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Presented by: M Smith
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General Pediatric Assessment Strategies
Pediatric Emergencies
Respiratory Emergencies Dehydration
INCLUDING : Identification of Severity of
Dehydration
INCLUDING : Identification, management andTransportation of the Shocked Paediatric
Intravenous Access and Fluid
Management
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Newborn (first 6 hours)
Neonate (first 28 days)
Infant (first year) Toddler (1 to 3 years)
Preschooler (3 to 5 years)
School age (6 to 12 years)
Adolescent (12 to adulthood)
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Parent
Frightened
Guilty Exhausted
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Paramedic
Frightened
May over-empathize
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Who has to control situation?
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Oxygenation, ventilation adequate to
preserve life, CNS function?
Cardiac output sufficient to sustain life,
CNS function?
Oxygenation, ventilation, cardiac output
likely to deteriorate before reaching
hospital? C-spine protected?
Major fractures immobilized?
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If invasive procedure considered, do
benefits outweigh risks?
If parent is not accompanying child, is
history adequate?
Transport expeditiously
Reassess, Reassess, Reassess
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Priorities are similar to adult
Greater emphasis on airway, breathing
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Limit to essentials
Look before you touch
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Circulation
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Initial Assessment (quick assessment that can bedone within seconds of arriving on scene)
AAppearance Mental status (alert, crying, obtunded, no response) Muscle tone (moving, not moving, limp)
BBreathing Respiratory rate (too fast, too slow, irregular)
Respiratory effort (use of accessory muscles, nasal flaring,
retractions, grunting) Check breath sounds
Circulation Skin color (pallor, peripheral cyanosis, central cyanosis)
C
apillary Refill (normal is within 2 seconds) Pulse (too fast, too slow, irregular, normal)
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Detailed assessment With adults this is typically done head to toe, with
pediatrics it is better to do the opposite Why?Why? Take a SAMPLE history (use the parents for
detailed hx if possible)
Determine
Hx of fever or infection Hx of vomitting or fever and check hydration status (skinturgor, check fontanalles in infants, look for xerosis)
Frequency of urination Why are these important questions to ask?Why are these important questions to ask?
Take vitals and measure pulse oximetry
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Detailed assessment (cont.) Try to invent a game you can play or begin a
conversation about something you can talk aboutfor at least several minutes (Batman, SesameStreet, toys, school, etc.).
Explain each step in your assessment (now Imgoing to feel your tummy).
With older patients explain why you are doingeach step (I need to make sure your stomach isOK).
With younger patients, avoid separating themfrom their parents if possible.
Why?Why?
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Detailed assessment (cont.) Explain things as simply as possible avoiding
technical terminology and jargon. Do NOT condescend.
Do NOT lie or make promises you cannot be sureto keep.
Be alert for injuries that seem inconsistent withtheir explanation this is usually a sign of childabuse.
Examples?Examples?
If you suspect child abuse, you must report it by
calling 0800 55555
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Categorize as:
Stable
Potential Respiratory Failure or Shock Definite Respiratory Failure or Shock
Cardiopulmonary Failure
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Essential elements
Proper equipment
K
nowledge of norms Carry chart of norms for reference
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Apical auscultation
Peripheral palpation
Tachycardia may result from: Fear
Pain
Fever
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Tachycardia + Quiet, non-febrile patient =
Decrease in cardiac output
Heart rate rises long before BP falls! Bradycardia + Sick child = Premorbid
state
Child < 60
Infant
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Proper cuff size
Width = 2/3 length of upper arm
Bladder encircles arm without overlap
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Children >1 year old
Systolic BP = (Age x 2) +80 Children >1 year old
BP = 70 + 2 x age (in years)
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Evaluate perfusion using:
Level of consciousness Pulse rate
Skin color, temperature
Capillary refill
Do not delay transport to get BP
Hypotension = Late sign ofHypotension = Late sign of
ShockShock
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Before touching
For one full minute
Approximate upper limit of normal =
(40 -Age[yrs])
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> 60/min = Danger!!
Slow = Danger, impending arrest
Rapid, unlabored
Metabolic acidosis
Shock
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Check by using your thumb against to
bottom of the heel (30seconds)
N
ormal < 2 seconds Increase suggests poor perfusion
Increases long before BP begins to fall
Cold exposure may falsely elevate
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Cold = Paediatric Patients Enemy!!!
Large surface : volume ratio
Rapid heat loss Normal = 370C
Do not delay transport to obtain
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Measurement:Measurement:AxillaryAxillary
Hold in skin fold 2 to
3 minutes
Normal = Depends on
peripheral
vasoconstriction/dila
tion
Measurement: OralMeasurement: Oral Glass thermometers
not advised
May be attempted
with school-agedchildren
Measurement: RectalMeasurement: Rectal
Lubricated
thermometer
4cm in rectum, 1 - 2
minutes
Do not attempt if child
Is < 2 months old
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After exposing during primarysurvey, cover child to avoid
hypothermia!
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Head
Anterior fontanel
Remains open until 12 to 18 months
Sinks in volume depletion
Bulges with increased ICP
C
hest Transmitted breath sounds
Listen over mid-axillary lines
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Neurologic
Eye contact
Recognition of parents Silence is NOT golden!
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Best source depends on childs age
Do not underestimate childs ability
as historian
Imagination may interfere with facts
Parents may have to fill gaps, correct
time frames
On scene observations important
Do not judge/accuse parent
Do not delay transport
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Brief, relevant
Allergies
Medications
Past medical history
Last oral intake
Events leading to call
Specifics of present illness
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Children not little adults
Do not forget parents
Do not forget to talk to child
Avoid separating children, parents
unless parent out of control
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Children understand more than they express
Watch non-verbal messages
Get down on childs level Develop, maintain eye contact
Tell child your name
Show respect
Be honest
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Children do not like:
Noise
Cold places Strange equipment
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In emergency do not waste time in
interest of rapport
Do not underestimate childs ability
to hurt you
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Respiratory distress is the leading cause ofCasualty visits and EMS calls for children
Respiratory compromise is one of the leadingcauses of death in children
Respiratory emergencies can effect children ofall ages
EMS intervention can be life-saving
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Several key
differences betweenadult and pediatric
airway
Larger floppier
epiglottis
Epiglottitis
More difficult
intubations
Smaller, funnel
shaped trachea
FBAO is more
likely
No blind finger
sweeps
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Foreign Body Airway Obstruction (FBAO) Usual causes are hard candy, nuts, small toys, coins, and
balloons
Recognition Apnea, inspiratory stridor, rales, rhonchi, wheezing, inability
to speak, anxiety, decreased breath sounds, muffled voice
Treatment If the patient is not breathing, open the airway and perform
the AHA approved maneuvers for clearing the obstruction Heimlich, backblows, abdominal or chest compressions.
If properly trained you may use a laryngoscope with Magillsforceps to try and remove the obstruction.
If patient is breathing, be as calming and supportive aspossible. Do not agitate the patient and transport sitting upas comfortably as possible. Be alert for change in status.
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Treatment (cont.)
If patient is not breathing ventilate using a
BVM.
Administer oxygen at 15 LPM by NRB.
If patient is wheezing
Administer Medications through Nebuliser
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Inflammation of theepiglottis andsurrounding structurescaused by bacterialinfection.
This condition is a trueemergency withmortality rates as high
as 10%.
Typically occurs inchildren 3-7 years old.
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Recognition
Rapid onset (6-8 hours) of sore throat,
dysphagia, muffled voice, high fever,drooling, inspiratory stridor or rattle
Child is often found obtunded in tripod
position
Signs of respiratory distress are often
present
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Treatment It is absolutely essential that the patient be
handled as calmly as possible. Anxiety oraggravation can cause increased swelling and
precipitate respiratory arrest. Defer all painful procedures. Transport patient sitting up in position of comfort.
Do not try to visualize the swelling or look in the mouth.
Administer high flow humidified O2 by NRB.
Administer 5 ml of EPINEPHRINE 1:1,000 bynebulizer. This can reduce upper airway swelling.
Have airway equipment (BVM, ET equip) ready incase patients condition deteriorates.
Inform medical control early so preparations canbe made at hospital for treatment.
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Inflammation of theupper airways causedby a viral infection.
Very common (50 per1000 children)
Usually occurs inchildren aged 6 months
to 3 years. (median ageof onset is 18 months).
Sites of inflammation in
paediatric airway infections
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Recognition
Low grade fever, barking cough,
hoarseness, inspiratory stridor, wheezing
Signs of respiratory distress
Often occurs at night
Treatment
Same as for epiglottitis.
The patient is likely to respond well to cool
humidified O2.
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Croup
6 months 3 years
Slow onset
Barking cough
No drooling
Low grade fever (104F)
Very Serious
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In contrast to croup
& epiglottitis,
asthma isinflammation of the
lower airways.
It is very common
(effects 50-100 outof 1000 children
under 10 YO)
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Recognition
Typically it is either exercise, allergy, or
infection induced
S/Sx include wheezing, prolonged
expiration, tachypnea, dyspnea, and
anxiety A silent chest is an especially bad sign.
Why?
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Bronchiolitis is a viral inflammation of
the lower airways.
It usually effects children under 2 Years
of Age.
Usually presents with symptoms
similar to those of asthma.
Can be very serious in infants.
Why do you think this is?
More common in the winter months.
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Recognition
Wheezing nd t chypnea are ost
commonsymptoms. lsoanxiety,shortnessof reath, andcyanosis.
reatment
ameasasthmaPatient isnot as li ely to respond ell to -
agonists ( PI, L ROL)
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Asthma
Occurs in all ages,
more common in
children > 2 YO
Occurs throughout the
year
Family hx of asthma
Responds well to -
agonists (EPI and
ALBUTEROL)
Bronchiolitis
Usually occurs in
children under 2 YO
Most common in winter,
spring
No family hx
Does NOT respond well
to EPI/ALBUTEROL
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Treat respiratoryemergencies
aggressi ely. eprepared forpatients
todecompensate. Donot hesitate togi eneonates
oxygen ifyoususpect theyneed it.
Remember to treat theparents too.
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An acute complex
pathophysiologic state of
circulatory dysfunction which
results in a failure of the organism
to deliver sufficient amounts of
oxygen and other nutrients to
satisfy the requirements of tissuebeds
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Uncontrolled blood or fluid loss Blood pressure less than 5th
percentile for age
Altered mental status, low urineoutput, poor capillary refill
None of the above
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Inadequate tissue perfusion to meet
tissue demands
Usually result of inadequate bloodflow and/or oxygen delivery
Shock is not a blood pressure
diagnosis!!
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End organ dysfunction:
reduced urine output
altered mental status
poor peripheral perfusion
Metabolic dysfunction:
acidosis
altered metabolic demands
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Gas exchange capability of lungs
Hemoglobin
Oxygen content
Cardiac output
Tissues to utilize substrate
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Hypovolemic
dehydration,burns,
hemorrhage Distributive
septic, anaphylactic,
spinal
Cardiogenic myocarditis,dysrhythmia
Obstructive
Compensated
organ perfusion
is maintained Uncompensated
Circulatory
failure with end
organdysfunction
Irreversible
Irreparable loss
of essential
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Fluid
Pump
Vessels
Flow
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Inadequate FluidVolume
(decreased preload)
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Fluid
depletion
internal external
Hemorrhage
internal external
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Pump Malfunction
(decreased
contractility)
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Electrical Failure
Mechanical Failure
Cardiomyopathy
metabolic
anatomic
hypoxia/ischemia
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Abnormal Vessel Tone(decreased afterload)
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Septic Shock
Decreas
ed
Volume
Decrease
d Pump
Function
Abnorma
l Vessel
Tone
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Heart rateHeart rate
Stroke volume:Stroke volume:PreloadPreload-- volume of blood in ventriclevolume of blood in ventricle
AfterloadAfterload-- resistance toresistance to contractioncontraction
ContractilityContractility-- force appliedforce applied
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Heart rate Peripheral circulation
capillary refill
pulses extremity temperature
Pulmonary
End organ perfusion brain
kidney
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Preload Volume
Contractili
ty
Inotropes
Afterloa
d
Vasodilato
rs
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Early (Warm)
Decreased peripheral vascular
resistanceIncreased cardiac output
Late (Cold)Increased peripheral vascular
resistance
Decreased cardiac output
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OBSTRUCTED
FLOW
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A: Airway
patent upper airway B: Breathing
adequate ventilation and oxygenation
C: Circulation optimize
cardiac function
oxygenation
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Patients in shock have:
O2 delivery
progressive respiratory fatigue/failure energy shunted from vital organs
afterload
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Early intubation provides:
O2 delivery and content
controlled ventilation which: reduces metabolic demand
allows C.O. to vital organs
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Colloid Solutions
Haemacel: Not used in Neonates as they
have a high risk of anaphylaxis.
Voluven (Hydoxy-ethyl starch): Not readilyavailable, but preferred to plasma. It does
not carry viral diseases.
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Crystalloids DD: Frequently used for rehydration and
maintenance in infants and children. (NOTNEONATES).
Ringer-Lactate: Ised for rehydration andvolume expansion. Do not give bicarbonatewith this solution as it contains calcium.
Maintelyte & Paeds maintenance solution:
Used as maintenance solution. Normal Saline: Used as a rehydration fluid,
and for volume expansion.
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Hypotension (state of shock): Colloid
over crystalloid.
Initially give 15-20ml bolus dose: this is
given rapidly. If this does not correct
the hypotension, repeat the bolus up to
3 times.
Failure of the Fluid Bolus correct thehypotension consider Inotropic
Support
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