16. ABC Assessment and
Management
Introduction
The “Appearance" portion of the Pediatric
Assessment Triangle measures a variety of
things, designed to determine whether the
child is experiencing mental status changes.
17. Components of the "Appearance" item
also help to determine whether the child's
airway is clear.
The acronym "TICLS" (pronounced "tickles")
is sometimes used by emergency medical
providers to recall the components of the
"Appearance" item:
18. Tone (muscle tone)
Abnormal: Rigid or absent muscle tone
Normal: Good muscle tone with good movement of
the extremities.
Infants should strongly resist attempts to straighten
their limbs.
Irritability
Abnormal: Crying is absent, or abnormal. In addition
to indicating an altered mental status, this may also
be a sign of an occluded airway.
Normal: Strong, normal cry (this is a reliable sign of
a clear airway)
19. Consolability
Abnormal: The child cannot be consoled or
comforted by usual caregivers. The child does
not respond normally to environmental stimuli,
like preferred toys.
Normal: The child is able to be consoled by
usual caregivers. The child responds in his or
her usual way to environmental stimuli.
20. Look (gaze)
Abnormal: Vacant stare with lack of eye
contact.
Normal: Child is able to make eye contact
Speech
Abnormal: The child is unable to express
himself or herself age appropriately. Speech
(or crying for babies) is absent or abnormal.
Normal: The child expresses himself or
herself age-appropriately. Speech (or
crying) is normal (this is a reliable sign of a
clear airway).
21. Work of Breathing
"Work of Breathing" measures respiratory effort
and visible signs of respiratory distress.
A normal score on the "Work of Breathing" item
requires that the child's breathing be noiseless,
effortless, and painless.
An abnormal score on this item indicates that the
child is exhibiting an abnormal respiratory effort.
The respiratory effort may be increased
(indicating that the child is trying harder than
normal to breathe), decreased, or absent.
22. Signs of increased work of
breathing
include:
Noisy breathing (including grunting in
infants)
Retractions
Use of accessory muscles of respiration
Nasal flaring in young children
Chest in drawing
23. Circulation to Skin
Circulation as measured by skin color and
capillary refill.
A child with normal circulation will have his or
her usual skin color and there will be no obvious
bleeding.
24. Abnormal circulation to the skin may be
indicated by:
Pallor (generally an early sign of decreased
circulation; pallor may also be an indication of
blood loss)
Cyanosis
Obvious blood loss
25. Airway Management
In the unconscious patient, the priority is airway
management.
Common problems with the airway with seriously
reduced level of consciousness involve blockage
of the pharynx by the tongue, a foreign body, or
vomit.
In the conscious patient, other signs of airway
obstruction that may be considered include
use of accessory muscles
tracheal deviation
noisy air entry or exit, and cyanosis.
26. At a basic level, opening of the airway is
achieved through manual movement of the
head using various techniques
Head tilt — chin lift
Jaw thrust
27. Airway Management including C-
spine Stabilization
If the airway is obstructed, inspect the mouth for a
foreign body
Do not perform a blind finger sweep
Suction to clear blood, secretions, or vomitus.
Perform an airway-opening maneuver
If there is any possibility of C-spine injury, do not
performed by head tilt maneuver.
28. If the child is unconscious, an oral airway
may be required to lift the soft palate away
from the base of the tongue.
Bear in mind that inserting an oral airway
into a semi-conscious child's mouth may
cause gagging and vomiting.
Administer high-flow oxygen via a non-
rebreathing face mask with an oxygen
reservoir.
29. Airway must be opened using chin lift with
head tilted (jaw thrust in trauma) to
appropriate position
1) Airway positions
Infant <12 months – NEUTRAL (nose up)
Child >12 months – SNIFFING (chin up)
Jaw thrust in trauma patient
30. 2) Insertion of an oropharyngeal Airway
Can be used in unconscious patient to improve
airway opening
Size–from centre of teeth to angle of jaw (convex
side up)
Infants– insert convex side (right way) up
Children- insert concave side up then 180 degree
Check airway opening before and after insertion
Give Oxygen
32. 1) Mouth to mouth/nose ventilation
A child with a pulse ≥ 60 bpm who is not breathing
should receive one breath every 3 to 5 seconds
(12 to 20 breaths per minute).
Infants and children who require chest
compressions should receive
2 breaths per 30 chest compressions for a single
rescuer and
2 breaths per 15 chest compressions for two
rescuers.
33. 2) Ventilate with Bag and Mask
Essential in child who is not breathing or is
gasping
Check bags in good working order regularly
and before use
Choose correct mask size
Ensure good seal around mouth/nose and
open airway (may need two people)
Squeeze bag slowly and evenly
Watch chest rise and allow to fall before
giving next breath
34. Face Mask Placement
Correct: Covers mouth,
nose, and chin
Incorrect:
Too large - covers eyes and
extends over chin
Too small - does not cover
nose and mouth
35. Testing Bag and Mask
Pressure against your
hand?
Pressure-release valve
opens?
36. Select correct-sized mask
Clear airway
Position head
Position yourself at
side or head of baby
37.
38. 3) Giving Oxygen
Oxygen should be given to any child with an
airway or breathing ‘E’ sign
Children with cyanosis need urgent oxygen
treatment
Delivery of oxygen
Nasal prongs
Nasal catheter
Face Mask
39. Management of Circulation
Stop bleeding if any
IV/IO access
Give 20ml/kg Ringer’s lactate or normal saline
as fast as possible
Reassess circulation
?No improvement
Repeat 20ml/s kg Ringers/Saline
Reassess
40. ?No improvement
Repeat 20ml/s kg Ringers/Saline
Reassess
?No improvement
Give 10ml/kg blood over 3hrs OR
In severe diarrhea repeat Ringers
Reassess
?No improvement, Treat underlying condition
41. CHEST COMPRESSIONS
Chest compressions are initiated if the infant's
heart rate remains <60 beats per minute despite
adequate ventilation for 30 seconds.
Two methods are used to deliver neonatal chest
compressions.
Thumb technique — In this method, both hands
encircle the infant's chest with the thumbs on the
sternum and the fingers under the infant.
Two-finger technique — In this method, the tips of
the first two fingers, or the middle and ring finger
are placed in a perpendicular position over the
sternum.
41
44. Signs of Improvement
1. Increasing Heart Rate (>100)
2. Improving color
3. Spontaneous breathing or crying
4. Improving muscle tone
45. Equipped emergency box or cart
Laryngoscope with blades.
The proper size for a straight (Miller) blade size,
according to patient age, is as follows: premature,
blade size 0; neonate, 0–1; 1 month to 2 years,
1; 2–6 years, 1–2; 6–12 years, 2; and older than
12 years, 2–3.
Extra batteries.
Uniform diameter ET tubes (2.5-, 3.0-, and 3.5-mm
46. Drugs, including epinephrine (1:10,000) and NaCl 0.9%.
Sodium bicarbonate (0.50 mEq/mL) and naloxone are
rarely useful.
Umbilical catheterization tray with 3.5 and 5F catheters.
Syringes {1.0, 3.0, 5.0, 10.0, and 20.0 mL), needles (18-
25 gauge).
Transport incubator.
47. Endotracheal Tube Size
Weight (g)
Gestational Age (wks) ET Tube Size (mm)
(internal diameter
Below 1,000 Below 28 2.5
1,000-2,000 28-34 3.0
Greater than 2,000 Greater than 34 3.5
48. Advanced Airways
Indications:
When you are unable to open airway using
head tilt-chin lift or jaw thrust maneuvers.
If you have difficulty forming a seal with the
face mask.
If the patient requiring continued ventilatory
support.
When the patient has a high risk for aspiration
(provide an ETT).
49. Endotracheal Tube (ETT)
Laryngoscope blades (average adult size):
MAC 3 or 4, Miller 2 or 3
Same sized laryngoscopes or smaller sizes
can be used for pediatrics.
ETTs require mastery of technique for
consistent appropriate placement.
50. Average size of ETT for orotracheal intubation
(mm):
Uncuffed: tube = (age/4)+4
Cuffed: tube = (age/4)+3
A unique technique to size pediatric
endotracheal tubes
• 3.5 mm at birth.
• 4.5 mm at 4 years.
• 5 mm at 5 years (then increase the size of tube by 1 mm for
every 5 years)
• 6 mm at 10 years.
51. 1. The ETT is placed into the trachea.
Children over 1 year: Depth of intubation (cm) =
age/2+13
Children under 1 year: Depth of intubation (cm) =
weight/2+8
2. Tracheal cuff of the ETT is then inflated.
Allows for positive pressure ventilation.
Reduces risk of aspiration.
Helps maintain placement of ETT.
53. PEDIATRICS DRUG
CALCULATION
Most drugs in children are dosed according to body
weight (mg/kg) or body surface area (BSA) (mg/m2).
Care must be taken to properly convert body weight
from pounds to kilograms (1 kg= 2.2 lb) before
calculating doses based on body weight.
Doses are often expressed as mg/kg/day or
mg/kg/dose.
Orders written "mg/kg/d," which is confusing require
further clarification from the prescriber.
54. Chemotherapeutic drugs are commonly dosed
according to body surface area, which requires an
extra verification step (BSA calculation) prior to
dosing.
Medications are available in multiple concentrations,
therefore orders written in "mL" rather than "mg"
are not acceptable and require further clarification.
55. Step 1. Convert pounds to kg: 22 lb × 1 kg/2.2 lb = 10 kg
Step 2. Calculate the dose in mg: 10 kg × 40 mg/kg/day = 400
mg/day
Step 3. Divide the dose by the
frequency:
400 mg/day ÷ 2 (BID) = 200
mg/dose BID
Step 4. Convert the mg dose to
mL:
200 mg/dose ÷ 400 mg/5 mL
= 2.5 mL BID
Example 1.
Calculate the dose of amoxicillin suspension in mLs for otitis media for a 1-yr-
old child weighing 22 lb. The dose required is 40 mg/kg/day divided BID and
the suspension comes in a concentration of 400 mg/5 mL.
56. Example 2.
Calculate the dose of ceftriaxone in mLs for
meningitis for a 5-yr-old weighing 18 kg. The dose
required is 100 mg/kg/day given IV once daily and
the drug comes prediluted in a concentration of 40
mg/mL.
Step 1. Calculate the dose in mg: 18 kg × 100 mg/kg/day = 1800 mg/day
Step 2. Divide the dose by the
frequency:
1800 mg/day ÷ 1 (daily) = 1800
mg/dose
Step 3. Convert the mg dose to mL: 1800 mg/dose ÷ 40 mg/mL = 45 mL
once daily
57. Example 3.
Calculate the dose of vincristine in mLs for a 4-yr-old with leukemia
weighing 37 lb and is 97 cm tall. The dose required is 2 mg/m2 and the
drug comes in 1 mg/mL concentration.
Step 1. Convert pounds to kg: 37 lb × 1 kg/2.2 lb = 16.8 kg
Step 2. Calculate BSA: √16.8 kg × 97 cm/3600 = 0.67 m
2
Step 3. Calculate the dose in mg: 2 mg/m
2
× 0.67 m
2
= 1.34 mg
Step 4. Calculate the dose in mL: 1.34 mg ÷ 1 mg/mL = 1.34 mL
