Transcript Pediatric Review - For Medical Professionals

Pediatric Emergencies
Aurora Health Care
South Region EMS System
4th Quarter, 2008 CE
Prepared by: Justin Klis, NREMT-P, CCEMT-P
Objectives
Upon successful completion of this module,
the EMS provider should be able to:
• identify critical situations in the pediatric
population
• identify and appropriately state
interventions for a variety situations
• successfully complete the quiz with a score
of 80% or better…..j/k
Children are
not small
adults!
Relationship of Head to Body
Changes
Pediatric Population Defined
• A patient under the age of 16 is considered
to be a pediatric patient
• This means the patient is 15 years of age or
less
• When medications are calculated based on
the pediatric patient weight, the dose is to
never exceed the amount that would be
administered to an adult!
Children and EMS
Adults may be glad to see EMS arrive
but
children are often frightened when EMS
comes to their rescue
Critical Determination
• Rapid assessment needs to be performed to
determine:
– Is this child sick or not?
– Any sick child needs immediate attention
and intervention
Pediatric Assessment Triangle
(PAT)
• Helps establish a general impression
• Used to:
establish a level of severity
determine urgency for life support
identify key physiological problems
• Provider to assess:
appearance
work of breathing
circulation to skin
Pediatric Assessment Triangle
(PAT)
Pediatric Assessment Triangle
(PAT)
•
•
•
•
Does not require any equipment to complete
Uses observational and listening skills
Can be completed in under 60 seconds
To be used as you “cross the room” to make
contact with the patient
Pediatric Assessment Triangle
(PAT)
• Evaluates underlying cardiopulmonary,
neurological, and metabolic states
• Can help identify the general physiological
problem for the child
• PAT does not replace vital signs and the
ABCDE’s but precedes & compliments them
Pediatric Assessment
• Scene size-up
• General assessment - pediatric assessment triangle
(PAT)
• Initial assessment
– ABCDE’s and transport decision
• Additional assessment
– focused history and physical exam; detailed physical
exam if trauma
• Ongoing assessment
Pediatric Assessment Triangle
Appearance
Reflects adequacy of:
oxygenation
ventilation
brain perfusion
homeostasis
CNS function
Assessing Appearance
Evaluate:
muscle tone
mental status/interactivity level
consolability
look or gaze
speech or cry
Pediatric Assessment Triangle
Breathing
Reflects:
adequacy of oxygen
oxygenation
ventilation
Assessing Breathing
Evaluate:
body position
visible movement of chest or abdomen
 <6-7 years old is primarily a
diaphragmatic breather (belly breather)
respiratory rate & effort
audible airway sounds
Pediatric Assessment Triangle
Circulation
Reflects:
adequacy of cardiac output and
perfusion of vital organs (core perfusion)
Assessing Circulation
Evaluate:
skin color
peripheral cyanosis refers to the extremities
central cyanosis is always pathological; evaluated in the
central part of the body: mucous membranes of the mouth
and trunk area
– reflects decreased oxygen in arterial blood
• Trunk mottling indicates hypoxemia
• Cyanosis indicates respiratory failure and
vasoconstriction
Principles of Infant Assessment
• Ask caregiver for patient’s name & use it
• To decrease the infant’s stress, perform assessment in
the following order:
observation
auscultation
palpation
• Approach infant slowly, calmly, and talk in quiet
voices; warm your hands before contact
• Try to be at patient’s eye level
Infant Assessment
• Observe interaction between caregiver and infant
• Consider offering a toy as a distraction
• Perform assessment based on acuity level
 if quiet & calm, obtain respiratory rate and breath sounds
 if critical, obtain most important information 1st
• Make non-threatening contact 1st
 make 1st contact with extremity & can also obtain
capillary refill simultaneously
Principles of Toddler Assessment
• Beginning to assert independence but fearful of
separation from caregiver
• Approach slowly; keep contact to a minimum
• Be at eye level
• If possible, allow toddler to stay on caregiver’s lap
• Introduce equipment slowly and use distraction (ie:
penlight, toy)
• A toddler is the center of his universe - ask questions
about them (ie: pets, clothing, events)
Toddler Assessment
• Keep choices limited (ie: “should I use the red or
blue package”)
• Ask open ended questions; avoid yes/no questions
• Praise toddler to get cooperation
• Use simple, concrete terms
• Perform most critical part of assessment 1st
moving in toe-to-head order
• Ask caregiver to assist (ie: removing clothing,
holding stethoscope)
• Toddlers do not sit still
Principles of Preschooler
Assessment
• Magical and illogical thinkers; fear loss of
control; short attention spans
• Use simple terms; explain procedures
immediately before performing
• Allow child to handle equipment
• It’s okay to set limits (ie: “you can cry but you
cannot kick”)
• Focus on one thing at a time
Principles of School-aged
Assessment
• Fear separation from caregiver; loss of
control, pain, & physical disability
• Speak directly to child, then to caregiver
• Respect privacy, these children are modest
• Don’t offer too much information; do use
terms the child can understand; explain
immediately before the procedure is done
School-Aged Assessment
• Don’t negotiate unless there really is a
choice (ie: IV in right or left hand, not if it
is okay to start the IV)
• Offer praise for cooperation
• Physical assessment okay to be performed
in head-to-toe format
Principles of Adolescent
Assessment
• Time for experimentation and risk-taking
behaviors
• Struggle with independence, loss of control,
body image, sexuality, and peer pressure
• Relying more on friends than family
• When ill or injured, often revert back to
lower maturity level
• Explain what you are going to do and why
Adolescent Assessment
• Encourage questions and involvement of the
adolescent
• Show respect; speak directly to teen
• Respect privacy and confidentiality
• Be honest and nonjudgmental
Pediatric Assessment - Appearance
• Provides most important look into the status of
the child - are they sick or not?
• Start observation as you 1st enter the scene and
while the child is still with the caregiver
– immediate hands-on may increase agitation,
crying and may interfere with a true picture
– immediate hands-on is necessary if the child
is unconscious or obviously critically ill
Normal/Abnormal Appearance
• Normal appearance
– good eye contact, has good muscle tone, and good color
• Abnormal appearance
– poor eye contact, listless, and pale
Appearance doesn’t indicate the cause of illness or
injury but reflects that a problem is going on
Normal Appearance In Setting Of
a Critical Situation
Maintain index of suspicion in children that look okay
initially but may soon become critically ill:
toxicological problems (overdoses)
blunt trauma
• powerful compensation abilities may fool the
examiner
• when the child “crashes” they will crash quickly
with rapid progression to decompensated shock
Work of Breathing
• In the pediatric patient, evaluation of work of
breathing gives great insight into the pediatric
patient’s oxygenation & ventilation status’
• Listen for abnormal airway sounds
• snoring, muffled or hoarse speech, stridor, grunting,
wheezing
– Look for signs of increased breathing effort
• sniffing position, tripoding, refusing to lie down
• retractions (neck, intercostal, substernal muscles)
• nasal flaring
Tripod
Positioning
leaning
forward,
hands resting
on thighs
Costal
retractions &
use of
accessory
neck muscles
Abnormal Breath Sounds
 Upper airway obstruction
– snoring, muffled, hoarse speech, stridor
• stridor - high-pitched inspiratory sound; abnormal
airflow across partially obstructed upper airway
• Potential causes
–
–
–
–
–
croup
foreign body
aspiration
bacterial upper airway infection
bleeding, edema
Abnormal Breath Sounds
 Grunting
–
–
–
–
–
exhaling against a partially closed glottis
keeps alveoli open for maximum gas exchange
sound heard best at end of exhalation
often present with moderate to severe hypoxia
reflects poor gas exchange due to fluid in lower airways
• Potential causes
– pneumonia
– pulmonary contusion
– pulmonary edema
Abnormal Breath Sounds
 Wheezing
–
–
–
–
continuous high-pitched musical sound; a whistle
movement of air across partially blocked small airways
in disease process heard earliest during exhalation
as obstruction increases, heard during inhalation and
exhalation
– with increased obstruction heard audibly
• Most common cause - asthma
• Other potential causes
– bronchiolitis
– lower airway foreign body aspiration
Abnormal Visual Signs Increased Work of Breathing
Providers must evaluate visually to determine evidence
of increased work of breathing
– this means all patients need to be eventually undressed for
observation of the neck & chestwall
• Sniffing position - severe upper airway obstruction;
used as attempt to increase airflow
• Tripoding - refuses to lie down, leans forward on
outstretched arms; attempting to use accessory
muscles to breath
• Retractions - use of accessory muscles to
help breath; using extra muscle power to
move air into lungs; more prominent in
child than adult;
– includes head bobbing - use of neck
muscles during severe hypoxia
– includes nasal flaring - exaggerated
nostril opening during inspiration;
moderate to severe hypoxia
Respiratory Distress
Evaluating Respirations
• Respiratory rate
– Best to count for a minimum of 30 seconds due to the
natural irregularity of the pattern
• Breath sounds
– Place the stethoscope as lateral as possible
• Pulse oximetry
– Evaluate results along with work of breathing
– Readings above 94% indicates probably good
oxygenation
Normal Respiratory Rates By Age
•
•
•
•
•
Infant
Toddler
Preschooler
School-aged child
Adolescent
30-60 breaths/minute*
20-30 breaths/minute*
20-30 breaths/minute*
20-30 breaths/minute*
15-20 breaths/minute*
Trending more helpful than a single reading
*Values differ by source
Abnormal Visual Signs Poor Circulation to the Skin
• Cold environment may cause false skin
signs
• Inspect skin and mucous membranes
• Look at face, chest, abdomen,
extremities, and lips
• Dark complexion patients
– assess lips and mucous membranes
• Circulation to skin reflects overall status of
core circulation
– pallor - early sign; compensated shock
– mottling - constriction of blood vessels to
the skin
– cyanosis - late finding of respiratory
failure or shock; critical finding that
indicates immediate resuscitative action
Evaluating Circulation
• Heart rate - bradycardia is ominous sign
• Pulse quality
– Brachial is the peripheral site for a child under one
– Central pulse - femoral in infants and young children; carotid
in older child or adolescent
• Skin temperature and capillary refill
– Good locations are at the kneecap or the forearm
• Blood pressure
– Should make an attempt on children older than 3
– Cuff size should cover 2/3 the length of the upper arm
Normal Heart Rates by Age
•
•
•
•
•
Infant
Toddler
Preschooler
School-aged child
Adolescent
100-160 beats per minute
90-130 beats per minute
80-120 beats per minute
70-120 beats per minute
70-120 beats per minute
Bradycardia indicates critical hypoxia and/or
ischemia and indicates need for immediate
interventions
Patient Deterioration
• Always be assessing for changes in patient status
• Key information that points to a patient change
– watch for rapid decrease in appearance
especially interactiveness
– watch heart rate especially if the rate begins to
drop
– watch for irregularity of the respiratory pattern
Pediatric Protocol’s
Routine Care
• General patient assessment - pediatric
assessment triangle (PAT)
appearance
work of breathing
circulation to skin
• Initial assessment - ABCDE’s
• Identify priority patient and make transport
decision
• Additional assessment and interventions
–
–
–
–
–
vital signs
determine weight and age
pulse oximeter before & during O2
cardiac rhythm if applicable
IV/IO access (20 ml/kg administered if fluid challenge
is necessary)
– determine blood glucose if indicated
• altered level of consciousness
• unconscious, unknown reason
• known diabetic and related problem
– reassess previous assessments & appropriateness of
interventions performed
• Detailed physical exam
• Contact Hospital
• Transport to closest most appropriate hospital
Always remember to keep child
warm; hypothermia increases the
rate of complications and negative
outcome
Patient Treatment
• Prior to any treatment, assessment must be
done
• EMS needs to obtain a general impression
– this drives the decision regarding which
SOP to work from
• EMS needs to think “cause” of the situation
which can also drive a decision on which
Protocol to use
Hypoglycemia
• Dextrose
– Sugar to replace depleted stores
– Brain extremely sensitive to a drop in glucose levels
– Dose if less than 1 year old
• 12.5% 2 ml/kg
– Dose for ages 1 - 2
• 25% 4 ml/kg
– Dose for ages older than 2
• 50% 2ml/kg
Glucose Dosing
• Diluting D 25% to make D 12.5%
– Calculate total dose volume required
– Half the dose volume is D 25%; half the dose
volume is normal saline
– Mix 50/50 solution and administer slowly
Case Study
• A 12 year-old boy calls 911 for his unconscious 2
year-old sister
• The brother reports a few minutes of full body
shaking by the sister; you are informed that the
patient was recently diagnosed as a diabetic and she
takes “shots”
• The patient is unresponsive, limp, pulse rate 140;
RR 30; B/P 98/68
• What is your impression?
• What is your approach/intervention?
Case Study
• This child is most likely hypoglycemic
• Sugar stores are quickly used and the brain is the most
sensitive organ to  glucose levels
• Protect the airway (positioning, have suction
available)
• Obtain IV access and evaluate the glucose level (this
patient’s blood sugar is 40)
• This patient needs dextrose (glucagon if no IV)
– 1-2 years old = D25% (4 ml/kg)
– Patient weighs 25 pounds
Practice Math - How much
Dextrose does this patient receive?
• 25 pounds  2.2 kg = ? kg
2.2 25 (move decimal to right in both
numbers)
22 250 = 11 kg
• D 25% formula: 4 ml/kg
· 4(ml) x 11(kg) = 44 ml D25%
• Administer slowly through largest vein
available (irritating to veins)
Hypoglycemia
• Glucagon
– In the absence of IV access
– If < 20 kg 0.5 mg IM
If > 20 kg 1 mg IM
– Must be reconstituted
– May be followed by Dextrose if IV access
obtained & no improvement in LOC
Asthma
• Earliest in disease will auscultate bilateral wheezing
breath sounds heard first on exhalation
• Eventually will hear audible wheezing standing next
to the patient
• A silent chest (no breath sounds can be heard with a
stethoscope) is a critical (deadly) situation in any
patient
• Patients in an acute asthma attack are dry (lose
moisture from the increased respiratory rate) and are
potentially hypoxic
Asthma
• Albuterol and Atrovent
– Bronchodilator with some cardiac side effects
(HR &  strength of contractions (“pounding
heart”))
– 2.5 mg / 3ml of Albuterol and 500 mcg of
Atrovent in nebulizer
– May need to use mask in place of mouthpiece
– Encourage deep & slow breaths
Nebulizer Mask - when the patient
can’t tolerate the mouthpiece
Pediatric Shock
• Hypovolemic
– Hemorrhage, diarrhea, vomiting,  fluid intake
• Cardiogenic
– Usually congenital
• Distributive
– Sepsis (massive infection), anaphylaxis
– If allergic response, add that protocol
• Treatment
– Fluid challenge 20 ml/kg; repeated once more
• Reassess as every 200 ml is being administered
Case Study
• You have been called to the home for a 6month-old vomiting for 24 hours.
• The infant is lying still with poor muscle tone;
irritable if touched; weak cry.
• No abnormal airway sounds, retractions, or nasal
flaring.
• Skin is cool, pale, mottled, with 4 second capillary
refill time, weak brachial pulse.
• Heart rate 180; RR 30; breath sounds clear.
• Abdomen is distended.
• Impression? Intervention needed?
Case Study
• This infant is severely ill - in shock
– Poor appearance, diminished tone, poor interactiveness,
weak cry
– Requires resuscitation & rapid transport
• Vital signs are deceptive
– Need to be correlated with pediatric assessment triangle
& full assessment
• Immediate airway support (possible BVM
support)
• IV/IO access - fluid challenge 20 ml/kg
Do The Math - How Much Fluid?
• The patient weighs 15.5 pounds.
• What is the amount of the fluid challenge that needs
to be administered?
• How is the fluid challenge to be administered?
• 15.5  2.2  2.2 15.5 (move decimal point over
to the right one space in each number)
• 22 155 = 7 kg
• 7 kg x 20 ml = 140 ml fluid challenge NS
• Administer in under 20 minutes; reevaluate
Pediatric Croup
• Viral; infant/toddler population; low grade
fever; barking cough
– Humidified O2
• 6 ml NS in nebulizer, place mask near child’s
face
– If wheezing, Albuterol 2.5 mg with Atrovent 500
mcg
– If unstable (cyanotic, respiratory distress), begin
BVM ventilations
Pediatric Epiglottits
• Bacterial; usually 4 year-old and upward in age
(no upper age limit); high fever; drooling; stridor
– Blow by O2
– If patient deteriorates, ventilation via BVM
True emergency requiring gentle handling,
avoidance of agitating the patient, and rapid
transport
Pediatric Seizures
• Remember to check glucose levels
– check on all altered/abnormal level of
consciousness patients & known diabetics with
diabetic related problem
Allergic Reactions
• There is exposure to an antigen and the response is to
form antibodies
• Immune response activated
• Antihistamines (ie: Benadryl) given to stop histamines
from their normal action/response
–
–
–
–
–
conjunctivitis - inflammation of the eye
rhinitis - inflammation of nasal mucous membranes
angioedema - localized edema in tissues
urticaria - itchy skin rash
contact dermatitis - inflammation of skin
• Vasopressors (Epinephrine) given in the
presence of airway swelling, difficulty
breathing, or clinical signs of shock
– Reverses bronchoconstriction to improve
the respiratory status
– Supports a falling blood pressure
– In shock, IM a more predictable
absorption than SQ route
Pediatric Allergic Reaction
Stable
• Patient alert, skin warm & dry
• Irritating signs and symptoms
– hives, itching, rash
– GI distress
Pediatric Allergic Reaction Stable
with Airway Involvement
• Patient alert; skin warm & dry
• Has external signs & symptoms now with itchy
or scratchy throat, hoarseness, wheezing
• Epinephrine 1:1000 SQ
– 0.01 mg/kg (maximum 0.3 ml/dose)
• Albuterol and Atrovent nebulizer
Pediatric Allergic Reaction
Anaphylactic Shock
• Patient with altered mental status
– THEY ARE IN SHOCK!!!
• Epinephrine 1:1000 IM 0.01 mg/kg (max
0.3 ml/dose)
• IV fluid challenge 20 ml/kg (max 60 ml/kg)
• Albuterol and Atrovent nebulizer
Epi-Pens
• Packaging
– Epi-pen (adult) - 0.3mg/0.3ml
– Epi-pen Jr (pediatrics) 0.15 mg/0.3ml
• Expiration dates need to be evaluated
• To use an Epi-pen
–
–
–
–
Form fist around unit
Remove black tip - keep fingers away from opening
Pull off gray safety release
Jab black tip firmly into outer thigh 900 angle
(perpendicular)
– Hold firmly for 10 seconds then remove
– Massage site for 10 seconds
– Dispose of unit
• Patients may have been instructed to replace unit into carrier
and return to prescribing MD for new prescription
Can go
through
clothing
Questions????