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DEFINITIONS AND ASSESSMENT respiratory failure is thought to • "Lower airway obstruction": the
APPROACHES FOR EMERGENCY be the end stage of respiratory major clinical signs typically occur
MEDICAL SERVICES FOR CHILDREN distress, it may occur with little during the expiratory phase of the
or no respiratory effort. At respiratory cycle. The child often
times, recognition of respiratory has wheezing and a prolonged
failure requires capnography or expiratory phase requiring
Severity Classification of
laboratory data (eg, blood gas) increased expiratory effort. The
Respiratory Disease to confirm the diagnosis. In other respiratory rate is usually elevated,
Respiratory distress and respiratory patients, the clinical examination particularly in infants. Inspiratory
failure are key concepts in PLS is sufficient to identify respiratory retractions become prominent
but have not been applied in a failure. when the lower airway obstruction
consistent manner across courses impairs inspiration and exhalation,
• “Respiratory arrest” is the absence
and programs. The task force requiring increased respiratory
of respirations with detectable
adopted a severity classification effort. Examples include asthma
cardiac activity.
of respiratory symptoms for PLS and bronchiolitis.
courses and programs to help guide • “Apnea” is the cessation of
breathing, typically defined as • "Parenchymal (tissue) lung
appropriate therapy. Specifically, PLS
longer than 15 seconds. Apnea disease": this etiologic condition is
courses should build on the general
may be further classified as used to describe disease involving
impression and primary, secondary,
“central” or “obstructive.” Central the substance (ie, parenchyma or
and diagnostic (tertiary) assessments
apnea indicates that the child tissue) of the lung. In this state,
of the child to identify severity,
is making no respiratory effort, the child’s lungs become stiff
followed by defining the specific
whereas obstructive apnea is when because of fluid accumulation in
etiology of the child’s respiratory
ventilation is impeded, resulting in the alveoli, interstitium, or both,
abnormality.
hypoxemia, hypercapnia, or both.8 requiring increased respiratory
• “Respiratory distress” is a clinical effort during inspiration and
state characterized by increased exhalation. Therefore, retractions
respiratory rate, effort, and and accessory muscle use are
Etiologic Classification of
work of breathing.8 Children can common. Hypoxemia is often
have respiratory distress, which Respiratory Disease8* marked due to alveolar collapse
spans a spectrum from mild • "Upper airway obstruction": the or reduced oxygen diffusion
tachypnea with increased effort major clinical signs typically occur caused by pulmonary edema
to severe distress with impending during the inspiratory phase of the fluid and inflammatory debris in
respiratory failure. A description of respiratory cycle, such as stridor, alveoli. Tachypnea is common and
the severity of respiratory distress hoarseness, or a change in voice often quite marked. The patient
typically includes respiratory rate or cry. Inspiratory retractions, frequently attempts to counteract
and effort, quality of breath sounds, use of accessory muscles, and alveolar and small airway collapse
and mental status. nasal flaring are often present. by increasing efforts to maintain an
The respiratory rate is often only elevated end-expiratory pressure.
• “Respiratory failure” is a clinical
mildly elevated because upper This is often manifested by
state of inadequate oxygenation,
airway obstruction is worse with grunting respirations.
ventilation, or both.8 Respiratory
faster breathing. Examples include
failure is recognized typically by • "Disordered control of breathing":
foreign body obstruction, croup,
abnormal appearance (particularly In this state, there is inadequate
and epiglottitis.
an altered level of consciousness, respiratory effort. Often the
which may be characterized by parent will state that the child is
agitation or a depressed level of *A patient may exhibit symptoms “breathing funny.” There may be
consciousness), poor color, and consistent with more than one class periods of increased respiratory
reduced responsiveness. Although of respiratory abnormality. rate, effort, or both followed by
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• “Distributive shock” refers to agreed that severity and clinical be an abnormal temperature or
a clinical state characterized signs of dehydration may be defined abnormal white blood cell count):
by reduced systemic vascular according to the clinical signs in
1. Core temperature above
resistance leading to Supplemental Table 3.14
38.5°C (101.3°F) or below 36°C
maldistribution of blood volume
(96.8°F)
and blood flow. This group
includes septic, anaphylactic, Sepsis 2. Tachycardia, defined as a
and neurogenic shock. In septic mean heart rate >2 SD above
and anaphylactic shock, there Sepsis represents an important cause normal for age in the absence
may also be increased capillary of shock in infants and children. of external stimulus, chronic
permeability, leading to loss of Sepsis, severe sepsis, septic shock, drugs, or painful stimuli,
volume from the intravascular and systemic inflammatory response or otherwise unexplained
space (ie, decreased preload). syndrome (SIRS) are terms used to persistent heart rate elevation
In neurogenic shock, there is characterize the host response to over a 0.5- to 4-hour period;
loss of sympathetic tone leading an infectious agent or inflammatory or for infants aged <1 year,
to vasodilation and lack of stimulus. These terms were based bradycardia, defined as a
compensatory mechanisms on 1992 consensus definitions for mean heart rate below the
(ie, tachycardia and peripheral SIRS, sepsis, severe sepsis, and septic 10th percentile for age in
vasoconstriction). shock in adult patients.15 Pediatric the absence of external vagal
definitions were introduced in stimulus, β-blocker drugs,
• “Obstructive shock” refers to
2001.16 There is national attention to or congenital heart disease;
conditions that physically impair
providing more consistent treatment or otherwise unexplained
blood flow by limiting venous
of pediatric sepsis and septic shock, persistent depression of the
return to the heart or the pumping 17 and an ad hoc consensus group
of blood from the heart. This heart rate over a 0.5-hour
provided updated definitions and period
results in decreased cardiac output.
treatment guidelines for pediatric
Conditions causing obstructive 3. Mean respiratory rate >2
sepsis and septic shock in 2005.18
shock include pericardial SD above normal for age or
tamponade, tension pneumothorax, • "Infection" is a pathologic process mechanical ventilation for an
pulmonary embolism, and ductal- caused by invasion of normally acute process not related to
dependent congenital heart sterile tissue, fluid, or a body an underlying neuromuscular
defects, such as coarctation of the cavity by pathogenic or potentially disease or the receipt of
aorta and hypoplastic left ventricle. pathogenic microorganisms. general anesthesia
Infection may be suspected or
proven by positive result of a 4. Leukocyte count elevated
Classification of Dehydration by culture, tissue stain, or polymerase or depressed for age (not
Severity chain reaction test. In the absence secondary to chemotherapy-
of these tests, evidence of infection induced leukopenia) or >10%
Dehydration is defined as a loss immature neutrophils.18
includes positive findings on
of water with varying loss of
clinical examination, imaging, or
electrolytes, leading to a hypertonic • "Sepsis" is defined by SIRS in
laboratory tests consistent with
(hypernatremic), isotonic, or the presence of or as a result of
tissue invasion by a pathogenic
hypotonic (hyponatremic) state. The suspected or proven infection.18
organism leading to a host
losses can be from some combination
response (eg, white blood cells • "Severe sepsis" is sepsis plus 1 of
of the interstitial, intracellular, and
in normally sterile body fluid, the following: cardiovascular organ
intravascular compartments; the
perforated viscus, chest radiograph dysfunction or acute respiratory
relative loss from each component
consistent with pneumonia, distress syndrome, or ≥2 other
helps determine clinical symptoms.
petechial or purpuric rash, purpura organ dysfunctions. Note that
Severity of dehydration is generally
fulminans).18 there is no generally recognized
related to the percentage of total
consensus on how to define organ
body water loss (ie, percent • "SIRS" is the host’s response to an
dysfunction. A set of definitions
dehydration), but the percentage is inflammatory stimulus, whether
is recommended in the pediatric
not consistent across all age groups caused by infection or some other
sepsis consensus document.18
because the relative proportion of stimulus. The definition of SIRS
fluid loss based on total body weight requires at least 2 of the following • "Septic shock" is defined
is size dependent. The task force characteristics (1 of which must by the presence of sepsis
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- Concussion may result in hypertension, and an irregular and programs use a variety of
neuropathologic changes, but the respiratory pattern) may be seen. classification schemes.
acute clinical symptoms largely • “Status epilepticus” is defined
reflect a functional disturbance as ≥5 minutes of continuous
rather than a structural injury; Role of Hyperventilation clinical and/or electrographic
as such, no abnormality is seizure activity or recurrent
The task force suggests that PLS
seen on standard structural seizure activity without recovery
courses discourage hyperventilation
neuroimaging studies. (returning to baseline) between
in the patient who is hypovolemic
- Concussion results in a graded or in cardiac arrest because seizures.28 In emergency settings,
set of clinical symptoms that hyperventilation can depress cardiac therapy for status epilepticus
may or may not involve loss of output by impairing venous return. should be initiated when seizure
consciousness. Resolution of the Hyperventilation must be used activity exceeds 5 minutes.
clinical and cognitive symptoms cautiously in the child with TBI • “Nonconvulsive status epilepticus”
typically follows a sequential because excessive hyperventilation may be caused by absence or
course. However, it is important may cause cerebral vasoconstriction, atonic seizures or by incomplete
to note that in some cases, leading to brain ischemia and a treatment of convulsive status
symptoms may be prolonged.24 worse outcome.10,25,26 In patients epilepticus. In the latter case,
• “Postconcussion syndrome” is a with severe TBI, hyperventilation is nonconvulsive status epilepticus
constellation of symptoms that indicated only when there are acute should be suspected when
have been related to TBI, which may signs of cerebral herniation and must the patient continues to have
vary between individuals. There be guided by capnography or blood a markedly impaired level of
are numerous definitions, but the gas measurements to ensure PaCO2 consciousness after visible
symptoms fall into 4 major domains. does not fall below 30 mm Hg. convulsive activity has ceased
because most patients will awaken
5. Physical, including headache,
relatively soon after effective
phonophobia/photophobia,
Spinal Injury therapy for convulsive status
disturbances of vision and
Injury to the spine confers the epilepticus.29
balance, nausea/vomiting, and
dizziness potential for lifelong morbidity. “Hypoglycemia” refers to blood sugar
Various terms are used to describe ≤60 mg/dL in a child and ≤40 mg/
6. Sleep, including problems with methods for minimizing the risk of dL in the newborn and may result
insomnia, sleeping too much, spinal injury. The task force endorses in brain injury if not recognized
fatigue, and drowsiness the following term: and effectively treated. Treatment
7. Cognitive, including memory • “Spinal motion restriction” refers decisions should be based on patient
difficulties, slow processing, to the preferred practice of symptoms and can include oral
“feeling foggy,” and maintaining the spine in anatomic glucose.
concentration or attention alignment to minimize gross “Drowning” is the process of
problems movement, without mandating experiencing respiratory impairment
8. Emotional, including problems the use of specific adjuncts. True from submersion or immersion in
with irritability, anxiety, spinal immobilization is difficult liquid.30 The terms “near drowning”
depression, and mood or to achieve. The use of a backboard and “secondary drowning” have
personality changes24 should be judicious, so that the become obsolete.
potential benefits outweigh the
• “Herniation syndrome” refers
risks.27
to the combination of clinical
symptoms seen with shifts and Hypothermia
compression of various cerebral Hypothermia may occur secondary
components caused by mass to environmental exposure or be
lesions and/or cerebral edema. MEDICAL CONDITIONS induced for therapeutic purposes.
Common findings in herniation The range of temperatures associated
syndrome include depressed level with exposure-induced (accidental)
of consciousness, asymmetric or hypothermia is classified differently
bilateral dilated, and unresponsive Seizures from the range of hypothermia
pupils. With central herniation, Seizures are common medical induced therapeutically. The
Cushing's triad (bradycardia, emergencies in children. PLS courses following definitions are used
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recognition and treatment of critical when a child’s weight cannot be specific, and both methodologies
conditions in pediatric patients. The obtained. appear to have similar predictive
task force recognizes that different 6. To avoid excessive dosing in value.
providers may have learned slightly children who are overweight, 16. The term altered mental status
different definitions and models, the weight provided on the is preferred over altered level of
but by recognizing and reinforcing length-based tape should not consciousness.
consensus definitions, it hopes to be adjusted based on presumed
focus attention on learning objectives 17. Motor vehicle collision or crash
increased body mass.
rather than slight differences in is the preferred term for injury
underlying concepts or terms. 7. PLS courses and programs mechanisms involving vehicle
A summary of the task force should classify respiratory crashes.
suggestions follows. disease by severity and etiology
18. TBI is the preferred term for
because these categorizations
all forms of head injury of all
drive emergency treatment.
degrees of severity.
Suggestions of the Task Force† 8. Provider-induced
19. Primary and secondary brain
1. The PAT should be the initial hyperventilation is harmful,
injury are key terms that allow
component of all emergency should be guided by
distinction in timing, treatability,
pediatric assessments to form capnography or blood gas
and prevention options after TBI.
an observational general measurements, and should only
impression. be used if the child has signs of 20. The definition of concussion
cerebral herniation. involves impact, impairment of
2. Primary assessment (primary neurologic function, and clinical
survey) should include ABCDE, 9. Capnography should be used as
symptoms.
vital signs, and pulse oximetry. an important adjunct to physical
This guides immediate assessment of the adequacy of 21. Spinal motion restriction
correction of life-threatening ventilation. refers to the preferred practice
conditions. of maintaining the spine in
10. It is important to realize that
anatomic alignment to minimize
3. Secondary assessment shock can occur without
gross movement, without
(secondary survey) should hypotension.
mandating the use of specific
consist of a focused history, adjuncts.
11. For optimal therapy, shock
focused examination, ongoing
assessment should lead to 22. Status epilepticus is defined
reassessment of physiologic
classification of shock into 1 of as ≥5 minutes of continuous
status, and response to
4 etiologic classes: hypovolemic, clinical and/or electrographic
treatment and is an essential
cardiogenic, distributive, or seizure activity or recurrent
part of the trauma evaluation.
obstructive. seizure activity without recovery
This guides correction of
underlying conditions that lead 12. Dehydration is a common and (returning to baseline) between
to life threats. important clinical entity with seizures. Therapy should be
specific identifiable clinical initiated when seizure activity
4. Diagnostic (tertiary) assessment
stages and pitfalls in assessment. exceeds 5 minutes.
should be a key component of
patient evaluation that relies 13. To improve communication and 23. Hypoglycemia refers to blood
on laboratory and radiologic classification of children with sugar ≤60 mg/dL in a child and
tests, usually in the emergency SIRS, sepsis, severe sepsis, and ≤40 mg/dL in the newborn and
department or hospital setting, septic shock, consensus terms may result in brain injury if
but also occurring at the point should be used. not recognized and effectively
of care in the out-of-hospital treated. Treatment decisions
setting. 14. Consistent application of the GCS, should be based on patient
PGCS, or AVPU scale is key to symptoms and can include oral
5. Use of a length-based tape to reduce interobserver variability glucose.
determine weight and drug in disability assessment.
dosing, as well as appropriate 24. Drowning is the preferred term
equipment sizing, is preferable 15. Appropriateness of the GCS or for submersion or immersion
PGCS versus the AVPU scale as in a liquid medium (usually
†These do not reflect AAP policy. a disability measurement is site water) causing any degree of
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age-specific criteria. GCS score of 13 to 15 indicates mild head injury; GCS score of 9 to 12 indicates moderate head injury;
and GCS score of ≤8 indicates severe head injury. Modified from James, Anas, and Perkin.20
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