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General Pediatric Assessment Strategies Pediatric Emergencies
± Respiratory Emergencies ± Dehydration
INCLUDING : Identification of Severity of Dehydration INCLUDING : Identification, management and Transportation of the Shocked Paediatric
Intravenous Access and Fluid Management
Newborn (first 6 hours) Neonate (first 28 days) Infant (first year) Toddler (1 to 3 years) Preschooler (3 to 5 years) School age (6 to 12 years) Adolescent (12 to adulthood) .
± In pain ± Frightened ± Guilty
± Frightened ± Guilty ± Exhausted
± Frightened ± May over-empathize
Who has to control situation? .
ventilation adequate to preserve life. cardiac output likely to deteriorate before reaching hospital? C-spine protected? Major fractures immobilized? . CNS function? Cardiac output sufficient to sustain life. CNS function? Oxygenation. ventilation. Oxygenation.
do benefits outweigh risks? If parent is not accompanying child. is history adequate? Transport expeditiously Reassess. Reassess. Reassess . If invasive procedure considered.
breathing . Priorities are similar to adult Greater emphasis on airway.
Limit to essentials Look before you touch .
central cyanosis) Capillary Refill (normal is within 2 seconds) Pulse (too fast. obtunded. normal) . nasal flaring. limp) ±Breathing Respiratory rate (too fast. peripheral cyanosis. no response) Muscle tone (moving. too slow. Initial Assessment (quick assessment that can be done within seconds of arriving on scene) ±Appearance Mental status (alert. not moving. irregular. too slow. irregular) Respiratory effort (use of accessory muscles. crying. grunting) Check breath sounds ±Circulation Skin color (pallor. retractions.
check fontanalles in infants. with pediatrics it is better to do the opposite Why? ± Take a SAMPLE history (use the parents for detailed hx if possible) ± Determine Hx of fever or infection Hx of vomitting or fever and check hydration status (skin turgor. Detailed assessment ± With adults this is typically done head to toe. look for xerosis) Frequency of urination ± Why are these important questions to ask? ± Take vitals and measure pulse oximetry .
± Explain each step in your assessment (³now I¶m going to feel your tummy«´). Why? .) ± Try to invent a game you can play or begin a conversation about something you can talk about for at least several minutes (Batman. ± With younger patients. Detailed assessment (cont. ± With older patients explain why you are doing each step (³I need to make sure your stomach is OK´). toys. etc. school. Sesame Street. avoid separating them from their parents if possible.).
you must report it by calling 0800 55555 . Detailed assessment (cont. ± Be alert for injuries that seem inconsistent with their explanation ± this is usually a sign of child abuse. ± Do NOT condescend.) ± Explain things as simply as possible avoiding technical terminology and jargon. ± Do NOT lie or make promises you cannot be sure to keep. Examples? ± If you suspect child abuse.
Categorize as: ± Stable ± Potential Respiratory Failure or Shock ± Definite Respiratory Failure or Shock ± Cardiopulmonary Failure .
ventilation. Identify. ± Support oxygenation. then correct the Life Threatening abnormalities If not correctable. perfusion ± Transport .
Essential elements ± Proper equipment ± Knowledge of norms Carry chart of norms for reference .
Why is weight a pedi vital sign? ± Determines Drug Administration ± Can help determine severity of dehydration ± Used to calculate fluid replacement \ How do you calculate weight in Paeds? (Age[yrs] x 2) + 8 .
Apical auscultation Peripheral palpation Tachycardia may result from: ± Fear ± Pain ± Fever .
Tachycardia + Quiet. non-febrile patient = Decrease in cardiac output ± Heart rate rises long before BP falls! Bradycardia + Sick child = Premorbid state ± Child < 60 ± Infant <80 .
Proper cuff size ± Width = 2/3 length of upper arm ± Bladder encircles arm without overlap .
Children >1 year old Systolic BP = (Age x 2) + 80 Children >1 year old BP = 70 + 2 x age (in years) .
temperature Capillary refill Do not delay transport to get BP . Hypotension = Late sign of Shock perfusion using: Evaluate ± ± ± ± Level of consciousness Pulse rate Skin color.
Before touching For one full minute Approximate upper limit of normal = (40 Age[yrs]) .
> 60/min = Danger!! Slow = Danger. impending arrest Rapid. unlabored ± Metabolic acidosis ± Shock .
Check by using your thumb against to bottom of the heel (30seconds) Normal < 2 seconds Increase suggests poor perfusion Increases long before BP begins to fall Cold exposure may falsely elevate .
Cold = Paediatric Patient¶s Enemy!!! ± Large surface : volume ratio ± Rapid heat loss Normal = 370C Do not delay transport to obtain .
1 .2 minutes ± Do not attempt if child Is < 2 months old Is struggling . Measurement: Axillary Measurement: Oral ± Glass thermometers not advised ± May be attempted with school-aged children ± Hold in skin fold 2 to 3 minutes ± Normal = ± Depends on peripheral Measurement: Rectal vasoconstriction/dila ± Lubricated tion thermometer ± 4cm in rectum.
cover child to avoid hypothermia! .After exposing during primary survey.
Head ± Anterior fontanel Remains open until 12 to 18 months Sinks in volume depletion Bulges with increased ICP Chest ± Transmitted breath sounds ± Listen over mid-axillary lines .
Neurologic ± Eye contact ± Recognition of parents ± Silence is NOT golden! .
correct time frames On scene observations important Do not judge/accuse parent Do not delay transport . Best source depends on child¶s age Do not underestimate child¶s ability as historian ± Imagination may interfere with facts ± Parents may have to fill gaps.
relevant ±Allergies ±Medications ±Past medical history ±Last oral intake ±Events leading to call ±Specifics of present illness . Brief.
parents unless parent out of control . Children not little adults Do not forget parents Do not forget to talk to child Avoid separating children.
Children understand more than they express Watch non-verbal messages Get down on child¶s level Develop, maintain eye contact Tell child your name Show respect Be honest
Children do not like:
± Noise ± Cold places ± Strange equipment
In emergency do not waste time in interest of rapport Do not underestimate child¶s ability to hurt you
Respiratory distress is the leading cause of Casualty visits and EMS calls for children Respiratory compromise is one of the leading causes of death in children Respiratory emergencies can effect children of all ages EMS intervention can be life-saving .
Many different etiologies ± Choking (FBAO) ± Epiglottitis ± Croup ± Asthma ± Bronchiolitis .
funnel shaped trachea FBAO is more likely No blind finger sweeps . Several key differences between adult and pediatric airway ± Larger floppier epiglottis Epiglottitis More difficult intubations ± Smaller.
Do not agitate the patient and transport sitting up as comfortably as possible. wheezing. inspiratory stridor. decreased breath sounds. backblows. coins. rales. muffled voice Treatment ± If the patient is not breathing. and balloons Recognition ± Apnea. open the airway and perform the AHA approved maneuvers for clearing the obstruction Heimlich. small toys. ± If patient is breathing. rhonchi. nuts. inability to speak. be as calming and supportive as possible. Foreign Body Airway Obstruction (FBAO) ± Usual causes are hard candy. anxiety. abdominal or chest compressions. Be alert for change in status. . If properly trained you may use a laryngoscope with Magills forceps to try and remove the obstruction.
) ± If patient is not breathing ventilate using a BVM. ± Administer oxygen at 15 LPM by NRB. ± If patient is wheezing Administer Medications through Nebuliser . Treatment (cont.
This condition is a true emergency with mortality rates as high as 10%. Typically occurs in children 3-7 years old. . Inflammation of the epiglottis and surrounding structures caused by bacterial infection.
drooling. muffled voice. high fever. Recognition ± Rapid onset (6-8 hours) of sore throat. inspiratory stridor or rattle ± Child is often found obtunded in tripod position ± Signs of respiratory distress are often present . dysphagia.
± Have airway equipment (BVM. ± Administer high flow humidified O2 by NRB. Treatment ± It is absolutely essential that the patient be handled as calmly as possible.000 by nebulizer. . Transport patient sitting up in position of comfort. Do not try to visualize the swelling or look in the mouth. Defer all painful procedures. ± Administer 5 ml of EPINEPHRINE 1:1. This can reduce upper airway swelling. Anxiety or aggravation can cause increased swelling and precipitate respiratory arrest. ± Inform medical control early so preparations can be made at hospital for treatment. ET equip) ready in case patient¶s condition deteriorates.
Inflammation of the upper airways caused by a viral infection. Sites of inflammation in paediatric airway infections . Very common (50 per 1000 children) Usually occurs in children aged 6 months to 3 years. (median age of onset is 18 months).
. hoarseness. Recognition ± Low grade fever. inspiratory stridor. ± The patient is likely to respond well to cool humidified O2. wheezing ± Signs of respiratory distress ± Often occurs at night Treatment ± Same as for epiglottitis. barking cough.
Croup 6 months 3 years Slow onset Barking cough No drooling Low grade fever (<104°F) Epiglottitis 3 7 years Rapid onset No barking cough Copious drooling High fever (>104°F) Responds well to tx Moderately serious Very Serious .
In contrast to croup & epiglottitis. It is very common (effects 50-100 out of 1000 children under 10 YO) . asthma is inflammation of the lower airways.
or infection induced ± S/Sx include wheezing. prolonged expiration. dyspnea. tachypnea. Why? . allergy. and anxiety ± A silent chest is an especially bad sign. Recognition ± Typically it is either exercise.
. ±Provide ventilations if breathing is inadequate ±Administer Medications via Nebuliser. Treatment ±Administer cool humidified oxygen.
Usually presents with symptoms similar to those of asthma. ± Why do you think this is? More common in the winter months. It usually effects children under 2 Years of Age. . Bronchiolitis is a viral inflammation of the lower airways. Can be very serious in infants.
shortness of reath. L ROL) ell to - . lso anxiety. and cyanosis. Recognition Wheezing nd t chypnea are ost common symptoms. reatment ame as asthma Patient is not as li ely to respond agonists ( PI.
Asthma Occurs in all ages. more common in children > 2 YO Occurs throughout the year Family hx of asthma Responds well to agonists (EPI and ALBUTEROL) Bronchiolitis Usually occurs in children under 2 YO Most common in winter. spring No family hx Does NOT respond well to EPI/ALBUTEROL .
Remember to treat the parents too. Treat respiratory emergencies aggressi ely. Do not hesitate to gi e neonates oxygen if you suspect they need it. e prepared for patients to decompensate. .
An acute complex pathophysiologic state of circulatory dysfunction which results in a failure of the organism to deliver sufficient amounts of oxygen and other nutrients to satisfy the requirements of tissue beds .
Uncontrolled blood or fluid loss Blood pressure less than 5th percentile for age Altered mental status. low urine output. poor capillary refill None of the above .
Inadequate tissue perfusion to meet tissue demands Usually result of inadequate blood flow and/or oxygen delivery Shock is not a blood pressure diagnosis!! .
End organ dysfunction: ± ± ± reduced urine output altered mental status poor peripheral perfusion acidosis altered metabolic demands Metabolic dysfunction: ± ± .
Gas exchange capability of lungs Hemoglobin Oxygen content Cardiac output Tissues to utilize substrate .
pneumothorax . spinal myocarditis.dysrhythmia organ perfusion is maintained Circulatory failure with end organ dysfunction Irreparable loss of essential organs Distributive ± Uncompensated ± Cardiogenic ± Obstructive ± Irreversible ± tamponade. Hypovolemic ± Compensated ± dehydration.burns. anaphylactic. hemorrhage septic.
Fluid Pump Vessels Flow .
Inadequate Fluid Volume (decreased preload) .
Fluid depletion ± internal ± external Hemorrhage ± internal ± external .
Pump Malfunction (decreased contractility) .
Electrical Failure Mechanical Failure ± ± ± ± Cardiomyopathy metabolic anatomic hypoxia/ischemia .
Abnormal Vessel Tone (decreased afterload) .
Vasodilation Venous Pooling Decreased Preload Maldistribution of regional blood flow .
Causes Sepsis Anaphylaxis Neurogenesis (spinal) Drug intoxication (TCA. Channel blocker) . calcium.
Septic Shock Decreas ed Volume Decrease d Pump Function Abnorma l Vessel Tone .
Heart rate Stroke volume: PreloadPreload.force applied .volume of blood in ventricle AfterloadAfterload.resistance to contraction ContractilityContractility.
Heart rate Peripheral circulation ± ± ± capillary refill pulses extremity temperature Pulmonary End organ perfusion ± ± brain kidney .
Preload Contractili ty Afterloa d Volume Inotropes Vasodilato rs .
Early (³Warm´) Decreased peripheral vascular resistance Increased cardiac output Late (³Cold´) Increased peripheral vascular resistance Decreased cardiac output .
OBSTRUCTED FLOW .
Causes Pericardial tamponade Pulmonary embolism Pulmonary hypertension .
A: Airway ± patent upper airway adequate ventilation and oxygenation optimize B: Breathing ± C: Circulation ± cardiac function oxygenation .
Patients in shock have: ± ± ± ± O2 delivery progressive respiratory fatigue/failure energy shunted from vital organs afterload .
O. Early intubation provides: ± ± O2 delivery and content controlled ventilation which: reduces metabolic demand allows C. to vital organs .
. ± Voluven (Hydoxy-ethyl starch): Not readily available. It does not carry viral diseases. Colloid Solutions ± Haemacel: Not used in Neonates as they have a high risk of anaphylaxis. but preferred to plasma.
± Normal Saline: Used as a rehydration fluid. ± Maintelyte & Paeds maintenance solution: Used as maintenance solution. . Crystalloids ± ½ DD: Frequently used for rehydration and maintenance in infants and children. ± Ringer-Lactate: Ised for rehydration and volume expansion. and for volume expansion. Do not give bicarbonate with this solution as it contains calcium. (NOT NEONATES).
If this does not correct the hypotension. repeat the bolus up to 3 times. Failure of the Fluid Bolus correct the hypotension ± consider Inotropic Support . Hypotension (state of shock): Colloid over crystalloid. Initially give 15-20ml bolus dose: this is given rapidly.
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