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Assessment And Managment Of Critically Ill Child 1
 

Assessment And Managment Of Critically Ill Child 1

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  • 13 Tony - note that oftentimes the status of the child improves dramatically with fluid resuscitation - rare that the child needs any additional therapy nor advanced airway management

Assessment And Managment Of Critically Ill Child 1 Assessment And Managment Of Critically Ill Child 1 Presentation Transcript

  • Pediatrics Assessment and Management of the Critically Ill Child
  • Kids are Tattle-Tales
  • Goals
    • Understand the Role of the Paramedic in Pediatric Emergency Care
    • Describe the Developmental Characteristics of different pediatric age groups
    • Describe the anatomical and physiological differences between the adult and pediatric patient
  • Goals
    • Describe assessment techniques for the critically injured and ill child
    • Discuss General Management of the Pediatric Patient
    • Utilize the Appropriate Assessment Technique to Rapidly Identify Treatment priorities
  • Roles of the Paramedic
    • Patient advocacy
    • Family Advocate
    • Professional Education
    • Professional Involvement
  • Roles of the Paramedic
    • Advocacy for the Patient
      • Patient Needs
        • Emergency = Stress = Fear
          • Separation
          • Further Injury and Pain
          • Unknown
        • Knowledge = Stress = Fear
          • Be Honest
          • Be Understandable
          • Be Timely
  • Roles of the Paramedic
    • Advocacy for the Family
      • Family Needs
        • Emergency = Stress = Fear
          • Guilt - Denial
          • Anger - Loss of Control
          • Grief
        • Knowledge = Stress = Fear
          • Be Professional
          • Be Honest
          • Be Organized
  • Roles of the Paramedic Professional Education
      • Pediatric Advanced Life Support (PALS)
      • Advanced Pediatric Life Support (APLS)
      • Pediatric Education for Prehospital Providers (PEPP)
      • Pediatric Prehospital Care (PPC)
      • Prehospital Trauma Life Support (PHTLS)
      • Regional and National Conferences
      • Life-Long Learning
        • Journals
        • Research
        • Web Resources
  • Roles of the Paramedic
    • Professional Involvement
      • Injury Prevention
        • Primary, Secondary, and Tertiary
        • The 4 E’s of Injury Prevention
          • Education – (Public Awareness)
          • Enforcement – (Seatbelt/Helmet law, Zoning Regs)
          • Environmental changes – (Free Helmets, gun locks)
          • Engineering – (Speed bumps, child-resistant bottles)
  • Roles of the Paramedic
    • Professional Involvement
      • EMS – Children
        • Federally Funded Program (1984/1991)
        • Designed to reduce impact from Illness and Injury
        • Address the Special Needs of Pediatrics
          • Assessment
          • Equipment
          • Education
  • Humboldt Siskiyou Modoc Lassen Shasta Trinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial EMSC Systems in Place and not Funded by EMSA (3 Single County Agencies) EMSC Projects Funded by EMSA (18 Agencies Representing 40 Counties) No EMSC System in Place (9 Agencies Representing 11 Counties) Calaveras Del Norte EMSC SYSTEMS Note: Patterned areas indicate EMS regions 4/16/02 EMSC Projects in Early Stage Implementation (funded by EMSA) (2 Agencies Representing 4 Counties)
  • Developmental Characteristics
    • Greatest Change Occurs in first Few years of Development
      • Muscle Coordination
      • Cognitive Process
      • Language Skills
      • Social Skills
    • Understanding allows a better and more complete assessment
    • Effects the Assessment Findings
  • Developmental Characteristics
    • Development and Assessment
      • Knowledge of appropriate developmental milestones
      • Information from Parents on child’s norm
      • Appropriate Communication Skills
      • Children will REGRESS when STRESSED
  • Infants and young children should be allowed to remain in their parent’s arms.
  • The approach to the pediatric patient should be gentle and slow.
  • A small toy may calm a child.
  • Anatomy and Physiology of Kids
    • Head
    • Airway
    • Chest and Lungs
    • Abdomen
    • Extremities
    • Skin and BSA
    • Respiratory
    • Cardiovascular
    • Nervous
    • Metabolic
  • Anatomy
    • Head
    • Proportionally Larger – Occipital region
    • Small Face/Flat Nose
    • Fontanelles
      • Posterior closes @ 4 months
      • Anterior Closes @ 9-18 months
    • Airway
    • Smaller Airways
    • Obligate Nose Breather (<6 months)
    • Large Tongues
    • Large/Floppy Epiglottis
    • Softer Trachea
    • Trachea Narrows
      • Cricoid ring
  • Head and Airway
  •  
  • Anatomy
    • Chest and Lungs
    • Ribs – Softer and more Flexible
    • Muscles – Fatigue Early
    • Belly Breathers
    • Thin Chest wall – Transmitted Sounds
    • Prone to Gastric Distention
    • Higher Energy Transfer from Blunt Trauma
    • Increased risk of Pneumo and Tension
    • Maxed out on Tidal Volume
  • Anatomy
    • Abdomen
    • Belly Breathers
    • Large Organs in Small Space
      • Liver and Spleen
    • Gastric Distention will Impede Tidal Volume
  • Anatomy
    • Extremities
    • Still Growing
      • Epiphyseal Plate
    • Soft and Flexible
      • Sprains, Strains, Fractures
    • Skin – BSA
    • Thinner
    • Less Subcutaneous Fat
    • Greater BSA:Weight
    • All increase risk
      • Heat Loss
      • Burn Severity
  • Physiology
    • Respiratory
    • Increased Oxygen Demand
    • Decrease Oxygen Supply (Reserve)
    • Vm = TV x RR
      • Minimal Change in TV
    • Cardiovascular
    • Skin Perfusion is Best Assessment Tool
    • CO = SV x HR
    • BP = (SV x HR) x SVR
    • Minimal Change in SV
    • Significant Shock W/O Hypotension
  • Physiology
    • Nervous
    • Still Developing
    • Prone to Increased Injury
    • Vagus Nerve
      • Direct Stimulation
      • Passive Control
    • Metabolic
    • Increase Rate for Compentsation
    • Limited Glygogen and Glucose stores
    • Newborns/neonate – don’t shiver
  • Assessment Techniques
    • Scene Size - Up
    • General Impression
    • Initial Assessment
    • Treatment/Transport Priority
    • Focused History And Physical
  • Assessment Techniques
    • Scene Size - Up
    • General Impression
    • Initial Assessment
    • Treatment/Transport Priority
    • Focused History And Physical
  • Assessment Techniques
    • Pediatric Assessment Triangle
      • Appearance
      • Work of Breathing
      • Circulation
  • Assessment Techniques
    • Rapid Cardiopulmonary Assessment
      • AHA – PALS
      • What you:
        • See
        • Hear
        • Feel
  • The Pediatric Assessment Triangle
    • Observational assessment
    • Formalizes the “general impression”
    • Establishes severity of illness or injury
    • Determines urgency of intervention
    • Identifies general category of physiologic abnormality
  • Pediatric Assessment Triangle
    • Appearance Work of Breathing
    • Circulation
  • The Pediatric Assessment Triangle
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    The Pediatric Assessment Triangle
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    The Pediatric Assessment Triangle
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    The Pediatric Assessment Triangle
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    The Pediatric Assessment Triangle
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    The Pediatric Assessment Triangle
    • Appearance
      • Alertness
      • Distractibility/ consolability
      • Eye contact
      • Speech or cry
      • Motor activity
      • Color
    The Pediatric Assessment Triangle
    • How do we recognize respiratory distress or respiratory failure by just looking at a child?
  • Pediatric Assessment Triangle
      • Work of Breathing
      • Abnormal breath sounds
      • Retractions
      • Nasal flaring
    Appearance Circulation
  • Respiratory Distress
      • Normal Work of Breathing
      • Appearance Retractions
      • Normal Circulation
  • Respiratory Failure
      • Abnormal Work of Breathing
      • Appearance
      • Circulation Normal or Poor
      • Appearance Work of Breathing
      • Circulation
      • Without the use of instruments, how can we rapidly assess the adequacy of circulation?
  • Skin Circulation
    • Skin temperature
    • Pulse strength
    • Capillary refill time
    • Color
  • Shock
      • Abnormal Normal Work of
      • Appearance Breathing
      • Poor Circulation
  • Brain Dysfunction
      • Abnormal Normal Work of
      • Appearance Breathing
      • Normal Circulation
  • PAT: Respiratory Distress Circulation to Skin Normal Work of Breathing Increased Appearance Normal
  • PAT: Respiratory Failure Circulation to Skin Normal or abnormal Work of Breathing Increased or decreased Appearance Abnormal
  • PAT: Shock Circulation to Skin Abnormal Work of Breathing Normal Appearance Abnorm al
  • PAT: (CNS) Dysfunction or Metabolic Abnormality Circulation to Skin Normal Work of Breathing Normal Appearance Abnormal
  • 2-week-old infant
    • Called to the home of 2-week-old infant who had stopped breathing
    • Infant turned pale, limp, revived when sitter “blew in her face”
    • Term delivery, no complications
    • Two days poor feeding; no fever
  • 2-week-old infant Circulation to Skin Face and trunk normal, hands and feet blue Work of Breathing Abdomen rises and falls with each breath Appearance Eyes open, moves arms and legs, strong cry
    • What do you think of this baby’s
    • work of breathing?
    • Are you concerned about her skin
    • signs?
  • 23-month-old toddler
    • Called to home of a 23-month-old with “trouble breathing”
    • Child is on mom’s lap, sees you, and starts to wail!
    • Patient is alert, with retractions and audible wheezing. Skin color is normal.
    • What can we tell from the PAT?
  • 23-month-old toddler
    • .
    Circulation to Skin Normal color . Work of Breathing Retractions, audible wheezing Appearance Seated, alert, strong cry
  • 9-month-old infant
    • A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.
  • 9-month-old infant Circulation to Skin Pale skin color Work of Breathing No retractions or abnormal airway sounds Appearance Agitated, makes eye contact
  • Initial Assessment
      • Airway - Open and maintainable
      • Breathing - RR 50 breaths/min, clear lungs, good chest rise
      • Circulation - HR 180 beats/min; cool, dry, pale skin; CRT 3 seconds; BP 74 mm Hg/palp
      • Disability - AVPU=A
      • Exposure - No sign of trauma, weight 8 kg
    • What is this child’s physiologic state?
    • What are your treatment priorities?
    • Assessment: Compensated shock, likely due to hypovolemia with viral illness
    • Treatment priorities:
      • Provide oxygen, as tolerated
      • Obtain IV access en route
        • Provide fluid resuscitation
          • 20 ml/kg of crystalloid, repeat as needed
    • 160 ml normal saline infused
    • HR decreased to 140 beats/min
    • Patient alert and interactive, receiving second bolus on emergency department arrival
  • General Management of the Pediatric Patient
    • Airway Management
    • Fluid and Medications
    • Electrical Therapy
    • C-Spine Consideration and Impact
    • Transport Considerations
  • Summary of BLS Maneuvers
  • Clearing an Infant’s Airway
  • Suctioning
    • Decrease suction pressure to less than 100 mm/Hg in infants.
    • Avoid excessive suctioning time—less than 15 seconds per attempt.
    • Avoid stimulation of the vagus nerve.
    • Check the pulse frequently.
  • Pediatric-size suction catheters. • Top: soft suction catheter. • Bottom: rigid or hard suction catheter.
  • Suction Catheter Sizes for Infants and Children
  • Oxygenation
    • Adequate oxygenation is the hallmark of pediatric patient management.
  • Inserting an oropharyngeal airway in a child with the use of a tongue blade.
  • a. In an adult, the airway is inserted with the tip pointing to the roof of the mouth, then rotated into position. b. In an infant or small child, the airway is inserted with the tip pointing toward the tongue and pharynx, in the same position it will be in after insertion.
  • Ventilation
    • Avoid excessive bag pressure and volume.
    • Obtain chest rise and fall.
    • Allow time for exhalation.
    • Flow-restricted, oxygen-powered devices are contraindicated.
    • Do not use BVMs with pop-off valves.
    • Apply cricoid pressure.
    • Avoid hyperextension of the neck.
  • In placing a mask on a child, it should fit on the bridge of the nose and cleft of the chin.
  • Sellick’s maneuver
  • Advanced Airway and Ventilatory Management
  • Infant/Child Endotracheal Tubes
  • The Pediatric Airway
    • A straight blade is preferred for greater displacement of the tongue.
    • The pediatric airway narrows at the cricoid cartilage.
    • Uncuffed tubes should be used in children under 8 years of age.
    • Intubation is likely to cause a vagal response in children.
  • Pediatric Endotracheal Tube Size
    • Use a resuscitation tape that estimates ET tube size based on height.
    • Estimate the correct diameter, based on the child’s little finger.
  • Pediatric Tube Size Formula
    • (Patient’s age in years + 16)
    • 4
  • Indications
    • Need for prolonged artificial ventilation
    • Inadequate ventilatory support with a BVM
    • Cardiac or respiratory arrest
    • Control of an airway in a patient without a cough or gag reflex
    • Providing a route for drug administration
    • Access to the airway for suctioning
  • Placement of the laryngoscope.
  • Endotracheal Intubation in the Child
  • Hyperventilate the child.
  • Position the head.
  • Insert the laryngoscope and visualize the airway.
  • Insert the tube and ventilate the child.
  • Confirm tube placement.
  • Nasogastric Intubation
  • Nasogastric Intubation
    • Indications:
    • Inability to achieve adequate tidal volume during ventilation due to gastric distention
    • Presence of gastric distention in an unresponsive patient
  • Oxygenate and continue to ventilate, if possible.
  • Measure the NG tube from the tip of the nose, over the ear, to the tip of the xiphoid process.
  • Lubricate the end of the tube. Then pass it gently downward along the nasal floor to the stomach.
  • Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while injecting 10–20 cc of air into the tube.
  • Use suction to aspirate stomach contents.
  • Secure the tube in place.
  • Rapid Sequence Intubation
    • Indicated in pediatric patients when intubation is difficult due to combativeness or clenched teeth.
    • Neuromuscular compliance is gained by the use of a paralytic.
  • Circulation
    • Two problems lead to cardiopulmonary
    • arrest in children:
    • Shock
    • Respiratory failure
  • Vascular Access
    • Neck veins
    • Scalp veins
    • Arms
    • Hands
    • Feet
    • Intraosseous infusion
  • Intraosseous Infusion Indications
    • Children less than 6 years of age
    • Existence of shock or cardiac arrest
    • Unresponsive patient
    • Unsuccessful peripheral IV
  • Intraosseous Infusion Contraindications
    • Fracture in the bone chosen for IO
    • Fracture of the pelvis or extremity fracture of bone, proximal to the chosen site
  • Intraosseous administration.
  • Drugs Administered by IO Route
    • Epinephrine
    • Atropine
    • Dopamine
    • Lidocaine
    • Sodium bicarbonate
    • Dobutamine
  • Correct needle placement for intraosseous administration.
  • Fluid Administration Accurate fluid dosing in children is crucial!
  •  
  •  
  • Electrical Therapy
    • Initial dose is 2 joules per kilogram of body weight.
    • If unsuccessful, increase to 4 joules per kilogram.
    • If still unsuccessful, focus on correcting hypoxia and acidosis.
    • Transport to a pediatric critical care unit, if possible.
  • Immobilizing a Patient in a Child Safety Seat
  • One paramedic stabilizes the car seat in an upright position and applies and maintains manual inline stabilization throughout the immobilization process.
  • A second paramedic applies an appropriately sized cervical collar. If one is not available, improvise using a rolled hand towel.
  • The second paramedic places a small blanket or towel on the child’s lap, then uses straps or wide tape to secure the chest and pelvic area to the seat.
  • The second paramedic places towel rolls on both sides of the child’s head to fill voids between the head and seat. He then tapes the head into place, taping over the chin, which would put pressure on the neck. The patient and seat can be carried to the ambulance and strapped to the stretcher, with the stretcher head raised.
  • Applying a Pediatric Immobilization System
  • Position the patient on the immobilization system.
  • Adjust the color-coded straps to fit the child.
  • Attach the four-point safety system.
  • Fasten the adjustable head-support system.
  • The patient fully immobilized to the system.
  • Move the immobilized patient onto the stretcher and fasten the loops at both ends to connect to the stretcher straps.
  • Emotional support of the infant or child continues during transport.
  • Never delay transport to perform a procedure that can be done en route to the hospital!
  • Case Studies