Transcript Examination and Assessment of the Pediatric Patient

Chapter 6
Examination and Assessment of
the Pediatric Patient
Introduction
• Obtaining a complete history on a
pediatric patient not only is necessary, but
also leads to the correct diagnosis in the
vast majority of children.
• The history usually is learned from the
parent, the older child, or the caretaker of
a sick child.
• After learning the fundamentals of
obtaining and recording historic data, the
nuances associated with the giving of
information must be interpreted.
Introduction
• During the interview, it is important to convey to the
parent interest in the child as well as the illness.
• The parent is allowed to talk freely at first and to express
concerns in his or her own words.
• The interviewer should look directly either at the parent
or the child intermittently and not only at the writing
instruments.
• Careful observation during the interview frequently
uncovers stresses and concerns that otherwise are not
apparent.
General Information
• Identifying data include the date, name, age and
birth date, sex, race, relationship of the child and
informant, and some indication of the mental
state or reliability of the informant.
• It frequently is helpful to include the ethnic or
racial background, address, and telephone
numbers of the informants.
Patient History
• The history for a new patient can be divided
into:
• Chief complaint or primary concern
• History of the present illness (HPI)
• Past medical history (PMH)
• Review of symptoms (ROS)
• Family history (FH)
• Social and environmental histories
Patient History (cont.)
• Chief complaint
• Current signs and symptoms
• Typically assessed by a parent or caregiver
• Includes cough/fever/chest pain…
• Given in the informant's or patient's own words, the
chief complaint is a brief statement of the reason
why the patient was brought to be seen. It is not
unusual that the stated complaint is not the true
reason the child was brought for attention.
Expanding the question of "Why did you bring him?"
to "What concerns you?" allows the informant to
focus on the complaint more accurately. Carefully
phrased questions can elicit information without
prying.
Patient History (cont.)
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History of Present Illness
Present illness are recorded in chronologic order.
"The child was well until "X" number of days before this visit.“
Statements should be recorded in number of days before the
visit or dates, but not in days of the week, because chronology
will be difficult to retrieve even a short time later if days of the
week are used. If the child is taking medicine, the amount
being taken, the name of the medicine, the frequency of
administration, and how well and how long it has been or is
being taken are needed.
• For the well child, a simple statement such as "No complaints"
or "No illness" suffices. A question about school attendance
may be pertinent. If the past medical history is significant to
the current illness, a brief summary is included. If information
is obtained from old records, it should be noted here or may
be recorded in the past medical history.
Past Medical History
• A. Antenatal: Health of mother during pregnancy. Medical
supervision, drugs, diet, infections such as rubella, etc., other
illnesses, vomiting, toxemia, other complications; Rh typing
and serology, pelvimetry, medications, x-ray procedure,
maternal bleeding, mother's previous pregnancy history.
• B. Natal: Duration of pregnancy, birth weight, kind and
duration of labor, type of delivery, presentation, sedation and
anesthesia (if known), state of infant at birth, resuscitation
required, onset of respiration, first cry.
• C. Neonatal: APGAR score; color, cyanosis, pallor, jaundice,
cry, twitchings, excessive mucus, paralysis, convulsions, fever,
hemorrhage, congenital abnormalities, birth injury. Difficulty
in sucking, rashes, excessive weight loss, feeding
difficulties. You might discover a problem area by asking if
baby went home from hospital with his mother.
Growth and Development:
Mother and Mental Development
• a. First raised head, rolled over, sat alone, pulled up,
walked with help, walked alone, talked (meaningful
words; sentences)
• b. Urinary continence during night; during day.
• c. Control of feces.
• d. Comparison of development with that of siblings and
parents.
• e. School grade, quality of work.
Growth and Development:
Nutrition
• 1. Breast or Formula: Type, duration, major formula changes,
time of weaning, difficulties. Be specific about how much milk
or formula the baby receives.
• 2. Vitamin Supplements: Type, when started, amount,
duration.
• 3. "Solid" Foods: When introduced, how taken, types.
• 4. Appetite: Food likes and dislikes, idiosyncrasies or allergies,
reaction of child to eating. An idea of child's usual daily intake
is important.
Past Illnesses
• A comment should first be made relative to the child's
previous general health, then the specific areas listed
below should be explored.
• 1. Infections: Age, types, number, severity.
• 2. Contagious Diseases: Age, complications following
measles, rubella, chickenpox, mumps, pertussis,
diphtheria, scarlet fever.
• 3. Past Hospitalizations: including operations, age.
• 4. Allergies, with specific attention to drug allergies detail type of reaction.
• 5. Medications patient is currently taking.
Immunizations and Tests
• Be familiar with departmental recommendations for
immunizations. List date and type of immunization as well as
any complications or reactions.
• Accidents and Injuries (include ingestions): Nature, severity,
sequelae.
• Behavioral History
• 1. Does child manifest any unusual behavior such as thumb
sucking, excessive masturbation, severe and frequent temper
tantrums, negativism, etc.?
• 2. Sleep disturbances.
• 3. Phobias.
• 4. Pica (ingestions of substances other than food).
• 5. Abnormal bowel habits, ex. - stool holding.
• 6. Bed wetting (applicable only to child out of diapers).
Family History
• A. Father and mother (age and condition of health). What
sort of people do the parents characterize themselves as
being?
• B. Marital relationships. Little information should be sought at
first interview; most information will be obtained indirectly.
• C. Siblings. Age, condition of health, significant previous
illnesses and problems.
• D. Stillbirths, miscarriages, abortions; age at death and cause
of death of immediate members of family.
• E. Tuberculosis, allergy, blood dyscrasias, mental or nervous
diseases, diabetes, cardiovascular diseases, kidney disease,
rheumatic fever, neoplastic diseases, congenital abnormalities,
cancer, convulsive disorders, others.
• F. Health of contacts.
System Review
• A system review will serve several purposes. It
will often bring out symptoms or signs missed in
collection of data about the present illness.
• It might direct the interviewer into questioning
about other systems that have some indirect
bearing on the present illness (ex. - eczema in a
child with asthma).
• Finally, it serves as a screening device for
uncovering symptoms, past or present, which
were omitted in the earlier part of the interview.
System Review
• A. Skin: Ask about rashes, hives, problems with hair, skin
texture or color, etc.
• B. Eyes: Have the child's eyes ever been crossed? Any foreign
body or infection, glasses for any reason.
• C. Ears, Nose and Throat: Frequent colds, sore throat,
sneezing, stuffy nose, discharge, post-nasal drip, mouth
breathing, snoring, otitis, hearing, adenitis.
• D. Teeth: Age of eruption of deciduous and permanent;
number at one year; comparison with siblings.
• E. Cardiorespiratory: Frequency and nature of
disturbances. Dyspnea, chest pain, cough, sputum, wheeze,
expectoration, cyanosis, edema, syncope, tachycardia.
• F. Gastrointestinal: Vomiting, diarrhea, constipation, type of
stools, abdominal pain or discomfort, jaundice.
System Review
• G. Genitourinary: Enuresis, dysuria, frequency, polyuria,
pyuria, hematuria, character of stream, vaginal discharge,
menstrual history, bladder control, abnormalities of penis or
testes.
• H. Neuromuscular: Headache, nervousness, dizziness,
tingling, convulsions, habit spasms, ataxia, muscle or joint
pains, postural deformities, exercise tolerance, gait.
• I. Endocrine: Disturbances of growth, excessive fluid intake,
polyphagia, goiter, thyroid disease.
• J. Special senses.
• K. General: Unusual weight gain or loss, fatigue, temperature
sensitivity, mentality. Pattern of growth (record previous
heights and weights on appropriate graphs). Time and pattern
of pubescence.
Physical Exam
Approaching the Child
• Adequate time should be spent in becoming acquainted
with the child and allowing him/her to become
acquainted with the examiner.
• The child should be treated as an individual whose
feelings and sensibilities are well developed, and the
examiner's conduct should be appropriate to the age of
the child. A friendly manner, quiet voice, and a slow and
easy approach will help to facilitate the examination.
Physical Exam
Observation of the Patient
• Although the very young child may not be able to speak,
one still may receive much information from him/her by
being observant and receptive.
• The total evaluation of the child should include
impressions obtained from the time the child first enters
until s/he leaves; it should not be based solely on the
period during which the patient is on the examining
table.
• In general, more information is obtained by careful
inspection than from any of the other methods of
examination.
General Physical Examination
Vital Signs and Measurements
• Temperature, pulse rate, and respiratory rate (TPR); blood
pressure (the cuff should cover 2/3 of the upper arm), weight,
height, and head circumference.
• The weight should be recorded at each visit; the height should
be determined at monthly intervals during the first year, at 3month intervals in the second year, and twice a year
thereafter.
• The height, weight, and circumference of the child should be
compared with standard charts and the approximate
percentiles recorded. Multiple measurements at intervals are
of much greater value than single ones since they give
information regarding the pattern of growth that cannot be
determined by single measurements.
General Physical Examination
General Appearance
Does the child appear well or ill?
Degree of prostration; degree of cooperation;
state of comfort, nutrition, and consciousness;
abnormalities, gait, posture, and coordination;
estimate of intelligence; reaction to parents,
physician, and examination; nature of cry and
degree of activity, facies and facial expression.
General Physical Examination
Skin
• Color (cyanosis, jaundice, pallor, erythema), texture,
eruptions, hydration, edema, hemorrhagic
manifestations, scars, dilated vessels and direction of
blood flow, hemangiomas, cafe-au-lait areas and nevi,
Mongolian (blue-black) spots, pigmentation, turgor,
elasticity, and subcutaneous nodules.
• Striae and wrinkling may indicate rapid weight gain or
loss. Sensitivity, hair distribution and character, and
desquamation.
General Physical Examination
• A. Loss of turgor, especially of the calf muscles and skin over abdomen, is
evidence of dehydration.
• B. The soles and palms are often bluish and cold in early infancy; this is of
no significance.
• C. The degree of anemia cannot be determined reliably by inspection, since
pallor (even in the newborn) may be normal and not due to anemia.
• D. To demonstrate pitting edema in a child it may be necessary to exert
prolonged pressure.
• E. A few small pigmented nevi are commonly found, particularly in older
children.
• F. Spider nevi occur in about 1/6 children under 5 years of age and almost ½
of older children.
• G. "Mongolian spots" (large, flat black or blue-black areas) are frequently
present over the lower back and buttocks; they have no pathologic
significance.
• H. Cyanosis will not be evident unless at least 5 gm of reduced hemoglobin
are present; therefore, it develops less easily in an anemic child.
• I. Carotenemic pigmentation is usually most prominent over the palms and
soles and around the nose, and spares the conjunctivas.
General Physical Examination
Thorax
• Shape and symmetry, veins, retractions and pulsations,
Harrison's groove, flaring of ribs, pigeon breast, funnel
shape, size and position of nipples, breasts, length of
sternum, intercostal and substernal retraction,
asymmetry, scapulas, clavicles.
• *Practical notes:
• At puberty, in normal children, one breast usually begins
to develop before the other. In both sexes tenderness of
the breasts is relatively common. Gynecomastia is not
uncommon in the male.
General Physical Examination
Lungs
• Type of breathing, dyspnea, prolongation of expiration, cough,
expansion, fremitus, flatness or dullness to percussion, resonance,
breath and voice sounds, rales, wheezing.
• *Practical notes:
• A. Breath sounds in infants and children normally are more intense
and more bronchial, and expiration is more prolonged, than in
adults.
• B. Most of the young child's respiratory movement is produced by
abdominal movement; there is very little intercostal motion.
• C. If one places the stethoscope over the mouth and subtracts the
sounds heard by this route from the sounds heard through the chest
wall, the difference usually represents the amount produced
intrathoracically.
General Physical Examination
Heart
• Location and intensity of apex beat, precordial bulging,
pulsation of vessels, thrills, size, shape, auscultation (rate,
rhythm, force, quality of sounds - compare with pulse as to
rate and rhythm; friction rub-variation with pressure),
murmurs (location, position in cycle, intensity, pitch, effect of
change of position, transmission, effect of exercise).
• *Practical notes:
• A. Many children normally have sinus arrhythmia. The child
should be asked to take a deep breath to determine its effect
on the rhythm.
• B. Extrasystoles are not uncommon in childhood.
• C. The heart should be examined with the child recumbent.
Pediatric Assessment Triangle
• Appearance
• Awake
• Aware
• Upright
• Work of breathing
• Retractions
• Noises
• Skin circulation
Appearance
• Tone
• Interactiveness
• Consolability
• Look/Gaze
• Speech/Cry
Appearance
• Appearance reflects adequacy of ventilation, oxygenation, brain
perfusion, body homeostasis, and central nervous system (CNS)
function.
• The “tickles” (TICLS) mnemonic helps to recall observations that give a
general impression of appearance.
• Tone: Is there normal motor movement? Is the infant/child limp and
listless, or moving vigorously?
• Interactiveness: Is the patient alert? Irritable? Lethargic? Does the
patient respond appropriately to the environment?
• Consolability: Is the patient easily comforted/consoled? Is he/she
agitated and inconsolable?
• Look/Gaze: Does the patient fix on a face or object, or is the patient
glassy-eyed, with a “nobody-home” stare?
• Speech/Cry: Is the cry/speech weak, muffled, hoarse? An infant with
poor brain perfusion, CNS infection, or brain injury often will have a
high-pitched or cephalic cry.
• Appearance is very dependent on the child’s developmental age.
Work of Breathing
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Abnormal airway sounds
Abnormal positioning
Retractions
Nasal flaring
Head bobbing
WOB
• Work of breathing is a quick observational indicator of the adequacy of
oxygenation and ventilation.
• Observe the patient carefully before laying on hands. Listen for audible
sounds, and look for signs of increased effort to breathe.
• Abnormal airway sounds include:
• Stridor, muffled speech, hoarse voice, and snoring all reflect upper airway
obstruction.
• Grunting is caused by an effort to exhale on a closed glottis to keep alveoli
from collapsing, and suggests lower airway disease.
• Wheezing is caused by lower airway partial obstruction as heard with asthma
or bronchiolitis.
• The position that a patient with increased work of breathing takes is
revealing. Tripoding is seen in patients trying to maximize use of
accessory muscles to improve ventilation. The “sniffing” position is seen
with severe upper airway obstruction as an attempt to line up the axes
of the airway to improve air flow.
• Look carefully for retractions in the intercostal and supraclavicular
areas.
• Nasal flaring and head bobbing are signs of severe respiratory distress.
Circulation to Skin
• Pallor
• Mottling
• Cyanosis
• The skin is an organ that has easily seen visual responses to
both early and late shock, as well as respiratory failure. Taking
time to observe skin color and signs is time well spent!
• Pallor cannot be ignored. In the trauma patient, it can be a sign
of significant occult internal bleeding and need for immediate
fluid/blood resuscitation. In the patient with septic or
hypovolemic shock, it suggests the need for rapid fluid
resuscitation. Children have excellent catecholamine
responses to shock, and this can be easily seen as pallor
when assessing the PAT.
• Mottling occurs when the skin starts to lose microvascular
integrity. Areas of vasodilatation interspersed with
vasoconstriction will give a patchy network of pallor, erythema,
and/or cyanosis that is referred to as mottling. This is a premorbid condition, and late sign of shock. In small infants,
mottling should not be confused with cutis marmorata, or
irregular marbled skin often seen in a cool ambient
environment.
• Cyanosis reflects poor tissue oxygenation, and can be seen
with respiratory failure or cardiorespiratory compromise.
General Approach
• Pediatric Assessment Triangle (PAT)
• Hands-on assessment of ABCDEs
• Pediatric differences
Airway
• Airway opening maneuvers:
•
Head tilt-chin lift, jaw thrust
• Suction:
•
Often dramatic improvement in infants
• Age-specific obstructed airway support:
• <1 year: Back blow/chest thrust
• >1 year: Abdominal thrust
• Advanced airway techniques
Breathing: Auscultation
• Midaxillary line, above sternal notch
• Stridor:
Upper airway obstruction
• Wheezing: Lower airway obstruction
• Grunting: Poor oxygenation; pneumonia,
drowning, pulmonary contusion
• Crackles: Fluid, mucus, blood in airway
• Decreased /
absent breath
sounds:
Obstruction
Vital Signs by Age
Age
Respirations
(breaths/min)
Pulse
(beats/min)
Systolic Blood
Pressure
(mm Hg)
Newborn: 0 to 1 mo
30 to 60
90 to 180
50 to 70
Infant: 1 mo to 1 yr
25 to 50
100 to 160
70 to 95
Toddler: 1 to 3 yr
20 to 30
90 to 150
80 to 100
Preschool age: 3 to 6 yr
20 to 25
80 to 140
80 to 100
School age: 6 to 12 yr
15 to 20
70 to 120
80 to 110
Adolescent: 12 to 18 yr
12 to 16
60 to 100
90 to 110
Older than 18 yr
12 to 20
60 to 100
90 to 140
•Slow or fast respirations are worrisome
Circulation
• Pulse: Central, peripheral pulse quality
• Skin temp: “Reverse thermometer” sign
• Capillary refill: ≤ 2 sec, warm finger, 5 sec
• B/P: Minimum = 70 + (2 X age in years)
Respirations
• Abnormal respirations are a common sign of illness or
injury.
• Count respirations for 30 seconds.
• In children less than 3 years, count the rise and fall of
the abdomen.
• Note effort of breathing.
• Listen for noises.
Pulse
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In infants, feel over the brachial or femoral area.
In older children, use the carotid artery.
Count for at least 1 minute.
Note strength of the pulse.
Blood Pressure
• Use a cuff that covers two thirds of the upper
arm.
• If scene conditions make it difficult to measure
blood pressure accurately, do not waste time
trying.
Skin Signs
• Feel for temperature
and moisture.
• Estimate capillary refill.
Disability (and Dextrose)
• AVPU scale:
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Alert
Verbal: Responds to verbal commands
Painful: Responds to painful stimulus
Unresponsive
• (Pediatric) Glasgow Coma Scale
• Check Dextrose (glucose) if impaired
Exposure / Environment
• Full Exposure Necessary
• Evaluate physiologic function
• Identify anatomic abnormalities
• Maintain warm ambient environment
• Minimize heat loss
• Monitor temperature
• Warm IV fluids
Reassess
• General impression (PAT)
• ABCDE
• Continually reassess ABCs for response to therapy
The Bottom Line
• Begin with PAT, then ABCDEs.
• Form a general impression to guide priorities.
• Treat respiratory distress, failure, and shock as they are
recognized.
• Focused history and detailed PE.
• Reassessment throughout ED stay.
Airway / Breathing
Objectives
• Compare anatomic, physiologic differences b/w adult &
pediatric airway
• Distinguish respiratory distress from failure
• Describe clinical features of upper and lower airway obstruction
and diseases of the lung
Respiratory arrest vs cardiac arrest intact
survival rates in children
90
80
70
60
50
40
30
20
10
0
Respiratory
Cardiac
Why do children have more respiratory
difficulties?
• Anatomic
• Physiologic
Anatomy
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Large occiput –
need shoulder roll
Large tongue –
obstruction
Cephalad larynx – difficult to visualize
Soft epiglottis –
use Miller blades
Smallest diameter below cords
Small airways –
high resistance
Physiology: Pediatric vs Adult
• Higher Basic Metabolic Rate = Shorter time to Desaturation
• (6-8 mL/kg vs 3-4)
• Smaller airways =
• Higher Airway Resistance (1/R4)
• Prolonged respiratory distress -> failure
Physiology: Time to Desaturation
Signs of Respiratory
Distress and Failure
•Respiratory Distress
• Tachypnea
• Stridor
• Retractions
• Head bobbing
• Nasal Flaring
•Respiratory Failure
• Altered mental
status
• Poor resp effort
• Bradypnea
• Bradycardia
• Apnea
•Resp failure = inadequate oxygenation or
ventilation
Care of the Pediatric Airway
• Positioning the airway:
• Place the patient on a firm
surface.
• Fold a small towel under
the patient’s shoulders and
back.
• Place tape across patient’s
forehead to limit head
rolling.
Oropharyngeal Airways
• Determine the appropriately sized
airway.
• Place the airway next to the face to
confirm correct size.
• Position the airway.
• Open the mouth.
• Insert the airway until flange rests
against lips.
• Reassess airway.
Nasopharyngeal Airways
• Determine the appropriately sized
airway.
• Place the airway next to the face
to make certain length is correct.
• Position the airway.
• Lubricate the airway.
(1 of 2)
Nasopharyngeal Airways
• Insert the tip into the right
naris.
• Carefully move the tip
forward until the flange
rests against the outside of
the nostril.
• Reassess the airway.
(2 of 2)
Assessing Ventilation
• Observe chest rise in older children.
• Observe abdominal rise and fall in younger children or
infants.
• Skin color indicates amount of oxygen getting to organs.
Oxygen Delivery Devices
• Nonrebreathing mask at 10 to 15
L/min provides 90% oxygen
concentration.
• Blow-by technique at 6 L/min
provides more than 21% oxygen
concentration.
• Nasal cannula at 1 to 6 L/min provides
24% to 44% oxygen concentration.
BVM Devices
• Equipment must be the right size.
• BVM device at 10 to 15 L/min provides 90% oxygen
concentration.
• Ventilate at the proper rate and volume.
• May be used by one or two rescuers
One-rescuer BVM Ventilation
•A
•B
•C
•D
Airway Obstruction
• Croup
• A viral infection of the airway below the level of the vocal cords
• Epiglottitis
• Infection of the soft tissue in the area above the vocal cords
• Foreign body airway obstructions
Signs and Symptoms
• Decreased or absent breath sounds
• Stridor
• Retractions
• Difficulty speaking
Signs of Severe
Airway Obstruction
• Signs and symptoms
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Ineffective cough (no sound)
Inability to cry
Increasing respiratory difficulty, with stridor
Cyanosis
Loss of consciousness
Removing a Foreign Body Airway
Obstruction
(1 of 5)
• In an unconscious child:
• Place the child on a firm, flat surface.
• Open airway using head tilt-chin lift maneuver.
• Inspect the upper airway and remove any visible object.
• Attempt rescue breathing.
• If unsuccessful, reposition head and try again.
• If ventilation is still unsuccessful begin CPR.
Removing a Foreign Body Airway
Obstruction
(2 of 5)
• Place heel of one hand on lower half of sternum between
the nipples.
• Administer 30 chest compressions at a depth of 1/3 to 1/2
the depth of the chest.
Removing a Foreign Body Airway
Obstruction
(3 of 5)
• Open airway using head tilt-chin lift maneuver. If you see
the object, remove it.
• Repeat process.
Removing a Foreign Body Airway
Obstruction
(4 of 5)
• In a conscious child:
• Kneel behind the child.
• Give the child five abdominal
thrusts.
• Repeat the technique until
object comes out.
Removing a Foreign Body Airway
Obstruction
(5 of 5)
• If the child becomes
unconscious, inspect the
airway.
• Attempt rescue breathing.
• If airway remains obstructed,
begin CPR.
Management of Airway
Obstruction in Infants
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Hold the infant facedown.
Deliver five back slaps.
Bring infant upright on the thigh.
Give five quick chest thrusts.
Check airway.
Repeat cycle as often as necessary.
Neonatal Resuscitation
• Resuscitation measures include:
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Positioning airway
Drying
Warming
Suctioning
Tactile stimulation
Additional Efforts
• Deliver chest compressions at 120
per minute.
• Coordinate chest compressions
with ventilations at a ratio of 3:1.
• If meconium is present, suction
infant vigorously.
BLS Review
• Cardiac arrest in children is commonly due to respiratory
arrest.
• Many causes of respiratory arrest
• For purposes of pediatric BLS:
• Infancy ends at 1 year of age.
• Childhood extends from 1 year of age to onset of puberty
(12 to 14 years of age).
Determine Responsiveness
• Gently tap on shoulder and speak loudly.
• If responsive, place in position of comfort.
• If you find an unresponsive child when you are not on duty:
• Provide BLS for about 2 minutes.
• Then call EMS system.
Airway
• Airway may be obstructed by tongue.
• Use head tilt-chin lift technique or jaw-thrust
maneuver to open the airway.
• Jaw-thrust maneuver is safer if possibility of neck
injury exists.
Past Medical History
• Components of the PMH that may contribute to
establishing a diagnosis:
• History of prematurity
• Birthweight
• Need for and duration of oxygen therapy and/or
assisted ventilation in the neonatal period
• Previous emergency room visits or hospitalizations
for respiratory disturbances (including ICU
admissions and any need for assisted ventilation)
• Previous surgeries
• Immunization history
Review of Symptoms
• Symptoms not recognized with HPI
• Multiple body systems
Family History
• Important conditions
• Biological parents
• Siblings
• Other close relatives
Social and Environmental History
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Home life
Caregivers
School
Social participation
Exposures
• Travel
History for Established
Patients
Pulmonary Examination
• Calm
• Expeditious
• Professional
Inspection
• Vital signs
• Signs of respiratory distress
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Grunting
Retractions
Accessory muscle use
Abdominal/chest wall synchrony
Inspection (cont.)
• Thoracic configuration
• AP diameter
• Shape
Palpation
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Vibrations
Chest excursion
Tracheal position
Masses
Percussion
• Limited benefit
• Hyperresonance
• Pneumothorax
• Dull
• Pleural effusion
Auscultation
• Stridor
• Stertor
• Wheezes
• Rhonchi
• Crackles
Nonpulmonary Assessment
• Height/weight
• Other body systems
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Neurologic
Adenopathy
Ears, eyes, nose, and throat
Cardiac
Abdomen
Skin
Extremities
Healthcare Team
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Physicians
Nurses
Respiratory therapists
Speech pathologists
Physical and occupational therapists
And others. . . .
Case 1 – Airway/Breathing
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cc:
“Funny breathing”
HPI: 14 month male with acute resp dist. No prior
symptoms. Mom in other room, noted “funny
breathing” while he was playing on the floor.
ROS: No fevers, Otherwise well
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PE:
Gen:
Pulm:
CV:
AF, VSWNL except RR 50
Awake, alert, stridor at rest, mod resp dist
Retractions x3, transmitted airway sounds
RRR, no m/r/g, nl pulses, cap refill
Case 1 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Start CPR
f)
Discharge home
Case 1 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Start CPR
f)
Discharge home
•Note that the coin is in the
esophagus as determined by
the circular AP projection,
linear lateral projection, and
airway visible in front of the
coin on the lateral.
Case 1 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Start CPR
f)
Discharge home
Case 1 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Start CPR
f)
Discharge home
Case 2 – Airway/Breathing
•
•
•
•
•
•
•
cc:
“Choked”
HPI: 9 month male with difficulty breathing. Mom
was feeding him grapes and peanuts. Had a choking
episode, was making “funny sounds”, then during
your exam stopped breathing and turned blue.
ROS: No fevers, Otherwise well
PE:
AF, resp effort at 60, HR 190, SpO2 65%
Gen: Limp, cyanotic.
Pulm: Supraclavicular retractions, no air entry
CV:
Tachycardic, no m/r/g, 2+ pulses, ↓ CR
Case 2 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Perform cricothyroidotomy
f)
Discharge home
Case 3 – Airway/Breathing
•
•
•
•
•
•
•
cc:
“Trouble breathing”
HPI: 9 month male with difficulty breathing.
Cough, difficulty breathing x 4 days. Not taking fluids
well, now “lethargic”.
ROS: Fever to 102 F, decreased wet diapers.
PE:
AF, RR 12, HR 190, SpO2 78%
Gen: Limp, shallow resp effort.
Pulm: Coarse bs, poor air entry
CV:
Tachycardic, no m/r/g, central pulses only, ↓
CR 5-6 seconds
Case 3 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Perform cricothyroidotomy
f)
Discharge home
Case 3 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Perform cricothyroidotomy
f)
Discharge home
Case 2 – Airway/Breathing
•
•
•
•
•
•
•
cc:
“Choked”
HPI: 9 month male with difficulty breathing. Mom
was feeding him grapes and peanuts. Had a choking
episode, was making “funny sounds”, then during
your exam stopped breathing and turned blue.
ROS: No fevers, Otherwise well
PE:
AF, resp effort at 60, HR 190, SpO2 65%
Gen: Limp, cyanotic.
Pulm: Supraclavicular retractions, no air entry
CV:
Tachycardic, no m/r/g, 2+ pulses, ↓ CR
Case 2 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Perform cricothyroidotomy
f)
Discharge home
Case 3 – Airway/Breathing
•
•
•
•
•
•
•
cc:
“Trouble breathing”
HPI: 9 month male with difficulty breathing.
Cough, difficulty breathing x 4 days. Not taking fluids
well, now “lethargic”.
ROS: Fever to 102 F, decreased wet diapers.
PE:
AF, RR 12, HR 190, SpO2 78%
Gen: Limp, shallow resp effort.
Pulm: Coarse bs, poor air entry
CV:
Tachycardic, no m/r/g, central pulses only, ↓
CR 5-6 seconds
Case 3 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Perform cricothyroidotomy
f)
Discharge home
Case 3 – Airway/Breathing
•
Would you:
a)
Use a BVM, prepare to Intubate
b)
Give abdominal thrusts
c)
Give back blows/chest thrusts
d)
Place in position of comfort
e)
Perform cricothyroidotomy
f)
Discharge home
•Cardiac Output
CO = HR x Stroke Volume
•Infants/children ↑ CO by ↑HR >> SV
•Pediatric patients primarily increase their cardiac
output by increasing their heart rate. Careful
attention should be paid to patients with tachycardia
without a clear cause, as it is often the first sign of
shock in a pediatric patient.
•However, a rapid heart rate may also be caused by
fever, fear, pain, or excitement.
•When assessing for shock or hypoxemia, the trends
of heart rate over time can be very helpful.