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

1. Veterinary Medicine:
Handling the Peds Patient
Veronica Bonales, M.D.
CEPAmerica Emergency Medicine

2. Your Patient

3. Your Patient

4. Information Source

5. Information Source

6. Objectives

7. Objectives
• Anatomical & Physiological Differences

8. Objectives
• Anatomical & Physiological Differences
• Assessing the Pediatric Patient

9. Objectives
• Anatomical & Physiological Differences
• Assessing the Pediatric Patient
• Common Pediatric Scenarios

10. Objectives
• Anatomical & Physiological Differences
• Assessing the Pediatric Patient
• Common Pediatric Scenarios
• Managing the Pediatric Patient

11. Anatomy & Physiology

12. Head Size
• Head larger in
proportion to body
• Children are top
heavy
• Head trauma
leading cause of
death from trauma

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

22. Head Circumference

23. Head Circumference

24. Head Circumference

25. Body Surface

26. Body Surface
• Greater surface area
to weight ratio

27. Body Surface
• Greater surface area
to weight ratio
• Prone to rapid
heat loss

28. Body Surface
• Greater surface area
to weight ratio
• Prone to rapid
heat loss
• Prone to
dehydration

29. Body Surface
• Greater surface area
to weight ratio
• Prone to rapid
heat loss
• Prone to
dehydration
• Wider distribution
of force in trauma

30. Chest Wall
• Compliant thoracic
cavity
• Minimal
protection
• Lung contusions
more common
than rib fractures

31. Abdomen

32. Abdomen
• Weak abdominal muscles
• Offer little protection

33. Abdomen
• Weak abdominal muscles
• Offer little protection
• Liver and spleen lie lower
and more anterior
• Not protected by rib
cage

34. 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

35. • 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

37. • Greater capacity to increase heart rate
• Heart rate >160 bpm tachycardic

38. • 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

39. Assessment

40. Arriving on the Scene

41. Arriving on the Scene

42. Arriving on the Scene
• First Always: Scene Safety

43. Arriving on the Scene
• First Always: Scene Safety
• Does location provide
clues?
• Where are you?
• Weapons, toys, objects
• Medications
• Witnesses

44. •Look at the child. Listen
to the parent.

45. Development
Developmental 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

46. PAT
• First Impression
• Pediatric Assessment
Triangle
• Appearance
• Work of breathing
• Circulation to skin

47. PAT
• First Impression
• Pediatric Assessment
Triangle
• Appearance
• Work of breathing
• Circulation to skin

48. PAT

49. PAT
• Appearance
• Tone
• Interactiveness
• Consolability
• Look/Gaze
• Speech/Cry

50. PAT
• Appearance • Work of Breathing
• Tone • Abnormal breath
sounds
• Interactiveness
• Consolability • Abnormal positioning
• Look/Gaze • Retractions
• Speech/Cry • Flaring

51. 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

52. Primary Assessment
• Airway
• Breathing
• Circulation
• Disability
• Exposure

53. ABC

54. ABC
• Airway
• Care in approach, may
agitate leading to
distress
• Assess patency of
airway

55. ABC
• Airway • Look at abdomen
• Care in approach, may
agitate leading to
distress
• Assess patency of
airway
• Breathing
• Rate, rhythm, tidal
volume

56. 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

57. Vital Signs

58. Disability
• Assess level of consciousness
• AVPU
• Alert
• Voice
• Pain
• Unresponsive

59. 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?

60. Don’t Let Appearances Fool You!

61. 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

62. Problem Children

63. Respiratory
• Most frequent prehospital medical calls
• Upper Airway Diseases (Croup)
• Lower Airway Diseases (Asthma)

64. Respiratory
• Upper Airway Diseases
• Croup
• Epiglottitis (vaccination status)
• Foreign Body Aspiration
• Anaphylaxis
• Congenital
• Trauma
• Other Infections

65. Respiratory
• Croup
• Most common upper airway problem
• Due to:
• Flu virus, RSV, Parainfluenza virus,
Adenovirus
• Late fall/early winter

66. Respiratory

67. 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

68. 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

69. Respiratory
• Poiseuille's Law

70. Respiratory
• Poiseuille's Law

71. Respiratory
• Poiseuille's Law

72. Respiratory
• Poiseuille's Law

73. Respiratory
• Treatment:
• Nebulizers
• Racemic epinephrine
• L epinephrine
• Steroids

74. 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

75. Respiratory
• Triggers lead to bronchial
spasming, mucosal edema,
increased secretions
• URI’s, exercise, cold air
exposure, emotional
stress, passive exposure
to smoke, allergens

76. Respiratory
• Symptoms:
• Tachypnea
• Tachycardia
• Retractions
• Wheezing or decreased breath sounds
• Normal or low O2 sats

77. 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

78. Respiratory
• Signs of Severe Asthma Attack
• Altered appearance
• Exhaustion
• Inability to recline
• Interrupted speech
• Severe retractions
• Decreased air movement

79. Respiratory
• Treatment
• Position of comfort
• Nebulized albuterol
• Oxygen
• Steroids
• SQ epinephrine if apneic
• May need intubation if no
improvement

80. 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

81. 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

82. Seizures
• Fever • Metabolic disorder
• Head trauma • Intracranial
hemorrhage
• Hypoxia
• Subtherapeutic
• Infection medication level
• Ingestion
• Hypoglycemia

83. Seizures
• Likely causes:
• First day of life - hypoxia
• First month of life - infection
• 6 months to 5 years - febrile seizure
• 3 years - idiopathic (epilepsy)

84. Febrile Seizures
• 5% of children
• Occur as fever spiking
• Usually stop spontaneously
• 30 - 50% will have second
seizure
• Needs medical evaluation

85. 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

86. ALOC

87. ALOC
• AEIOUTIPS • Trauma, temperature
• Alcohol • Infection
• Epilepsy, endocrine, • Psychogenic, poison
electrolytes
• Shock, space-
• Insulin occupying lesion, SAH
• Opiates, overdose
• Uremia

88. ALOC
• Hypoglycemia
• Low glycogen stores in the liver
• Alcohol, accidental ingestion of anti-
hyperglycemic agents,
overmedication with insulin
• Inborn errors of metabolism

89. ALOC
• Treatment
• <2 years old D25W
• >2 years old D50W
• Will need re-bolus or drip if long-
acting medication

90. Ingestions
• Ingestions
• Two peaks
• Toddlers -
accidental
• Teens -
intentional

91. One Pill Can Kill
• Theophylline
• Tricyclic antidepressants
• Clonidine (0.2mg, temporary reverse Narcan)
• Verapamil
• Propanolol
• Camphor
• Methyl salicylate (oil of wintergreen)

92. Trauma
• Leading cause of death in children
• Head injury most common
• Chest and abdomen follow 2nd

93. 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

94. Trauma
• Head larger
• Ligaments flexible
• Flexible chest
• Weak abdominal muscles
• Protruding spleen and liver
• Larger surface area to mass

95. Trauma
• Head larger
• Ligaments flexible
• Flexible chest
• Weak abdominal muscles
• Protruding spleen and liver
• Larger surface area to mass

96. 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

97. Trauma
• Goals of treatment
• open airway
• assist ventilation
• minimize secondary brain
injury
• avoid hypoxia &
hypotension
• stabilize the spine

98. Trauma
• Airway Management
• First do no harm
• Increased ICP in head injuries
• Position, open, suction, BVM
ventilation
• Age + 16 divided by 4 = ETT size

99. Trauma
• Vascular access
• Peripheral IV
• IO device in R leg
• 20 ml/kg LR or NS
• Rebolus until
hemodynamically
stable

100. Trauma
CUPS
Critical
Absent airway, breathing, or circulation
Perform rapid initial interventions and transport simultaneously
Severe traumatic injury with respiratory arrest or cardiac arrest
Unstable
Compromised airway, breathing, or circulation with altered mental status
Perform rapid initial interventions and transport simultaneously
Significant injury with respiratory distress, active bleeding, shock; near-drowning; unresponsiveness
Potentially unstable
Normal airway, breathing, circulation, and mental status BUT significant mechanism of injury or illness
Perform initial assessment with interventions; transport promptly; do focused history and physical exam during transport
if time allows
Minor fractures; pedestrian struck by car but with good appearance and normal initial assessment; infant younger than
three months with fever
Stable
Normal airway, breathing, circulation, and mental status; no significant mechanism of injury or illness
Perform initial assessment with interventions; do focused history and detailed physical exam; routine transport
Small lacerations, abrasions, or ecchymoses; infant older than three months with fever

101. Trauma
• Patients require frequent reassessments
• Due to compensatory mechanisms
• A little external damage can hide a lot
of internal damage

102. Questions??

103. Thank You...!
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