161857558-2011-July-Pediatrics

8/10/2019 161857558-2011-July-Pediatrics

1/78

Pediatric Assessment

Provena Regional EMS SystemJuly 2011 Continuing Education

8/10/2019 161857558-2011-July-Pediatrics

2/78

PEPP

This continuing education lesson is

drawn from a national program called

PEPP

Pediatric Emergencies for Pre-hospital

Professionals

Developed by the American Academy of

Pediatrics

8/10/2019 161857558-2011-July-Pediatrics

3/78

When dealing with sick kids there is

a Core Dilemma:

Sick? Not Sick? Not Sure?A sick child demands immediate management

and frequent assessments.

8/10/2019 161857558-2011-July-Pediatrics

4/78

Pediatric Assessment:

Which of These Patients is Sick?

2-week-old

Fever, less responsive

A/B RR 60, patent airway,belly breathing, SaO2

unobtainable C HR 160, skin pink,

marbled centrally, handsand feet blue; radial pulsehard to palpate

D AVPU eyes open, noeye contact, no vocalization,moves extremitiessporadically

10-year-old

Fever, less responsive

A/B RR 60, patent airway,

belly breathing, SaO2

unobtainable

C HR 160, skin pink,

marbled centrally, hands and

feet blue; radial pulse hard to

palpate D AVPU eyes open, no

eye contact, no vocalization,

moves extremities

sporadically

8/10/2019 161857558-2011-July-Pediatrics

5/78

The assessments made on the 2 week

old are all normal assessments

The assessments on the 10 year-old

reveal a very ill child.

8/10/2019 161857558-2011-July-Pediatrics

6/78

Objectives

Identify the challenges in pediatric assessment.

Define a pediatric-specific assessment.sequence, including the Pediatric Assessment

Triangle. Integrate knowledge of pediatric development

to form a general impression and make thesick/not sick decision for children of different

ages. Discuss the stay or go decision, with regard

to treatment on scene versus transport.

8/10/2019 161857558-2011-July-Pediatrics

7/78

The Challenge of Pediatric

Assessment

Pediatric age range: 0 21 years

Tremendous variation in physical,

cognitive, and emotional development Distinguishing normal from

abnormal requires age-specific

knowledge.

8/10/2019 161857558-2011-July-Pediatrics

8/78

What assessments can be made

From the door

Before you touch the child

Before you upset the child

8/10/2019 161857558-2011-July-Pediatrics

9/78

Pediatric Assessment Triangle

Observational assessment

Formalizes the general

impression

Identifies general categoryof physiologic abnormality

Establishes the severity of

illness or injury Determines the urgency of

intervention

8/10/2019 161857558-2011-July-Pediatrics

10/78

Pediatric Assessment Triangle

AppearanceWork of Breathing

Circulation to Skin

8/10/2019 161857558-2011-July-Pediatrics

11/78

Steps in Pediatric Assessment

1. Prearrival Preparation2. Scene Size-up

3. General Impression Assessment PAT

4. Initial Assessment ABCDEs andTransport Decision

5. Additional Assessment FocusedHistory and Physical Exam, DetailedPhysical Exam (Trauma)

6. Ongoing Assessment

8/10/2019 161857558-2011-July-Pediatrics

12/78

Transport Decision: Stay or Go?

Indications for immediate on-scene treatment:

Cardiac arrest

Complete airway obstruction

Decompensated shock Impending newborn delivery

Seizures

Wheezing Stridor

Severe pain with normal blood pressure

8/10/2019 161857558-2011-July-Pediatrics

13/78

Stay or Go?

Indications for immediate transport andtreatment en route:

Incomplete airway obstruction

Compensated shock

Closed head injury with normal airway,breathing

Multisystem trauma

Inability to treat on-scene.

Safety problems

Equipment failure

Procedure failure

8/10/2019 161857558-2011-July-Pediatrics

14/78

Case Presentations

Look at the scenario Discuss what you need to be keeping in mind

before you arrive? What could be causing the problem?

What do you need to be gathering prior to arrival? Equipment

Supplies

Scene size upIs the child safe with the

caregivers? PAT

ABC

SAMPLE

8/10/2019 161857558-2011-July-Pediatrics

15/78

Case Presentation

You respond to a call in the early

morning

Three-day-old infant who is

unresponsive.

Is this a problem? Why is the infant

unresponsive?

What equipment do you need to take

with you to the patient?

8/10/2019 161857558-2011-July-Pediatrics

16/78

Prearrival Preparation

Causes of unresponsivenessin a 3-day-old?

Sepsis

Congenital heart disease Inborn error of metabolism

Seizure

Abuse

Equipment/medication

Car seat available?

Airway/IV

Psychosocial issues

8/10/2019 161857558-2011-July-Pediatrics

17/78

Scene Size-up

You arrive at a low-rise publichousing complex.

A very young mother and a fairly

young grandmother meet you at

the pavement with the baby in

arms.

The mother is crying. The

grandmother is agitated. Whats

wrong with him? I told them he

shouldnt leave the hospital so

soon!

A large crowd of bystanders has

gathered.

8/10/2019 161857558-2011-July-Pediatrics

18/78

General Assessment: PAT

Circulation to Skin

Skin mottled, hands

and feet blue

Work of

Breathing

See-saw

breathing;

intercostal and

subcostal

retractions and

nasal flaring

Appearance

Tiny baby, little

spontaneousmovement; eyes

open but no eye

contact; high-

pitched cry

8/10/2019 161857558-2011-July-Pediatrics

19/78

Sick or not sick?

8/10/2019 161857558-2011-July-Pediatrics

20/78

General Impression

The baby is sick.

Physiologic abnormality:

cardiopulmonary failure

High pitched cry

Respirations abnormal

Circulation abnormal

Begin management as you

continue your assessment.

8/10/2019 161857558-2011-July-Pediatrics

21/78

Initial Assessment: ABCDEs

A patent

B RR 80; air entry

decreased; SaO2 unattainable

C HR 180; capillary refill 5seconds; brachial pulse faint;

femoral pulse palpable

D baby stiff when taken

from moms arms; arches,high-pitched whimper

E no rashes, bruises

8/10/2019 161857558-2011-July-Pediatrics

22/78

Transport Decision

Stay or go?

Are there

problems withABCs?

BLS versus ALS?

Do you need anintercept?

8/10/2019 161857558-2011-July-Pediatrics

23/78

Management Priorities

Stay and provide immediatemanagement:

Provide supplemental oxygen;

consider bag-mask ventilation.

Place on cardiorespiratorymonitor.

Make vascular attempt on scene.

Transport and give crystalloid en

route. Transport to pediatric receiving

facility or critical care center based

on local policy.

8/10/2019 161857558-2011-July-Pediatrics

24/78

Additional Assessment: Focused

History SAMPLE Signs/symptoms: felt warm; did not awake tofeed; difficult to arouse this morning.

Allergies: none

Medications: breastfeeding mom taking Demerol. Past medical problems:

Normal vaginal delivery at 37-weeks-gestation to 17-year-old mom.

Pregnancy complicated by hypertension.

20-hour rupture of membranes, no maternal or infantfever.

Home at 24 hours

Last meal: breastfed 0300

Events leading to illness: ?

8/10/2019 161857558-2011-July-Pediatrics

25/78

What kind of problems did you find in the

SAMPLE history?

8/10/2019 161857558-2011-July-Pediatrics

26/78

Case Conclusion

En route: infant placed on oxygen and

bag-mask ventilation begun.

In the ED: infant resuscitated with fluids,

cultures taken, and antibiotics given.

Diagnosis: group B strep pneumonia and

meningitis

Outcome: hospitalized in pediatric ICU

for 2 weeks.

8/10/2019 161857558-2011-July-Pediatrics

27/78

Case Presentation

3-year-old with approximately

20-foot fall from construction

scaffolding.

Could this be a problem?

What are critical elements of a

fall?

What equipment do you need

to take with you to the patient?

8/10/2019 161857558-2011-July-Pediatrics

28/78


What types of injuries is a 3-year-oldlikely to sustain with fall from height?

Head intracranial bleed, skull

fracture

Chest pulmonary contusion;hemo-pneumothorax

Abdomen liver and spleen injury

Musculoskeletal extremity

fractures Equipment/medications pediatric

stabilization device; cervical collar;

airway; IV

Psychosocial

8/10/2019 161857558-2011-July-Pediatrics

29/78

Scene Size-Up

You pull up to a suburbanhouse under construction.

A dad frantically leads youinto the structure, where a

small child is sobbing inher mothers arms.

Dad gestures upward toindicate the platform from

which the child fell onto aconcrete pad.

8/10/2019 161857558-2011-July-Pediatrics

30/78


How do we categorize this childs physiologic statusbased on the PAT?

Is she seriously injured?

Circulation to Skin

Pink

Work of Breathing

No retractions,

flaring, grunting

Appearance

Alert; makes

eye contact;

cries vigorously;sits up and yells,

Go away!

8/10/2019 161857558-2011-July-Pediatrics

31/78

Sick or not sick?

8/10/2019 161857558-2011-July-Pediatrics

32/78

General Impression and

Management Priorities The child is stable and

acting normally for a child

her age, but the mechanismof injury is concerning, with

potential for serious injury.

8/10/2019 161857558-2011-July-Pediatrics

33/78


A patent; actively resistscervical immobilization

B RR 48; crying with good air

entry; SaO2not picking up

C HR 160; CRT < 2 seconds;radial pulse strong; BP 110/80

D AVPU alert; kicks and

thrashes

E obvious deformity leftforearm, skin intact; superficial

abrasion left temple

8/10/2019 161857558-2011-July-Pediatrics

34/78

Transport Decision

Stay or go?

Spinal stabilization?

How?

ALS versus BLS? Do you need an

intercept?

Destination: Trauma

center versus

community hospital?

8/10/2019 161857558-2011-July-Pediatrics

35/78


Stay and provide immediate management.

Provide supplemental oxygen.

Place monitors.

Stabilize spine.

Go transport and attempt IV access enroute.

Assess weight and begin fluidresuscitation.

Transport to pediatric receiving facilityversus trauma center based on localpolicy.

8/10/2019 161857558-2011-July-Pediatrics

36/78

SAMPLE History

Obtain SAMPLE history en route: Signs/symptoms: complaining of pain left arm.

Allergies: none

Medications: cold medication

Past medical problems: ear infection and cold Last meal: burger and fries 45 minutes ago

Events leading to illness/injury

Family meeting with contractor at new home site.

Child unobserved for 5 minutes.

Parents witnessed fall.

Cried immediately, no LOC.

8/10/2019 161857558-2011-July-Pediatrics

37/78

Was this child neglected or abused?

Does the parents story make sense?

Are the parents acting appropriately?

8/10/2019 161857558-2011-July-Pediatrics

38/78

Detailed Physical Exam (Trauma)

Complete a detailed

physical exam en route.

Reassess frequently tomonitor response to

treatment.

8/10/2019 161857558-2011-July-Pediatrics

39/78

Case Conclusion

En route: an IV started and 200 mLof normal saline was infused.

In the ED: child became sleepy and

required head and abdominal CTscan.

Diagnosis: right parietal skullfracture, liver laceration, and elbowfracture.

Outcome: admitted to pediatric ICU;home on day 5.

8/10/2019 161857558-2011-July-Pediatrics

40/78

Case Presentation

You respond to a residence where a 3-year-oldgirl has been found unconscious.

The parents tell you that the child was fine

when put to bed at eight the night before. Theyawoke this morning to find toddler asleep onthe living room floor, unable to arouse.

You note partially filled cocktail glasses on the

coffee table and an open bottle of gin on itsside on the floor. The parents admit that theywere too tired to clean up after a party lastnight.

8/10/2019 161857558-2011-July-Pediatrics

41/78


Appearance

Unresponsive,lying sprawled in

a pool of vomit

Work of Breathing

Normal

Circulation to Skin

Normal

What is your general impression?

8/10/2019 161857558-2011-July-Pediatrics

42/78

Sick or not sick?

8/10/2019 161857558-2011-July-Pediatrics

43/78

General Impression and

Management Priorities General impression:

Sick

Brain dysfunction; likely ametabolic/toxic cause

Management priorities:

Immediate treatment:

BLS: position, suction, supplemental O2.

ALS: check blood glucose level.

8/10/2019 161857558-2011-July-Pediatrics

44/78


Airway open, vomit in mouth

Breathing RR 16; symmetric chestrise; clear lungs; SaO294%

Circulation HR 90; skin moist; capillaryrefill 2 seconds; BP 80/60

Disability AVPU = P; pupils sluggish

but equal; decreased tone Exposure breath and clothes smell of

alcohol; no signs of trauma

8/10/2019 161857558-2011-July-Pediatrics

45/78

SAMPLE

Signs and symptomsunresponsive child

Allergies -- none per mother

Medicationsnone per mother

Past historynormal healthy child

Last mealsupper at 6 pm night before snack

at 8 pm

Eventsparents awoke to find child in thiscondition

8/10/2019 161857558-2011-July-Pediatrics

46/78

Was this child neglected or abused?

Does the parents story make sense?

Are the parents acting appropriately?

8/10/2019 161857558-2011-July-Pediatrics

47/78


The patient is in impending respiratoryfailure because of alcohol ingestion.

BLS:

Consider airway adjunct.

Prepare for bag-mask ventilation. Transport.

ALS:

Treat documented hypoglycemia.

Establish IV access. Perform electronic monitoring.

Consider ETI for airway protection ifALOC and absent gag reflex.

8/10/2019 161857558-2011-July-Pediatrics

48/78

Blood glucose is 30 mg/%.

IV started on scene.

D25

W, 1 mL/kg IV administered. Patient becomes somewhat more

responsive, but she remains sleepy.

Case Progression

8/10/2019 161857558-2011-July-Pediatrics

49/78

Key Concept: Hypoglycemia

Hypoglycemia is common complication

of alcohol ingestion in young children.

If the patient is awake, ask the caregiverto give oral glucose (soda or juice).

If patient is not alert or the gag reflex isdepressed, give IV dextrose.

8/10/2019 161857558-2011-July-Pediatrics

50/78

Key Concept: Risk Assessment

Determine:

The substance ingested.

Toxicity Dose ingested: mg toxin ingested

per/kg body weight.

Time since exposure.

Call:

Poison center or medical oversight

to help with risk assessment.

8/10/2019 161857558-2011-July-Pediatrics

51/78

Key Concept: Ingestions by

Toddlers Toddlers frequently ingest household

products: solvents, cosmetics, plants,

and cleaning liquids. Most ingestions in this age group

involve single toxins.

Few ingestions require charcoal or anyspecific treatment.

8/10/2019 161857558-2011-July-Pediatrics

52/78

Case Progression

En route: patient remains stable,with progressive improvement inthe level of consciousness.

8/10/2019 161857558-2011-July-Pediatrics

53/78

ED Course

In the ED: repeat blood glucose 58. IV glucoseinfusion started, electrolytes, blood gas, andblood alcohol level sent. Social work consultobtained to evaluate home safety.

Diagnosis: alcohol ingestion; hypoglycemia

Outcome: social work call to childrensprotective services (CPS) reveals an open

case, with a past report of child neglect. Child isdischarged the following day in the care of thematernal grandmother, pending CPSinvestigation.

8/10/2019 161857558-2011-July-Pediatrics

54/78

Summary

Toddlers are highly susceptible to the metabolic

effects of alcohol, particularly hypoglycemia.

Accidental ingestions peak in the 2- to 3-year

age group.

Prevention of poisoning in the home requires

constant vigilance by caregivers and multiple

rounds of childproofing!

8/10/2019 161857558-2011-July-Pediatrics

55/78

Case Presentation

You are called to a residence for a

10-year-old boy who is having

trouble breathing.

What could be the cause of a 10year-old with trouble

breathing?

What equipment will you need to

take to the patient on arrival?

8/10/2019 161857558-2011-July-Pediatrics

56/78


Review the causes ofrespiratory distress inschool-aged children.

Asthma Pneumonia

Foreign body aspiration

Anaphylaxis

Chest trauma Review team roles and

possible management(airway equipment,

medication doses, IV).

8/10/2019 161857558-2011-July-Pediatrics

57/78

Scene Size-Up

You are first on scene to a

home where you are waved

into the living room by an

anxious mother.

The father is attending to a

10-year-old boy who is

obviously working hard tobreathe.

8/10/2019 161857558-2011-July-Pediatrics

58/78


What is your general impression?

Appearance

Anxious, alert, able

to respond to

questions with only

single words

Work of Breathing

Seated, leaning

forward on

outstretched arms;

marked retractions

and nasal flaring;

audible wheeze

Circulation to skin

Pale, lips slightly blue

8/10/2019 161857558-2011-July-Pediatrics

59/78

Sick or not sick?

8/10/2019 161857558-2011-July-Pediatrics

60/78

General Impression

General impression:

Sick

Respiratory distress

Physiologic problem:

Lower airway obstruction

8/10/2019 161857558-2011-July-Pediatrics

61/78


A patent, no stridor

B RR 48; poor airentry; diffuse wheezing;

SaO288% C HR 140; radial pulse

full; capillary refill < 2seconds; nail beds blue;

BP 100/70 D AVPU alert

E no signs of traumaor rash

8/10/2019 161857558-2011-July-Pediatrics

62/78


Immediate treatment: Leave child in a position of comfort.

BLS: Oxygen 15L by mask Nebulized

albuterol 2.5 mg every 20 minutes for

2 doses.

Repeat albuterol as necessary.

ALS: Terbutaline SubQ .005 mg/kg

Stay or Go?

Give first albuterol treatment on scene

and then continue en route.

8/10/2019 161857558-2011-July-Pediatrics

63/78

Focused History: SAMPLE

Signs/symptoms: cold symptoms for 2 days,shortness of breath this morning

Allergies: penicillin, seafood

Medications: Flovent inhaler; Albuterolinhaler

Past medical problems: asthma; anaphylaxisto seafood

Last meal: breakfast 3 hours ago

Events leading to illness/injury: wheezingstarted during PE class.

8/10/2019 161857558-2011-July-Pediatrics

64/78

Key Concept: Asthma

Asthma is the most common chronic

disease of childhood.

Five million children have the disease.

Death from asthma is rising and half of all

pediatric deaths occur in the prehospital

setting.

8/10/2019 161857558-2011-July-Pediatrics

65/78

Key Concept: Factors that Suggest a

More Severe Asthma Exacerbation A severe or fatal asthma attack is more likely

in a child with: Prior intensive care unit admissions or intubation

More than three ED visits in a year

More than two hospital admissions in past year

Use of more than one metered dose inhalercanister in the last month

Use of bronchodilators more frequently thanevery 4 hours

Progressive symptoms despite aggressive hometherapy

8/10/2019 161857558-2011-July-Pediatrics

66/78

Key Concept: Asthma Triggers

Common triggers of an asthma attack

include:

Upper respiratory infection

Exercise

Exposure to cold air

Emotional stress

Passive exposure to smoke

8/10/2019 161857558-2011-July-Pediatrics

67/78

Key Concept: Asthma

Pathophysiology and Clinical Signs Asthma is a disease of small airway

inflammation.

It leads to bronchoconstriction, mucosal edema, and

increased secretions.

Clinical signs and symptoms:

Tachypnea

Tachycardia

Retractions Wheezing or decreased breath sounds

Pulse oximetry may be normal or low

Key Concept: Signs of Severe

8/10/2019 161857558-2011-July-Pediatrics

68/78

Key Concept: Signs of Severe

Asthma

Beware of the following features of theinitial assessment, which suggest severebronchospasm and respiratory failure:

Altered appearance Exhaustion

Inability to recline

Interrupted speech

Severe retractions

Decreased air movement

8/10/2019 161857558-2011-July-Pediatrics

69/78


Alert respiratory distress

Position of comfort

Supplemental oxygen

Inhaled albuterol

Not alert respiratory failure

Bag-mask ventilation

Subcutaneous terbutaline ETI if apneic

8/10/2019 161857558-2011-July-Pediatrics

70/78

Case Progression

En route: patient received two 2.5 mg

nebulized albuterol treatments.

ED Course: the patient received

continuous nebulized albuterol and IVcorticosteroids and was admitted to the

Pediatric Intensive Care Unit.

Diagnosis: acute asthma exacerbation

8/10/2019 161857558-2011-July-Pediatrics

71/78

Summary

Asthma is the most commonchronic disease of childhood.

The severity of symptoms varies

widely between individuals. Treat aggressively in children with

a past history of severe attacks orsigns of respiratory fatigue on

exam. Inhaled beta-agonists and oxygen

are the cornerstones of both fieldand hospital treatment.

8/10/2019 161857558-2011-July-Pediatrics

72/78

Review

Answer the following questions as a group.

If doing this CE individually, please e-mail your

answers to: [email protected]

Use July 2011 CE in subject box. You will receive an e-mail confirmation. Print

this confirmation for your records, and

document the CE in your PREMSS CE record

book.
mailto:[email protected]:[email protected]

8/10/2019 161857558-2011-July-Pediatrics

73/78

Follow Up Quiz

1. What are the assessments made

using the PAT Triangle?

1.

2.

3.

8/10/2019 161857558-2011-July-Pediatrics

74/78

2 Why is the PAT such a valuable tool

when approaching children?

A. It involves touching children early in the

assessment. B. It involves observing the child from a

distance before touching and agitating them.

C. The assessment must be done within 6inches of the child.

D. It is useful for children under age 2 only.

8/10/2019 161857558-2011-July-Pediatrics

75/78

3. Another value of the PAT triangle isthat it allows the provider to:

A. estimate the childs age

B. estimate vital signs

C. determine which protocol to use

D. determine if the child is sick or not sick

8/10/2019 161857558-2011-July-Pediatrics

76/78

Low blood sugar in children:

A. May be seen with ingestion of alcohol

B. Is rare

C. Need not be measured

D. Is common in asthma attacks

8/10/2019 161857558-2011-July-Pediatrics

77/78

Which of these signs and symptomsdoes not suggest respiratory failure in a

child?

A. Unable to speak in sentences withouttaking a breath between words

B. Extreme fatigue

C. able to lay flat D. Retractions

A

8/10/2019 161857558-2011-July-Pediatrics

78/78

Answers

1. PAT =

Appearance

Work of Breathing

Circulation to skin

2. B

3. D

4. A

5. C

161857558-2011-July-Pediatrics

Documents