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INTRODUCTION TO PEDIATRIC EMERGENCIES & INJURIES
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Of the approximately 140 million annual emergency department (ED) visits in the United States, over 30 million (20%) are for pediatric patients. Though the vast majority (97%) of children presenting for ED evaluation are discharged home, nearly 1 million each year require hospital admission in the ED and, sadly, nearly 3000 children die every year in US EDs.
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INITIAL APPROACH TO THE ACUTELY ILL INFANT OR CHILD
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Most causes of pediatric cardiac arrest are due to hypoxia from respiratory failure.
Hypotension is a late finding in pediatric shock; early signs may include tachycardia, capillary refill > 2 seconds, skin mottling, and decreased mental status.
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A pediatric patient in serious distress may either present with a known diagnosis or in cardiorespiratory failure of unknown cause. The initial approach must be simple and consistent to rapidly identify and reverse life-threatening conditions. Once stabilized, the provider must then carefully consider the underlying cause, focusing on those that are treatable or reversible. Specific diagnoses can then be made, and targeted therapy initiated.
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Pediatric cardiac arrest most commonly results from progressive respiratory deterioration or shock. Unrecognized deterioration may lead to bradycardia, agonal breathing, hypotension, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even if the child survives the arrest. When cardiopulmonary arrest does occur, survival is rare and most often associated with significant neurological impairment. Current data reflect a 6% survival rate for out-of-hospital cardiac arrest, 8% for those who receive prehospital intervention, and 27% survival rate for in-hospital arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. In fact, more than 70% of children with respiratory arrest who receive rapid and effective bystander resuscitation survive with good neurologic outcomes. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs.
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Of note, “compressions only” cardiopulmonary resuscitation (CPR) has been touted to encourage bystander CPR for adult out-of-hospital cardiac arrests. In the pediatric population, however, giving rescue breaths as well as chest compressions is still recommended and should be provided for infants and children in cardiac arrest due to the predominance of respiratory causes of arrest.
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THE ABCs OF RESUSCITATION
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A severely ill child should be rapidly evaluated in a deliberate sequence known as the ABCs: Airway patency, Breathing adequacy, and Circulation integrity. Each should be addressed before proceeding to the next step (keeping in mind that a patient in pulseless arrest should have the ABCs addressed simultaneously per PALS [pediatric advanced life support] guidelines).
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Age-appropriate equipment ...