What Are THE Major Pediatric ER Points

LoveMyBugs, BSN, CNA, RN · Aug 10, 2010

I am a new grad not a lot of advice to give, except I found the PALS class very informative, I really learned a lot from it. Kids compenstate for a lot longer than adults and then crash a lot faster than adults

Does your hospital have a pediatric section? The current hospital I work for does not have peds so if someone is needing to be admitted then the are transfered out. The pediatric hospital in my area has there own transport team for the very critical pt or the go by regular ambulance.

ObtundedRN, BSN, RN · Aug 10, 2010

Perhaps there is some type of ped's continueing education class you could go to? Or maybe go to a few meetings for a pediatric nurses association? I've never worked with peds as a nurse, but I have had plenty working in EMS. How you interact with them will depend on their age. If you have your own children, it will help alot. I think your biggest adjustment will be learning to be an ER nurse. I'm not sure how often you will get peds patients, but you'll get comfortable with them over time. As for clinical knowledge, textbooks may be your best place to start.

wooh, BSN, RN · Aug 10, 2010

Peds is all about the airway. And if they look a little bit bad, fix them before they look a lot bad. You just can't let a kid go as long as an adult without fixing them. They don't have the reserves that an adult has.

That said, don't do more than you have to. You have a kid come in with what I'd consider mild asthma (bad enough to come to the ER, not so bad they're going to get admitted), if you try to stick and IV in and get labs, you can make them so mad that it will turn into bad asthma.

So be aggressive, but judicious.

FlyingScot, RN · Aug 10, 2010

The Emergency Nurses Association (ENA) offers a course called Emergency Nursing Pediatric Course (ENPC). This is something that should be mandatory for any ER nurse that works in a department without a dedicated peds ER. It covers much more than PALS and is worth every penny.

Here are my thoughts FWIW:

1. Kids respiratory arrest before their hearts stop. Fix the respiratory issue and you will have prevented disaster.

2. A mottled kid (especially under age 2) is a kid that is going to do something ugly...pay attention.

3. Check capillary refill centrally (ie on the sternum) rather than in the extremities.

4. Scalp veins can be life savers even if they look scary.

5. When assessing a kid do not touch the owie part first. If you do, it will get them screaming and you will not be able to figure out if they are hurt anywhere else.

6. Nursemaids elbow really, really hurts. Do not make them wait in triage. Grab the first mid-level provider or doc

that you see and have them reduce it immediately. Save the x-rays for later. Best way to assess if it's fixed,

have mom hold kiddo on lap and restrain good arm. Hand child a popsicle. If they reach for it with their bad

arm you're golden.

That's it for now. I'm sure I will come up with more.

Editorial Team / Moderator · Aug 10, 2010

Second that -- ENPC and PALS, for sure. Peds aren't little adults ... it's a good idea to know the basic vital sign parameters by age. It's tough to remember them all, always, but a general idea is good. Bradycardia in a child -- VERY BAD. Hypotension -- VERY BAD. Both are a sign of something VERY BAD about to happen!

The pediatric assessment triangle is a great "quick look" type of assessment -- it can give you that immediate sense of sick vs. not sick. Check this out, this is spiffy:

http://www.health.state.ny.us/nysdoh/ems/pdf/pediatricreferencecard-04.pdf

kids · Aug 10, 2010

Kids have very little reserve and they don't go down slowly like adults do, they squeeze every bit out they can and crash hard and fast. If you have a kiddo who doesn't feel right in your gut, trust your gut.

See if you can find one and ENPC class put on by the ENA. It covers different material and doesn't take the place of PALS and covers a lot of more general Peds urgent/emergent stuff. http://www.ena.org/statecouncils/states/Pages/StateLanding.aspx

Redhead28 · Aug 11, 2010

Airway, Airway, Airway. Kids respiratory arrest. Think O2. Only if they have a congenital heart, is it usually heart. Kids compensate until the end, will only drop sats, bp, heart rate when it is very bad. Listen to the parents, if they say they are not acting like themselves listen. Approach slowly. ENPC/PALS should be mandatory for all ER nurses. IV's are all about the holding, get help. Pediatric RN's travel in packs.

cjcsoon2bnp, MSN, RN, NP · Aug 11, 2010

Having worked in a strictly Peds. ED I find it really helpful when you approach young children to do an exam if you have some sort of toy or distracter with you so that they will let you touch them. When I was shopping in Disney World I found these plastic potato chip bag clips that are shaped like Disney things (I use the Mickey Mouse head) and I thought it would be a cool thing to have for work. So I clip it right to my stethoscope and when I go to exam a small child I ask the child to hold it for me while I do the exam. Most children know who Mickey Mouse is and they start to play with it and they don't even care what you do to them and when your done with your exam you ask for it back and wipe it down with an alcohol pad or something. If you have a really tough kid who is more adamant that you can't touch them or they are crying, ask if you can listen to Mom or Dad first and focus on the parent. It usually works out pretty well.

!Chris :specs:

patrice meursault · Aug 15, 2010

Other posters are giving great tips, another aspect to think about is the visitor dynamics are a bit different. Parents can be very tricky to deal with, not only do you have to win over the confidence of the patient but the parents too.

Some can be very demanding and a big PIA, but also remember (especially if the kid is very sick) that they may be experiencing the worst day of their life and they need comfort too. Basically you almost always have two patients when dealing w/ a peds patient.

And along the lines of the previous poster, keep hip to kid's entertainment.

Watch kid's cartoons and shows. I always win kids over w/ my Sponge Bob impersonations.

MikeyBSN · Aug 16, 2010

I agree with all of the above, and I have a few additional practice tips. I would also like to stress PALS and ENPC if you are working in the ED with kids. Breathing is going to be your number one issue with most kids. The first thing I do when I examine a "sick" kids is look at their belly and chest to see how they are breathing. Nasal flaring or retracting is bad news. Here are some additional things:

-Fever in baby under 3 months old is bad news. This is an "emergent" patient.

-Mottled baby is bad

-Watch how a kid walks into triage. Kids with appendicitis will have a waddle-walk and hold their stomach.

-Don't let your sugar guard down just because it's a kid. I can't tell you how many sick, lethargic, or "not eating well" kids I've done an accu-check on and it comes up hypo or hyperglycemia.

-Bradycardia in children is bad news. You will learn this is PALS, but you need to do compressions with bradycardia under 60, even if the kid has a pulse.

-You should get a blood pressure on all kids 6 and over (it drives me crazy when I get a kid from triage who doesn't have a documented blood pressure).

I'll try to think of more later

LilgirlRN, ADN, RN · Aug 16, 2010

Bringing 30 years of ICU experience to the ER! You'll be a godsend! Don't let the pediatric population scare you. I'm going to assume a lot and assume that you are a parent. You know what a sick kid looks like. Trust your judgement, that little voice that tells you if an adult is sick will also tell you that a kid is. Be a little sponge, soak up all you can from your fellow nurses and don't be afraid to ask for help. We have standing orders for treating fever, so we treat it before a seizure can occur. Lots of times parents bring their kid in because of rapid heart rate which almost always fever induced. ENPC is a great course! Take it, then take PALS. Your hospital will probably require PALS but I think you'll get more out of it when you take ENPC 1st. Always, always be honest with kids. If you have to do something unpleasant tell them. I always give them the opportunity to cooperate but sometimes you have wrastle with 'em. I live close to a big city with a Children's hospital. If you have one nearby you can ask to shadow one of their nurses much like student nurses do. If it would make you more comfy in your new role, it can't hurt to ask, the most they can do is say no.