Pediatric Review

Richard Trierweiler

–http://www.realclearscience.com/blog/2011/09/science-­of-­the-­hitchhikers-­guide-­to-­the-­galaxy.html

Objectives• Know how children are different from adults• Discuss methods for dealing with children• Be aware of vital sign differences in children• Discuss the anatomic differences between adults and children

• Discuss common pediatric problems and demonstrate knowledge through case studies.

• Review problems of pregnancy and how to assist with a precipitous delivery

Dealing with children

• Check yourself• Be polite to the parents• Infants (0-­1)• Toddlers (1-­3)• Preschoolers (3-­6)• School age (6-­12)• Adolescents (12-­18)

Anatomical differences

• Infants have proportionately large tongues, small (4mm) tracheas

• Children’s heads are proportionately larger, Infants -­ fontanel (soft spot)

• Larger body surface area per mass (2.5X)• Ribs are more pliable, less developed abdominal wall muscle

• Faster metabolic rate

–http://www.aafp.org/afp/2000/0515/p3057.html

–http://www.aafp.org/afp/2000/0515/p3057.html

Normal vital signs

Age Heart Rate RespiratoryRate

Infant 80-­200 30-­60Pre schooler 75-­190 22-­40School age 60-­140 18-­30adolescent 50-­100 12-­16

Airway obstruction

• Partial airway Obstruction– S/S: Stridor, noisy breathing, retractions but alert

– Tx.: Position of Comfort, O2, transport, do not agitate

–http://commons.wikimedia.org/wiki/File:Sternal_retractions.JPG

–http://www.accessmedicine.ca/search/searchAMResultImg.aspx?rootterm=chest+wall+retraction&rootID=45319&searchType=1

Airway

• Complete obstruction– S/S: not speaking, cyanosis, no crying, increased resp effort, LOC, AMS

– Tx.: Clear airway (backblows, chest thrust, abdominal thrust), Attempt BVM

–http://t1.gstatic.com/images?q=tbn:ANd9GcQV5-­tK03tXprKjXgFoQ_hN5PaKmnk-­4ci3dnFpTD-­PYsSy1CeLcQ

Case

• A frantic mother runs over to you while you are checking for contraband in a campground, shoves a 4 month old, cyanotic baby into your hands while saying “I was feeding him peanuts and he stopped breathing!”

• Now what?

Upper Airway Disease

Croup:• When: fall, winter, 3mo-­3yr, largely viral • S/S: Barky cough, stridor, low fever, if more severe: stridor, retractions

• Tx.: Cool mist/air, racemic Epi, steroids

–http://youtu.be/jjf7LZxrwK8

Case–9 month old, barky cough, dyspnic with this finding when she inhales. –Now what?

Upper Airway disease

Epiglottitis: • S/S: hoarse, stridor, fever, drooling• Tx: This is an emergency!, transport quickly in position of comfort. Do not disturb, get advanced airway capabilities headed your way.

–http://voicedoctor.net/media/structural-­injury-­inflammation-­bacterial/acute/supraglottitis-­or-­epiglottitis

–http://doktermudatrader.blogspot.com/2010/06/epiglottitis-­in-­children.html

Lower airway disease

Asthma and Bronchiolitis-­S/S: -­ Wheezing and breathing effort on exhalation-­ Rapid breathing (tachypnea) without stridor -­Tx.: Calm, reassure, Assist with personal MDI

–http://youtu.be/VA9C_aCH7F0

–http://www.mckinley.illinois.edu/handouts/asthma/asthma.html

–http://www.fingerlakesfamilycare.com/?page_id=332

Case

• 13 yo male is brought to you by worried parents at the sled dog kennel. They think he may be allergic to dogs and he is having trouble breathing. He appears short of breath and has wheezing.

• Now what?

Cardiac Arrest• C-­A-­B• start with 30 chest compression (single rescuer, 15 for two rescuer)

• Then Airway/two rescue breaths• Push >100 times per minute, 1/3 depth of chest

• Don’t check pulse for >10 seconds• Defibrillation – Preferred manual at 2-­4 jules/Kg, 2nd would be AED with pedsattenuator, last choice is “adult” AED.

• Just remember COMPRESSIONS

–http://thirdtierreality.blogspot.com/2012/10/third-­tier-­explosive-­diarrhea.html

Dehydration, Diarrhea, Vomiting

• S/S – lots of poop or vomitMild – irritable, decreased urineModerate – more tachycardic,

compensated BP, dry membranes• Severe – low BP, tachycardic, dry mucous Membranes, sunken eyes, lethargy, cool mottled extremities, threadypulse

Dehydration, Diarrhea, Vomiting

• Causes – gastroenteritis – virus, bacterial, giardia;; intestinal maladies, etc

• Tx.: – mild and moderate can be treated with oral rehydration – small amounts (5-­10ml) frequently (Q5 min) (pedialyte, Gatorade, WHO: 1L water, 1 tsp salt, 8 tspsugar)

• Tender abd, rebound or bloody stool is concerning

–http://rehydrate.org/solutions/homemade.htm

Near Drowning

• Consider traumatic injuries and cold exposure

• CAB• Not dead until warm and dead

Poisoning

• Try to determine what was taken, when, and how much

• Tx: medical command, supportive care, O2, transport, rarely consider charcoal

Fever

• Temp greater than 100.4• Often in response to infection to decrease bacterial/viral replication

• Assess hydration status• Cool quickly if >105: shade, AC, fan, cool water. (APAP)

–http://t0.gstatic.com/images?q=tbn:ANd9GcQMyCgs-­iCzpQMCtOX-­IcanlUWFvuK97qRQuQ3De9Ch23EuRYBg3g

Seizure

• S/S: Tonic, clonic, spasms, unresponsive• Caused by fever, infections, poisoning, hypoglycemia, trauma, decreased levels of oxygen, head injury or could be idiopathic in children.

• Ask: Prior episodes? Similar pattern? Taking anitseizure meds?

–http://t3.gstatic.com/images?q=tbn:ANd9GcTpeCV3GzMvWswnp9SAJ8Jw1Z3Hw89SR_bkHTJp_tPl69t08418Qw

Seizure

• Tx.: Asses for injury, prevent injury (but don’t restrain), Asses airway, place on side, suction as needed, provide O2, transport, BVM if needed

• Seizures lasting more than 15 minutes is an Emergency! – status epilepticus

–http://t2.gstatic.com/images?q=tbn:ANd9GcS2ebJKRcl8eBIv_Q7VyifqJGlEZroVzQlF6g7RXz7gHTLRJG0

Case

• 11 yo female is having a clonic seizure, laying on top of a low stone wall and is unresponsive. The parents report this started about 30 seconds ago.

• Now what?

Shock (hypoperfusion)

• Causes: Diarrhea and dehydration, Trauma, Vomiting, Blood loss, Infection, Abdominal injuries

Shock• a) Mental status changes • b) Rapid respiratory rate • c) Pale, cool, clammy skin • d) Weak or absent peripheral pulses • e) Delayed capillary refill• f) Decreased urine output. Measured by asking parents about diaper wetting and looking at diaper.

• g) Absence of tears, even when crying

ShockTx:a) Assure airway/oxygen.b) Be prepared to artificially ventilate. c) Manage bleeding if present. d) Elevate legs. e) Keep warm.f) Transport.

Trauma#1 cause of Deaths in pediatricsBlunt is common• MVC: unrestrained: head and neck– Restrained: abdomen, lower spine

• Pedestrian Struck: head, LE, abomen• Falls• Burns• Sports• Child abuse

–http://t3.gstatic.com/images?q=tbn:ANd9GcTpeCV3GzMvWswnp9SAJ8Jw1Z3Hw89SR_bkHTJp_tPl69t08418Qw

–http://learnpediatrics.com/body-­systems/musculoskeletal-­system/approach-­to-­non-­accidental-­injuries/

TraumaHead• Concerns: Bobble heads, resp arrest• S/S: N/V, AMS, contusions, blood from ears/nose

• Tx: keep calm, Manage airway and C-­Spine (jaw thrust)

–http://www.charlydmiller.com/LIB02/2003jemstricksreview.html

TraumaChest• Concerns: Ribs are Pliable• S/S: Contusion, flail chest, crepitus, sucking chest wound, decreased breath sounds, tracheal deviation

• Tx: keep calm, Manage airway, splint, Occlusive dressing, (needle decompression)

–http://www.primary-­surgery.org/ps/vol2/html/sect0255.html

–http://www.sharecare.com/question/how-­care-­sucking-­chest-­wound

–http://www.tactical-­life.com/tactical-­weapons/seal-­a-­sucking-­chest-­wound/

–http://t3.gstatic.com/images?q=tbn:ANd9GcQ2-­dVH7FbpMHCsnhbh7XyfNR7Qw6oQsVgxIXwopthYXRT1-­XpVww

TraumaAbdomen• Concerns: internal injury (Spleen, liver)• S/S: N/V, pain, contusion, rigid abdomen• Tx: keep calm, transport quicklyExtremities: same as Adults

Obstetrics• Expectant mother: best thing for unborn child? (and not flat on back)

• Precipitous Delivery: • 1st Stage – cervical dilatation• 2nd Stage – fetal expulsion• 3rd Stage – expulsion of placenta

–http://www.chw.org/display/PPF/DocID/22463/router.asp

–http://www.scripps.org/articles/2901-­delivery-­presentations

–https://www.statkit.com/store/details.php?prodId=217&category=

Obstetrics -­ problems• Breech• Shoulder Dystocia• Prolapsed umbilical Cord• Uterine atony and hemorrhage

–http://helid.digicollection.org/en/d/Jwho43e/5.2.6.html

–http://www.google.com/imgres?q=shoulder+dystocia&safe=off&client=safari&rls=en&biw=1244&bih=611&tbm=isch&tbnid=Hx0CHu6GxE02yM:&imgrefurl=http://www.aafp.org/afp/2004/0401/p1707.html&docid=ZI6EMijBRmaPGM&imgurl=http://www.aafp.org/afp/2004/0401/afp20040401p1707-­f1.jpg&w=310&h=307&ei=3SWnUf38KeKdiQKYsoC4BA&zoom=1&ved=1t:3588,r:1,s:0,i:162&iact=rc&dur=981&page=1&tbnh=181&tbnw=204&start=0&ndsp=11&tx=99&ty=57

–http://t2.gstatic.com/images?q=tbn:ANd9GcRe-­NyLn1EzpJgh4x0ZfSrcu7gV38jaB3VuNPZHvefofoODC0md-­A

–http://t2.gstatic.com/images?q=tbn:ANd9GcRLGsfvgeiDiHv0wKql2kkiRxwizQ05w0EKbJmChTayZSN63-­q1CQ

–http://www.rnpedia.com/home/notes/maternal-­child-­nursing-­notes/cord-­prolapse

–http://www.aafp.org/afp/2007/0315/p875.html

Case

• 34 yo female waddles over to you at Wonder Lake campground and says “I am 39 weeks pregnant, I am feeling contractions, and I think my water just broke.”

• What stuff would you try to find and what are you going to do?

Hypothermia -­ Treatment• Prevention• Passive re-­warming• Active External re-­warming

• Active Core re-­warming

Passive

• Remove from cold

• Prevent further loss

• Be proactive and reverse if not too late

• Limited by ability to heat self

Active External

• 108ºF (42C) is the magic Temperature

• Warm water• Bair Hugger• Radiant heat• Down side: rewarming shock

Active Core Rewarming• Inhalation• Heated IVF• GI tract lavage• Bladder Lavage• Peritoneal lavage• Pleural Lavage• Extracorporeal• Mediastinal via thoracostomy

Conservative

• Or Heated IV, warm O2 and forced air• 36 pt.s with severe hypo and pulse present:– Rewarming rate of 1.09C/hr– 92% rewarmed but 42% in hospital mortality

• Time intensive, large amounts of fluid

Gastric/bladder lavage

• Less invasive• Slower due to less mucosal area than more invasive methods

• Rewarming rate: ~1C/hr

Perotineal lavage

• Easier than other forms of ACR• Rewarming rate: 1-­3C/hr

Thoracic Lavage

• Can be preformed with equipment available in most EDs

• Quick, rewarming rate:3C/hr (reported up to 6c/20 min with 40L of tap water)

• In review of 14 pt.s had 28% mortality

Endovascular temp control

• Rewarming rate: 2.8C/hr

Venovenous

• Must have pulse to use• Easier and less invasive than some forms of ACR

• Rewarming rates of 2-­3C/hr

Hemodialysis/filtration

• Advantages: may be easier to establish and equipment availability in smaller hospitals compared to CPB

• Especially useful if renal failure or hyperkalemia is present

• Rewarming rate: 2-­3C/hr

Hypothermia ACLS AlgorithmInitial Therapy of all Patients

-­remove wet clothing-­Protect against heat loss and wind

-­Maintain horizontal position-­Avoid rough movement and excess activity

-­Monitor core Temp-­Monitor cardiac rhythm

Asses responsiveness, breathing, pulse

Pulse and Breathing – next slidePulse or Breathing absent

Start CPR

Give one shock then resume CPR

Secure airway, ventilate with warm humid O2 (108-­115F or 42-­46C)

Establish IV, infuse warm NS (109F/43C)

Core T <86F (30C)

-­continue CPR

-­withhold IV meds

-­limit to one shock

-­transport to hospital for Tx of severe hypo

Core T >86F (30C)-­Continue CPR

-­Give IV meds as indicated, but increase time intervals

-­repeat defib for VT/VF as core T rises

-­transport for AIR

What is core Temp?

93.2-­96.8F (34-­36C)

Mild hypothermia-­passive rewarming

-­Active external rewarming

86-­93.2F (30-­34C)

Moderate hypothermia-­Passive rewarming

-­Active external rewarming of trunc only

<86F (30C)

Severe hypothermia-­Active Internal rewarming sequence

Active internal rewarming-­Warm IV Fluids (109F [43C])

-­Warm humid O2

-­Peritoneal lavage (KCl free fluid)

-­Extracorporeal rewarming

-­Esophageal rewarming tubes

Continue internal rewarming until

-­core temp >95F (35C) or

-­return of spontaneous circulation or

-­Resuscitative efforts cease

Hypothermia extras• Check pulse for full minute• Transcutaneous pacing not recomended, but have been case reports of success in humans, and in dogs it decreased rewarming time by 50%

• In one swine model, EtOH did not have affect on cooling/rewarming, but did lead to increase hemodynamic instability with/after rewarming

• Avoid hyperventilation – hypocapnic ventricular irritability• Avoid rough handling – in dog model, rough handling/manipulation lead to arrhythmia in over 50%

• Consider transport to more advanced care for Severe hypothermia

• Not DEAD until WARM AND DEAD

Summary• Children are not just small adults• They tend to have higher pulse and respiratory rates and lower blood pressures

• Anatomic differences• Common problems• Review problems of pregnancy and how to assist with a precipitous delivery

Questions?Richard Trierweiler, MD, MPH, FAWMRichard.Trierweiler@gmail.com