Medical Emergencies Occurring
at School
Francisco J Cervantes MD FAAP
August 5th, 2014
www.laredopediatrics.com
Pediatric Emergency
Quick Assessment Goals:
• Identify Children in Need of Pediatric
Emergency care
• Identify signs of possible emergency care
• Identify or list pediatric Emergencies
Statistics for Laredo
• LISD: yearly average of 25,000 enrolled
students and over 4,500 employees
• UISD: 43,321 students for 2012-2013
Children In need of Emergency Care
• Special Care Needs Children
• Chronic Illness Children
• Everybody else
Special Services at School
• Approximately 8% of children entering
kindergarten and 16% of adolescents entering
high school have a chronic physical,
developmental, behavioral, or emotional
condition that requires health and related
services of a type or amount beyond that
generally required by children
Special Health Care Needs
• Children with special health care
needs attending schools require
special equipment, preparation and
training of personnel, medications
and supplies, and/or transport
decisions and arrangements.
Procedures at Schools
• children with special health care needs
– Requiring special procedures, ie
•
•
•
•
•
G-Tube feeding
Trach
Oxygen
Cath
Nebulizer Treatments
School Population
• 25% Children attending school have special
health care needs or chronic medical
conditions
Chronic Medical Conditions
– Asthma
– ADHD
– Diabetes
– Epilepsy
– Cerebral Palsy
Types of Emergencies at Schools
•
•
•
•
•
•
injury-related
status asthmaticus
diabetic crises
status epilepticus
sudden cardiac death
other medical emergencies
Injuries at School
• Injuries are the leading cause of death and
disability in the United States,
• 70% of injury deaths occurring in school-aged
youth (5–19 years of age)
• It is estimated that 10% to 25% of injuries to
children occur while they are in school
• A national survey of 573 school nurses
conducted by Olympia et al* revealed that
68% of the school nurses managed a lifethreatening emergency requiring EMS
activation in the school year before the
survey. Although 86% of the surveyed schools
reported having a medical emergencyresponse plan, 35% of the schools had not
tested it during a drill.
*Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children:
a national survey of school nurses. Pediatrics.2005;116 (6). Available at:
www.pediatrics.org/cgi/content/full/116/6/e738
Never underestimate
the importance of
your role as school
nurse.
CALL 911 IF……
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The child is unconscious, semi-conscious or unusually confused.
The child’s airway is blocked.
The child is not breathing.
The child is having difficulty breathing, shortness of breath or is choking.
The child has no pulse.
The child has bleeding that won’t stop.
The child is coughing up or vomiting blood.
The child has been poisoned.
The child has a seizure for the first time or a seizure that lasts more than five minutes.
The child has injuries to the neck or back.
The child has sudden, severe pain anywhere in the body.
The child’s condition is limb-threatening (for example, severe eye injuries, amputations)
The child’s condition could worsen or become life-threatening on the way to the hospital.
Moving the child could cause further injury.
The child needs the skills or equipment of paramedics or emergency medical technicians.
Distance or traffic conditions would cause a delay in getting the child to the hospital.
• If any of the previous conditions exist,
• or if you are not sure,
Call 9-1-1.
Non Urgent Care
Student may require:
• referral for routine medical care.
• Minor or non-acute conditions.
• Minor abrasions or bruises
• Muscle sprains and strains
Urgent Care
Student requires medical intervention within 2 hours.
• Deformity suggesting fracture of a long bone
without
• circulatory compromise
• Lacerations in which sutures are required but
bleeding is controlled and there is no significant
blood loss
• Moderate pain following abdominal trauma
• Head injury with brief loss of consciousness
• Minor burns
• Persistent nausea, vomiting, or diarrhea
Emergent
requires immediate medical attention.
Condition is acute and has the potential to threaten life, limb, or vision
•
•
•
•
•
•
•
•
•
•
•
Cardiopulmonary arrest
Shock (hypovolemic, cardiogenic, or distributive)
Severe respiratory distress or failure
Major burns
Cervical spine compromise
Severe medical problems, such as diabetic complications
Poisoning or overdose
Emergency childbirth
Acute seizure states
Prolonged loss of consciousness
Caustic chemical spills in the eyes
Conducting the Initial Assessment
Accurately determine the severity
of the student’s condition
Initial Assessment minimizes the
possibility that you will overlook
important physical and historical
findings.
Components of Assessment:
• Across-the-room
• Scene safety
• Brief physical
• Brief health history
Across-the-Room Assessment
• Is your first contact with the ill or injured
student.
– Quickly observe the student’s general appearance,
airway status, work of breathing, circulatory
status, and disability (neurologic status),
– The entire assessment should take less than a
minute.
Scene Safety Assessment
For incidents taking place outside the health office, assess
the scene to determine whether you can safely approach
the student. Before rendering aid, you must ensure your
own safety as well as that of bystanders and of the
student. Look for hazards in the form of :
• Substances: blood or other body fluids, noxious fumes,
toxic chemicals
• Situational dangers: an armed perpetrator, hostages,
weapons
• Environmental dangers: an unstable structure, fire,
electrical hazards
Physical Assessment
• Airway: Position, sounds, obstruction.
• Breathing: Work of breathing, adventitious
sounds, rate, effort, odors.
• Circulation: Skin color, temperature, and
moisture; capillary refill time; rate and quality of
pulses; bleeding.
• Disability: Activity level, mentation, pupil size and
reactivity, emotional state. Orientation to time,
place, and person. AVPU level of consciousness
Brief health history
• Past medical history: Record information
about preexisting physical or psychological
disabilities.
• A history of previous trauma or a chronic
condition is particularly relevant.
• Make sure immunization status is current,
including tetanus prophylaxis.
Sudden Cardiac Arrest
• Sudden cardiac arrest has an estimated annual
incidence of 0.7 to 1.0 per 1000 population and is
responsible for 50% of all deaths attributable to
cardiovascular disease in the United States.
• If no CPR is provided, each minute that defibrillation is
delayed decreases the chances of survival for victims of
sudden cardiac arrest attributable to ventricular
fibrillation by 8% to 10%
• High school athlete sudden death is rare, However,
sudden cardiac deaths in adult spectators have been
reported, and schools need to prepare for them
Classroom Emergency
In the event a student or adult collapses in the classroom and is
unresponsive, the following steps should be taken:
• Using either the phone in the room or a cell phone, someone
should call 911.
– a) Confirm the location of the patient.
– b) Confirm the situation with the 911 operator.
•
Using either another phone or sending a student to the adjacent
room, the administrative office should be called.
– a) The administrative office should overhead page for the First
Responder team to respond to the affected classroom.
– b) The administrative office will also send someone with the
Automated External Defibrillator (AED) to the classroom.
– c) Someone should be placed outside to direct EMS to the proper
location.
Classroom Emergency Cont…
•
•
•
•
Assess the victim: airway, breathing and circulation
Initiate CPR, if needed, while the AED is brought to the scene.
Upon arrival, place the AED near the victim’s head, close to the AED operator
Prepare to use the AED.
–
–
–
–
–
a) Make sure power is on.
b) Bare and prepare the chest for AED use.
c) Attach the AED to the victim, considering appropriate use of pediatric or adult pads.
d) Stop CPR while the device analyzes the heart rhythm.
e) Follow the device prompts for further action. If a shock is indicated, be sure all
rescuers and bystanders are “clear” before the shock is administered.
– f) If no shock is indicated, follow prompts to reassess and continue CPR.
•
Upon arrival, EMS shall take charge of the situation.
– a) Provide victim information: name, age, known medical problems, and time of
incident.
– b) Provide information as to current condition and number of shocks administered
*If the patient has suffered any trauma or a fall, the patient should not be moved unless the scene is unsafe.
*Prior to EMS arrival, someone in the administrative office should get the patient’s emergency contact information
from the file.
Pediatric Advanced Life Support (PALS)
Task Force of the International Liaison Committee on
Resuscitation (October 2002):
• Automated external defibrillators (AEDs) may
be used for children 1 to 8 years of age who
have no signs of circulation. Ideally the device
should deliver a pediatric dose. The
arrhythmia detection algorithm used in the
device should demonstrate high specificity for
pediatric shockable rhythms, ie, it will not
recommend delivery of a shock for nonshockable rhythms (Class IIb).
Upon arrival at the scene the school nurse/AED responder will
• Assess responsiveness
– If unresponsive, activate emergency response system by calling 911
– Verify 911 has been contacted
• Check ABC’s (Airway, Breathing, Circulation)
– If no breathing, provide rescue breathing
– If no circulation, perform CPR and prepare for defibrillation
•
•
•
•
If chest is wet----DRY IT
If chest is hairy----SHAVE IT
If heart device implanted----WORK AROUND IT
If jewelry is in place----REMOVE IT
• DO NOT USE AED ON A VICTIM <8 YEARS OLD OR 55LBS/25KGS
• REMOVE VICTIM FROM CONTACT WITH WATER AND DRY CHEST
American Heart Association
Guidelines for AED/CPR Integration*
• For a sudden, witnessed collapse in a child, use the AED
first. Prepare AED to check heart rhythm and deliver 1
shock as necessary. Then, immediately begin 30 CPR chest
compressions followed by 2 normal rescue breaths.
Complete 5 cycles of CPR (30 compressions to 2 breaths).
Then prompt another AED assessment and shock. Continue
with cycles of 2 minutes CPR to 1 AED rhythm check.
• For unwitnessed cardiac arrest, start CPR first. Continue for
5 cycles or about 2 minutes. Then prepare the AED to check
the heart rhythm and deliver a shock as needed. Continue
with cycles of 2 minutes CPR to 1 AED rhythm check.
*Currents in Emergency Cardiovascular Care, American Heart
Association, Winter 2005-2006.
Rationale for AED Use
• The primary determinant of survival from VF
cardiac arrest is the time interval from collapse
until defibrillation. Out-of-hospital defibrillation
within the first 3 minutes of witnessed adult VF
arrest results in survival rates >50%. But the
success of resuscitative efforts decreases
dramatically with the passage of time. For every
1-minute delay in defibrillation, the survival rate
may decrease by 7% to 10%, although this
number is influenced by the presence and quality
of bystander CPR. After >12 minutes of VF, the
survival rate of adults is <5%.
Pediatric Ventricular Fibrillation (VF)
• All commercially available AEDs use algorithmic
rhythm analysis programs derived from in vitro
rhythm libraries of adult shockable and nonshockable rhythms. AED developers use an
empirical, iterative process to create and adjust
filters, measurements, and decision rules. This
process enables the AED to “decide” to
recommend a shock for the highest possible
percentage of shockable rhythms (maximum
sensitivity) and to avoid shocking the highest
possible percentage of non-shockable rhythms
(maximum specificity).
Pediatric Ventricular Fibrillation (VF)
• Gutgesell and colleagues conducted the largest
clinical study of an effective defibrillation dose for
children. They retrospectively evaluated the
efficacy of defibrillation attempts at energy doses
of 2 J/kg. The authors reviewed 71 transthoracic
defibrillation attempts in 27 children whose ages
ranged from 3 days to 15 years and who weighed
from 2.1 to 50 kg. The authors reported that 91%
of shocks within 10 J of the standard 2 J/kg dose
successfully terminated VF.
EKG Variants
AEDs in Pediatrics
• The success of defibrillation depends on delivery
of sufficient current flow (amperes) for a
sufficient length of time to depolarize a critical
mass of myocardium. In the 1970s, animal studies
established that inadequate current through the
myocardium led to unsuccessful defibrillation,
whereas too much current resulted in post
resuscitation myocardial damage. These studies
further established that the density of current
through the myocardium determined the balance
between effectiveness of the shock and
myocardial damage.
AEDs in Pediatrics
• Current evidence suggests that AEDs are capable
of appropriate sensitivity and specificity for
pediatric arrhythmias and are both safe and
effective for defibrillation of children 1 to 8 years
of age. Ideally pediatric pads/cables should be
used, whenever available, to deliver a child dose.
Each specific AED model must be tested against a
library of pediatric arrhythmias to document its
efficacy in detection of shockable and
nonshockable rhythms.
AEDs in Pediatrics
• The basic principles of electrical cardiac
defibrillation have been reviewed. For any given
waveform, current flow increases with higher
shock energy (J) and decreases with higher
impedance or resistance (ohms). Several factors
increase impedance along the path between
defibrillator paddles or electrode pads and
decrease current through the myocardium. These
factors include a paddle or electrode pad that is
too small, large lung volumes, and lack of
conducting gel between the skin and defibrillator
paddles or electrode pads.
Current Recommendations in Pediatric
Guidelines for Use of AEDs
The 2000 International Guidelines recommend use of AEDs for:
• rhythm identification in children 8 years of age (Class IIb).
• Attempted defibrillation of VF/pulse less VT detected by an AED
may be considered in these older children (Class Indeterminate).
Attempted defibrillation of children less than approximately 8 years
of age is not recommended, however. The average 8-year-old child
weighs 25 kg. The current recommended initial dose of 150 to 200 J
would provide 6 to 8 J/kg for the average 8-year-old. If the initial
shock fails to eliminate VF, some AEDs are programmed to provide
escalating doses to a maximum dosage of up to 360 J. Thus, second
and subsequent doses deliver 150 to 360 J, resulting in a shock of 1
to 4 J/kg in an adult who weighs 80 to 125 kg and 6 to 15 J/kg in an
8-year-old child who weighs 25 kg.
Why Do People Faint?
• Fainting is pretty common in teens. The good news is
that most of the time it's not a sign of something
serious.
• When someone faints, it's usually because changes in
the nervous system and circulatory system
• circulatory system cause a temporary drop in the
amount of blood reaching the brain. When the blood
supply to the brain is decreased, a person loses
consciousness and falls over. After lying down, a
person's head is at the same level as the heart, which
helps restore blood flow to the brain. So the person
usually recovers after a minute or two.
Causes of Fainting
• Physical triggers: Getting too hot or being in a
crowded, poorly ventilated setting are common
causes of fainting in teens. People can also faint
after exercising too much or working out in
excessive heat and not drinking enough fluids (so
the body becomes dehydrated). Fainting also can
be triggered by other causes of dehydration, as
well as hunger or exhaustion. Sometimes just
standing for a very long time or getting up too
quickly after sitting or lying down can cause
someone to faint.
Causes of Fainting
• Emotional stress. Emotions like fright, pain, anxiety, or
shock can affect the body's nervous system, causing blood
pressure to drop. This is the reason why people faint when
something frightens or horrifies them, like the sight of
blood.
• Hyperventilation. A person who is hyperventilating is
taking fast breaths, which causes carbon dioxide (CO2) to
decrease in the blood. This can make a person faint. People
who are extremely stressed out, in shock, or have certain
anxiety disorders may faint as a result of hyperventilation.
• Drug use. Some illegal drugs (like cocaine or
methamphetamine) or using inhalants ("huffing") can cause
fainting.
Causes of Fainting
•
•
•
Low blood sugar. The brain depends on a constant supply of sugar from the blood
to work properly and keep a person awake. People who are taking insulin shots or
other medications for diabetes can develop low blood sugar and pass out if they
take too much medicine or don't eat enough. Sometimes people without diabetes
who are starving themselves (as with crash dieting) can drop their blood sugar low
enough to faint.
Anemia. A person with anemia has fewer red blood cells than normal, which
decreases the amount of oxygen delivered to the brain and other tissues. Girls
who have heavy periods or people with iron-deficiency anemia for other reasons
(like not getting enough iron in their diet) may be more likely to faint.
Pregnancy. During pregnancy the body normally undergoes a lot of changes,
including changes in the circulatory system. This leads to low blood pressure that
may cause a woman to faint. In addition, the body's fluid requirements are
increased, so pregnant women may faint if they aren't drinking enough. And as the
uterus grows, it can press on and partially block blood flow through large blood
vessels, which can decrease blood supply to the brain.
Causes of Fainting
• Eating Disorders: People with anorexia or bulimia may faint
for a number of reasons, including dehydration, low blood
sugar, and changes in blood pressure or circulation caused
by starvation, vomiting, or over exercising.
• Cardiac problems. An abnormal heartbeat and other heart
problems can cause a person to faint. If someone is fainting
a lot, especially during exercise or exertion, doctors may
suspect heart problems and run tests to look for a heart
condition.
• Some medical conditions — like seizures or a rare type of
migraine headache — can cause people to seem like they
are fainting. But what's happening is not the same thing as
fainting and is handled differently.
Helping Someone Who Faints
• Make sure the person is lying flat, but avoid moving the person if
you think he or she might have been injured when falling (moving
an injured person can make things worse).
• Loosen any tight clothing — such as belts, collars, or ties — to help
restore blood flow. Propping the person's feet and lower legs up on
a backpack or jacket can also help move blood back toward the
brain.
• Someone who has fainted will usually recover quickly. Because it's
normal to feel a bit weak after fainting, be sure the person stays
lying down for a bit. Getting up too quickly may bring on another
fainting spell.
• Call 911 if someone who has fainted does not regain consciousness
after about a minute or is having difficulty breathing.
Primary hypertension:
•
•
•
Significant health problem, with
overweight/obesity being a major contributor to
much of the pre-hypertension and stage1
hypertension.
Body mass index (BMI) should be calculated
and plotted on the CDC growth curves in
pediatric patients.
The prevalence of hypertension increases with
increased BMI; hypertension is present in about
30 percent of those with BMI above the 95th
percentile
Resources
• School Nurse Emergency Care Course. Maywood,
IL: Illinois Emergency Medical Services for
Children; 2003.
• The American Heart Association recommends
schools develop an emergency response plan
http://circ.ahajournals.org/cgi/content/full/109/
2/278#SEC4.
• “Guidelines for Emergency Medical Care in
Schools” available at:
http://aappolicy.aappublications.org/cgi/content/
full/pediatrics;107/2/435 .