obstruction. Immediate removal of foreign body. Prevent local tissue inflammation. Prevent secondary infection, and treat with appropriate antibiotics. Place child in an atmosphere of high humidity. Educate Parents, baby care takers about emergency procedure.

Prevention
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 with balloons. c) As a Nurse you can educate parents singly or in group about hazards of aspiration. a) 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 all poisoning episodes involve ingestion of substance which are nontoxic or have mild toxicity.

A poison is any substance that when ingested, inhaled or absorbed even in relatively small amounts can cause damage to a structure or disturbance of body function by its chemical action.
Poisoning is defined as a morbid condition caused by the ingestion of a toxic substance. Common Clinical Manifestation Gastrointestinal Disturbances: Nausea, vomiting, anorexia, abdominal pain, and diarrhoea. Respiratory and Circulatory Symptoms: possible unexplained cyanosis, shock, and collapse. Central Nervous System: lethargy, sudden loss of consciousness and convulsions, dizziness, stupor, coma. Management for Poisoning and Overdose

Nursing Care or Children with Paediatric Emergencies

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

Phone Number: getting the caller's telephone number is necessary in case he requires follow-up calls. Address: This may be crucial if emergency equipment needs to be dispatched 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 symptoms or 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 or signs as well as well as evaluation of laboratory data and other prognostic 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 chronic medications or allergies with the current ingestion. Type of Exposure: Products, names and ingredients should be obtained from labels or from the POISONINDEX system. Amount of Exposure: How many tablets or how much fluid has been consumed should be estimated. Tablets or fluid remaining in the container should be counted or measured. Route of Exposure: To determine whether the exposure was by ingestion, 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 cause soft tissue swelling of the airway.
Attain Control of the Airway, ventilation, and oxygenation. In the absence of cerebral or renal damage, the patient's prognosis depends largely 6n successful management and support of vital functions. Subsequent Assessment

Identify the poison. - Try to determine the product taken: where, when, why, how much, who witnessed the event, time since ingestion.

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the poison control center in the area if an unknown toxic agent as 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 head down), 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 superactivated charcoals 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 be administered. 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 patient is 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 the usual adult dose. For children between age 1 and 12, give 15 ml followed by 8 to 16 ounces of water.
Gasteric lavage for the obtunded patient. Save gastric aspirate for toxicology screening.

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

- Hemoperfusion (process of blood through an extracorporeal circuit and

a cartridge containing an adsorbent, such as charcoal, after which the detoxified blood is returned to patient).

Nursine Care . of Children with Paediatric Emergencies

-

- Hemodialysis-used in selected patients to purify blood and accelerate

the elimination for circulating toxins.

I
I
I

- Repeated doses of charcoal-for binding nonabsorbed drugs/toxins. - Gastric lavage may be used in conjunction with activated charcoal, and
a cathartic to maximize elimination of the substance.

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

Administer the specific antidote as early as possible to reverse or diminish effects of the toxin.

Outcome
Although all forms of childhood poisoning can be serious, most children recover after prompt treatment and follow-up care.

Prevention
Provide 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 are parental vigilance and firm guiding discipline.

6.3.6 Respiratory Distress Syndrome

Respiratory 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 601min and/or use of accessory muscles of respiration. This is often accompanied by grunting, retraction of the intercostal muscles. Central cy anosis, lethargy and - . .. . L , . r

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

1 1 .

..-----

Nurcing Care of Children with Medical and Surglcrl problems-Il

It is symptom complex that originates secondary to a deficiency of the quantity or the quality of pulmonary surfactant superimposed on a structurally and functionally immature cardiopulmonary system. It is important to remember that in addition to surfactant deficiency immaturity of cardio pulmonary system significantly 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 edema

a a a
a

Oral cavity: macroglossia, micrognathia Neck: congenital goiter, cystic hygroma Larynx: web, stenosis, cord paralysis, laryingomalacia Trachea: tracheamalacia, tracheo-esophageal fistula

Lung Parenchymal Disorders

Aspiration syndromes: Liquor, meconium, blood

a a

Air leak: pnemothorax, pneumomedistinum Pneumonia Pulmonary hemorrhage Transient techypnea of newborn.

Congenital Malformations

Diaphragmatic hernia Metabolic causes: acidosis, hypothermia, hypoglycemia Birth 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) and metabolic hypoglycemia, acidosis hypothermia. Respiratory Distress or Hyaline Membrane Disease (HMD) is caused 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 meconium aspiration syndrome (MAS). Babies born through meconium stained liquor could have MAS and aspiration may occur in utero, during delivery or immediately after birth. Thick meconium could block air passages and cause atelectasis and air leak syndromes. Postnatally milk can be aspirated in 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~distress in new born. Primary pneumonia are more common among term or post term infants because of higher incidence of prenatal aspiration due to fetal hypoxia as a result of placental dysfunction. Preterrn babies may develop pneumonia as a consequence of septicemia, aspiration of feeds and respiratory failure. Pneumonia may be due to aspiration (tracheo esophageal fistula) gestro-esophageal reflux or may be of bacterial or viral etiology. Bacterial organisms are usually gram-ve or staphylococci.
Pneumothorax: In neonates could be spontaneous but it is more often due to MAS or staphylococcus pneumonia. Air leaks are seen more common in

babies or when aggressive rees&ation

is dm for bah

asphyxia. The distress is usually sudden in onset and heart sound become less distinct. Immediate management in hemodynamically unstable neonate is by a needle aspiration and later chest drainage.

Nursing Care of Children with Peediatric Emergencies

Pulmonary Hemorrhage: Massive amount of bleeding from the lungs signifies 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 wall recession and nasal flaring, . . expiratory grunting, tackycardia and cyanosis.
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) c) Polymorph count 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 on clinical monitoring. - All babies with significant distress should be kept on IV fluids, and
k

Nursing Care of Children with Medical and Surgical 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 Ventilatory Support.

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 the concept 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 PROGRESS

Check Your Progress 1

1) By Palpating central pulses - fermal in infants and carotid in children. 2) 5:l

3) 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 the first 24 hours, irrespective of the eventual outcome. 2) i) 80-100

'

ii) Cardio Pulmonary Resuscitation

iii) 60
Check Your Progress 3
1)

Scald injury from moist heat Flame injury Electrical injury Chemical injury Radiation injury

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

Broadribb's Margaret G Marks, Introductory Pediatric Nursing. 4th ed. J.B. Lippincott Corflpary Philadelphia: 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 sager publications. Sandra M Neltina. The Lippincott Manual of Nursing Practice. 6th ed, Philadelphia; Lippincott 964-967.