Pediatrics Part 2 Assessment and Management of the Critically Ill Child
Pediatric Assessment Triangle <ul><li>Appearance  Work of  Breathing </li></ul><ul><li>Circulation </li></ul>
<ul><li>Organized Approach to Pediatric Patient </li></ul><ul><li>Initial Impression of Child </li></ul><ul><ul><li>Sick  ...
Sick or Not Sick? Why?
Rapid Cardiopulmonary Assessment <ul><li>Level of Consciousness (See) </li></ul><ul><ul><li>Aware of Environment </li></ul...
What Do You See? Alert & Responding to Environment Minimal Work of Breathing   Airway is Patent and Maintained Activity is...
What Do You Hear? Good Air Movement No Audible Wheeze or Grunting
What Do You Feel? Skin is Warm and Dry  to Touch Peripheral and Central Pulses are Strong and Equal Cap Refill is Brisk (<...
Case Studies
Case Scenario #1 <ul><li>6 month-old female with respiratory distress x 6 hours. As you approach the child, you can hear h...
What Do You See? No Eye Contact Nasal Flaring Accessory Muscles Skin is Pale and Cyanotic Increased Respiratory Rate
What Do You Hear? Audible Wheezing Grunting
What Do You Feel? Cool Extremities Weak Peripheral Pulses
2-week-old infant <ul><li>Called to the home of 2-week-old infant who had stopped breathing </li></ul><ul><li>Infant turne...
2-week-old infant Circulation to Skin Face and trunk normal, hands and feet blue Work of Breathing Abdomen rises and falls...
<ul><li>What do you think of this baby’s  </li></ul><ul><li>work of breathing? </li></ul><ul><li>Are you concerned about h...
23-month-old toddler <ul><li>Called to home of a 23-month-old with “trouble breathing” </li></ul><ul><li>Child is on mom’s...
23-month-old toddler <ul><li>. </li></ul>Circulation to Skin Normal color . Work of Breathing Retractions, audible wheezin...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
9-month-old infant <ul><li>A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake. </li></ul>
9-month-old infant Circulation to Skin Pale skin color Work of Breathing No retractions or abnormal airway sounds Appearan...
Initial Assessment <ul><ul><li>Airway   - Open and maintainable  </li></ul></ul><ul><ul><li>Breathing  - RR 50 breaths/min...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
3-year-old toddler <ul><li>Toddler is found cyanotic and unresponsive </li></ul><ul><li>Child last seen 1 hour prior to di...
3-year-old toddler Circulation to Skin Cyanotic, mottled Work of Breathing Gurgling breath sounds Appearance No spontaneou...
Initial Assessment <ul><ul><li>Airway   - Partial obstruction by tongue </li></ul></ul><ul><ul><li>Breathing  - RR 15 brea...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
<ul><li>The monitor shows the following rhythm. </li></ul><ul><li>What are your treatment priorities for this patient? </l...
12-month-old child <ul><li>You arrive at the house of a 12-month-old child. </li></ul><ul><li>Mother states the child has ...
12-month-old child Circulation to Skin Lips and nailbeds blue Work of Breathing Mild retractions Appearance Alert but agit...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
<ul><li>On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to ...
<ul><li>How can you distinguish SVT from sinus tachycardia?   </li></ul>SVT Sinus Tachycardia
<ul><li>Blow-by oxygen administered </li></ul><ul><li>IV started </li></ul><ul><li>Adenosine 0.1 mg/kg (1mg), given rapid ...
9-month-old infant <ul><li>You are dispatched to the scene of a 9-month-old infant with difficulty breathing and fever.  <...
9-month-old infant  Circulation to Skin Normal color Work of Breathing Retractions, nasal flaring Appearance Alert, lookin...
Initial Assessment <ul><li>Airway  - Open </li></ul><ul><li>Breathing  - RR 80 breaths/min, wheezing with good air movemen...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
4-year-old child <ul><li>You are dispatched to the scene of a 4-year-old child with trouble breathing. </li></ul><ul><li>M...
4-year-old child Circulation to Skin Pale skin color Work of Breathing Stridor, severe retractions Appearance Unresponsive...
Initial Assessment <ul><ul><li>Airway  - Obstructed </li></ul></ul><ul><ul><li>Breathing  - RR 12 breaths/min, decreased b...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
3-year-old child <ul><li>You are called to the home of a child who has had a fever for one day </li></ul><ul><li>Prior to ...
3-year-old child Circulation to Skin Normal color Work of Breathing Normal Appearance Drowsy, but interacts
Initial Assessment <ul><li>Airway  - Open, no stridor  </li></ul><ul><li>Breathing  - RR 25 breaths/min, clear breath soun...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
Etiologies of Seizures What is the significance of fever in this patient? •  Ingestion  •  Low level anti-seizure medicine...
Fever <ul><li>Fever may indicate a serious infection in the blood or central nervous system. </li></ul><ul><li>Ominous sig...
Fever <ul><li>Temperature < 105º F is not harmful and does not cause brain damage. </li></ul><ul><li>Treatment:  Body subs...
4-year-old child <ul><li>You are dispatched to the home of a child “not acting right”.  </li></ul><ul><li>She was recently...
4-year-old child   Circulation to Skin Normal color Work of Breathing Normal Appearance Disoriented
Initial Assessment <ul><li>Airway  - Open, no stridor  </li></ul><ul><li>Breathing  - RR 30 breaths/min, clear breath soun...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
3-year-old child <ul><li>You are called to the street where a  3-year-old child is found lying after a 20-foot fall from a...
3-year-old child What is your assessment of this patient? Circulation to Skin Pale skin color Work of Breathing Tachypnea,...
Initial Assessment <ul><li>Airway  - Clear, no stridor </li></ul><ul><li>Breathing  – RR 40 breaths/min with good air move...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
<ul><li>This patient is in decompensated shock due to hemorrhage . </li></ul>
7-year-old child <ul><li>You are called to the home of a 7-year-old child with trouble breathing. </li></ul><ul><li>He is ...
7-year-old child Appearance Listless, poor muscle tone Work of Breathing No chest rise visible Circulation to Skin Pale sk...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
<ul><li>What immediate action should be taken to manage this child? </li></ul>
Immediate Management <ul><li>Disconnect the ventilator, and begin ventilation using bag-valve device via the tracheostomy ...
Initial Assessment <ul><li>Child is not breathing spontaneously </li></ul><ul><li>There is resistance to bagging </li></ul...
<ul><li>This child has an obstructed tracheostomy tube, a common complication of tracheostomy tube placement  </li></ul><u...
Treatment Priorities <ul><li>Suction the tracheostomy tube </li></ul><ul><ul><li>Instill 2 ml normal saline into tube prio...
Treatment Priorities  <ul><li>Attempt to ventilate again </li></ul><ul><li>If no chest rise, remove tracheostomy tube  </l...
Treatment Priorities <ul><li>If no chest rise after suctioning tube, immediately remove and replace the tracheostomy tube ...
Treatment Priorities <ul><li>Parents may have replacement tracheostomy tube </li></ul><ul><li>Endotracheal tube may be sub...
<ul><li>Tracheostomy tube suctioned  </li></ul><ul><li>Good chest rise with bagging  </li></ul><ul><li>HR decreases to 90 ...
<ul><li>A feeding tube is used for nutritional supplementation when the child cannot take adequate nourishment by mouth </...
2-year-old child <ul><li>You are called to the home of a 2-year-old child whose parents state she has been crying since fa...
2-year-old child  Appearance Crying, scared,  not consoled by parents   Work of Breathing Normal Circulation to Skin Normal
Initial Assessment <ul><ul><li>Airway  - Open, clear </li></ul></ul><ul><ul><li>Breathing  - RR 28 breaths/min, breath sou...
<ul><li>How sick is this child? </li></ul><ul><li>What are the “red flags” in the history and physical examination that ra...
<ul><li>Child is physiologically stable - immediate medical treatment not necessary </li></ul><ul><li>“ Red flags” for mal...
<ul><li>Four types: </li></ul><ul><ul><li>Physical abuse </li></ul></ul><ul><ul><li>Emotional abuse </li></ul></ul><ul><ul...
Patterns of Physical Abuse <ul><li>Stocking/glove burn </li></ul><ul><li>Donut shaped burn </li></ul>
Patterns of Physical Abuse <ul><li>Human bite marks </li></ul><ul><li>Multiple fractures </li></ul>   Facial bruising
Signs that Mimic Abuse <ul><li>Mongolian  spots </li></ul><ul><li>Cupping </li></ul><ul><li>Coin rubbing </li></ul>
Risk Factors <ul><li>Younger children, < 5 years of age </li></ul><ul><li>Drug or alcohol use  </li></ul><ul><li>History o...
2 ½ y/o boy - Fever <ul><li>Father meets you at the door – “I don’t think he’s breathing!” </li></ul><ul><li>As you enter,...
Pediatric Assessment Triangle <ul><li>Appearance  Work of  Abnormal Breathing </li></ul><ul><li>Decreased </li></ul><ul><l...
Initial Assessment <ul><li>Airway  – Snoring </li></ul><ul><li>Breathing  – RR:12 BPM; breath sounds:minimal Chest Excursi...
Rhythm – Sinus Brady
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
4-year-old “Sick Child” <ul><li>On Arrival Parents tell you has been SOB all day. He is also 2 weeks Post-Op for cardiac S...
Pediatric Assessment Triangle <ul><li>Appearance     Work of  Abnormal Breathing </li></ul><ul><li>Increased rate </li></u...
Initial Assessment <ul><li>Airway  - Open </li></ul><ul><li>Breathing  – RR 50: breath sounds – Diminished - equal, SaO 2:...
Rhythm - VT
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
Case #
Pediatric Assessment Triangle <ul><li>Appearance  Work of  Breathing </li></ul><ul><li>Circulation </li></ul>
Initial Assessment <ul><li>Airway  - Open </li></ul><ul><li>Breathing  – RR: breath sounds:, SaO 2:  </li></ul><ul><li>Cir...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
Case #
Pediatric Assessment Triangle <ul><li>Appearance  Work of  Breathing </li></ul><ul><li>Circulation </li></ul>
Initial Assessment <ul><li>Airway  - Open </li></ul><ul><li>Breathing  – RR: breath sounds:, SaO 2:  </li></ul><ul><li>Cir...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
Case #
Pediatric Assessment Triangle <ul><li>Appearance  Work of  Breathing </li></ul><ul><li>Circulation </li></ul>
Initial Assessment <ul><li>Airway  - Open </li></ul><ul><li>Breathing  – RR: breath sounds:, SaO 2:  </li></ul><ul><li>Cir...
<ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
 
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Assessment And Managment Of Critically Ill Child 2

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  • Sue - put this information in instructor script: For infants &lt;4 weeks, symptoms may be vague: fussiness, poor feeding, lethargy Children with chronic illness are more at risk for serious illness
  • Assessment And Managment Of Critically Ill Child 2

    1. 1. Pediatrics Part 2 Assessment and Management of the Critically Ill Child
    2. 2. Pediatric Assessment Triangle <ul><li>Appearance Work of Breathing </li></ul><ul><li>Circulation </li></ul>
    3. 3. <ul><li>Organized Approach to Pediatric Patient </li></ul><ul><li>Initial Impression of Child </li></ul><ul><ul><li>Sick </li></ul></ul><ul><ul><li>Not Sick </li></ul></ul><ul><li>30 - 60 Seconds </li></ul><ul><li>Rapid Reassessments </li></ul><ul><li>Assessment “From Across the Room” </li></ul><ul><li>What Do You See ? </li></ul><ul><li>What Do You Hear ? </li></ul><ul><li>What Do You Feel ? </li></ul>Rapid Cardiopulmonary Assessment
    4. 4. Sick or Not Sick? Why?
    5. 5. Rapid Cardiopulmonary Assessment <ul><li>Level of Consciousness (See) </li></ul><ul><ul><li>Aware of Environment </li></ul></ul><ul><ul><li>Reaction to Providers </li></ul></ul><ul><li>Airway (See) </li></ul><ul><ul><li>Patent </li></ul></ul><ul><li>Breathing (See/Hear) </li></ul><ul><ul><li>Rate - Color </li></ul></ul><ul><ul><li>Effort - Audible Sounds </li></ul></ul><ul><ul><li>Tidal Volume </li></ul></ul><ul><li>Circulation (See/Feel) </li></ul><ul><ul><li>Peripheral vs. Central Pulses </li></ul></ul><ul><ul><li>Heart Rate </li></ul></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><ul><li>Color, Temp </li></ul></ul></ul><ul><ul><li>Cap Refill </li></ul></ul>
    6. 6. What Do You See? Alert & Responding to Environment Minimal Work of Breathing Airway is Patent and Maintained Activity is Spontaneous Skin is Pink
    7. 7. What Do You Hear? Good Air Movement No Audible Wheeze or Grunting
    8. 8. What Do You Feel? Skin is Warm and Dry to Touch Peripheral and Central Pulses are Strong and Equal Cap Refill is Brisk (< 2 seconds)
    9. 9. Case Studies
    10. 10. Case Scenario #1 <ul><li>6 month-old female with respiratory distress x 6 hours. As you approach the child, you can hear her grunting with every breath. Wheezing is also audible. She does not appear to acknowledge your presence in the room. </li></ul>Begin your assessment?
    11. 11. What Do You See? No Eye Contact Nasal Flaring Accessory Muscles Skin is Pale and Cyanotic Increased Respiratory Rate
    12. 12. What Do You Hear? Audible Wheezing Grunting
    13. 13. What Do You Feel? Cool Extremities Weak Peripheral Pulses
    14. 14. 2-week-old infant <ul><li>Called to the home of 2-week-old infant who had stopped breathing </li></ul><ul><li>Infant turned pale, limp, revived when sitter “blew in her face” </li></ul><ul><li>Term delivery, no complications </li></ul><ul><li>Two days poor feeding; no fever </li></ul>
    15. 15. 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
    16. 16. <ul><li>What do you think of this baby’s </li></ul><ul><li>work of breathing? </li></ul><ul><li>Are you concerned about her skin </li></ul><ul><li>signs? </li></ul>ALTE
    17. 17. 23-month-old toddler <ul><li>Called to home of a 23-month-old with “trouble breathing” </li></ul><ul><li>Child is on mom’s lap, sees you, and starts to wail! </li></ul><ul><li>Patient is alert, with retractions and audible wheezing. Skin color is normal. </li></ul><ul><li>What can we tell from the PAT? </li></ul>
    18. 18. 23-month-old toddler <ul><li>. </li></ul>Circulation to Skin Normal color . Work of Breathing Retractions, audible wheezing Appearance Seated, alert, strong cry
    19. 19. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    20. 20. 9-month-old infant <ul><li>A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake. </li></ul>
    21. 21. 9-month-old infant Circulation to Skin Pale skin color Work of Breathing No retractions or abnormal airway sounds Appearance Agitated, makes eye contact
    22. 22. Initial Assessment <ul><ul><li>Airway - Open and maintainable </li></ul></ul><ul><ul><li>Breathing - RR 50 breaths/min, clear lungs, good chest rise </li></ul></ul><ul><ul><li>Circulation - HR 180 beats/min; cool, dry, pale skin; CRT 3 seconds; BP 74 mm Hg/palp </li></ul></ul><ul><ul><li>Disability - AVPU=A </li></ul></ul><ul><ul><li>Exposure - No sign of trauma, weight 8 kg </li></ul></ul>
    23. 23. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    24. 24. 3-year-old toddler <ul><li>Toddler is found cyanotic and unresponsive </li></ul><ul><li>Child last seen 1 hour prior to discovery </li></ul><ul><li>Open bottle of clonidine found next to child </li></ul>
    25. 25. 3-year-old toddler Circulation to Skin Cyanotic, mottled Work of Breathing Gurgling breath sounds Appearance No spontaneous activity; unresponsive
    26. 26. Initial Assessment <ul><ul><li>Airway - Partial obstruction by tongue </li></ul></ul><ul><ul><li>Breathing - RR 15 breaths/min, poor air entry </li></ul></ul><ul><ul><li>Circulation - HR 30 beats/min; faint femoral pulse; CRT 3 seconds; BP 50/30 mm Hg </li></ul></ul><ul><ul><li>Disability - AVPU=P </li></ul></ul><ul><ul><li>Exposure - No sign of trauma </li></ul></ul>
    27. 27. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    28. 28. <ul><li>The monitor shows the following rhythm. </li></ul><ul><li>What are your treatment priorities for this patient? </li></ul>
    29. 29. 12-month-old child <ul><li>You arrive at the house of a 12-month-old child. </li></ul><ul><li>Mother states the child has a history of congenital heart disease and has been fussy for the last 3 hours. </li></ul><ul><li>Mother states the child weighs 22 pounds. </li></ul>
    30. 30. 12-month-old child Circulation to Skin Lips and nailbeds blue Work of Breathing Mild retractions Appearance Alert but agitated
    31. 31. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    32. 32. <ul><li>On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count. </li></ul><ul><li>What rhythm does the monitor show? </li></ul>
    33. 33. <ul><li>How can you distinguish SVT from sinus tachycardia? </li></ul>SVT Sinus Tachycardia
    34. 34. <ul><li>Blow-by oxygen administered </li></ul><ul><li>IV started </li></ul><ul><li>Adenosine 0.1 mg/kg (1mg), given rapid IVP with 5 ml saline flush </li></ul><ul><li>Five seconds of bradyasystole, followed by conversion to NSR </li></ul>
    35. 35. 9-month-old infant <ul><li>You are dispatched to the scene of a 9-month-old infant with difficulty breathing and fever. </li></ul><ul><li>What important information must you </li></ul><ul><li>gather from the history and assessment? </li></ul>
    36. 36. 9-month-old infant Circulation to Skin Normal color Work of Breathing Retractions, nasal flaring Appearance Alert, looking around, crying
    37. 37. Initial Assessment <ul><li>Airway - Open </li></ul><ul><li>Breathing - RR 80 breaths/min, wheezing with good air movement, SaO 2 90% </li></ul><ul><li>Circulation - HR 180 beats/min; skin warm and normal color; CRT normal </li></ul><ul><li>How sick is this infant? </li></ul>
    38. 38. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    39. 39. 4-year-old child <ul><li>You are dispatched to the scene of a 4-year-old child with trouble breathing. </li></ul><ul><li>Mother states that he was playing with a small superball prior to collapsing. </li></ul>
    40. 40. 4-year-old child Circulation to Skin Pale skin color Work of Breathing Stridor, severe retractions Appearance Unresponsive, poor muscle tone
    41. 41. Initial Assessment <ul><ul><li>Airway - Obstructed </li></ul></ul><ul><ul><li>Breathing - RR 12 breaths/min, decreased breath sounds, little or no chest rise, unable to speak or cry </li></ul></ul><ul><ul><li>Circulation - HR 100 beats/min and dropping; pulses present; BP deferred </li></ul></ul><ul><ul><li>Disability - AVPU=U </li></ul></ul><ul><ul><li>Exposure - No sign of trauma </li></ul></ul>
    42. 42. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    43. 43. 3-year-old child <ul><li>You are called to the home of a child who has had a fever for one day </li></ul><ul><li>Prior to your arrival she experiences a single generalized seizure followed by confusion </li></ul>
    44. 44. 3-year-old child Circulation to Skin Normal color Work of Breathing Normal Appearance Drowsy, but interacts
    45. 45. Initial Assessment <ul><li>Airway - Open, no stridor </li></ul><ul><li>Breathing - RR 25 breaths/min, clear breath sounds </li></ul><ul><li>Circulation - HR 115 beats/min; skin warm to the touch; normal capillary refill; BP 105/65 mm Hg </li></ul><ul><li>Child begins to have another seizure </li></ul><ul><li>What are your treatment and transport priorities? </li></ul>
    46. 46. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    47. 47. Etiologies of Seizures What is the significance of fever in this patient? • Ingestion • Low level anti-seizure medicine • Infection • Bleeding into brain • Hypoxia • Metabolic disorder • Head trauma • Hypoglycemia • Fever
    48. 48. Fever <ul><li>Fever may indicate a serious infection in the blood or central nervous system. </li></ul><ul><li>Ominous signs suggesting a serious cause: bulging fontanelle, stiff neck, prolonged CRT, purplish rash </li></ul><ul><li>Newborns and young infants may have nonspecific symptoms of serious infection such as fussiness, poor feeding, or decreased activity. </li></ul>
    49. 49. Fever <ul><li>Temperature < 105º F is not harmful and does not cause brain damage. </li></ul><ul><li>Treatment: Body substance precautions, passive cooling </li></ul><ul><li>Transport priorities: If initial assessment is normal, do focused history and physical exam, and detailed physical exam on scene; if initial assessment is abnormal, treat en route to the hospital </li></ul>
    50. 50. 4-year-old child <ul><li>You are dispatched to the home of a child “not acting right”. </li></ul><ul><li>She was recently diagnosed with diabetes and is on insulin. </li></ul>
    51. 51. 4-year-old child Circulation to Skin Normal color Work of Breathing Normal Appearance Disoriented
    52. 52. Initial Assessment <ul><li>Airway - Open, no stridor </li></ul><ul><li>Breathing - RR 30 breaths/min, clear breath sounds, SaO 2 96% </li></ul><ul><li>Circulation - HR 140 beats/min; skin moist and warm; CRT 2 seconds; BP 95/65 mm Hg </li></ul><ul><li>Disability - AVPU=V, normal pupillary response to light </li></ul><ul><li>Exposure - No sign of trauma </li></ul>
    53. 53. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    54. 54. 3-year-old child <ul><li>You are called to the street where a 3-year-old child is found lying after a 20-foot fall from a third-story window. </li></ul>
    55. 55. 3-year-old child What is your assessment of this patient? Circulation to Skin Pale skin color Work of Breathing Tachypnea, retractions Appearance Unresponsive
    56. 56. Initial Assessment <ul><li>Airway - Clear, no stridor </li></ul><ul><li>Breathing – RR 40 breaths/min with good air movement bilaterally </li></ul><ul><li>Circulation – HR 190 beats/min; pulses thready; CRT 4 seconds; BP 70 mm Hg/palp </li></ul><ul><li>What is the child’s perfusion status? </li></ul>
    57. 57. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    58. 58. <ul><li>This patient is in decompensated shock due to hemorrhage . </li></ul>
    59. 59. 7-year-old child <ul><li>You are called to the home of a 7-year-old child with trouble breathing. </li></ul><ul><li>He is lying in a hospital-style bed, with a ventilator and suction machine on the nightstand. </li></ul><ul><li>He is being ventilated through a tracheostomy tube. </li></ul>
    60. 60. 7-year-old child Appearance Listless, poor muscle tone Work of Breathing No chest rise visible Circulation to Skin Pale skin color
    61. 61. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    62. 62. <ul><li>What immediate action should be taken to manage this child? </li></ul>
    63. 63. Immediate Management <ul><li>Disconnect the ventilator, and begin ventilation using bag-valve device via the tracheostomy tube </li></ul>
    64. 64. Initial Assessment <ul><li>Child is not breathing spontaneously </li></ul><ul><li>There is resistance to bagging </li></ul><ul><li>Poor chest rise with bag-valve-tracheostomy ventilation </li></ul><ul><li>HR 160 beats/min by palpation of femoral pulse </li></ul><ul><li>What is going on with this patient? </li></ul>
    65. 65. <ul><li>This child has an obstructed tracheostomy tube, a common complication of tracheostomy tube placement </li></ul><ul><li>Usually due to mucus plugging </li></ul><ul><li>Caregivers will often have attempted to clear tracheostomy prior to 911 call </li></ul><ul><li>What are your management priorities now? </li></ul>
    66. 66. Treatment Priorities <ul><li>Suction the tracheostomy tube </li></ul><ul><ul><li>Instill 2 ml normal saline into tube prior to suctioning </li></ul></ul>
    67. 67. Treatment Priorities <ul><li>Attempt to ventilate again </li></ul><ul><li>If no chest rise, remove tracheostomy tube </li></ul><ul><li>Begin BVM ventilation over the mouth, while partner covers stoma </li></ul><ul><li>If no chest rise, ventilate using small mask over the stoma </li></ul><ul><li>Rapid transport </li></ul>
    68. 68. Treatment Priorities <ul><li>If no chest rise after suctioning tube, immediately remove and replace the tracheostomy tube </li></ul>
    69. 69. Treatment Priorities <ul><li>Parents may have replacement tracheostomy tube </li></ul><ul><li>Endotracheal tube may be substituted </li></ul><ul><ul><li>Use tube of same internal diameter as tracheostomy tube </li></ul></ul><ul><ul><li>Insert into stoma 1/2 the length used for oral intubation </li></ul></ul><ul><li>Begin bagging via the newly inserted tube </li></ul>
    70. 70. <ul><li>Tracheostomy tube suctioned </li></ul><ul><li>Good chest rise with bagging </li></ul><ul><li>HR decreases to 90 beats/min </li></ul><ul><li>Child becomes alert and interactive </li></ul><ul><li>This child also has a feeding tube in place. </li></ul><ul><li>What are some potential complications of this device? </li></ul>
    71. 71. <ul><li>A feeding tube is used for nutritional supplementation when the child cannot take adequate nourishment by mouth </li></ul><ul><li>Common complications include: </li></ul><ul><ul><li>Dislodged tube </li></ul></ul><ul><ul><li>Leakage of stomach/bowel contents around the tube </li></ul></ul><ul><ul><li>Infection of the insertion site </li></ul></ul>
    72. 72. 2-year-old child <ul><li>You are called to the home of a 2-year-old child whose parents state she has been crying since falling off a chair one hour ago. </li></ul><ul><li>Parents insist the child be transported immediately, but do not hold or comfort child. </li></ul>
    73. 73. 2-year-old child Appearance Crying, scared, not consoled by parents Work of Breathing Normal Circulation to Skin Normal
    74. 74. Initial Assessment <ul><ul><li>Airway - Open, clear </li></ul></ul><ul><ul><li>Breathing - RR 28 breaths/min, breath sounds clear </li></ul></ul><ul><ul><li>Circulation - HR 100 beats/min; CRT 2 seconds </li></ul></ul><ul><ul><li>Disability - AVPU=A </li></ul></ul><ul><ul><li>Exposure - Multiple brown, yellow, and purple bruises on buttocks and trunk </li></ul></ul>
    75. 75. <ul><li>How sick is this child? </li></ul><ul><li>What are the “red flags” in the history and physical examination that raise your suspicion for child maltreatment? </li></ul>
    76. 76. <ul><li>Child is physiologically stable - immediate medical treatment not necessary </li></ul><ul><li>“ Red flags” for maltreatment: </li></ul><ul><ul><li>History is inconsistent with findings of trunk and buttock bruising </li></ul></ul><ul><ul><li>Caregiver interaction is inappropriate </li></ul></ul><ul><ul><li>Child does not look to parents for reassurance </li></ul></ul>
    77. 77. <ul><li>Four types: </li></ul><ul><ul><li>Physical abuse </li></ul></ul><ul><ul><li>Emotional abuse </li></ul></ul><ul><ul><li>Sexual abuse </li></ul></ul><ul><ul><li>Neglect </li></ul></ul><ul><li>Child maltreatment occurs in all ethnic and socioeconomic groups. </li></ul>Types of Child Maltreatment
    78. 78. Patterns of Physical Abuse <ul><li>Stocking/glove burn </li></ul><ul><li>Donut shaped burn </li></ul>
    79. 79. Patterns of Physical Abuse <ul><li>Human bite marks </li></ul><ul><li>Multiple fractures </li></ul> Facial bruising
    80. 80. Signs that Mimic Abuse <ul><li>Mongolian spots </li></ul><ul><li>Cupping </li></ul><ul><li>Coin rubbing </li></ul>
    81. 81. Risk Factors <ul><li>Younger children, < 5 years of age </li></ul><ul><li>Drug or alcohol use </li></ul><ul><li>History of domestic violence </li></ul><ul><li>Family history of maltreatment </li></ul><ul><li>What are your management priorities for this patient? </li></ul>
    82. 82. 2 ½ y/o boy - Fever <ul><li>Father meets you at the door – “I don’t think he’s breathing!” </li></ul><ul><li>As you enter, you see a child sitting on a couch, but slumped over to the side </li></ul><ul><li>No reaction to you as you approach </li></ul><ul><li>Decreased Respiratory effort – Snoring Respiration </li></ul><ul><li>Cool extremities, Cyanotic lips </li></ul>
    83. 83. Pediatric Assessment Triangle <ul><li>Appearance Work of Abnormal Breathing </li></ul><ul><li>Decreased </li></ul><ul><li>Circulation </li></ul><ul><li>Poor/Abnormal </li></ul>
    84. 84. Initial Assessment <ul><li>Airway – Snoring </li></ul><ul><li>Breathing – RR:12 BPM; breath sounds:minimal Chest Excursion-end expiratory wheeze, SaO 2: N/A </li></ul><ul><li>Circulation – HR:70 skin: Cyanotic, cool extrem. Weak pulses CRT:4seconds; BP N/A </li></ul><ul><li>Disability - AVPU=U, </li></ul><ul><li>Exposure - No sign of trauma </li></ul>
    85. 85. Rhythm – Sinus Brady
    86. 86. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    87. 87. 4-year-old “Sick Child” <ul><li>On Arrival Parents tell you has been SOB all day. He is also 2 weeks Post-Op for cardiac Surgery </li></ul><ul><li>4 y/o boy-lying quietly in bed – does not react to your arrival </li></ul><ul><li>Shallow/fast Respiratory rate </li></ul><ul><li>Skin is pale and cool at the distal extremities – pulse is tachycardic and weak </li></ul>
    88. 88. Pediatric Assessment Triangle <ul><li>Appearance Work of Abnormal Breathing </li></ul><ul><li>Increased rate </li></ul><ul><li>shallow TV </li></ul><ul><li>Circulation </li></ul><ul><li>Abnormal/Pale </li></ul><ul><li>No peripheral pulses </li></ul>
    89. 89. Initial Assessment <ul><li>Airway - Open </li></ul><ul><li>Breathing – RR 50: breath sounds – Diminished - equal, SaO 2: N/A </li></ul><ul><li>Circulation – HR: Too fast to count skin: Pale & Cool CRT: >4 seconds; BP 62/P mm Hg </li></ul><ul><li>Disability - AVPU=P, </li></ul><ul><li>Exposure - No sign of trauma </li></ul>
    90. 90. Rhythm - VT
    91. 91. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    92. 92. Case #
    93. 93. Pediatric Assessment Triangle <ul><li>Appearance Work of Breathing </li></ul><ul><li>Circulation </li></ul>
    94. 94. Initial Assessment <ul><li>Airway - Open </li></ul><ul><li>Breathing – RR: breath sounds:, SaO 2: </li></ul><ul><li>Circulation – HR: skin: CRT:seconds; BP mm Hg </li></ul><ul><li>Disability - AVPU=V, </li></ul><ul><li>Exposure - No sign of trauma </li></ul>
    95. 95. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    96. 96. Case #
    97. 97. Pediatric Assessment Triangle <ul><li>Appearance Work of Breathing </li></ul><ul><li>Circulation </li></ul>
    98. 98. Initial Assessment <ul><li>Airway - Open </li></ul><ul><li>Breathing – RR: breath sounds:, SaO 2: </li></ul><ul><li>Circulation – HR: skin: CRT:seconds; BP mm Hg </li></ul><ul><li>Disability - AVPU=V, </li></ul><ul><li>Exposure - No sign of trauma </li></ul>
    99. 99. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
    100. 100. Case #
    101. 101. Pediatric Assessment Triangle <ul><li>Appearance Work of Breathing </li></ul><ul><li>Circulation </li></ul>
    102. 102. Initial Assessment <ul><li>Airway - Open </li></ul><ul><li>Breathing – RR: breath sounds:, SaO 2: </li></ul><ul><li>Circulation – HR: skin: CRT:seconds; BP mm Hg </li></ul><ul><li>Disability - AVPU=V, </li></ul><ul><li>Exposure - No sign of trauma </li></ul>
    103. 103. <ul><li>What is this child’s physiologic state? </li></ul><ul><li>What are your treatment priorities? </li></ul>
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