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Managing pediatric emergencies: No small matter



Here's how to handle some common emergencies involving school-age children.

Use these guidelines from an experienced school nurse to shepherd a child through a crisis.

Celina M. Siwula is a school nurse at Kathryn D. Markley Elementary School in Malvern, Pa.

CHILDREN CAN GET HURT anywhere, but because they spend so much time at school, the school nurse is often the first responder to an injury or emergency. Even if you're not a school nurse, these practical guidelines can help you deal with four common pediatric emergencies calmly and efficiently.

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Fixing fractures

Nine-year-old Peter fell from the top of the monkey bars while playing on a school playground. Because you're on duty as the school nurse, a playground aide calls you for help. You tell her not to move Peter, get your emergency response bag, and head for the playground.

When you arrive, you find Peter lying on the ground but awake and alert. You ask him what happened and where he's hurt. He tells you he slipped on the monkey bars and fell on his back, landing on his right arm, which is still under his back. You ask him if it hurts to move his arm, and he says that he tried to sit up and move his arm but couldn't move it at all. Quickly assess Peter from head to toe, looking for bleeding or deformities, checking sensation in all extremities, and assessing his ability to move his arms and legs. You don't suspect a head or neck injury, so help him sit up so you can assess his arm.

Peter's right forearm is deformed in a Z shape, so you suspect a displaced fracture. You check for warmth and sensation of his right hand and fingers, check for a distal pulse, then gently splint the forearm above and below the injury without correcting the deformity. (If you didn't have your emergency bag, you could improvise splints with whatever's handy, such as folded newspapers or an umbrella.) Apply an ice pack to the injured area for 20 to 30 minutes at a time to help reduce pain and swelling. Place a towel around the ice pack or between the pack and the skin so that the ice doesn't touch the skin. Stabilize and support the injured arm, using a sling if feasible, to prevent further movement and damage. Recheck Peter's arm for warmth, sensation, and pulses after splinting, and loosen the splint if necessary.

Peter isn't in shock and can walk, so you help him into your office and have him rest while you contact his family. If ice wasn't applied at the scene, apply it to the fracture now. Because he may need surgery to fix the fracture, keep him N.P.O.

When his parents arrive, you give them details of the injury and your treatment and advise them to take Peter to the emergency department.

Fractures are one of the most common emergencies involving school-age children. Your priorities are to immobilize the extremity to prevent pain and further injury and refer the patient to the emergency department for further treatment. If you suspect leg, pelvic, or spinal fractures or a head injury, don't move him unless leaving him where he is would be dangerous. If he's not breathing, use a jaw-thrust maneuver (instead of a head tilt–chin lift) before starting rescue breathing, because of possible trauma to the head or neck.

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Seeing to eye injuries

Alicia, 7, comes to your office crying, with her hand over her right eye. She says she fell into the loose fill under the playground equipment at recess and something's in her eye. Telling her not to rub her eye, you lead her to a cot and ask her to lie down.

Make sure the room is well-lighted. To inspect Alicia's eye, ask her to look up. Gently pull down her lower eyelid to expose the sclera and conjunctiva. You see several small pieces of mulch resting on her inner-lower lid. To remove these, use a cotton swab and gently roll it over the mulch, away from the eyeball. The mulch should adhere to the cotton swab.

You'll need to evert the upper eyelid to make sure you removed all foreign bodies from Alicia's eye. To inspect her upper lid, ask Alicia to look down. Next, raise her upper lid slightly so that her eyelashes protrude. Then grasp her upper eyelashes and pull them gently down and outward. With your other hand, place a tongue blade at least 1/2 inch above the outer part of the eyelid. Push down on the tongue blade as you gently raise the edge of the lid and turn the eyelid inside out. Don't push on the eyeball. Hold the upper lashes securely against Alicia's eyebrow with your thumb and carefully inspect the superior palpebral conjunctiva. If you see a piece of mulch on Alicia's upper eyelid, gently remove it with a cotton swab as you did with her lower lid. Be careful not to touch the cornea with the cotton swab, which could cause an abrasion.

Afterward, grasp the upper eyelashes and gently pull them forward, then ask Alicia to look up; her eyelid will return to its normal position.

To help prevent irritation, rinse Alicia's eye with 0.9% sodium chloride solution using an eyewash bottle. You may instill one to two drops of a rinsing eyedrop that mimics natural tears to soothe and further rinse her eye. Apply a cool compress, and tell Alicia not to touch or rub her eye. Recheck it in an hour and check her visual acuity by having her read the letters on a Snellen eye chart or a special handheld card. If she continues to have pain, develops vision problems, or says her eye feels as if something's still in it, refer her to an eye-care specialist. Notify her parents about the incident and the care you provided, and tell them what to do if problems develop at home.

Never attempt to remove a foreign object that's embedded in any part of the eye. In that case, you'd cover the affected eye with gauze pads and crisscrossed adhesive tape. Or, put a small (3- or 4-ounce) paper cup over the eye and tape it in place. Covering both eyes minimizes eye movement but can make some children feel panicky. Continuously reassure the child, and don't leave her unattended. Refer her to an eye-care specialist immediately.

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Responding to an asthma attack

Most children who have asthma keep a rescue medication (typically a short-acting bronchodilator such as albuterol, delivered by metered-dose inhaler [MDI]) in the school nurse's office.

If you're the school nurse, keep a peak expiratory flow (PEF) meter with disposable mouthpieces in your office, along with a record of the baseline PEF readings for the children who have asthma. Measure baseline PEF when the child is free of asthma symptoms and isn't in respiratory distress.

If the child uses the three-zone asthma management system, follow the treatment plan established by the child's health care provider, based on which zone the child's PEF falls in. The green zone is 80% to 100% of the child's personal best reading, the yellow zone is 50% to 80% of the personal best reading, and the red zone is anything below 50% of his personal best.

Say, for example, that 10-year-old Jake, who has a history of asthma, comes to see you after recess. His breathing is somewhat labored and he's pale. You auscultate diffuse expiratory wheezing throughout all lung fields bilaterally.

Remember that most children with asthma cough before they start to wheeze and become short of breath. In some cases, however, you may not hear wheezing, al-though the child is coughing and short of breath.

Jake's albuterol MDI and albu-terol for nebulizer treatments are in your office. But before providing his medication, you ask him to remain standing while you measure his PEF. Have him breathe in as deeply as he can, place his lips around the mouthpiece to create a tight seal, then blow out as hard and as fast as he can. Have him do this three times, and record the highest measurement.

Jake's PEF is in his yellow or caution zone, indicating moderate asthma symptoms. Have him sit down while you set up an albuterol nebulizer treatment. Auscultating his lungs after the treatment, you hear very mild expiratory wheezing only in the right lower lobe. Jake denies any difficulty breathing and his color is good. You measure his PEF again after 5 minutes; it's in the low green zone. Keep Jake in your suite for another 20 minutes and have him use the MDI. This time when you auscultate his lungs, they're clear and his PEF is back in the green zone. Now that he's stable, you can send him back to his class.

Notify Jake's parents and teacher, and ask the teacher to have Jake return to you if asthma symptoms recur. Document your interventions in Jake's record. If his asthma attack had been more severe, you'd have called 911.

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Averting anaphylaxis

Anaphylaxis, a life-threatening hypersensitivity reaction to a previously encountered allergen, can occur in people with no history of allergic reactions. Symptoms, which generally occur within 15 minutes of exposure to the allergen, can include sudden nasal congestion; itchy eyes; cool, pale skin; sweating; swelling of the lips, tongue, or throat; hives; pruritus; weakness; severe anxiety; confusion; dyspnea; tachycardia; hypotension; and loss of consciousness. Anaphylaxis is always an emergency requiring immediate administration of epinephrine and a call for the emergency medical system (EMS).

Although many substances can precipitate anaphylaxis, the most common triggers are an insect bite or sting, certain foods (such as peanuts or seafood), or medications. A patient who's had a mild reaction to a substance could have a more severe reaction the next time he's exposed to that substance.

If the child's parents know he's at risk for an anaphylactic reaction, they must have an emergency treatment plan in place and provide you with emergency medications, typically two EpiPens and liquid diphenhydramine, unless contraindicated. Generally, children under 66 pounds (30 kg) use the EpiPen Jr.; those over 66 pounds can use adult EpiPens. The liquid diphenhydramine should be labeled with the dosage appropriate for the child's weight.

Brett, 8, is severely allergic to peanuts. At lunchtime, he tells you that his lips feel “tingly” after taking a bite of a cookie that a classmate had offered him. You see that his lips are swollen and he's becoming very apprehensive. Immediately administer one of his EpiPens. If an oral antihistamine is part of his emergency kit, give it if he's alert and can swallow. Have the school office call 911 and Brett's parents. Reassure Brett and try to keep him calm; anxiety can worsen his respiratory status. If his symptoms return before the EMS team arrives, administer another EpiPen dose immediately.

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Small patients, big rewards

Appropriate and quick assessments and interventions by the school nurse can help a child in need and may be able to prevent complications and death.

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American School Health Association

National Association of School Nurses

Last accessed on January 7, 2003.

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        Wolfe, L., and Selekman, J.: “School Nurses: What It Was and What It Is,” Pediatric Nursing, 28(4):403–407, July-August 2002.
          © 2003 Lippincott Williams & Wilkins, Inc.