1. PEDIATRIC
EMERGENCIES
Myrna D.C. San Pedro, MD, FPPS

2. Scope
Injury risk factors, assessment,
emergency treatment and prevention
Foreign body accidents clinical features
and management
Burn types, assessment and management
Near-drowning accidents assessment and
management
Poisoning common causes, diagnosis and
management

3. Injury versus Accident
Accident (WHO): an event independent of human
willpower, caused by an external force, acts
rapidly and results in bodily or mental damage
Injury: refers to the damage resulting from acute
exposure to physical and chemical agents
Accident is the event while injuries the
consequences
Accidents are random, chance, uncontrollable
events but injuries are describable, epidemiologic
conditions that can be controlled and prevented
The term “accident” has been abandoned in favor
of the more accurate term “injury

4. Interactive Model of Injuries
AGENT
VICTIM
(HOST)
HUMAN
ENVIRONMENT
PHYSICAL
ENVIRONMENT

5. Child Development and Injuries
Temperament: a child’s behavioral style
1. Difficult child: irregular rhythm, high energy,
negative mood, low adaptability
2. Easy child: opposite
3. Slow to warm up child: low activity, positive
approach, highly adaptable, mild energy
Motivation: interest in accomplishing a task
1. Normal drive for autonomy
2. Interest in imitating behavior
3. Risk-taking or self-destructive behaviors

6. Child Development and Injuries
Competencies: level of functioning
1. Infants’ drive to explore and become
autonomous but still underdeveloped
2. Preschool children have cognitive and motor
limitations
3. School children tend to be daring, impulsive
and adventurous; inclined to disregard rules;
still unable to appreciate speed and danger;
have reduced ability to localize sounds and
impaired perception of movement
4. Adolescents become overly involved in abstract
matters and sometimes lose touch with reality
combined with innate need for experimentation
and the tendency to imitate older adolescents
and adults

7. Primary Factors in Pediatric Accidents
Psychosocial
(endogenous)
Predisposing Factors
Environmental
(exogenous)
Predisposing Factors
Increased vulnerability
and/or risk situation
Precipitating
Factors
Precipitating
Factors
Accident

8. Psychosocial (endogenous)
Predisposing Factors
Unawareness of risks
Lack of experience
Need to explore and innovate
Role models (motorcyclist as hero)
Risk-taking behavior
Use of a motor vehicle to build up self-esteem
Psychological maladjustments (extreme
personality traits, unbalanced personality)
Sociopathic behavior (aggressiveness, deviance)
Family dysfunctions (chronic family syndrome)

9. Environmental (exogenous)
Predisposing Factors
Habitual use of a two-wheeled vehicle without
due protection
Lack of body protection (helmet, gloves, etc.)
Increased commercial advertising promoting
vehicles that are dangerous
Inadequate age-specific driving regulations
Inadequate enforcement of existing laws
Increasing need to make long trips to and from
work, school, etc.
Inadequately or excessively expensive public
transport

10. Precipitating Factors
Heightened emotional
tension
(endocrinological and
psychological)
Alcoholic condition
Driving under
influence of medicines
or drugs (especially
hallucinogenic)
Special traffic
conditions
Social pressure to
“perform” in a certain
way (traveling in
groups)
Use of poorly
maintained vehicles
Use of stolen vehicles

11. Classification of Injuries
Unintentional
Injuries:
Road traffic
injuries
Poisoning
Falls
Fire and burn
injuries
Drowning
Intentional Injuries:
Homicides
Sexual assaults
Neglect and
abandonment
Maltreatment
Suicides
Collective violence
(war)

12. Unintentional Injuries
Unintentional
Injuries:
400,000
deaths/year
globally –
the majority
in children
Survivors
may suffer
lifelong
disability
Non-intentional injuries in children under
15 years (WHO, 2001)

13. U.S. Injury Mortality
Injuries almost 40% of deaths among 1-4 years
Motor vehicle injuries leading cause of deaths
due to injury at all ages
Drowning ranks 2nd with peaks in the preschool
and later teenage years
Fire and burn deaths account for nearly 10% of
all trauma deaths and more than 20% in <5 yr
Asphyxiation and choking account for about 40%
of all unintentional deaths in <1 yr
Homicide leading cause of injury death in <1 yr,
4th leading cause for ages 1-14 years and 2nd
leading cause in 15-19 years
Suicide is only 1% in <15 yr but is the 3rd leading
cause of death for 15-19-yr-olds

14. U. S. Injury Morbidity
Twenty to 25% of children receive
medical care for injury every year in
hospital ERs and at least an equal
number in physician offices
Falls leading cause of both ER visits
and hospitalizations
Bicycle-related trauma most common
type of sports and recreational injury

15. DOH 2003 Study
By the Department of Health: 1 out of every 5
Filipino children die from injuries
2003 DOH study done with help from the United
Nations Children’s Fund and the Alliance for
Safe Children revealed that the top causes of
death among children ages 1-17 years are:
1. Drowning (8:100,000)
2. Road accidents (5.85:100,000)
3. Violence (2.52:100,000)
4. Falls (2.11:100,000)
5. Suicide (1.93:100,000)
The study was made on 99,446 households or
418,552 people

16. Safe Kids Philippines Study
The study was conducted in the ERs of 3 hospitals
in Parañaque, Pasay, and Olongapo
At least 20 million Filipino children are at risk of
dying or being injured in road accidents every yr
At least one in four children brought to hospital
for treatment were between 12-14 years
Most of the injuries happen after 1 p.m. and their
peak incidence between 9 p.m. and 12 a.m.
Accidental injuries are the third leading cause of
death for children 1-14 years in the Philippines

17. Safe Kids Philippines Study
80%
Boys
67%
70%
60%
50%
40%
30%
20%
10%
0%
Road accidents
50%
Assault
Intentionally
28%
Inflicted, 28%
Falls
20% Cuts
14%
Road
Accidents
30%
Home
accidents
38%
Bicycles 29%
Tricycles 23%
Motorcycles
18%
Girls
33%

18. Anticipating Cardiopulmonary Arrest
Many Causes
Respiratory Failure
Shock
Cardiopulmonary Failure
Death
Cardiovascular Recovery
Neurological Impairment
Neurological Recovery
Path of various disease states leading to
cardiopulmonary failure in infants and children

19. Rapid Cardiopulmonary Assessment
(requires 20-30 seconds to complete)
Airway patency
1) Patent and clear
2) Maintainable with suctioning, head positioning or
adjuncts
3) Unmaintainable, requiring interventions such as
intubation, foreign body removal or cricothyrotomy
Breathing
1) Respiratory Rate: normal in neonate is 40-60/min;
1-year-old is 24/min; 18-year-old is 12/min
2) Mechanics: nasal flaring, grunting, retractions, use
of accessory muscles
3) Air Entry: stridor, wheezing, breath sounds, chest
expansion, paradoxical chest movement
4) Color of the skin and mucous membranes
Central cyanosis – presence of 5 g desaturated
hemoglobin/dl of blood

20. Rapid Cardiopulmonary Assessment
Circulation
1) Heart Rate:
Newborn-3 mo
85-200/min
3 mo-2 yr
100-190/min
>2 yr
80-140/min
All ages
<60/min bradycardia
2) Blood Pressure: lower limit (5th%) systolic
0-1 mo
60
>1 mo-1 yr
70
>1 yr
70 + (2 x age in years)
Hypotension – 25% circulating blood volume loss
3) Peripheral pulses: whether present or absent,
volume/strength
4) Capillary Refill Time: normal <2 seconds

21. Rapid Cardiopulmonary Assessment
Circulation
5) Skin color: mottling, ashen, pale or cyanotic
6) Skin temperature: whether warm or cold
7) Level of consciousness (brain perfusion):
A – Awake
V – responsive to Voice
P – responsive to Pain
U – Unresponsive
8) Urine Output: normal averages 1-2 ml/kg/hr,
reflects renal blood flow and end-organ perfusion

22. Classification of Physiologic Status
Stable – adequate ventilation (elimination of CO2),
oxygenation (O2 exchange) and perfusion
In respiratory failure – inadequate ventilation or
oxygenation
 Potential RF – improves after initial therapy such
as oxygen administration
 Probable RF – deteriorates, more aggressive
therapy needed
In shock – inadequate perfusion of vital organs
 Compensated shock – blood pressure is normal
 Decompensated shock – hypotension develops
In cardiopulmonary failure – insufficient ventilation,
oxygenation and perfusion

30. Pediatric Cardiopulmonary Arrest
Sudden Cardiac Arrest
Uncommon in young
children
Ventricular fibrillation
only 10-15% of <10
years with pulseless
arrest outside the
hospital
Prehospital
normothermic asystolic
or pulseless cardiac
arrest in infants and
children with 10%
survival rate
Many suffer permanent
neurological damage
Respiratory or Circulatory
Failure
More common
Injury or disease
causes respiratory or
circulatory failure with
hypoxemia and acidosis
ending in asystolic or
pulseless cardiac arrest
Respiratory arrest
alone >50% survival
rate with prompt
resuscitation
Most patients survive
neurologically intact

31. Basic Life Support Maneuvers
PALS 2006-2007
MANEUVER
ADULT
> 8 Years
CHILD
1-8 Years
INFANT
< 1 Year
Activate
EMS (lone
rescuer)
When victim FOUND
unresponsive, activate
EMS.
If asphyxial arrest
likely, activate AFTER
5 cycles 2 min CPR.
When victim FOUND
unresponsive, activate
AFTER 5 cycles CPR.
For SUDDEN,
WITNESSED COLLAPSE,
activate after verifying
victim unresponsive.
Airway
Head tilt-chin lift maneuver.
If trauma suspected, use jaw thrust maneuver.
Breaths
Initial
2 effective breaths at 1 sec per breath

32. MANEUVER
ADULT
> 8 Years
CHILD
1-8 Years
INFANT
< 1 Year
Rescue Breaths
Without chest
compression
10-12
breaths/min
(about 1
breath every
5-6 seconds)
12-20 breaths/min (about
1 breath every 3-5
seconds)
Rescue Breaths
for CPR With
advanced airway
8-10 breaths/min (about 1 breath every
6-8 seconds)
Foreign-body
airway
obstruction
Abdominal thrusts
Back slaps
and chest
thrusts (5)
Circulation
Pulse check
(<10 sec)
Carotid (can use Femoral
in the child)
Brachial or
Femoral

33. MANEUVER
ADULT
> 8 Years
CHILD
1-8 Years
INFANT
< 1 Year
Compression
landmark
Center of chest between
nipples
Just below the
nipple line
Compression
method:
Push hard and
fast allowing
complete
recoil
Heel of 1
hand on top
of other
hand
2 Hands: Heel
of 1 hand on
top of second
hand
1 Hand: Heel
of 1 hand
only
1 rescuer: 2
fingers
2 rescuers: 2
thumbs with
encircling hands
Compression
depth
1 ½-2
inches
Approximately 1/3-1/2 the
depth of the chest
Compression
rate
Approximately 100/min
Compressionventilation
ratio
1 or 2
rescuers
30:2
1 rescuer 30:2
2 rescuers 15:2

34. Basic Life Support Core
1. Push hard and fast at a
compression rate of 100/min
2. Allow full chest recoil between
chest compression
3. Minimize interruptions
4. Avoid hyperventilation

35. Airway

36. Rescue Breaths
The correct volume for each
breath is the volume that
causes the chest to rise.

37. Foreign-body Airway Obstruction

38. Pulse Check

39. Chest Compression

40. Airway Adjuncts
Oxygen (O2): highest concentration for all seriously
ill with respiratory insufficiency, shock, or trauma
 Room air: 21% O2
 Mouth-to-mouth: 16-17% O2
Suctioning: 80-120 mm Hg suction force usually
Head positioning: position of comfort if alert, head
tilt-chin lift or jaw thrust if unconscious
Oropharyngeal airway: for the unconscious infant or
child if procedures to maintain airway fails
Bag-valve–mask assisted ventilation
 Self-inflating bag-valve device: 21% O2
 If hooked to O2 10 L/min: 30-80% O2
 If hooked to O2 10-15 L/min and with reservoir:
60-95% O2

41. Airway Adjuncts
Endotracheal intubation indications:
 Respiratory failure or arrest
 Airway obstruction (actual or expected)
 GCS < 8, comatose or significant alteration of
mental status
 Suspected increase in intracranial pressure
 Need for mechanical ventilatory support
Cricothyrotomy indications:
 Foreign body complete upper airway obstruction
 Severe orofacial injuries
 Infection
 Laryngeal fracture
Respiratory monitoring
 Pulse oximetry – noninvasive
 Arterial Blood Gas analysis – most accurate

42. DELIVERY SYSTEMS
OXYGEN (%)
FLOW RATE
(L/min)
Low Flow System
Nasal cannula
22-60
2-4
Oxygen mask
35-60
6-10
High Flow System
Face tent
< 40
10-15
Oxygen hood
80-90
10-15
Oxygen tent
> 50
> 10
Partial rebreathing mask with
reservoir
50-60
10-12
Nonrebreathing mask with
reservoir
95
10-15
Venturi mask
25-60 (mask
specific)
variable

43. Oxygen Delivery Systems

44. Airway Adjuncts

45. Endotracheal Intubation

46. Cricothyrotomy

51. Pediatric Trauma Resuscitation
Trauma is the leading cause of death and
disability in the pediatric age group
In the average multiple trauma victim: head
injuries 59% while extremities 26%
Two major causes of death:
1) Airway compromise
2) Unrecognized hemorrhage
Traumatic injuries that may affect successful
resuscitation:
1) Cervical spine injury
2) Hemorrhage
3) Chest trauma
Priority is to assess and stabilize first before
surgery

52. Pediatric Trauma Score of > 8 indicates
multisystem trauma or significant mortality risk

53. Cervical Spine Injury
Cervical spine injury less common in pediatric than
in adult trauma because
 Child’s spine more elastic and mobile
 Pediatric vertebrae softer, less likely to fracture
But risk of cervical spine injury increased whenever
child is subjected to inertial forces applied to neck
during acceleration-deceleration e.g., motor vehicle
injuries or falls from a height
Spinal cord injury without radiographic abnormality
(SCIWORA) is now recognized as important cause of
pediatric spinal cord injury because of
 Relative laxity of cervical spine ligaments
 Incomplete development of cervical musculature
 Shallow orientation of facet joints

54. Cervical Spine Immobilization

55. Hemorrhage in Pediatric Trauma
Control external hemorrhage immediately by direct
pressure over the wound
Hypotension will not be present until 25-30% or
more of the child’s blood volume is lost acutely
Reliable vascular access must be obtained quickly
If shock persists despite control of external
hemorrhage and volume resuscitation, internal
bleeding is likely
Isolated head injury rarely causes sufficient blood
loss to cause shock but scalp lacerations may
produce significant blood loss
Intra-abdominal bleeding signs due to organ
rupture: abdominal tenderness, distention that
does not improve with NGT decompression and
shock – a life-threatening surgical emergency

57. Fluid Resuscitation in Hemorrhagic Shock
20 ml/kg Isotonic crystalloid solution
Reassess
20 ml/kg Isotonic crystalloid solution
Reassess
20 ml/kg Isotonic crystalloid solution OR
10 ml/kg PRBC or 20 ml/kg FWB
Reassess --Urgent transfusion should be considered if child fails to respond
to 2-3 boluses of crystalloid solution (about 40-60 ml/kg)

58. Life-Threatening Chest Injuries
Chest injuries uncommon in pediatric trauma
because chest wall extremely compliant
When there is history of blunt trauma, intrathoracic
injuries must be ruled out
Tension pneumothorax: ABCs, needle
decompression followed by chest tube
Open pneumothorax (sucking chest wound) – rare
but lethal: ABCs, occlusive dressing followed by
chest tube, positive-pressure ventilation
Flail chest: ABCs, prolonged positive-pressure
ventilation
Massive hemothorax: ABCs, urgent placement of a
chest tube

61. / Drugs

63. Principles of Injury Control
Education or persuasion
Changes in product design
Modification of the social or
physical environment

64. Haddon’s 10 Strategies
1. Prevent the creation of hazard
2. Reduce amount of hazard brought into
being (decrease number of cars
manufactured; use fuel that permits
only low speed)
3. Prevent the release of hazard (drive
only in daylight)
4. Modify the rate of release of the hazard
from its source (use seat belts, child
safety seat)
5. Separate the hazard by time and space
(separate bicyclists from cars; use
pedestrian lanes)

65. Haddon’s 10 Strategies
6. Separate the hazard by a physical barrier
(install air bags)
7. Modify relevant basic qualities of the
hazard (eliminate hard surfaces in cars;
use energy absorbing materials to
increase space within)
8. Make what is to be protected resistant
(wear helmets)
9. Begin to counter the damage done by the
hazard (maintain airway, stop
hemorrhage, immobilize neck)
10. Stabilize, repair, rehabilitate the object of
the damage (develop a regional trauma
system, trauma and rehabilitation center)

66. Gustafsson Safety Equation
H. P.
S. E.
H = environmental Hazard
P = Proneness/“Personality factors”/Psychosocial
S = Supervision
E = Education
When, in any context, the 1st term of the
equation balances the 2nd one, there is no chance
of accident
When it is not the case, the risk of accidents
arises
The equation is useful for preventive programs

67. Three DELAYS that KILL
1. DELAY in decision-making
2. DELAY in transporting patient
3. DELAY in managing patient