FCA 0411 - Pediatric

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RMH Field Care Audit 04/11/11 - Taking Care of the Pediatric Patient

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FCA 0411 - Pediatric

  1. 1. Veterinary Medicine:Handling the Peds Patient Veronica Bonales, M.D. CEPAmerica Emergency Medicine
  2. 2. Your Patient
  3. 3. Your Patient
  4. 4. Information Source
  5. 5. Information Source
  6. 6. Objectives
  7. 7. Objectives• Anatomical & Physiological Differences
  8. 8. Objectives• Anatomical & Physiological Differences• Assessing the Pediatric Patient
  9. 9. Objectives• Anatomical & Physiological Differences• Assessing the Pediatric Patient• Common Pediatric Scenarios
  10. 10. Objectives• Anatomical & Physiological Differences• Assessing the Pediatric Patient• Common Pediatric Scenarios• Managing the Pediatric Patient
  11. 11. Anatomy & Physiology
  12. 12. Head Size• Head larger in proportion to body• Children are top heavy• Head trauma leading cause of death from trauma
  13. 13. Airway• Larger proportion of soft tissue - high susceptibility to swelling with any irritation• Newborns up to 4 months must breathe through nose• Children up to 8 yrs old breathe using belly or diaphragm - consider during transport
  14. 14. Head Circumference
  15. 15. Head Circumference
  16. 16. Head Circumference
  17. 17. Body Surface
  18. 18. Body Surface • Greater surface area to weight ratio
  19. 19. Body Surface • Greater surface area to weight ratio • Prone to rapid heat loss
  20. 20. Body Surface • Greater surface area to weight ratio • Prone to rapid heat loss • Prone to dehydration
  21. 21. Body Surface • Greater surface area to weight ratio • Prone to rapid heat loss • Prone to dehydration • Wider distribution of force in trauma
  22. 22. Chest Wall• Compliant thoracic cavity • Minimal protection • Lung contusions more common than rib fractures
  23. 23. Abdomen
  24. 24. Abdomen • Weak abdominal muscles • Offer little protection
  25. 25. Abdomen • Weak abdominal muscles • Offer little protection • Liver and spleen lie lower and more anterior • Not protected by rib cage
  26. 26. Abdomen • Weak abdominal muscles • Offer little protection • Liver and spleen lie lower and more anterior • Not protected by rib cage • Looks distended so bleeding can be missed
  27. 27. • Metabolic rate higher • Require more energy and consume more oxygen • Illness or stress accelerates• Higher fluid requirement • Newborn 70 - 80% water (adult 50 - 60%) • Prone to dehydration (diarrhea, emesis, blood loss)• 25% more total circulating blood volume per body weight
  28. 28. • Greater capacity to increase heart rate • Heart rate >160 bpm tachycardic
  29. 29. • Greater capacity to increase heart rate • Heart rate >160 bpm tachycardic• Vessels “clamp down” • Peripheral pulses will become thready and disappear before central pulses • Skin color and cap refill important
  30. 30. Assessment
  31. 31. Arriving on the Scene
  32. 32. Arriving on the Scene
  33. 33. Arriving on the Scene• First Always: Scene Safety
  34. 34. Arriving on the Scene• First Always: Scene Safety• Does location provide clues? • Where are you? • Weapons, toys, objects • Medications • Witnesses
  35. 35. •Look at the child. Listen to the parent.
  36. 36. DevelopmentDevelopmental Aspects of Pediatric Patients Characteristics Age* Keys to Successful Interaction Normally alert, looking around Focuses well on Newborn (birth to 1 month) Likes to be held and kept warm May be soothed by faces Flexed extremities having something to suck on Avoid loud noises, Infant (1–12 months) bright lights Normally alert, looking around Eyes follow examiner Slightly flexed extremities Can straighten Toddler (1–3 years) Likes to be held Parents should be nearby Examine arms and legs Can sit unaided by 6–8 months from toes to head Distract with a toy or penlight Preschooler (3–6 years) Normally alert, active Can walk by 18 months Does Make a game of assessment Distract with a toy or not like to sit still May grab at penlight or push School-age child (6–12 years) penlight Examine from toes to head Allow parents hand away to participate in exam Respect modesty, keep child Adolescent (12–18 years) covered when possible Normally alert, active Can sit still on request Can cooperate with examination Understands speech Explain actions using simple language Tell child Will make up explanations for what will happen next Tell child just before anything not understood procedure if something will hurt Distract child with a story Respect modesty Will cooperate if trust is established Wants to participate and retain some control Respect modesty Let child make treatment choices when Can make decisions about care possible Allow child to participate in exam *Note that children who are frightened or in pain Explain the process as to an adult Treat the may act younger than their age adolescent with respect Has clear concepts of future
  37. 37. PAT• First Impression• Pediatric Assessment Triangle • Appearance • Work of breathing • Circulation to skin
  38. 38. PAT• First Impression• Pediatric Assessment Triangle • Appearance • Work of breathing • Circulation to skin
  39. 39. PAT
  40. 40. PAT• Appearance • Tone • Interactiveness • Consolability • Look/Gaze • Speech/Cry
  41. 41. PAT• Appearance • Work of Breathing • Tone • Abnormal breath sounds • Interactiveness • Consolability • Abnormal positioning • Look/Gaze • Retractions • Speech/Cry • Flaring
  42. 42. PAT• Appearance • Work of Breathing • Tone • Abnormal breath sounds • Interactiveness • Consolability • Abnormal positioning • Look/Gaze • Retractions • Speech/Cry • Flaring • Circulation to Skin • Pallor, Mottling, Cyanosis
  43. 43. Primary Assessment• Airway• Breathing• Circulation• Disability• Exposure
  44. 44. ABC
  45. 45. ABC• Airway • Care in approach, may agitate leading to distress • Assess patency of airway
  46. 46. ABC• Airway • Look at abdomen • Care in approach, may agitate leading to distress • Assess patency of airway• Breathing • Rate, rhythm, tidal volume
  47. 47. ABC• Airway • Look at abdomen • Care in approach, may • Circulation agitate leading to distress • Brachial artery for pulse • Assess patency of • Compare peripheral & airway central pulses• Breathing • Cap refill (< 2 - 3 sec) • Rate, rhythm, tidal • Correct for low temps volume • Control bleeding
  48. 48. Vital Signs
  49. 49. Disability• Assess level of consciousness • AVPU • Alert • Voice • Pain • Unresponsive
  50. 50. Exposure• Assess color, temperature and moisture • Color assessed during PAT • With good perfusion, skin should be warm near wrist and ankles• Baby in car seat, local protocol?
  51. 51. Don’t Let Appearances Fool You!
  52. 52. Don’t Let Appearances Fool You!• Fever < 3 months old• Toxic Ingestion• Unconscious or seizure• Potential anaphylaxis• High impact trauma• Evidence of child abuse or sexual assault
  53. 53. Problem Children
  54. 54. Respiratory• Most frequent prehospital medical calls• Upper Airway Diseases (Croup)• Lower Airway Diseases (Asthma)
  55. 55. Respiratory• Upper Airway Diseases • Croup • Epiglottitis (vaccination status) • Foreign Body Aspiration • Anaphylaxis • Congenital • Trauma • Other Infections
  56. 56. Respiratory• Croup • Most common upper airway problem • Due to: • Flu virus, RSV, Parainfluenza virus, Adenovirus • Late fall/early winter
  57. 57. Respiratory
  58. 58. Respiratory• Usually affects infants and toddlers• Cold symptoms 2 - 3 days• Nasal congestion, hoarseness• Tachypnea, low grade fever• Worse at night• Inflammation, edema of upper airways• 58% stridor• 94% barking or seal-like cough
  59. 59. Respiratory• Usually affects infants and toddlers• Cold symptoms 2 - 3 days• Nasal congestion, hoarseness• Tachypnea, low grade fever• Worse at night• Inflammation, edema of upper airways• 58% stridor• 94% barking or seal-like cough
  60. 60. Respiratory• Poiseuilles Law
  61. 61. Respiratory• Poiseuilles Law
  62. 62. Respiratory• Poiseuilles Law
  63. 63. Respiratory• Poiseuilles Law
  64. 64. Respiratory• Treatment: • Nebulizers • Racemic epinephrine • L epinephrine • Steroids
  65. 65. Respiratory• Asthma • Most common chronic disease of childhood • Admission rate for age <5 is higher than for all other age groups • Mortality rising • 1/2 of all deaths in pre-hospital setting • Length of final attack < 2hr in 50% of deaths
  66. 66. Respiratory • Triggers lead to bronchial spasming, mucosal edema, increased secretions • URI’s, exercise, cold air exposure, emotional stress, passive exposure to smoke, allergens
  67. 67. Respiratory• Symptoms: • Tachypnea • Tachycardia • Retractions • Wheezing or decreased breath sounds • Normal or low O2 sats
  68. 68. Respiratory• Factors of Severe Attack • Prior ICU admission or intubation • >3 ED visits in a year • >2 Hospital admissions in a year • Use of >1 MDI canister in last month • Use of rescue inhaler >Q4H • Worsening symptoms despite aggressive home therapy
  69. 69. Respiratory• Signs of Severe Asthma Attack • Altered appearance • Exhaustion • Inability to recline • Interrupted speech • Severe retractions • Decreased air movement
  70. 70. Respiratory• Treatment • Position of comfort • Nebulized albuterol • Oxygen • Steroids • SQ epinephrine if apneic • May need intubation if no improvement
  71. 71. Seizures• Most often tonic-clonic type• Infants may have gaze preference, sucking or lip smacking, leg bicycling• Cyanosis common due to airway compromise & decreased respiratory drive
  72. 72. Seizures• Supportive care if not seizing on arrival• Any child seizing on arrival should be considered as status epilepticus (>5min) • Maintain airway • Benzos • Eliminate treatable causes
  73. 73. Seizures• Fever • Metabolic disorder• Head trauma • Intracranial hemorrhage• Hypoxia • Subtherapeutic• Infection medication level• Ingestion• Hypoglycemia
  74. 74. Seizures• Likely causes: • First day of life - hypoxia • First month of life - infection • 6 months to 5 years - febrile seizure • 3 years - idiopathic (epilepsy)
  75. 75. Febrile Seizures• 5% of children• Occur as fever spiking• Usually stop spontaneously• 30 - 50% will have second seizure• Needs medical evaluation
  76. 76. Seizures• Most often tonic-clonic type• Infants may have gaze preference, sucking or lip smacking, leg bicycling• Cyanosis common due to airway compromise & decreased respiratory drive
  77. 77. ALOC
  78. 78. ALOC• AEIOUTIPS • Trauma, temperature • Alcohol • Infection • Epilepsy, endocrine, • Psychogenic, poison electrolytes • Shock, space- • Insulin occupying lesion, SAH • Opiates, overdose • Uremia
  79. 79. ALOC• Hypoglycemia • Low glycogen stores in the liver • Alcohol, accidental ingestion of anti- hyperglycemic agents, overmedication with insulin • Inborn errors of metabolism
  80. 80. ALOC• Treatment • <2 years old D25W • >2 years old D50W • Will need re-bolus or drip if long- acting medication
  81. 81. Ingestions• Ingestions • Two peaks • Toddlers - accidental • Teens - intentional
  82. 82. One Pill Can Kill• Theophylline• Tricyclic antidepressants• Clonidine (0.2mg, temporary reverse Narcan)• Verapamil• Propanolol• Camphor• Methyl salicylate (oil of wintergreen)
  83. 83. Trauma• Leading cause of death in children • Head injury most common • Chest and abdomen follow 2nd
  84. 84. Trauma• MVC most common mechanism (#1 killer - includes passenger, bicycle, pedestrian, & ATV)• Falls (most frequent children <5)• Drowning (2nd most)/sports-related• Penetrating injuries (urban)• 20 - 40% of deaths preventable
  85. 85. Trauma• Head larger• Ligaments flexible• Flexible chest• Weak abdominal muscles• Protruding spleen and liver• Larger surface area to mass
  86. 86. Trauma• Head larger• Ligaments flexible• Flexible chest• Weak abdominal muscles• Protruding spleen and liver• Larger surface area to mass
  87. 87. Trauma• In trauma must consider multisystem injuries • Belted patient: solid organs, bowel, spine • Fall: head and neck, chest, abdomen, extremities • Handlebar flip: Head and neck, abdomen, extremities
  88. 88. Trauma • Goals of treatment • open airway • assist ventilation • minimize secondary brain injury • avoid hypoxia & hypotension • stabilize the spine
  89. 89. Trauma• Airway Management • First do no harm • Increased ICP in head injuries • Position, open, suction, BVM ventilation • Age + 16 divided by 4 = ETT size
  90. 90. Trauma• Vascular access • Peripheral IV • IO device in R leg• 20 ml/kg LR or NS • Rebolus until hemodynamically stable
  91. 91. Trauma CUPS CriticalAbsent airway, breathing, or circulationPerform rapid initial interventions and transport simultaneouslySevere traumatic injury with respiratory arrest or cardiac arrestUnstableCompromised airway, breathing, or circulation with altered mental statusPerform rapid initial interventions and transport simultaneouslySignificant injury with respiratory distress, active bleeding, shock; near-drowning; unresponsivenessPotentially unstableNormal airway, breathing, circulation, and mental status BUT significant mechanism of injury or illnessPerform initial assessment with interventions; transport promptly; do focused history and physical exam during transportif time allowsMinor fractures; pedestrian struck by car but with good appearance and normal initial assessment; infant younger thanthree months with feverStableNormal airway, breathing, circulation, and mental status; no significant mechanism of injury or illnessPerform initial assessment with interventions; do focused history and detailed physical exam; routine transportSmall lacerations, abrasions, or ecchymoses; infant older than three months with fever
  92. 92. Trauma• Patients require frequent reassessments • Due to compensatory mechanisms• A little external damage can hide a lot of internal damage
  93. 93. Questions??
  94. 94. Thank You...!• www.slideshare.net/docmontey

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