assessment and managment of critically ill child 1

Pediatrics

Assessment and Management of the Critically Ill Child

Kids are Tattle-Tales

Goals

• Understand the Role of the Paramedic in Pediatric Emergency Care

• Describe the Developmental Characteristics of different pediatric age groups

• Describe the anatomical and physiological differences between the adult and pediatric patient

Goals

• Describe assessment techniques for the critically injured and ill child

• Discuss General Management of the Pediatric Patient

• Utilize the Appropriate Assessment Technique to Rapidly Identify Treatment priorities

Roles of the Paramedic

• Patient advocacy

• Family Advocate

• Professional Education

• Professional Involvement

Roles of the Paramedic

• Advocacy for the Patient– Patient Needs

• Emergency = Stress = Fear– Separation– Further Injury and Pain– Unknown

• Knowledge = Stress = Fear– Be Honest– Be Understandable– Be Timely

Roles of the Paramedic

• Advocacy for the Family– Family Needs

• Emergency = Stress = Fear– Guilt - Denial– Anger - Loss of Control– Grief

• Knowledge = Stress = Fear– Be Professional– Be Honest– Be Organized

Roles of the ParamedicProfessional Education

– Pediatric Advanced Life Support (PALS)

– Advanced Pediatric Life Support (APLS)

– Pediatric Education for Prehospital Providers (PEPP)

– Pediatric Prehospital Care (PPC)

– Prehospital Trauma Life Support (PHTLS)

– Regional and National Conferences

– Life-Long Learning• Journals• Research• Web Resources

Roles of the Paramedic

• Professional Involvement – Injury Prevention

• Primary, Secondary, and Tertiary• The 4 E’s of Injury Prevention

– Education – (Public Awareness)– Enforcement – (Seatbelt/Helmet law, Zoning

Regs)– Environmental changes – (Free Helmets, gun

locks)– Engineering – (Speed bumps, child-resistant

bottles)

Roles of the Paramedic

• Professional Involvement – EMS – Children

• Federally Funded Program (1984/1991)• Designed to reduce impact from Illness and

Injury• Address the Special Needs of Pediatrics

– Assessment– Equipment– Education

Humboldt

Siskiyou Modoc

LassenShastaTrinity

TehamaPlumas

SierraButte

Glenn

Nevada

Placer Colusa

Mendocino

Lake

Sonoma Napa

Yolo

Su

tter

Yub

a

El Dorado

Amador Alpine

Mono

Tuolumne

Sacr

amen

to

SanJoaquin

Solano

ContraCosta

Marin

San Francisco

San Mateo

Santa Cruz

Alameda

SantaClara

Stanislaus

Merced

Mariposa

Madera

SanBenito

Monterey

Fresno

Inyo

KingsTulare

KernSan Luis Obispo

Santa Barbara

VenturaLos Angeles

San Bernardino

Riverside

Orange

San DiegoImperial

EMSC Systems in Placeand not Funded by EMSA (3 Single County Agencies)

EMSC Projects Funded by EMSA(18 Agencies Representing 40 Counties)

No EMSC System in Place(9 Agencies Representing 11 Counties)

Calaveras

DelNorte

Note: Patterned areas indicate EMS regions

4/16/02

EMSC Projects in Early Stage Implementation (funded by EMSA) (2 Agencies Representing 4 Counties)

Developmental Characteristics

• Greatest Change Occurs in first Few years of Development– Muscle

Coordination– Cognitive Process– Language Skills– Social Skills

• Understanding allows a better and more complete assessment

• Effects the Assessment Findings

Developmental Characteristics

• Development and Assessment– Knowledge of appropriate developmental

milestones– Information from Parents on child’s norm– Appropriate Communication Skills– Children will REGRESS when STRESSED

Infants and young children should be allowed to remain

in their parent’s arms.

The approach to the pediatric patient should

be gentle and slow.

A small toy may calm a child.

Anatomy and Physiology of Kids

• Head• Airway• Chest and Lungs• Abdomen• Extremities• Skin and BSA

• Respiratory • Cardiovascular• Nervous• Metabolic

Anatomy

Head• Proportionally Larger

– Occipital region • Small Face/Flat Nose• Fontanelles

– Posterior closes @ 4 months

– Anterior Closes @ 9-18 months

Airway• Smaller Airways• Obligate Nose

Breather (<6 months)• Large Tongues• Large/Floppy

Epiglottis• Softer Trachea• Trachea Narrows

– Cricoid ring

Head and Airway

Anatomy

Chest and Lungs• Ribs – Softer and

more Flexible• Muscles – Fatigue

Early• Belly Breathers• Thin Chest wall –

Transmitted Sounds

• Prone to Gastric Distention

• Higher Energy Transfer from Blunt Trauma

• Increased risk of Pneumo and Tension

• Maxed out on Tidal Volume

Anatomy

Abdomen

• Belly Breathers

• Large Organs in Small Space– Liver and Spleen

• Gastric Distention will Impede Tidal Volume

Anatomy

Extremities• Still Growing

– Epiphyseal Plate

• Soft and Flexible– Sprains, Strains,

Fractures

Skin – BSA• Thinner• Less

Subcutaneous Fat• Greater

BSA:Weight • All increase risk

– Heat Loss– Burn Severity

Physiology

Respiratory• Increased Oxygen

Demand• Decrease Oxygen

Supply (Reserve)• Vm = TV x RR

– Minimal Change in TV

Cardiovascular• Skin Perfusion is

Best Assessment Tool

• CO = SV x HR• BP = (SV x HR) x SVR• Minimal Change in SV• Significant Shock W/O

Hypotension

Physiology

Nervous• Still Developing• Prone to Increased

Injury• Vagus Nerve

– Direct Stimulation– Passive Control

Metabolic• Increase Rate for

Compentsation• Limited Glygogen

and Glucose stores

• Newborns/neonate – don’t shiver

Assessment Techniques

• Scene Size - Up

• General Impression

• Initial Assessment

• Treatment/Transport Priority

• Focused History And Physical

Assessment Techniques

• Scene Size - Up

• General Impression

• Initial Assessment

• Treatment/Transport Priority

• Focused History And Physical

Assessment Techniques

• Pediatric Assessment Triangle– Appearance– Work of Breathing– Circulation

Assessment Techniques

• Rapid Cardiopulmonary Assessment– AHA – PALS– What you:

• See • Hear• Feel

The Pediatric Assessment Triangle• Observational assessment

• Formalizes the “general impression”

• Establishes severity of illness or injury

• Determines urgency of intervention

• Identifies general category of physiologic abnormality

Pediatric Assessment Triangle

Appearance Work of Breathing

Circulation

The Pediatric Assessment Triangle

• Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

The Pediatric Assessment Triangle

Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

The Pediatric Assessment Triangle

Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

The Pediatric Assessment Triangle

Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

The Pediatric Assessment Triangle

Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

The Pediatric Assessment Triangle

Appearance

– Alertness

– Distractibility/ consolability

– Eye contact

– Speech or cry

– Motor activity

– Color

The Pediatric Assessment Triangle

How do we recognize respiratory distress or respiratory failure by just looking at a child?

Pediatric Assessment Triangle

Work of BreathingAbnormal breath sounds

Retractions

Nasal flaring

Appearance

Circulation

Respiratory Distress

Normal Work of Breathing

Appearance Retractions

Normal Circulation

Respiratory Failure

Abnormal Work of Breathing

Appearance

Circulation Normal or Poor

Appearance Work of Breathing

Circulation

Without the use of instruments, how can we rapidly assess the adequacy of circulation?

Skin Circulation

• Skin temperature

• Pulse strength

• Capillary refill time

• Color

Shock

Abnormal Normal Work of

Appearance Breathing

Poor Circulation

Brain Dysfunction

Abnormal Normal Work of

Appearance Breathing

Normal Circulation

PAT: Respiratory Distress

Circulation to SkinNormal

Work of BreathingIncreased

AppearanceNormal

PAT: Respiratory Failure

Circulation to SkinNormal or abnormal

Work of BreathingIncreased or decreased

AppearanceAbnormal

PAT: Shock

Circulation to SkinAbnormal

Work of BreathingNormal

AppearanceAbnormal

PAT: (CNS) Dysfunction or Metabolic Abnormality

Circulation to SkinNormal

Work of BreathingNormal

AppearanceAbnormal

2-week-old infant• Called to the home of 2-week-old

infant who had stopped breathing

• Infant turned pale, limp, revived when sitter “blew in her face”

• Term delivery, no complications

• Two days poor feeding; no fever

Circulation to SkinFace and trunk normal, hands and feet blue

Work of BreathingAbdomen rises and falls with each breath

AppearanceEyes open, moves arms and legs, strong cry

2-week-old infant

What do you think of this baby’s

work of breathing?

Are you concerned about her skin

signs?

23-month-old toddler• Called to home of a 23-month-old

with “trouble breathing”• Child is on mom’s lap, sees you, and

starts to wail!• Patient is alert, with retractions and

audible wheezing. Skin color is normal.

What can we tell from the PAT?

23-month-old toddler

.

Circulation to SkinNormal color

.

Work of BreathingRetractions, audible wheezing

AppearanceSeated, alert, strong cry

9-month-old infant

• A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.

9-month-old infant

Circulation to SkinPale skin color

Work of BreathingNo retractions or abnormal airway sounds

AppearanceAgitated, makes eye contact

Initial Assessment

– Airway - Open and maintainable – Breathing - RR 50 breaths/min, clear lungs,

good chest rise– Circulation - HR 180 beats/min; cool, dry, pale

skin; CRT 3 seconds; BP 74 mm Hg/palp – Disability - AVPU=A– Exposure - No sign of trauma, weight 8 kg

What is this child’s physiologic state?

What are your treatment priorities?

• Assessment: Compensated shock, likely due to hypovolemia with viral illness

• Treatment priorities:– Provide oxygen, as tolerated– Obtain IV access en route

• Provide fluid resuscitation– 20 ml/kg of crystalloid, repeat as needed

• 160 ml normal saline infused

• HR decreased to 140 beats/min

• Patient alert and interactive, receiving second bolus on emergency department arrival

General Management of the Pediatric Patient

• Airway Management

• Fluid and Medications

• Electrical Therapy

• C-Spine Consideration and Impact

• Transport Considerations

Summary of BLS Maneuvers

Clearing an Infant’s Airway

Suctioning

• Decrease suction pressure to less than 100 mm/Hg in infants.

• Avoid excessive suctioning time—less than 15 seconds per attempt.

• Avoid stimulation of the vagus nerve.

• Check the pulse frequently.

Pediatric-size suction catheters. • Top: soft suction catheter. • Bottom: rigid or hard suction catheter.

Suction Catheter Sizes for Infants and Children

Oxygenation

Adequate oxygenation is the hallmark of pediatric patient management.

Inserting an oropharyngeal airway in a child with the use of a tongue blade.

a. In an adult, the airway is inserted with the tip pointing to the roof of the mouth, then rotated

into position. b. In an infant or small child, the airway is inserted with the tip pointing toward

the tongue and pharynx, in the same position it will be in after insertion.

Ventilation

• Avoid excessive bag pressure and volume.

• Obtain chest rise and fall.• Allow time for exhalation.• Flow-restricted, oxygen-powered devices

are contraindicated.• Do not use BVMs with pop-off valves.• Apply cricoid pressure.• Avoid hyperextension of the neck.

In placing a mask on a child, it should fit on the bridge of the nose and cleft of the chin.

Sellick’s maneuver

Advanced Airway and Ventilatory

Management

Infant/Child Endotracheal Tubes

The Pediatric Airway

• A straight blade is preferred for greater displacement of the tongue.

• The pediatric airway narrows at the cricoid cartilage.

• Uncuffed tubes should be used in children under 8 years of age.

• Intubation is likely to cause a vagal response in children.

Pediatric Endotracheal Tube Size

• Use a resuscitation tape that estimates ET tube size based on height.

• Estimate the correct diameter, based on the child’s little finger.

Pediatric Tube Size Formula

(Patient’s age in years + 16)

4

Indications• Need for prolonged artificial ventilation• Inadequate ventilatory support with a BVM• Cardiac or respiratory arrest• Control of an airway in a patient without a

cough or gag reflex• Providing a route for drug administration• Access to the airway for suctioning

Placement of the laryngoscope.

Endotracheal Intubation in the Child

Hyperventilate the child.

Position the head.

Insert the laryngoscope and visualize the airway.

Insert the tube and ventilate the child.

Confirm tube placement.

Nasogastric Intubation

Nasogastric Intubation

Indications:

• Inability to achieve adequate tidal volume during ventilation due to gastric distention

• Presence of gastric distention in an unresponsive patient

Oxygenate and continue to ventilate, if possible.

Measure the NG tube from the tip of the nose, over the ear, to the tip of

the xiphoid process.

Lubricate the end of the tube. Then pass it gently downward along the

nasal floor to the stomach.

Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while

injecting 10–20 cc of air into the tube.

Use suction to aspirate stomach contents.

Secure the tube in place.

Rapid Sequence Intubation

• Indicated in pediatric patients when intubation is difficult due to combativeness or clenched teeth.

• Neuromuscular compliance is gained by the use of a paralytic.

Circulation

Two problems lead to cardiopulmonary

arrest in children:

• Shock

• Respiratory failure

Vascular Access

• Neck veins

• Scalp veins

• Arms

• Hands

• Feet

• Intraosseous infusion

Intraosseous Infusion Indications

• Children less than 6 years of age

• Existence of shock or cardiac arrest

• Unresponsive patient

• Unsuccessful peripheral IV

Intraosseous Infusion Contraindications

• Fracture in the bone chosen for IO• Fracture of the pelvis or extremity fracture

of bone, proximal to the chosen site

Intraosseous administration.

Drugs Administered by IO Route

• Epinephrine

• Atropine

• Dopamine

• Lidocaine

• Sodium bicarbonate

• Dobutamine

Correct needle placement for intraosseous administration.

Fluid Administration

Accurate fluid dosing in children is crucial!

Electrical Therapy• Initial dose is 2 joules per kilogram

of body weight.• If unsuccessful, increase to 4 joules

per kilogram.• If still unsuccessful, focus on

correcting hypoxia and acidosis.• Transport to a pediatric critical care

unit, if possible.

Immobilizing a Patient in a Child Safety Seat

One paramedic stabilizes the car seat in an upright position and applies and maintains manual inline stabilization

throughout the immobilization process.

A second paramedic applies an appropriately

sized cervical collar. If one is not available, improvise using a rolled hand towel.

The second paramedic places a small blanket or towel on the child’s lap, then uses straps or wide tape to secure the

chest and pelvic area to the seat.

The second paramedic places towel rolls on both sides of the child’s head to fill voids

between the head and seat. He then tapes the head into place, taping over the chin, which would put pressure on the neck. The patient

and seat can be carried to the ambulance and strapped to the stretcher, with the stretcher

head raised.

Applying a Pediatric Immobilization

System

Position the patient on the immobilization system.

Adjust the color-coded straps to fit the child.

Attach the four-point safety system.

Fasten the adjustable head-support system.

The patient fully immobilized to the system.

Move the immobilized patient onto the stretcher and fasten the loops at both ends to connect to the stretcher

straps.

Emotional support of the infant or child continues during

transport.

Never delay transport to perform a procedure that can be done

en route to the hospital!

Case Studies