Transcript The Pediatric Patient

Pediatric Disaster Life Support
(PDLS©):
Pediatric Disaster Medicine
The Fundamentals: Anatomy, Physiology,
Disaster Specific Patterns of Injury
Body Size and Composition
• height and weight increase throughout childhood
• less protective fat and muscle
• large surface area predisposes to hypothermia
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Anatomic Differences
• The youngest children have relatively larger and heavier
heads
• Relatively larger and less protected abdomens
– Penetrating injuries
– Primary and secondary impact from objects or blast wave
• Predisposition to more serious traumatic damage during
disasters compared to adult for the same injury
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Anatomic Differences
• Smaller mass may cause children to be thrown
further and faster, resulting in greater secondary
injuries upon impact
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Surface to Body Ratio
• Higher surface area and thinner skin
• Risk of exposure-related injuries
– Burns
– Hypothermia after decontamination
– Toxic exposure to the skin
– Dehydration
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Higher Baseline Metabolism
• Faster Respiratory Rate
– Dehydration
– Ingestion of toxins, smoke, dust
• Lower Blood Volume
– Shock from bleeding
– Greater risk from dehydration
• Greater relative metabolic needs
– Higher risk for malnutrition sooner than adults
– ↑ susceptibility to hypoglycemia?
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Size
• Live Closer to the Floor
– Risk of exposure to debris and water
– Greater chance of exposure to chemical or radioactive
residue
– Example: Infant contracts cutaneous anthrax on arm after
visiting ABC television studios targeted during the 2001
attack
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Size
• Hand-to-Mouth Activity
– Children routinely place hands and objects in mouth,
increasing risk of exposure to chemicals, toxins
– Increases risk of contracting vomiting and diarrheal
illness during unsanitary conditions such as in a shelter or
with exposure to contaminated water supply
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Immune Systems
• Young children do not have the same capacity as
adults to respond to infectious disease
– Biological agents
– Routine infections during sheltering
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How Children Decompensate
• Differently than adults
• Children rarely have primary cardiac event
• Pathway is predictable
– Focus is on respiratory problems and shock
– To know it is to prevent decompensation
– Recognize early signs and symptoms of respiratory
distress and shock
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Many Causes
Asthma, Shock
FB, Secretions
Toxins, etc.
Respiratory Distress
Compensated
Circulatory Distress
Compensated
Respiratory Distress
DECOMPENSATED
Circulatory Distress
DECOMPENSATED
RESPIRATORY FAILURE
CIRCULATORY FAILURE
FULL ARREST
DEATH
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Body Proportions
• body proportions account for unique injury patterns
in childhood
• large head increases risk of head injury
accompanying any other major traumatic injury
• large, “unprotected” intraabdominal organs
increases risk of liver, spleen, bowel injury following
less severe trauma
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Etiologies of Cardiopulmonary Failure
Many Etiologies
Respiratory
Failure
Circulation Failure
(shock)
Cardiopulmonary
Failure
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Respiratory Distress and Failure
• respiratory distress: increased work of breathing
• respiratory failure: inadequate oxygenation and/or
ventilation to meet metabolic needs
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Signs of Respiratory Distress and Failure
• signs of respiratory distress:
– tachypnea, tachycardia
– retractions (intercostal, supraclavicular, nasal flaring)
– grunting
• signs of respiratory failure
– altered mental status
– poor color
– hypotonia
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Infant with Increased
Respiratory Effort
 Note use of intercostal and
accessory muscles
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Features of the Pediatric Upper Airway
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large occiput
small mouth
large tongue
anterior and cephalad larynx
angled cords
large, floppy epiglottis overriding airway
narrow cricoid ring
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Neonatal Airway
 Large head
 Small nares
 Large tongue
 High glottis
 Overhanging
epiglottis
 Angled cords
 Narrow cricoid region
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Airway Equipment for
the Young Pediatric Patient
• straight blade: compresses large tongue and
mandibular tissue
• **uncuffed tube in children < 8 years
• tube size =
age years
+4
4
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Features of the Pediatric Lower Airway
• short trachea
• narrow caliber of all airway structures
• chest wall compliance
• lung compliance & elastic recoil
• diaphragm as a respiratory muscle
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Features of
the Pediatric Cardiovascular System
• SHOCK:
– defined as the clinical state of inadequate perfusion to meet
metabolic needs
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Features of
the Pediatric Cardiovascular System
• degree of shock is based on evaluation of the end organs of
perfusion:
– skin (color, temperature, cap refill)
– CNS (developmentally appropriate behavior, lethargy,
anxiety)
– central vs. peripheral pulses
– renal (urine output)
– Lactate levels
– Central venous pressures & mixed venous sats
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Simultaneous Palpation of Proximal and Distal
Pulses
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Features of
the Pediatric Cardiovascular System
• cardiac output is rate dependent: infants cannot
increase stroke volume to compensate for shock
• smaller total blood volume: 80-100cc/kg
• increased parasympathetic output: increased vagal
tone
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Hemodynamic Changes with Blood Loss
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Pediatric Vital Signs
• mean heart rate decreases with age
• tachycardia is an early and nonspecific sign of shock
• mean blood pressure increases with age
• blood pressure is usually normal even in a child with
moderate-severe hypoperfusion
• increased peripheral vascular tone allows for normal blood
pressure until end-stage shock
• vital signs not helpful in gauging degree of shock in children
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Pediatric Cervical Spine
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fulcrum is at C2-3
growth plate of dens
weak neck muscles
large head increases momentum
SCIWORA because of ligamentous laxity
most fractures occur at C1-2
difficulty with immobilization: large head/small chest
allow for excessive flexion in supine position
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Head Injury in
the Young Pediatric Patient
• skull is more compliant offers less protection to
the brain
• open sutures and fontanel
• mobile middle meningeal artery
• intracranial bleeds occur without accompanying
fracture
• intracranial bleed can cause shock
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Localized Head Trauma
• Assessment
– history
– vital signs
– local findings
• Treatment Goals
– prevent secondary brain damage
– maintain good cerebral perfusion pressure
• Treatment
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control external bleeding
oxygenate & hyperventilate as needed
fluid resuscitate to maintain adequate perfusion
keep head in midline position and HOB elevated 30 degrees
control seizures if possible
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Isolated Spinal Trauma
• Assessment
– history (mechanism, amount of force)
– vital signs
– local findings (thorough neuro exam, palpation etc.)
• Treatment Goals
– immobilization of the cervical spine and the child
• Treatment
– appropriate size hard collar or rolls to immobilize the neck
– back board or modified board with proper restraints
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Features of the Pediatric Abdomen
• thinner abdominal wall with less fat and muscle
• decreased anterior-posterior diameter
• large liver and spleen extend below ribs
• kidney contains less perinephric fat
• gastric distention (with ventilation or crying) can
present as a tense abdomen
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Isolated Abdominal Trauma
• Assessment
– history
– vital signs
– local findings
• Goal of Treatment
– early assessment and prevention of complications
• Treatment
– monitor ventilatory status and assist when necessary
– decompress abdomen
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Soft Tissue Injuries
• Assessment
– visual and palpation exam
– vital signs
• Treatment Goals
– prevention of complications
• Treatment
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close monitoring of oxygenation
maintenance of adequate ventilation with assist if needed
oxygen delivery as needed
restore intravascular volume if needed for excessive blood loss
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Skeletal System
• Fractures seen exclusively in children:
– growth plate (Salter Harris) fracture
– torus fractures
– bowing fractures
– greenstick fracture
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Skeletal System
• physis is site of growth
• physis is the weakest part of bone
• physis is composed of cartilage and separates
epiphysis from metaphysis
• fractures of the physis are described by the Salter
Harris Classification
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Musculoskeletal Injuries
• Assessment
– history (mechanism, force)
– vital signs (peripheral perfusion)
– local findings (discoloration, deformity etc.)
• Goal of Treatment
– prevention of complications
– minimize discomfort
• Treatment
– ice, elevation, immobilization
– frequent evaluation of peripheral vascular perfusion
– reassess neuromuscular function
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Environmental Emergencies
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Burns and Thermal Injuries
Smoke and Inhalation Injuries
Hyperthermia
Hypothermia
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Burns & Thermal Injuries
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Airway..Breathing..Circulation
Assessment
Fluid Therapy
Care of the Burn Wound
Pain Management
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Fluid Therapy for the Burn Victim
 Parkland Formula
- 4 ml/kg/%BSA of crystalloid over the first 24
hours.
- Half during the first 8 hours and half over the next
16 hours
Rule of Thumb
Children should produce 1 ml/kg/hr of urine ...
Care of the Burn Wound
 Goals
- promote rapid healing, prevent infection
 Cleanse
- using large volumes of lukewarm sterile saline
 Cover
- with loose, clean, preferably sterile dressings or sheets
Pain Management for Burn Victim
 Covering burn from moving air
 Analgesic medications
 Drug of Choice
- Morphine 0.1-0.5 mg/kg
- Fentanyl 1-2 mcg/kg
Smoke & Inhalation Injuries
• Assessment
– Clinical Manifestations
• Treatment
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Hints of Smoke Inhalation
 Exam may show:
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facial burns
singed nasal hairs
soot in pharynx
mental confusion
Tachypnea, cough or stridor may or may
not be present.
Treatment of Smoke Inhalation
 Remove from contaminated environment
 CPR as needed
 Provide 100% supplemental oxygen
 Ensure patent airway…..ABC’s
 Intubate early
Hyperthermia
Assessment & Exam
• Heat exhaustion
– T <41C, dry or wet skin, lethargy, thirst, headache,
increased heart rate
• Heat stroke
– T > 41C, hot skin, severe CNS dysfunction, circulatory
collapse
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Treatment of Hyperthermia
 Remove clothing
 Begin active cooling
 Transport to cool environment
 Cardiovascular support
 Fluid Resuscitation: 20 mg/kg lactated Ringers
or 0.9% sodium chloride
Hypothermia
Assessment & Exam
 Internal vs. External Etiologies
 Pale or cyanotic
 Shivering mechanism
 CNS function progressively impaired with
falling temp. Comatose at approx 27 C.
 Decreased BP, heart rate, or both
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Treatment for Hypothermia
 Mild [32-35C/89.6-95F]
 Passive External Rewarming
• Warm environment, dry clothes
 Moderate [28-32C/82.4-89.6F]
 Active External Rewarming
•
Bair Hugger, radiant sources, warm water bottles
 Severe [<28C/<82.4F]
 Active Core Rewarming
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Warm peritoneal lavage, nasogastric lavage, IV fluids, thoracotomies
Extracorporeal Blood Rewarming – Cardiopulmonary bypass
Hazardous Materials Exposure
Goal:
-provide guidelines for scene
management
-care and transportation of patients
contaminated by radiation or hazardous
chemicals
General Instructions
• Upon discovery of Hazmat scene, notify communication
center to dispatch Hazmat expert
• Delay entry until appropriate team and protective
equipment is available
• Expect the Hazmat team to initially remove any patients
• Follow advice of Hazmat team regarding personal
protection or patient decontamination
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Additional Rules
• Don’t be a hero...
• Always maintain a high index of suspicion
– Secondary devices
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General Signs and Symptoms of Hazmat Exposure
 Local Effects
- complaints of burning skin, teary eyes, dry or
sore throat, a cough or sneezing.
 Systemic Effects
- complaints of difficulty breathing, bizarre
behavior, stupor, seizures, coma.
Psychological & Social Emergencies
• Separation Anxiety
• Child Safety
• Lack of Communication and Comprehension
Skills
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Questions?
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