Pediatric

Emergencies

By: Adam Khoo

Amanina
Ameera
Yea

Christa
Yee L
Yeon

Assessment of a Child

Effort of Breathing

Appearance

Pediatric
Assessment
Triangle

Circulation to Skin

Appearance

TICLS

Techniques: Observe from a distance, allow child to be with caregiver, use

distractions like bright lights, get down to eye level with child.
Hands on approach may cause child to cry, making examination difficult.

 The

apparently well child:

Severe acute intoxication by paracetamol,

iron, cyclic antidepressants may cause a

child to have early benign presentations
and develop lethal complications in
minutes or hours.
Children with blunt trauma
The

irritable/inconsolable child

Sign of inadequate brain perfusion

Alternate between lethargy and irritability
Glassy eyed stare a sign of altered

consciousness.

Effort of Breathing
Listen:

Abnormal breath sounds

Look: Increased respiratory effort
Abnormal Breath
Sounds

Visual signs

Altered tone of
voice/Stridor= Upper
airway obstruction
Grunting = hypoxia/
lower airway obstruction

Head
bobbing/tripoding:
abnormal positions
Retractions: increased
effort of to move air into
lungs
Nasal flaring: effort to
increase ventilationand
oxygenation = hypoxia

Combining Appearance and

Effort of Breathing

Normal appearance + increased effort of

breathing = Respiratory distress

Abnormal appearance + increased effort of

breathing = Early respiratory failure

Abnormal appearance + decreased effort of

breathing = Late respiratory failure

Circulation of Skin

When cardiac output is inadequate, the body reduces perfusion of blood

from the non essential organs ie. Skin to the essential organs ie. Brain,
liver, kidneys.
Pallor is an early sign of shock. Late signs are mottling and cyanosis, which
signify a loss of compensatory mechanisms.
# Cold may give false positive skin signs like mottling and cyanosis.

Primary Survey
Airway
Breathing
Circulation

Airway
Abnormal

breath sounds indicate ANY

upper or lower airway obstructions.
Head Tilt chin lift maneuvre in children
with no neck or head trauma. Jaw
thrust otherwise.
Intubate if indicated.

Breathing
Rapid

rates may be due to anxiety, pain or high fever.

Normal rates may be due to fatigue from breathing
rapidly
Very rapid (>60 breaths/min: any age) with abnormal
appearance and retractions may indicate respiratory
distress or failure.
Abnormally slow indicate respiratory failure
Watch out:
< 20/min for child < 2 years old or
< 10/min for child > 2 years old.
Through ETT: 100% oxygen at a rate of 12 20
breaths/min, using tidal volume necessary for adequate
chest rise and relieve cyanosis.

Circulation
Children

in compensated shock are

tachypnoiec.
Pulse and Capillary refill time
Blood pressure: low BP in
decompensated shock, normal BP in
compensated shock.
Heart rate:
Inverse with age
May be due to hypoxia or low tissue

perfusion or due to fever, anxiety or pain

Shock
Shock
Hypovole
mic Shock

Cardiogeni
c Shock

Distributiv
e Shock

Traumatic
Shock

Neurogeni
c Shock

Anaphylac
tic Shock

Septicemic
Shock

Hypovolemic shock
Loss

of blood (external/internal)
Loss of plasma (burns)
Loss of fluids (vomiting, diarrhea,
sweating)
Traumatic shock: associated with
neurogenic shock; severe pain
inhibits vasomotor center

Cardiogenic Shock
Failure

of the heart as an efficient

pump to maintain cardiac output
Myocardial infarction
Arrythmia
Valvular disorder

Obstructive Shock
Obstruction

of diastolic filling of the

heart
Pulmonary embolism
Cardiac tamponade
Tension pneumothorax

Distributive Shock
Due

to massive exudation of plasma from blood

vessels to the interstitial spaces.
Neurogenic shock: due to marked reduction in
sympathetic vasomotor tone (deep GA, spinal
anesthesia, spinal injury, brain concussion)
Anaphylactic shock: reduced TPR due to
release of histamine. Vasodilation and increased
capillary permeability leading to excessive
exudation
Septicemic shock: bacterial toxins that produce
vasodilation. Acts systemically by stimulation
cellular metabolism and produce fever.

Cushings Reflex
Cerebral

Perfusion Pressure = CPP

Intracranial Pressure = ICP
Mean Arterial Pressure = MAP
CPP = MAP ICP
Cardiovascular receptors: Carotid
and aortic sinus (Baroreceptors)

Cushing Reflex
Raised
ICP>MAP

Cerebral
Ischaemia

Sympathetic
activation

Heart rate
increased +
peripheral
vasoconstrictio
n

Reflex
bradycardia

Parasympatheti
c response to
reduce heart
rate

Cerebral
perfusion
maintained +
baroreceptor
reflex activated

Systemic Blood
Pressure
increased

Second Stage
High ICP,
brainstem
distortion

Third Stage

Abnormal
breathing/
apnea

First Stage

Triage
System

Triage System at UMMC

Primary

Triage

Proactive triage: outside A&E

Static Triage: counter

Secondary

Triage

Vital signs assesment

First aid and initial treatment

Definitive

Triage

Triage and rapid sequence examination

at various zones of patient management

Triage Zones
Red

Zone; T1
Life threatening (ABCD problems)
Limb threatening
Time Critical (Thrombolytic Therapy)
Yellow Zone; T2
May progress to life/limb threatening
conditions or morbidity if not treated in 30
mins.
Relief of severe pain
In a trolley
Green Zone; G1, G2, G3, G4

G1, Fast-track
Senior

citizen >65 years old

Acute back or flank pain, Score <4
OSCC case: INSAN, SCAN
Psychotic patient
Suicidal patient
Jaw dislocation
PV bleed, haemodynamically stable

Green Zone
G2
Patients requiring initial management or

first aid before seeing a doctor

G3
Patients who can wait

G4
Patients who can be seen outpatient
RM 50

Resuscitation
Focused

on correcting identified
abnormalities in oxygenation and
perfusion and preventing further
deterioration.
Oxygen supplementation: improve
oxygen saturation
Circulation: fluid bolus with isotonic
crystalloids (normal saline, lactated
Ringer solution) 10-20 mL/kg.

 Vasoactive

substances:

Hypovolemic shock and distributive

shock: druges that increase systemic

vascular resistance (-agonist activity
like epinephrine or norepinephrine)
Cardiogenic shock: chronotrophic drugs
(epinephrine, norepinephrine, dopamine)
or afterload reduction (dobutamine,
nitroprusside)

 Vasoactive

substances:

Hypovolemic shock and distributive

shock: druges that increase systemic

vascular resistance (-agonist activity
like epinephrine or norepinephrine)
Cardiogenic shock: chronotrophic drugs
(epinephrine, norepinephrine, dopamine)
or afterload reduction (dobutamine,
nitroprusside)

DISCLAIMER
The following case scenario was taken
from
http://www.hawaii.edu/medicine/pedi
atrics/pedtext/s18c03.html

Case 1
An ambulance brings a 15 month old boy
to A&E with a seizure a/w fever. He has
been in good health except for a high
fever that developed today to about 39.440.0 C.
His mother gave him a small dose of
acetaminophen. About 20 minutes ago
when the mother was checking up on her
child, she noticed shaking of the arms and
legs and his eyes had a blank stare. This
went on for what seemed like 5 minutes.

She called 911 and an ambulance was

dispatched. He has been ill with a high
fever today and a slight cough and mild
nasal congestion. Just prior to the seizure,
he was playing with some toys.
There is no vomiting, diarrhea, or rash
PMHx is unremarkable.
FHx is significant for an uncle who has
epilepsy.

Physical Examination
Vital signs:
T: 39.8 C
PR: 165 bpm
RR: 30 bpm
BP: 90/60 mmHg
O2 sat 100% on RA.

 He

is clingy, alert to his surroundings, and otherwise is

in no distress. His mother appears anxious and there
appears to be good bonding between her and her
child.
Skin is without bruising or neurocutaneous stigmata.
Anterior fontanelle is closed.
Pupils are equal and reactive. The red reflex is present
bilaterally. There is no sunsetting of the eyes.
Tympanic membranes are normal. His mouth exam
shows moist mucosa without erythema.
The Brudzinski and Kernig signs are difficult to assess.
Respirations are regular. Neurologically, he moves
both arms and legs equally. His tone appears normal.
The rest of the examination is normal.

Questions
1. At what ages do febrile seizures occur? How
common is this problem?
2. What are the differences between simple and
complex febrile seizures? Why is it important to
know this distinction (think of recurrence risk of
febrile seizures, development of epilepsy, and
work-up)?
3. A febrile seizure is a diagnosis of exclusion. What
other diagnoses should be considered in a child
with fever and seizures?
4. Who should be strongly considered to receive a
lumbar puncture?

5. Most patients with febrile seizures can be

discharged home. What are indications for a
child who should be hospitalized for overnight
observation?
6. Although diazepam (Valium) can be used to
prevent recurrences when given at the start
of a febrile illness, what are its
disadvantages?
7. A key part to management is reassurance.
What are the ways parents should be
reassured and educated?

Question 1
The

age at which febrile seizures

most frequently occur is in the
second year of life, and they occur
slightly more commonly in boys than
in girls.

Question 2
Febrile seizures can be divided into two

types: simple and complex.

Simple

Complex

Duration < 15 minutes

Duration >15 minutes

Generalized seizure

Focal seizure

Does not recur during

the febrile episode

>1 seizure during the

febrile episode
Residual neurological
deficit post-ictally (i.e.
Todds paralysis)

Question 3
DDX

Differential
Infection
Trauma

Metabolic

Others

Example
meningitis/ encephalitis
UTI
brain lesion (in head trauma,
intracranial bleed)
shaken baby syndrome

hypoglycemia
hypocalcemia / hypomagnesemia
hypo- or hypernatremia
poisons/toxins/drugs
hypoxic ischemic insult

Question 4
Must

be done if (unless contraindicated)

Any signs of intracranial infection
Prior antibiotic therapy
Persistent lethargy and not fully interactive 6
hours after the seizure
Strongly recommended if
Age < 12 months old
1st complex febrile convulsion
In district hospital w/o peadiatrician
Parents have a problem bringing the child in
again if deterioration at home

Question 5
Indications:
1. To exclude intracranial pathology
especially infection
2. Fear of recurrent fits
3. To investigate and treat the cause
of fever besides meningitis or
encephalitis
4. To allay parental anxiety, especially
if they are staying far from the
hospital

Question 6
Disadvantages:
1. Lethargy
2. Drowsiness
3. Ataxia
4. Masking of CNS infection

Question 7
Prognosis
in remain
febrile seizures
Febrile
seizures
a benign

Febrile
convulsions are benign events with
condition
excellent prognosis
3-4% of population have febrile convulsions
30% recurrence after 1st attack
48% recurrence after 2nd attack
2-7 % develop subsequent afebrile seizure or
epilepsy
no evidence of permanent neurological
deficits following febrile convulsions or even
febrile status epilepticus
no deaths were reported from simple febrile
convulsion

Control fever:
1. Take off clothing and tepid sponging
2. Antipyretic i.e. syrup or rectal
Paracetamol 15mg/kg 6 hourly
*antipyretic is indicated for patients
comfort, but has not been shown to
reduce the recurrence rate of febrile
convulsion.

First aid measures

1.
2.
3.
4.
5.
6.
7.

Keep calm and note time of onset of fit

Loosen childs clothing, esp. around the neck
Place child in the left lateral position with the
head lower than the body
Wipe and vomitus or secretion from the
mouth
Do no insert any object into the mouth even
if the teeth are clenched
Do not give any fluids or drugs orally
Stay near the child until the convulsion is
over and comfort the child as he/she is
recovering

Question

a)
b)
c)
d)
e)

5 month old child presents to the emergency

room with generalized tonic clonic seizure activity
of about 30-min duration that stops upon
administration of lorazepam. The most helpful
information to gather from the mother would be:
Whether the child has had congestion without
fever for the past 3 days
Whether the child is developmentally normal, as
are his siblings
Whether the mother has been diluting the
infants formula to make it last longer
The number of pets at home
Whether the mother works as a secretary in an
energy trading firm

SCENARIO 2
A

8-year old girl

Fever , RN , cough 4 days
Abrupt onset of high grade fever + chills
Fever reduced by Paracetamol but recurred
Generalised rashes
Abdominal pain , vomiting 1-2 times and diarrhea 45 times per day
Reduced appetite and reduced activity
No recent travel history and eating outside food
Past medical hx bronchial asthma (well-controlled)
No drug or food allergy

Differential diagnosis
Dengue
Acute
URTI

fever

gastroenteritis

secondary to bronchial asthma

What to look for in physical

examination
Assess

mental state ans GCS score

Assess hydration status
Assess haemodynamic status
skin colour
Cold/warm extremities
CRT (normal <2sec)
pulse rate, pulse volume, blood
pressure, pulse pressure

 Look

out for tachypnoea/acidotic

breathing/pleural effusion
Check for abdominal
tenderness/hepatomegaly/ascites
Examine for bleeding manifestation
bleeding mucosal
Tourniquest test ( +ve when 20or more
petechiae in 2.5cm (1 inch) of square.
Repeat test if ve or if there is no
bleeding manifestation

MILD

MODERATE

SEVERE

BODY WEIGHT
LOSS
GENERAL
APPEARANCE

<5%

5-10%

>10%

THIRST

THIRSTY,RESTLESS
OR LETHARGIC

DROWSY,COLD,SWE
ATING

TEARS

PRESENT

REDUCED/ABSENT

ABSENT

TISSUE
ELASTICITY
MUCOUS
MEMBRANE
CAPILLARY REFILL
TIME
BLOOD PRESSURE

PRESENT

REDUCED/ABSENT

ABSENT

DRY

DRY

VERY DRY

NORMAL

PROLONGED(>2s)

NORMAL

NORMAL/PROLONGE
D
NORMAL/LOW

URINARY OUTPUT

REDUCED

REDUCED

PULSE RATE

NORMAL

RAPID

EYES

NORMAL OR SUNKEN SUNKEN

GROSSLY SUNKEN

ANTERIOR
FRONTANELLE

FLAT

VERY SUNKEN

SUNKEN

LOW/UNRECORDABL
E
MARKED OLIGURIA
RAPID,WEAK,MAY
IMPALPABLE

Investigations
Full

blood count
- WCC : high indicate bacterial infection
:low indicate dengue fever
-platelet :low dengue fever
-haematocrit : high dengue fever ( can also be low
after hydration)
BUSE
- to see the hydration status and any electrolyte
imbalance
Liver function test
- AST / ALT increase in dengue fever
ABG , coagulation profile
Dengue serology

Management (dengue
fever)
Whether

to admit or go back home

If admission not indicated, daily or frequent
f/up is necessaryespecially from day 3 illness
untill patient becomes afebrile for at least 2448h
Criteria for admission
-sx: warning signs, bleeding manifestations,
inability to tolerate fluids orally,reduced urine
output,seizure
-signs: dehydration, shock, bleeding, any
organ failure
-rising HCT accompanied by thrombocytopenia

 Febrile

phase

rest
antipyretic
no aspirin (why?)
no antibiotic is necessary
ORS / IV therapy
food should be given according to
appetite
Platelet <100000 & rise in Hct of 20%
-significant plasma loss & indicates
the need for IV fluid therapy

 If

vital signs still not stable IV fluid

colloid solution (if Hct increasing)
or blood transfusion (if Hct
decreasing)
If Hct still decreasing internal
bleeding should be suspected
Oxygen should be given to all
patients in shock

Criteria for discharging

patient
Absence

of fever for 24h without the

use of antipyretic and return of
appetite
Visible improvement in clinical
picture
Stable Hct
3 days after recovery from shock
Platelet count >50000& rising
No respiratory distress

QUIZ
Dengue

fever :a) What kind of rash can you see in

dengue
b) List the warning signs

ANSWER
A)

isles of white in the sea of red &

blanching
B) intense abdominal pain
- persistent vomiting
-clinical fluid accumulation
-mucosal bleed
-lethargy, restlessness
-liver enlargement >2cm
-lab : increase Hct with concurrent
rapid decrease in Plt count.

Scenario 3
A 3 year old Malay boy presents to ED
by his parents with 2 days history of
coughing. He has low grade fever, rapid
breathing and audible wheeze.

DDx
Common

Asthma, URTI, pneumonia, bronchiolitis,

viral wheeze
Less

common but 'important not to

miss'
Aspiration of foreign body, whooping cough

Uncommon

Congenital lung abnormality, congenital

cardiovascular abnormality

History

3rd attack of cough and wheeze, no hospitalization before, attack

once yearly

Antenatal history was normal, SVD, full term

No developmental delay, Immunization is up to date

History of eczema & allergic rhinitis NKD/FA

Not compliance to the inhaler with spacer

Negative family history

Positive sick contact at day care

There is cat at home

Father is a smoker and smokes even at home

Rapid Triage Assessment

RR:

44 breaths/min (Tachypnoea)

HR:

140 bpm (Tachycardia)

SpO2:

90% (Low)

Temperature:

37.8 C (Low-grade)

Physical Examination
General

examination: alert, looks agitated,

respiratory distress (tachypnea, nasal flaring, use
of accessory muscles), injected pharynx, no
cyanosis or clubbing

Respiratory

system: audible wheeze, subcostal

and intercostal recession, hyperresonance,
generalized rhonchi

Absence
Other

of liver dullness and cardiac dullness.

systemic examinations were normal.

Investigation
O2

saturation -90%
Peak Expiratory Flow Rate(PEFR) not done as the child is under 5y/o
CXR and blood investigationsnotroutinely indicated
Monitor electrolyte (hypoK is
complication of 2-agonist)

Management
Pharmacological method:
Reassure the child and parents
Give oxygen via mask
Short-acting 2-agonist(SABA),
salbutamol via nebulizer
Oral steroid, Prednisolone 1-2mg/kg
(14 mg) is started and continues
SABA (patients weight: 7kg)

EVERE ASTHMA EXACERBATION!

The patient improves with the treatment

given. He has no more dyspnea, audible
wheeze and his lung is clear. He is then
discharged home.

Non-pharmacological method:
Educate the parents and child about
importance of compliance to inhaler,
allergen avoidance, smoking cessation as
well as Influenza and pneumococcal
vaccination.

Quizzes

(True/False with
negative marking)
1)

Asthma usually leads to permanent damage of the lungs if not

treated.

2)

Childrens asthma is commonly caused by allergy.

3)

Child with moderate asthma exacerbation should use nebulizer

instead of using Aerochamber.

4)

Antibiotics are useful in treating asthma.

5)

Inhaled steroids have severe side effects.

Answers
1)

Asthma usually leads to permanent damage of the lungs if not treated.

(T)

2)

Childrens asthma is commonly caused by allergy. (T)

3)

Child with moderate asthma exacerbation should use nebulizer instead

of using Aerochamber. (F)

4)

Antibiotics are necessary in treating asthma. (F)

5)

Inhaled steroids have severe side effects. (F)

SCENARIO 4
2

weeks-old, Chinese baby boy

Increased work of breathing
Poor feeding
Irritability
X 2/7
Sudden onset

DDX
Cardiac

- congenital heart disease,

arrhythmia
Diet - coffee,drugs
Psychological stress, anxiety
Other- electrolyte imbalance, febrile,
hyperthyroidism, dehydration

HISTORY
SVD,

no complications
NKD/FA
No significant past medical history
Not on any medication
Family history negative

VITAL SIGNS
Temperature:
SpO2
PR
RR
BP

:
:
:
:

36 C

92%
240 bpm
48 bpm
normotensive

PHYSICAL
EXAMINATIONS
General appearance : pale, irritable, alert,
mild mottling, no cyanosis
A : patent
B :clear breath sounds, no retractions
C : strong pulses, CRT<2 sec
S1, S2 heard, no gallop rhythm/murmur
No evidence of trauma
No hepatosplenomegaly

INVESTIGATION
ECG

MANAGEMENT
NON-PHARMACOLOGICAL

Manouvre that enhances vagal activity

Diving reflex
One-sided carotid sinus massage

 PHARMALOGICAL

Acute : Adenosine
Chronic : Digoxin, B-blocker

IF hypotensive, poor perfusion??

Quizzes

What is the common tachyarrthmia in

paediatrics?

What is the common presentation in

1)neonates?
2)older children?

How do you manage it?

non-pharmacology
pharmacology

Answers

What is the common tachyarrthmia in

paediatrics? SVT

What is the common presentation in

1)neonates? (poor feeding, restlessness, irritability)
2)older children? (palpitation, SOB, chest
discomfort)

How do you manage SVT?

non-pharmacology (diving reflex, valsava
maneuvre)
Pharmacology (adenosine)

Case Scenario 5
-A 5-month-old infant arrives at the emergency center
strapped to a backboard with a cervical collar in place.
-The father was holding him in his lap in the front passenger
seat of their car when the driver lost control and crashed.
The child was ejected from the car through the windshield.
-He loss conscious after the accident. He had a self-limited,
2-minute generalized tonic-clonic seizure when transfer to
the hospital.
*ref: Eugene CT, Robert JY, Rebecca GG, et al. Case Files: Pediatrics. The McGraw- Hill
Companies, Inc. 3rd edition, 2009. pg321-328.

Approach:
Rapid primary survey
Resuscitation
Detailed secondary
survey
Definitive care

1. Rapid Primary Survey

resuscitation
Airway

maintenance with cervical

spine control
Breathing
Circulation
Disability (GCS)
Exposure and Environment
(temperature control)

1. Rapid Primary Survey

resuscitation
Airway
Breath spontaneously
Respiratory rate = 50 bpm.
SpO2 = 90%
GCS= 6 (opens eyes to pain, moans to pain,
and demonstrates abnormal extension)
What to do?
Open airway jaw thrust
Endotracheal intubation

 Indication

for intubation:

Unable to protect airway (GCS < 8;

airway trauma)
Inadequate oxygenation with
spontaneous respiration (SpO2<90% or
rising pCO2)
Profound shock
Anticipatory: in trauma, overdose,
congestive heart failure, asthma, COPD,
smoke inhalation injury

Breathing
Look for chest movement, colour,
nasal flaring
Listen for breath sound
Feel for tracheal shift, chest wall for
crepitus, flail segment, sucking chest
wounds
His SpO2 improved to 95% after
intubation.
Symmetry breath sounds and

Circulation
Pulse rate= 180 bpm
Respi rate= 50 bpm
BP= 90/70
CRT = 5 sec
Is he in shock?
Yes. Compensated shock
Apply pressure to stop bleeding
Insert two large venous cannulae or
intraosseous infusion in the tibia
What to give?
Crystalloid (20 ml/kg)

Disability
GCS = 6
He has several facial and scalp lacerations.
His anterior fontanelle is bulging, his sutures are
slightly separated
What is the most likely etiology for this childs
altered mental status?
Simple cerebral concussion or increased
intracranial pressure due to subdural hematomas
This child is younger than 1 year, and subdural
hematomas are more common in this age group;
epidural hematomas are more common in older
children.
Seizures are more common with subdural

Eyes

GCS (4-15 yo)

Childrens coma scale

(<4 yo)

Open spontaneously

Open spontaneously

Verbal command

React to speech

Pain

Motor

Verbal

React to pain

Score

No response

No response

Obeys

Spontaneous

Localises pain

Localises pain

Withdraw

Withdraw

Abnormal flexion

Abnormal flexion

Abnormal extension

Abnormal extension

No response

No response

Oriented and converses

Smile, orientated to sounds,

follow object, interact

Disoriented and converses

Fewer than usual words,

spontaneous irritable cry

Inappropriate words

Cries only to pain

Incomprehensive words

Moans to pain

Exposure
Remove all clothing
Assess entire body for injury
Logroll to examine the back
Digital rectal examination
Avoid hypothermia

2. Detailed secondary
survey
History
SAMPLE
Sign and symptom LOC and seizures
Allergy
Medication
Past medical history
Last meal
Events related to injury - ejected
through the windshield

Physical examination
Head to toe
Pupils left sided dilated non-reactive
pupils
Funduscopic examination reveals bilateral
retinal hemorrhages.
FAST (Focused assessment with
sonography for trauma) reveals no
abnormalities
Fracture of left humerus
What will you order?
CT-brain, X-Ray (C-spine, chest, pelvis, left
humerus)

CT- brain
Left

sided
subdural
haematoma
Note the high
signal intensity
of acute blood
and the (mild)
midline shift of
the ventricles.

3. Definitive care
Signs of ICP
Deteriorating
LOC
Deteriorating
respiratory
pattern
Cushing
reflex (high
BP, low HR)
Lateralizing
CNS signs
Seizures
Nausea and
vomitting,
headache

Treatment of
ICP
Elevated
head of bed
Mannitol
Hyperventilati
on
Paralyzing /
sedating
agent

Disposition
Neurosurgical
ICU

Quiz (Choose the best

answer)
A 17-year-old adolescent female is brought to the hospital after a
motor vehicle crash. She and her boyfriend had been drinking beer and
were on their way home when she lost control of the car and hit the side
wall of the local police station. She reportedly had a brief loss of
consciousness but currently is oriented to name, place, and time. She
responds appropriately to your questions. While waiting for her cervical
spine series, she vomits and lapses into unconsciousness. She becomes
bradycardic and develops irregular respirations. Which of the following
brain injuries is most likely in this case?
A. Subdural hemorrhage
B. Epidural hemorrhage
C. Intraventricular hemorrhage
D. Post-traumatic epilepsy
E. Concussion

Answer
A 17-year-old adolescent female is brought to the hospital after a motor
vehicle crash. She and her boyfriend had been drinking beer and were on
their way home when she lost control of the car and hit the side wall of
the local police station. She reportedly had a brief loss of consciousness
but currently is oriented to name, place, and time. She responds
appropriately to your questions. While waiting for her cervical spine
series, she vomits and lapses into unconsciousness. She becomes
bradycardic and develops irregular respirations. Which of the following
brain injuries is most likely in this case?
A. Subdural hemorrhage
B. Epidural hemorrhage
C. Intraventricular hemorrhage
D. Post-traumatic epilepsy
E. Concussion

Overview
Paediatric

Assessment Triangle:
Appearance, Breathing, Circulation
Primary Survey (ABCD)
Triage System (T1,T2,T3)
Resuscitation:
Airway: advanced airway
Breathing: Supplementary Oxygen
Circulations: Bolus fluids, Types of shock