Pediatric emergency medicine trisk 0150 0150
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Breathing
After the airway has been evaluated and secured as necessary, breathing is assessed to
assure adequate air exchange. Continuous oxygen saturation measurement and endtidal carbon dioxide (ETCO2 ) monitoring in both intubated and nonintubated patients
allows for continued assessment of oxygenation and ventilation. The most common
causes of hypoxemia in children are ventilation/perfusion (VQ) mismatch and
hypoventilation. ETCO2 may help distinguish between these two entities; providers
will note normal or low ETCO2 in cases of primary VQ mismatch, while in cases of
hypoventilation, physicians will often see hypercarbia out of proportion to
hypoxemia. It is important to note that in trauma patients, compromise of ventilatory
function most often occurs secondary to a depressed sensorium rather than a primary
pathology of the respiratory system itself.
Circulation
Circulation is assessed by examining the character of the pulse, skin color, and
capillary refill time. There is no single physical or laboratory finding that will identify
shock, however, the physical signs exhibited by the patient in shock are ultimately
due to insufficient oxygen and substrate delivery to the tissues. The physical
manifestations vary with type of shock but include tachycardia, decreased skin
perfusion, and hypotension (cold shock) or tachycardia, bounding pulses and flushed
skin with hypotension (warm shock). If cardiogenic shock is present, HR may be
normal or only modestly elevated. Remember that in children, hypotension is a late
finding requiring a 50% decrease in the circulating volume to affect a decrease in
systolic pressure. In trauma, external hemorrhage visualized during the primary
survey should be controlled by direct pressure or pneumatic splints.
Disability
CNS failure is manifested by altered MS or by the presence of focal neurologic
deficit(s). Recall that the CNS is composed of the brain and meninges, the blood
vessels, and the cerebrospinal fluid. Many diseases that cause CNS failure are caused
by compartment physiology, as in the case of elevated intracranial pressure (ICP).
Examples of primary CNS disease include intracranial hypertension secondary to
mass or hemorrhage, and status epilepticus. The CNS may also be secondarily
affected by respiratory or circulatory disease as oxygen delivery to the tissues of the
CNS is impaired. The AVPU scale and GCS ( Table 7.2 ) are used to measure level of
consciousness in a standardized way. Interventions to treat CNS failure include
modest hyperventilation and hypertonic therapy (in the case of elevated ICP),
maintenance of MAP and oxygenation to ensure adequate CNS perfusion, and
avoidance of hyperthermia. Other therapies aimed at the underlying cause of CNS
failure include anticonvulsants, antimicrobials, and surgical decompression.
