Cardiac & Resuscitation, Patient Care

Treating Pediatric Summertime Emergencies

Issue 7 and Volume 40.

EMS is called to a daycare for a 4-year-old child with difficulty breathing. On arrival, they find a 33-lb child in moderate distress with inspiratory and expiratory wheezing. A quick history reveals that a bee stung the patient 15 minutes prior to arrival. Ten minutes later, the patient vomited and started wheezing.

The patient is quickly placed on a monitor and vital signs show a heart rate of 160, respiratory rate of 40, oxygen saturation of 88% and a blood pressure of 80/40. His physical exam reveals a patient in obvious distress, moist mucous membranes and normal oropharynx without tongue swelling. His heart is tachycardic with a regular rhythm. Auscultation of the chest shows the patient is tachypneic with inspiratory and expiratory wheezing coupled with intercostal and substernal retractions. His abdomen is soft, non- tender and non-distended. An examination of the skin show a blanching, raised, erythematous rash around the sting site on his leg that has spread to his trunk. The patient is quickly placed on oxygen. The steps that are taken next save this patient’s life.

Deadly Season

Summer, a much-anticipated season of the year for both adults and children, is unfortunately a time for significant unintentional injury and death to kids. This is secondary to a combination of children being out of school and spending more time outdoors, coupled with decreased adult supervision. Statistics from the National SAFE Kid Campaign Study reveal that nearly half of the unintentional deaths of children under 14 years of age occur between May and August, with a peak occurring in July. During these summer months approximately 9 million children are seen in EDs across the country and over 9,000 children will die as a result of these injuries.1 Through proper assessments and symptom identification, first responders can provide key initial stabilization for common summertime emergencies and prevent further mortality

Children are at higher risk for traumatic injuries based on anatomy alone. A smaller body size can lead to multiple injuries from just a single impact. Children also have a decreased circulating blood volume indicating that hypovolemic shock can result from a relatively small blood loss. A relatively cartilaginous skeleton can lead to visceral and brain injuries that are common in the absence of bony injuries.

Bites & Stings

Reactions to insect stings are seen commonly in pediatric practice, ranging from simple local reactions to systemic anaphylaxis. Both warmer weather and spending more time outdoors are risk factors. Though a rare occurrence from a sting, one has to be prepared for anaphylaxis when transporting these patients. Stinging insects include honeybees, bumblebees, wasps, yellow jackets, hornets, harvester ants and fire ants. Biting insects include mosquitoes, fleas, horseflies, ticks and chiggers.

How it occurs: Immediately after contact with the insect, a local reaction occurs at that site with associated edema and pruritic local erythema. Irritant substances concentrated in insect saliva cause these local reactions in an insect bite. In insect stings, the female insect has a barbed stinging apparatus that becomes lodged in the skin and rips away, along with the venom sac, from the insect’s body following a sting event.

Treatment: These local reactions usually last several hours and respond to the application of cool compresses. Antihistamines such as diphenhydramine (Benadryl) and analgesics may also be helpful. Stingers should be removed as rapidly as possible using something stiff–such as thick paper or a credit card–because venom can continue to be released for several seconds. The area should then be washed with soap and water and elevated if on an extremity. Larger local reactions can also occur, involving areas of approximately 5–10 cm in diameter that are adjacent to the site of the sting. The swelling generally peaks in 24–48 hours, but the reactions can last up to 10 days. Steroids are usually not indicated for insect stings unless there’s anaphylaxis.

Severe cases: Although systemic reactions to insect stings and bites are the exception with less than 1% of children experiencing them, they can be life-threatening.2 Anaphylaxis is a serious allergic or hypersensitivity reaction that’s rapid in onset and may cause death secondary to rapid mast cell degranulation. In order to have an anaphylactic reaction, one must have had a previous sting. Higher-risk patients are immunocompromised patients (e.g. AIDS, cancer, medically fragile) or patients with known anaphylaxis or severe allergies. Per the latest guidelines from the American Academy of Allergy, Asthma, and Immunology, there are different ways to diagnose anaphylaxis but the important points are that it can be an abrupt or delayed onset and usually two of the following criteria have to be met: Skin or mucosal involvement;

  1. Respiratory compromise such as wheezing or persistent cough;
  2. Hypotension;
  3. Persistent vomiting or diarrhea; or
  4. End organ dysfunction.

The immediate initial therapy for anaphylaxis is epinephrine (1:1000) 0.01 mg/kg, with max of 0.3 mg intramuscularly in the anterolateral thigh. Please note that this is a change from the past when epinephrine was given subcutaneously. Giving it intramuscularly provides more rapid absorption. In patients with true anaphylaxis, intramuscular epinephrine should be given first before IV access is obtained. Epinephrine can be repeated if needed and in severe cases an epinephrine drip can be started. Once IV access is established, an antihistamine such as diphenhydramine should be administered. A normal saline bolus should be considered if the patient has decreased capillary refill or is hypotensive. Nebulized albuterol can be used if the patient is wheezing or in respiratory distress. If EMS protocol allows, a corticosteroid such as solumedrol at a dose of 2 mg/kg should be given to a maximum dose of 125 mg. Patients who meet criteria for anaphylaxis should never been left on the scene and should always be transported to the nearest appropriate ED, even if there’s dramatic improvement or complete resolution of symptoms after epinephrine. This is because there’s a rebound phenomenon that can occur approximately 4–6 hours after the initial exposure.

Drowning

Drowning is the second leading cause of injury related death in children less than 15 years old.1 Recent studies conducted by the CDC reveal that the rates of drowning deaths in children less than 19 years of age have decreased in the past 10 years, but drowning still remains the number one cause of unintentional injury leading to death in boys ages 1–4. Between the months of May and August, two thirds of all deaths from drowning occur, with most of them occurring on the weekends.

If the drowning patient doesn't have an adequate respiratory effort, it's acceptable to provide bag-valve mask ventilation assistance.

If the drowning patient doesn’t have an adequate respiratory effort, it’s acceptable to provide bag-valve mask ventilation assistance.

 

Statistics for nonfatal drowning are even more difficult to obtain, but nonfatal drowning events may occur several hundred times as frequently as reported drowning deaths.

Risk factors: Risk factors for drowning include inability to swim, as well as risk-taking behaviors, particularly in adolescents. There’s a bimodal age distribution, which includes children less than 5 years of age and those 15–19 years of age who are more likely to drown. The location of the drowning accident is also age dependent; children less than 1 year of age drown most frequently in the bathtub, children ages 1–4 drown in swimming pools, and adolescents and teens are most likely to drown in natural bodies of water. Children of low-to-middle income background account for 90% of all drownings, indicating that children of lower economic status are at higher risk.1 Various primary medical conditions preclude some children to drowning accidents such as children with seizures, who are 4 times more likely to drown. Likewise, children with a primary cardiac arrhythmia are at high risk, particularly if it is a cold- water drowning or a significant amount of exercise is involved.

If intubation isn't necessary, the drowning patient should be placed on a non-rebreather mask with 100% oxygen to help correct hypoxia.

If intubation isn’t necessary, the drowning patient should be placed on a non-rebreather mask with 100% oxygen to help correct hypoxia.

 

Pathophysiology: Both fatal and non- fatal drownings begin with a period of panic. Contrary to popular belief, the victim won’t wave his or her arms and call for help. With panic, there will be a loss of the normal breathing pattern, air hunger and periods of breath holding. The patient will be holding himself upright with arms extended laterally to assist with posture and lung expansion, and may be mistaken for playing or splashing as they struggle to stay above water. The struggle for children to remain above water may only last for 10 seconds, while adults may struggle for 60 seconds.

As carbon dioxide level rises, the patient will experience episodic contractions of the diaphragm, thus forcing a reflex inspiratory gasp. This persists once submerged and leads to swallowing large amounts of water. Inevitably, the victim will be unconscious in 2–3 minutes, leading to large amounts of water being passively aspirated into the lungs.

Heat stroke patients with altered mental status, vital sign changes or evidence of dehydration should be cooled and transferred to the nearest hospital for observation and further treatment.

Heat stroke patients with altered mental status, vital sign changes or evidence of dehydration should be cooled and transferred to the nearest hospital for observation and further treatment.

 

In 20% of cases, reflexive laryngospasm occurs and water isn’t aspirated into the lungs.3 The combination of hypoxia, hypercarbia and acidosis can decrease myocardial contractility, elevate pulmonary artery and systemic vascular resistance, and produce cardiac arrhythmias, seizures and death.

Initial assessment and transport: The initial presentation of a victim of a submersion injury is quite varied, depending on initial submersion time and resulting hypoxemia. Signs and symptoms may include loss of consciousness, apnea, dyspnea, tachypnea, tachycardia, altered mental status, seizures, coughing or decreased breath sounds on exam.

Initial treatment of the potential drowning child includes supporting the ABC’s (airway, breathing and circulation) by providing high-quality CPR. If the patient doesn’t have an adequate respiratory effort, it’s acceptable to provide bag-mask ventilation if good chest rise is noted and transport time is short. If the patient aspirated a significant amount of water, they may require a slightly higher pressure (positive end-expiratory pressure) to bag. Should the patient be difficult to bag or there will be a prolonged transport time, intubation should be considered. If intubation isn’t necessary, the patient should be placed on a non-rebreather mask with 100% oxygen to help correct hypoxia.

Only place the patient in a C-collar if a C-spine injury is truly suspected. Routine C-spine immobilization isn’t recommended as it can interfere with airway management. One should avoid the Heimlich or other techniques to remove water as they haven’t proven to demonstrate any benefit. Correction of the hypoxia is the key to a positive patient outcome. Near-drowning patients should always be transported to the nearest appropriate ED given the risk of rapid decompensation. Even the asymptomatic near-drowning victim requires observation of at least four hours.

Heat Exposure Spectrum

Heat illnesses occur along a spectrum of very minor (heat rash, cramps) to life-threatening conditions such as heat stroke. Most episodes of heat illness occur during times of increased environmental heat as well as increased exposure to heat. The heat exposure spectrum includes heat rash (miliaria), heat cramps, heat edema, heat syncope, heat exhaustion and heat stroke.

Pathophysiology: A normal body temperature of 98.6 degrees F is maintained within a narrow range by balancing heat load and dissipation. As the body’s core temperature rises from hot weather or exercise, heated blood is transferred to the skin surface if it’s cooler. In an effort to more rapidly dissipate heat, the body dilates blood vessels and pores and evaporates sweat to help with cooling. Unfortunately, this mechanism becomes ineffective once the relative humidity is over 75%. With heavy work, the body may lose 1–2 liters of fluid. After several hours of fluid loss, a person may start to become symptomatic with loss of endurance, increased thirst and becoming uncomfortable. After 3–5 hours, the body has decreased blood to circulate to the rest of the body, which may lead to decreased alertness, nausea, muscle cramps, headache and/or loss of strength. If not treated with fluid resuscitation, this may lead to heat stroke. Heatstroke by definition is a core temperature greater than 105 degrees F, decreased level of consciousness and an environment consistent with heat stroke.

Initial assessment and transport: The key to treating heat exposure spectrum is to identify approximately where the patient is on the spectrum. Heat rash presents with a possibly pruritic maculopapular rash treated by cool baths, loose clothing and removing the patient from the environment. Heat cramps present as brief, intermittent muscular cramps that are relieved by increased salt intake. If they’re more severe they may require IV fluids. Heat syncope is a temporary loss of consciousness associated with vasodilation and venous pooling. It occurs usually after standing a long time or a quick adjustment in position. These patients usually have a normal core temperature and mental status will quickly improve once supine and IV fluids are administered.

The definition of heat exhaustion involves a known heat exposure and core temperature between 37–40 degrees C. These patients present with evidence of mild tomoderate volume depletion, variable nonspecific symptoms including nausea, fatigue, confusion, headache and tachycardia. Treatment consists of removal from the heat to a cool environment, removal of excessive clothing, chilled oral rehydration with salt containing fluids or IV hydration.

Central nervous system dysfunction is the hallmark for heat stroke. When first assessing these patients, the ABCs are paramount as these patients may need an airway intervention. Wet sheets without air movement tend to increase the core temperature and should be avoided. When treating these patients, it’s helpful to recall the treatment mantra of Corey Slovis, MD, chairman of emergency medicine at Vanderbilt Medical Center: “Wet and windy.” Use ice packs on the groin and the axilla, fans to help with convection cooling, and IV fluids as needed for hydration. Those patients with altered mental status, vital sign changes or evidence of dehydration should be transferred to the nearest hospital for observation and further treatment.

Conclusion

In the medical community, summertime involves a unique set of medical issues along with an increase in trauma patients. First responders must be prepared to treat these patients quickly and efficiently so that morbidity and mortality can be minimized.  

References

  1. Unintentional Drowning: Get the facts. (Oct. 24, 2014.) Centers for Disease Control and Prevention. Retrieved May 4, 2015, from www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html.
  2. Curtis J. Insect sting anaphylaxis. Pediatr Rev. 2000;21(8):256.
  3. Salomez F, Vincent JL. Drowning: A review of epidemiology, pathophysiology, treatment and prevention. Resuscitation. 2004;63(3):261–268.

Resources

Questions

1. What is the number one cause of unintentional injury/death in boys ages 1-4?
A. Motor vehicle crash
B. Non-accidental trauma
C. Drowning
D. Electrocution
E. Overdose

2. What is the first thing to assess in drowning patient?
A. Oxygen saturation
B. Airway
C. Clothing removal
D. Water in mouth
E. Temperature

3. What is the first line medication for anaphylaxis in a conscious patient?
A. Epinephrine 0.01mg/kg IM
B. Epinephrine 0.1mg/kg IV
C. Diphenhydramine 0.05 mg/kg PO
D. Diphenhydramine 0.1mg/kg IV
E. Topical Hydrocortisone cream

4. What slogan should lead your treatment of heat exposure spectrum?
A. Dry as a Bone
B. Hot as a Hare
C. Wet and Windy
D. Dark and Dreary
E. Cold and Clammy

5. True or False: The Heimlich Manuever is key in removing water after a drowning.

Answers

1. C, 2. B, 3. A, 4. C, 5. False

Learning Objectives

  • Understand common pediatric summertime emergencies and their pathophysiology.
  • Know the treatment methods for each emergency.
  • Review initial stabilization and safe transport for each specific emergency.

 

Key Terms

Anaphylaxis: An exaggerated, life- threatening hypersensitivity reaction to a previously encountered antigen.
Drowning: Death by asphyxia after submersion.
Heat stroke: Life-threatening failure of the body’s temperature-regulating mechanisms after exposure to high or prolonged heat stress.
Laryngospasm: A sudden, temporary closure of the larynx.