Chapter 6

Chapter 6Chapter 6Examination and Assessment of Examination and Assessment of

the Pediatric Patientthe 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.)• 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 3-month 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 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.


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.


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.


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.


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

• 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 pre-morbid 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• 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:• 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

0

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90

Respiratory Cardiac

Why do children have more respiratory difficulties?

• Anatomic • Physiologic

Anatomy

• 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 (1 of 2)

• Determine the appropriately sized airway.

• Place the airway next to the face to make certain length is correct.

• Position the airway.• Lubricate the airway.

Nasopharyngeal Airways (2 of 2)

• 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.

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 SevereAirway Obstruction

• Signs and symptoms• 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.


• 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.


• Open airway using head tilt-chin lift maneuver. If you see the object, remove it.

• Repeat process.


• In a conscious child:• Kneel behind the child.• Give the child five abdominal

thrusts.• Repeat the technique until

object comes out.


• If the child becomes unconscious, inspect the airway.

• Attempt rescue breathing.• If airway remains obstructed,

begin CPR.

Management of AirwayObstruction in Infants• 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:

• 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

• Home life• Caregivers• School • Social participation• Exposures

• Travel

History for Established Patients

Pulmonary Examination• Calm• Expeditious• Professional

Inspection• Vital signs• Signs of respiratory distress

• Grunting• Retractions• Accessory muscle use• Abdominal/chest wall synchrony

Inspection (cont.)• Thoracic configuration

• AP diameter• Shape

Palpation• 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

• Neurologic• Adenopathy• Ears, eyes, nose, and throat• Cardiac• Abdomen• Skin• Extremities

Healthcare Team• Physicians• Nurses• Respiratory therapists• Speech pathologists• Physical and occupational therapists• And others. . . .

Case 1 – Airway/Breathing

• 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

• PE: AF, VSWNL except RR 50• Gen: Awake, alert, stridor at rest, mod resp

dist• Pulm: Retractions x3, transmitted airway

sounds• CV: RRR, no m/r/g, nl pulses, cap refill


• 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


• Would you:





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.


• Would you:





e) Start CPR

f) Discharge home


• Would you:





e) Start CPR

f) Discharge home


• 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


• Would you:





e) Perform cricothyroidotomy

f) Discharge home


• 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


• Would you:






f) Discharge home


• Would you:






f) Discharge home


• 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


• Would you:






f) Discharge home


• 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


• Would you:






f) Discharge home


• Would you:






f) Discharge home

CO = HR x Stroke Volume

•Cardiac OutputCardiac Output

•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.

Chapter 6

Documents

patient historythe history

complete history

older child

sick child

new patient

past medical historya

medical supervision

current illness