Chapter 52 Pediatric Considerations in Emergency Nursing

Pediatric patients present a unique challenge to the emergency nurse because of the physiologic and anatomic differences and the vast growth and developmental characteristics specific to this population. Table 52-1 provides information about physical and psychosocial characteristics of the growing child along with guidelines for nursing assessment.¹ In addition, keep in mind that family plays an important role in a child’s health care experience.

TABLE 52-1 PEDIATRIC GROWTH AND DEVELOPMENT

Pediatric Triage (Prioritization of Care)

There are four components in pediatric triage (or prioritization of care): the pediatric assessment triangle (PAT), focused assessment (objective information), focused pediatric history (subjective information), and assignment of an acuity rating decision.

Pediatric Assessment Triangle

The PAT is a simple observational tool for performing a rapid, visual, across-the-room assessment of children presenting to the emergency department (ED) regardless of presenting complaint.² The PAT consists of the following three components:

• Appearance: Muscle tone, consolability, spontaneous movements, speech or cry, distress level

• Breathing: Respiratory distress, abnormal airway sounds

• Circulation: Skin color, such as pale, mottled, cyanotic, or flushed

Allow the caregiver to remain with the patient, as appropriate. Look for additional assessment cues that will prioritize care for each pediatric patient, such as:

• Patient’s developmental stage: Is this current behavior in line with his or her typical behavior?

• Significant developmental delays

• Illnesses and injuries common to different developmental ages

• Risk factors for maltreatment

• Compensatory mechanisms of pediatric patients that may mask serious illness or injury

• Risk level for rapid deterioration

The rationale for additional history may include the following:

• Caregiver concerns and perceptions: crying and “fussiness” are vague symptoms

• Rashes that may be a concern for potentially contagious diseases

• Delay in definitive care and nonuse of emergency medical services because of the portability of children

• Use of cultural and home treatments prior to arrival at the ED

• Lack of primary care provider or lack of preventive care (immunization status)

Focused Assessment and History

Following the rapid visual across-the-room assessment, the next step in triage is the focused assessment, which includes the primary and secondary assessments. Refer to Chapter 44, Pediatric Trauma, for more information. Systematically obtain a history, which can be done by using the pneumonic CIAMPEDS (Table 52-2).

TABLE 52-2 CIAMPEDS MNEMONIC

	DEFINITION	DESCRIPTION
C	Chief complaint	Reason for the pediatric patient’s ED visit and duration of complaint (e.g., fever for past two days).
I	Immunizations	Evaluation of the pediatric patient’s current immunization status. The completion of all scheduled immunizations for the patient’s age should be evaluated. If the pediatric patient has not received immunizations because of religious or cultural beliefs, document this information.
I	Isolation	Evaluation of the pediatric patient’s exposure to communicable diseases (e.g., meningitis, chickenpox, shingles, whooping cough, and tuberculosis) A pediatric patient with active disease or who is potentially infectious must be placed in respiratory isolation on arrival to the ED. Other exposures that may be evaluated include exposure to meningitis and scabies.
A	Allergies	Evaluation of the pediatric patient’s previous allergic or hypersensitivity reactions. Document reactions to medications, food, products (e.g., latex), and environmental allergens. The type of reaction must be documented.
M	Medications	Evaluation of the pediatrics patient’s current medication regimen, such as prescription medications, over-the-counter medications, and herbal and dietary supplement, including: • Dose administered • Time of last dose • Duration of use
P	Past medical history	A review of the pediatric patient’s health status, including prior illnesses, injuries, hospitalizations, surgical procedures, and chronic physical and psychiatric illnesses. Use of alcohol, tobacco, drugs, or other substances of abuse should be evaluated as appropriate. The medical history of the neonate should include the prenatal and birth history: • Maternal complications during pregnancy or delivery • Infant’s gestational age and birth weight • Number of days infant remained in the hospital after birth • The medical history of the menarche of the female patient should include date and description of her last menstrual period The medical history for sexually active patients should include the following: • Type of birth control used • Barrier protection • Prior treatment for sexually transmitted infections • Gravida (pregnancies) and para (pregnancies carried to the 20^th week of gestation)
P	Caregiver’s impression of the pediatric patient’s condition	Evaluation of the caregiver’s concerns and observations of the patient’s condition. These factors are especially significant when evaluating the special needs pediatric patient. Consider cultural differences that may affect the caregiver’s impressions.
E	Events surrounding the illness or injury	Evaluation of the onset of the illness or circumstances and mechanism of injury. Time and date injury occurred: • M: Mechanism of injury, including the use of protective devices (seat belts and helmets) • I: Injuries suspected • V: Vital signs in the prehospital environment • T: Treatment by prehospital providers Description of circumstance leading to injury. Witnessed or unwitnessed. Illness • Length of illness, including date and day of onset and sequence of symptoms • Treatment provided before the ED visit
D	Diet	Assessment of the pediatric patient’s recent oral intake and changes in eating patterns related to the illness or injury. Time of last meal and last fluid intake. Changes in patterns or fluid intake. Usual diet: Breast milk, type of formula, solid foods, diet for age and developmental level, and cultural differences. Special diet or diet restrictions.
D	Diapers	Assessment of the patient’s urine and stool output: • Frequency of urination during the past 24 hours and changes in frequency • Time of last void • Changes in odor or color of urine • Last bowel movement and color and consistency of stool • Change in the frequency of bowel movements
S	Symptoms associated with the illness or injury	Identification of symptoms and progression of symptoms since the onset of the illness or injury event.

ED, Emergency department.

Reprinted from Emergency Nurses Association. (in press). Emergency nursing pediatric course (4th ed.). Des Plaines, IL: Author.

Vital Signs

For pediatric patients, obtain a full set of vital signs, including weight in kilograms; obtain a measured weight whenever possible. If circumstances do not permit a measured weight using a scale or length-base resuscitation tape, the weight may be estimated using the following formula: Weight in kilograms = (3 × Age) +7.³ The nurse should be aware of the normal vital signs for a pediatric patient and recognize when vital signs deviate from normal. Normal heart and respiratory rates are described in Table 52-3.

TABLE 52-3 NORMAL RESPIRATORY AND HEART RATES BY AGE GROUP

AGE GROUP	NORMAL RESPIRATORY RATE, BREATHS PER MINUTE	NORMAL HEART RATE, BEATS PER MINUTE
Infant (1 to 12 months)	30–60	100–160
Toddler (1 to 3 years)	24–40	90–150
Preschooler (3 to 5 years)	22–34	80–140
School-aged child (5 to 11 years)	18–30	70–120
Adolescent (11 to 18 years)	12–16	60–100

Reprinted from Emergency Nurses Association. (in press). Emergency nursing pediatric course (4th ed.). Des Plaines, IL: Author.

Temperature

• Obtain temperature via an appropriate route considering the pediatric patient’s age and condition.

• Avoid rectal temperatures in immunocompromised patients.

• Fever can be associated with abnormal activity, respiratory patterns, or dermal warning signs, such as rashes, cyanosis, or mottling.

• Temperature variations that may indicate a serious condition include the following:

• Rectal temperature greater than 38.5°C (101.3°F) in infants younger than 1 month of age ⁴

• Rectal temperature greater than 40°C (104°F) in infants aged 3 months to 2 years, with no localized sign of infection

• Rectal temperature less than 34.2°C (93.2°F)⁴

Blood Pressure

Determine the minimum normal systolic blood pressure for pediatric patients using the following formula: Systolic blood pressure = 70 + (Age in years × 2).

A blood pressure change in children is considered a late change and not always reliable. Blood pressure should be determined by serial measurements, not a single reading.

Acuity Rating Decision

The final step in the prioritization of care process is the triage nurse’s interpretation of the pediatric patient’s assessment, resulting in an acuity rating decision. The determination of the acuity rating decision provides conclusion for the urgency and order for care. Follow your institution’s guidelines for which acuity rating system to use.

Medication Administration and Intravenous Therapy

Because virtually all pediatric medications are dosed according to the pediatric patient’s weight, obtain an accurate measurement as part of the focused assessment. If this is not possible, use a length-based resuscitation tape to calculate estimated body mass or use the formula described above. Pediatric patients present unique risk factors that can contribute to medication errors; therefore reducing or managing these risk factors is important. The age and developmental stage of the pediatric patient are essential to consider whenever administering medications. Not only will age influence drug absorption, distribution, and excretion, but the patient’s age will often determine the best route for administration and appropriate developmental approaches.⁵

Oral Medications

Children who cannot or will not swallow pills present a nursing challenge. Tips for successful oral medication administration include the following:

• Ask the caregiver how the patient usually takes oral medication.⁵

• Mix or dilute medications in a minimal amount of fluid, applesauce, or chocolate syrup to encourage the patient to ingest the entire dose. When mixing medication with food or liquids use as little diluent as possible.⁵

• For infants, consider administration of liquid medication through a nipple followed by 5 mL of water. Avoid mixing medication with formula or breast milk because it may lead the infant to refuse formula later.⁵

• Demonstrate to caregiver how to use a syringe to administer medications in the young pediatric patient’s buccal cavity.

• Place the syringe between the gum and cheek. Administer no more than 0.5 mL at a time.⁵

• Administer oral medication while the pediatric patient’s head is raised or while the patient is in a sitting position to prevent asphyxiation.⁵

• Consult the pharmacist before opening capsules for administration.⁵

• Do not crush enteric-coated tablets or caplets.⁵

• Do not open sustained-release capsules.⁵

Intramuscular Medications

When determining an injection site, consider the pediatric patient’s age, weight, and muscle mass, along with the medication volume and viscosity. Table 52-4 provides information regarding intramuscular injections in children.

TABLE 52-4 PEDIATRIC INTRAMUSCULAR INJECTION SITES

SITE	RECOMMENDED AGE
Vastus lateralis	Infant
Vastus lateralis	Can be used at any age and is the preferred site in children younger than 3 years
	Considerations
	Large muscle mass, free of important nerves and blood vessels
	Acceptable injection volumes: Infants, 0.5–1 mL; older children, up to 2 mL
	Use a 22- to 25-gauge needle (length, to 1 inch)
SITE	RECOMMENDED AGE
Ventrogluteal	Child
Ventrogluteal	Consider for children older than 3 years
	Considerations
	Large muscle mass, free of important nerves and blood vessels
	Easily accessible site
	Injection volume up to 2 mL
	Use a 20- to 25-gauge needle (length, 1 to 1.5 inch)
SITE	RECOMMENDED AGE
Deltoid	Infant
	Considerations
	Small muscle mass, easily accessible, with a rapid absorption rate
	Danger of radial nerve injury in young children
	Injection volumes of 0.5–1 mL
	Use a 22- to 25-gauge needle (length, to 1 inch)

Data from Bindler, R., & Howry, L. (2005). Pediatric drug guide. Upper Saddle River, NJ: Pearson Education.

Subcutaneous Injections

• Sites considered include the upper lateral arm, the anterior thigh, and the anterior abdominal wall.⁵

• Limit the injection volume to 0.5 to 1 mL, depending on the age of the patient and the site of the injection.⁵

• Insert needle at a 45- to 60-degree angle in a thin pediatric patient with little subcutaneous tissue or at a 90-degree angle in the patient with generous amounts of subcutaneous fat.⁵

Veins on the dorsum of the hand or foot are the preferred sites for infants and children, while the scalp vein is ideal for infants for over-the-needle intravenous catheter insertion (24 gauge or larger).

Intravenous Therapy

Establishing and maintaining vascular access in the young pediatric patient is one of the most difficult and stressful emergency nursing tasks. Tips for successful intravenous (IV) therapy include the following ⁶:

• Provide emotional support to patients and their caregivers; this procedure is anxiety-provoking for both. Give caregivers permission to stay with the patient or leave the room during the procedure.

• Infants tend to have deep veins that are well covered with subcutaneous tissue. In these patients, scalp veins are an excellent alternative to extremity sites.

• In the presence of volume depletion, younger pediatric patients may have no visible peripheral veins, even after a tourniquet has been applied.

• Quickly consider an intraosseous site if the patient is critically ill or injured and requires emergent vascular access. Intraosseous lines offer many benefits and few drawbacks. Refer to Chapter 10, Intravenous Therapy, for more information.

• When selecting a site, try to avoid the antecubital fossa, veins over joints, or the dominant hand.

• Use a warm pack (consider use of a commercially available heel warmer) to dilate potential veins.

• Immobilize the pediatric patient’s extremity before venipuncture if possible. A padded pediatric armboard works well.

• Insert the IV device into the skin at an angle, generally 10 degrees, although this may vary. Flush the catheter with a small amount of saline to ensure patency.

• Inserting the IV device with a bevel down can minimize the risk of puncturing the distal wall.

• Once venous access is obtained, be sure to secure the device well according to hospital guidelines.

• Always use extension tubing and an infusion pump with pediatric IV infusions.

• Volume loss is treated by administering isotonic crystallized fluid boluses (lactated Ringer solution or normal saline). The amount of the bolus is usually calculated at a rate of 20 mL/kg and may be repeated based on the patient’s response.

• After any volume losses have been replaced, run the patient’s IV at maintenance rate. This rate is calculated based on the patient’s age and weight. Table 52-5 provides pediatric maintenance formulas.

TABLE 52-5 MAINTENANCE INTRAVENOUS FLUID RATES IN CHILDREN

WEIGHT	AMOUNT PER HOUR (mL)
1–10 kg	100 mL/kg/24 hr
10–20 kg	1000 mL plus 50 mL/kg for each additional kilogram over 10 (up to 20 kg), given over 24 hr
≥21 kg	1500 mL plus 20 mL/kg for each additional kilogram over 21, given over 24 hr

Data from National Institutes of Health. (2008, June 23). Intravenous fluid management. Retrieved from http://www.cc.nih.gov/ccc/pedweb/pedsstaff/ivf.html

When starting an intravenous line, the characteristic “pop” may not be felt in small children. The blood flashback seen with a successful venipuncture may be minimal.

Nasal Administration

Nasal administration of medication may be used to treat respiratory conditions or induce anesthesia. Nasal medications are best administered in infants and toddlers with the patient’s head slightly hyperextended on a caregiver’s lap. For older children, position the patient with pillows under his or her shoulders to create the hyperextension. Administer drops slowly to prevent choking.

Dermal Administration

• Wear gloves.

• Apply a thin layer of medication and spread in the direction of hair growth.

• If applying an anesthetic cream, apply an occlusive dressing and have a caregiver hold the dressing in place and distract the patient for 30 to 60 minutes.

Pediatric Cardiopulmonary Arrest

The pediatric patient in respiratory failure or shock is at high risk for further decompensation and subsequent cardiopulmonary arrest. Advanced life support interventions must be implemented emergently. Begin with basic life support (BLS) maneuvers by immediately opening the airway, assisting ventilations, and initiating cardiac compressions as needed. Refer to current American Heart Association Basic Life Support and Pediatric Advanced Life Support (PALS) guidelines for pediatric resuscitation.⁷ Be sure to facilitate family presence at the bedside and to arrange for transfer to a higher level of care, such as admission to a pediatric intensive care unit (PICU) or to another facility. Start this process early.

Apparent Life-Threatening Events

An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer because of a change in the infant’s breathing.⁸ Previously this condition was referred to as a “near-miss” sudden infant death syndrome (SIDS). ALTEs are characterized by a combination of the following:

• Apnea: central (no respiratory effort) or obstructive

• Color change: cyanosis or pallor

• Marked change in muscle tone (limp)

• Choking or gagging

Parents may fear that the child has died. Reversal or recovery of the condition occurs after the child is stimulated or resuscitated. A detailed and precise description of the event is of paramount importance; the emergency nurse should identify and address any underlying causes such as:

• Events immediately preceding the ALTE (e.g., recent illness, immunizations, daily activities)

• Usual sleep conditions (e.g., position, bedding, bed sharing)

• Precise time when ALTE occurred and association with time of last feeding or presence of fever

• Place where ALTE occurred (e.g., caregiver’s arms, crib, bed, car)

• State of infant when found (e.g., awake or asleep; position of sleep, face covered or uncovered)

• If awake, activities during ALTE (e.g., feeding, bathing, crying)

• Reason that led to discovery of the infant (e.g., abnormal cry)

• Caretakers who discovered or witnessed ALTE

Sudden Infant Death Syndrome

SIDS is the sudden death of a child (generally <12 months old) that remains unexplained after postmortem examination, investigation of the death scene, and review of the patient’s case history. SIDS is a diagnosis of exclusion. The peak SIDS incidence is between 2 and 4 months of age.¹⁰

Etiology

The cause of SIDS is unknown, but several different factors may cause infant death. SIDS incidents occur most often between the ages of 0 and 6 months, with Native Americans and African Americans having the highest incidence.¹⁰ It occurs most often in the winter months, with January having the peak incidence.¹¹ SIDS affects boys more often than girls.¹⁰ Almost all SIDS deaths occur without any warning or symptoms and usually when the infant is thought to be asleep.¹¹

The following have been linked to an increased risk of SIDS:

• Exposure to cigarette smoke while in the womb or following birth

• Babies who sleep on their stomachs

• Late or no prenatal care

• Teen mothers

• Multiple-birth babies

• Babies who have soft bedding in their cribs

• Babies who sleep in the same bed as their parents

Pacifiers at naptime and bedtime can reduce the risk of SIDS.¹² It is thought that the pacifier may keep the airway open more and also that the infant does not fall into a deep sleep. Other preventative measures include the following:

• Teach the parents infant cardiopulmonary resuscitation.

• Implement BLS and PALS resuscitation guidelines.

Because of the poor prognosis, prehospital protocols may allow the pronouncement of death at the scene without initiation of futile resuscitation efforts.

Most therapeutic interventions are directed toward the grieving family. These include the following:

• Permit the family to say goodbye before discontinuing resuscitation.

• Allow family members to hold the deceased infant (as permitted by municipal rules related to handling of the body by family members); do not rush them.

• Provide mementos such as a lock of hair, footprints, or handprints (these also can be obtained from the funeral home).

• Consult with the antepartum and postpartum nursing staff as they may have a protocol for infant loss that may be helpful in the loss of an infant in the ED.

• Explain to the family that it is unlikely they did anything to cause the infant’s death and that there was nothing they could have done to prevent it.

• Describe what will happen next: autopsy, then release to the funeral home.

• Encourage follow-up grief counseling and support groups.

• Many SIDS websites are available as resources for distraught families and staff members.

Despite a 50% decline in the number of SIDS deaths since 1992, thought to be because of the “Back to Sleep” initiative, SIDS remains the leading cause of postneonatal infant death in the United States.¹²

General Pediatric Emergencies

Pediatric Fever

Fever is the most common single complaint in pediatric patients and accounts for as many as 20% to 25% of pediatric visits to the ED.¹³ Fever is defined in a neonate as 38°C (100.4°F).¹⁴ Hyperthermia has a variety of causes, most commonly infection, but it also can result from poisoning, dehydration, heat exposure, metabolic disorders, or collagen-vascular diseases. The presence of fever on presentation, or fever reported at home, may influence triage and treatment decisions in pediatric patients who are at increased risk for sepsis or other serious illness (e.g., neonate, immunocompromised).