As published in Fire engineering Magazine.

By Steven Kanarian, MPH, Instructor CUNY, LaGuardia Community College Paramedic program e-mail: StevenKan@optonline.net

At 2:24 pm on a fall afternoon; paramedics and an engine company are dispatched to a call for a “child not breathing.” Dispatch stated that the mother caller said her “7-year-old child is not waking up, possibly not breathing.” Upon arrival the engine company and observe a 7-year-old boy lying on the couch. The patient’s head and shoulders are draped over the arm rest of the couch, and he barely notices the firefighters entering the room with their equipment and radio’s chirping. The patient has a vacant look, is very pale, diaphoretic and barely responds to painful stimuli.

“What happened?” Paramedic Miguel asks the mother. “He has been feeling ill since 11:00 o’clock. All of a sudden he had a seizure. It scared the life out of me to see my child like that” states the mother. “Does he have a history of seizures?” Miguel asks. “No, he only has mild asthma.” The first responder engine places the hi-concentration oxygen mask and ECG electrodes on the patient. With a little stimulation the patient’s respirations increase to 16.

Bob from the CFR company obtains vitals, “BP 150/100, 124 on the pulse, 16 on the resps, he responds to stimuli but is disoriented, pulse ox is 94%.” Bob puts a stethoscope to the boy’s chest, “clear and shallow bilaterally.” “Thanks brother”, Miguel replies.

Miguel asks the mother what parts of her son was shaking when he had the seizure, “his head went back and his arms were shaking up and down,” the mother explained. While showing how her son’s arms were positioned during the seizure she displays arms flexed and fists rotated inward during the seizure, classic decorticate posturing. Chris asks “how long did the seizure last?” “About 3 minutes” the mother informs the medics. “What was he doing before he got sick?” “He was playing video games all morning. He stopped at 11:00 o’clock and took a nap.” “Has he ever had seizures before or felt ill while playing video games?” Chris asks. “No, he plays those games all the time”.

Miguel asks his partner Chris, “What could cause a first time seizure in a 7-year-old with no history of seizures?” “Maybe trauma or an overdose” Chris answers. Chris then asks the mother if the boy possibly took any medications or poisons. No, I was watching him before and he slept on the couch. “Does he take any medications ma’am?” Chris asks. “A Proventil pump, he has asthma,” the mother replies. “Is he treated for any other medical problems?” “No”, states the mother. “Any allergies to medications?” “No” the mother replies. “Any recent injuries or falls?” “No” she replies.

As Chris begins to gather the equipment to start an IV, Miguel talks to his partner, “what could cause a seizure in healthy child?” Thinking back Miguel reviews the acronym OPQRST, “onset, duration, quality, radiation, severity and time.” to ensure they have obtained a complete history of present illness, and pertinent positives for seizures. Moving to the past medical history Miguel reviews SAMPLE. Miguel thinks, “Signs and symptoms, allergies, medications, past medical problems, last oral intake, and events leading up to the seizure. “What was the last thing he ate or drank?” “He ate around 7:00 am, he only had toast.” Thinking of past medical problems Miguel asks, “Ma’am, when was he in the hospital last?” He was in the hospital 3 weeks ago for nasal polyps.” “Did he stay overnight or just go to the emergency room?” He was there for 5 days, he had surgery, he had a nasal polyps removed.” “Do you have the discharge paperwork and instructions?” “Yes,” the mother digs the paperwork out of a pile in the kitchen table. “Here it is.” Miguel sees discharge instructions for surgery, discharge information about nasal polyps and a prescription for Augmentin. “Did you fill this prescription?” “No I have no insurance; they wanted $130.00 for those pills.” I am a part-time employee of the Parks Department. “Ma’am, Augmentin is a antibiotic which prevents infection. Your son may have an infection from his surgery.” Miguel thanks the mother for the information.

Miguel calls out from the kitchen, “Chris, Lieutenant, have everybody wear masks and gloves, he may have encephalitis or meningitis.” “Meningitis? Where did you pull that one out of Miguel?” “He was admitted for nasal polyps and never received antibiotics on discharge, could be an infection, encephalitis, sepsis or meningitis.” Miguel explains, “Good job, the lieutenant from the engine company states, “Gloves and goggles boys, and universal precautions.” “Chris and Miguel put on their N95 masks and start an IV normal saline lock. Chris samples the glucose level from the IV catheter. “His glucose level is 58, let’s get rolling, we can give him and Dextrose during transport.” When the child is sat upright to be transported he vomits yellow bile.

On route to the hospital the patient receives 0.5 gms / kg Dextrose 25% without improvement, the D₂₅ is repeated. The child’s mental status does not change. Chris asks the child if he has any neck pain, the boy shakes his head weakly indicating no. Palpation of the posterior neck and flexing of the legs do not provoke pain indicative of meningeal irritation from meningitis.  

Upon arrival at the hospital Miguel gives a presentation, including HPI, pertinent positives, PMH and vitals. The ED staff places the patient on Meningitis isolation precautions. After a 12-day stay in the hospital on antibiotics the boy is discharged.

Post-run review

Many of the seizure calls we respond to are in patients who have epilepsy. EMS providers regard seizure calls as routine and rely on standard diagnosis of epilepsy or febrile seizures. A response to a call for a lethargic 7-year-old child with a first time seizure is a significant incident that is sure to get the attention of even the most experienced fire department personnel. When responding to a medical emergency in a pediatric patient it is paramount to rapidly assess the child for life threatening problems, elicit a systematic history of present illness and past medical history.

Pediatric patient assessment begins with the “doorway” assessment. Upon entering a room with a pediatric patient we visualize the child to see if the patient is conscious and alert, or lethargic and apathetic. If a child’s does not respond to the fire department arriving with their equipment and radios chirping, there is probably a serious pathology causing altered mental status.

Assessment and Management of Pediatric Life Threats

The Pediatric Assessment Triangle (PAT) is the standard assessment tool for initial evaluation of the pediatric patient. The PAT consists of assessing the child’s appearance, breathing and circulation. Evaluating appearance includes assessing the patents muscle tone, mental status, interaction with the caregiver, consolability, gaze and speech. A quiet, lethargic child is a patient in need of immediate resuscitation. Evaluating breathing involves assessing the patency of airway, oxygenation, and ventilation. Assess airway by looking at body position, chest excursion, respiratory rate and effort and lung sounds. Sniffing position and tripod position are some of the hallmark signs of respiratory distress. Grunting and paradoxical respirations are ominous signs of respiratory failure. Assessment of the circulation reflects the adequacy of cardiac output and perfusion of vital organs. In assessing circulation of a pediatric patient we observe the skin color, end organ perfusion and level of consciousness. Mottled skin, restlessness and oliguria are signs of circulatory failure.

Using the PAT to gain an initial impression of the pediatric patient’s condition provide pre-hospital providers with a tool for a rapid size-up of a child’s potential life threats.

Once threats to life have been identified and treated, we can obtain a thorough history of present illness (HPI). A systematic HPI and physical are the keys to diagnosing the presenting medical problem and determining the correct course of treatment. Systematic collection of patient information leads to quality care. Most presenting problems are easy to determine and accepted at face value. Thorough pre-hospital care providers consider the obvious diagnosis then dig deeper to consider other possible diagnoses. The most interesting diagnoses, like this one of meningitis in a 7-year-old with a seizure, are made with a careful history and considering possible alternative diagnoses. Without a thorough history and considering the cause of the seizure the fire fighters, paramedics and hospital staff would have been unnecessarily exposed to meningitis and a prescription antibiotic. The case in this article was diagnosed using the information about the patient’s recent hospitalization and recent surgery, which was developed during the HPI, coupled with knowledge about the causes of altered mental status. When faced with a disoriented and lethargic child we must rule out the causes of AMS.

Presumptive Diagnosis Using “AEIOU-TIPPS”

The differential diagnosis of altered mental status in a patient can facilitated by using SAMPLE for the past medical history and the acronym AEIOU-TIPPS¹ for reviewing the causes of AMS/Seizures. Systematic Assessment and HPI, PMH are essential to accurately and rapidly diagnose your patients. AIOU-TIPPS is a tool to consider all the causes of AMS / Seizures in addition to the first impression we form on the scene. As seen in the case presented, consideration of all causes of AMS resulted in better patient care and increased safety for the responders treating the child with meningitis.

The treatment of a patient in an emergency is performed rapidly by following a standard approach. Pre-hospital we use the initial impression and review of life threats to rapidly categorize and care for our patients. The acronym AEIOU-TIPPS can be useful in recalling the causes of AMS. AEIOU-TIPPS should be memorized or more practically, laminated and mounted in your drug bag for quick reference on the scene.

• Alcohol
• Epilepsy
• Infection
• Overdose
• Uremia
• Trauma
• Insulin
• Psychosis
• Poison
• Stroke

Febrile Seizures: The Familiar Diagnosis

EMS personnel may form a presumptive diagnosis of a child’s seizure as a febrile seizure because of a history of illness and rapid increase in fever. Febrile seizures occur in about 2% to 5% of children < 6-years of age; most occur at age 18-months to 6-years of age. Seizures are diagnosed as febrile after exclusion of other causes.² Causes of AMS / Seizures from uremia, infection, lesions and electrolyte causes should be ruled out before assuming the patient has febrile seizures.

In this case presented with the 7-year-old male having seizures, the patient did not present with a fever and was more than 6 years of age, making he diagnosis of febrile seizure unlikely. Febrile seizure may be a dangerous assumption to rule out in a pre-hospital pediatric patient presenting with seizure and AMS. All the causes of seizures should be considered before a diagnosis of febrile seizures is made.

A More Serious Problem–Meningitis

In the case presented the recent history of surgery and lack of follow up with antibiotics was the key element that alerted the crew to the possibility of meningitis. Meningitis is an illness in which there is inflammation of the tissues that cover the brain and spinal cord. Viral or “aseptic” meningitis, which is the most common type, is caused by an infection with one of several types of viruses. In the United States, there are between 25,000 and 50,000 hospitalizations due to viral meningitis each year. ³ Staphylococcal meningitis can occur after penetrating head wounds or neurosurgical procedures. Bacterial meningitis is much more severe and can result in coma and death with a rapid onset.

Bacterial meningitis, which has a rapid onset and is much more severe, can result in coma and death. Or does only the one with a rapid onset result in death as you have it?

Meningitis occurs when an infection breaches the natural protection of the central nervous system. The blood supply of the meninges lies adjacent to the venous system of the nasopharynx, mastoid process, and middle ear. When the organism eludes the immune system and enters the cerebral circulation through one of these openings, infection spreads quickly through the subarrachnoid space. ⁴ Meningitis can occur with or without neck pain. Neck pain may be difficult to assess in younger children or those with AMS. Nuchal rigidity, which is neck stiffness with movement of the neck, may not be present in younger children. Verbal children will often complain of headaches and neck pain.

Meningitis can infect a patient with gradual or sudden onset. Gradual onset of meningitis is preceded by several days of lethargy, fever, GI, respiratory symptoms and increased irritability. Meningitis with rapid onset can present with shock, petechiae (small pinpoint red spots) purpuric spots (large purple or black spots), disseminated intravascular coagulation (DIC) and reduced levels of consciousness, frequently resulting in death within 24 hours.

Physical symptoms of patients with bacterial meningitis depend on the age of the patient, underlying medical condition and causative organism A respiratory illness or sore throat often precedes the more characteristic symptoms of fever, headache, stiff neck, and vomiting. Kernig’s and Brudzinski’s signs appear in about half of patients. In children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Kerning’s sign or Brudzinski’s sign. To detect nuchal rigidity in older children, ask them to sit upright and touch their chin to their chests. Younger children can be persuaded to touch their chin to their chest by following a small toy or light beam.⁵ Adults may become desperately ill within 24-hours, and children even sooner. Seizures occur in about 30% of patients. In patients > 2-years of age, changes in consciousness progress through irritability, confusion, drowsiness, stupor, and coma. ⁶

Management

Management of patient with meningitis begins with proper PPE by wearing gloves, mask and gown or BBP ensemble. In the management of a critical pediatric patient with meningitis attention to the PAT and life saving interventions such airway maintenance, suctioning, oxygenation and fluid resuscitation are important. In the AMS child administration of Dextrose 0.5 gms / kg will help establish normal glucose levels. In the event of seizure activity Diazepam or Midazolam can be given to stop seizure activity. Monitoring of the airway, ventilation assistance and intubation may be necessary following benzodiazepine administration.

Conclusion

The presenting case of a 7-year-old boy with new onset of seizure should appear as a serious call. We have discussed how important a detailed history of present illness, past medical history can be in making an accurate diagnosis. We also discussed the danger of incorrectly assuming a patient is having a febrile seizure. Proper PPE for pediatric patients having AMS and seizures is crucial for protecting EMS and public safety personnel responding to aid children. Febrile seizures are isolated seizures that can only be diagnosed following testing for infection and occur in children from 18-months of age to 6-years of age who have a fever. Use of the AEIOU-TIPPS acronym is useful in systematically considering all causes of AMS. By being diligent in detecting life threats, eliciting a thorough history and considering all the causes, we can help our patients. We must always be diligent in protecting ourselves and delivering high quality care to pediatric patients. The discerning and outstanding pre-hospital provider will always think, “It looks like this is the problem, what else should I consider?”

References

1. Caroline, Nancy. Emergency Care in the Streets, Jones and Bartlett Publishers. Sudbury, MA, 2008. Book 3, page 41-42.

2. Merck Manuals online Library. “Febrile Seizures”. http://www.merck.com/mmpe/sec19/ch283/ch283c.html obtained on 08/13/2008

3. Centers for Disease Control and Prevention. “Viral (“Aseptic”) Meningitis FAQs” http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/viral_meningitis.htm obtained on 08/13/2008

4. Aehlert, Barbara. Comprehensive Pediatric Emergency Care, . Elsevier/Mosby.

St. Louis, MO. 2005.

5. Bates’ Guide to Physical Examination – 9^th edition/ Bickley, Lynn S., Szilagyi., Lipincott Williams & Wilkens, 2007. Bates, page 751

6. Merck Manuals online Library. “Acute Bacterial Meningitis” http://www.merck.com/mmpe/sec16/ch218/ch218b.html obtained on 08/13/2008

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Dr. Cooper

KEEP THE BABY WARM! – (Cold baby → hypoglycemia → seizures → death)

Make sure baby is not hypoglycemic. Neonates have non-shivering thermogenesis. They burn glucose to generate heat. They cannot shiver. (Brown fat)

Hypoxia → Bradycardia

Newborn – first 12-24 hours

Neonate – first month

6-10% of out of hospital births require ALS care

Maternal History

M – M – M – M

• Maturity
• Multiplicity
• Meconium
• Medications

Transition from fetus to newborn

• as a fetus lungs are collapsed and filled with fluid, most expelled during birth process
• must take first deep breath to inflate the lungs
• causes of delayed transition
• hypoxia
• meconium or blood aspiration
• acidosis
• hypothermia
• pneumonia
• hypotension

Anatomic Differences

• Airway
• shorter trachea
• delicate upper airway
• small soft epiglottis
• flexible tracheal rings
• obligate nose breathers
• Breathing
• fewer alveoli – less bronchial branches
• 30 m/kg lung fluid
• Preemies lack surfactant (<34 weeks)
• Circulation
• smaller blood volumes
• umbilical cord present
• Disability
• smaller glycogen stores
• delicate choroid plexuses (in brain – secrete CSF – can bleed profusely)
• larger TBSA/TBM – quicker hypothermia
• hypoxia and hypoglycemia poorly tolerated – leads to MR/DD – Death
• Family
• 97% babies are normal – scared family
• anger typically represents misdirected guilt

Cord clamping initiates the circulatory transition – closure of foramen ovale –Wait around 30 seconds to get most blood possible from placenta into baby.

maternal and fetal blood supply are separate and do not mix.

Problematic obstetrics conditions

• uterine/placental dysfunction
• placental disruptions
• ABO/D incompatibly – fetal hydrops
• fetal pelvic disproportions
• laryngeal webs
• nuchal cord
• prolapsed cord

Primary vs Secondary apnea (look up)

Prepare for delivery

4 ohs

• Ob kit
• Other hands
• Overheat ambulance
• Obstetric history

EMT ABC DEF

• Excretions, Meconium, Temp
• ABCs
• Dextrose, Epinephrine, Fluid

Suction secretions room nose first so as not to stimulate breathing, turn baby to side allow secretions to drain into cheek then suction mouth

When intubating for thick sticky meconium, the tube is the actual suction tube. use with a meconium adapter. pass a new tube up to three times then stop.

Dry thoroughly by patting , not rubbing

Chapter 358: Shock

Copied from the AAP Textbook of Pediatric Care

Chapter 358: Shock

March 29, 2009, Dr Cooper

Pediatric Circulatory Emergencies

PAT

Is he in shock? Volume or Cardiogenic, assess vitals, mentation, etc, (BP last indicator)

Peds, who present with dysrhythmias, present like they are in shock. They won’t tell you that they have palpitations, etc, do not presume that if a child is in shock you always give fluid…must rule out cardiogenic causes.

Shock- failure of circulation to meet the metabolic demands of the tissues (energy)

• Hypoperfusion – inability of circulation to deliver blood to tissues, results in hypoxia
• Hypotension – not enough pressure to deliver blood to core organs
• Compensated shock – inability to meet needs of peripheral tissues
• Decompensated shock – inability to meet metabolic demands of core organs
• Cardiopulmonary failure – moribund state resulting in from total respiratory and/or circulatory collapse

Preload – tension in ventricle wall at end diastole – corresponds with RAP/LAP (potential amount of force that can be generated by the ventricle based upon the amount of stretching by the muscle fibers – determined by end diastolic volume

Afterload- tension in ventricular wall at end systole (covaries with PVR peripheral vascular resistance) (pressure head against which the heart has to squeeze)

Contractility – force developed by the ventricular wall during systole

Pediatric Hemodynamic changes

• Blood Loss Heart rate immediately increases and only drops at around 45% loss
• BP maintains until about 30% loss and then drops severely (soft arteries can constrict much better than adults)
• CO starts dropping immediately and also drops severely of at 30% loss

Shock – A Hydraulic Solution

Pump Failure (cardiogenic)

• Electrical dysrhythmias (defib cardiovert)
• Mechanical – cardiomyopathy (inotrope, vasopressor)

Pipe Failure

• Distributive –(anaphylaxis, neurogenic – decreased vascular tone) (volume resuscitation MAST, Epi, contain the spread)
• Obstructive (Pneumothorax, Tamponade) (decompress tension pneumo)

Prime Failure

• Hypovolmic dehydration, hemorrhage, GI
• Dissociative –CO poisoning (o2 specific antidote)

Kids have proportionally larger blood volume but absolute volume is smaller

Softer more compliant vessels – capable of intense vasoconstriction

Smaller heart ventricles less compliant – less stretch per Starling’s Law – cannot really increase contractility – more dependent on rate to increase CO

Pulse higher than 150 – (5x age in years) is tachycardia, BP <70 +2 x age is lowest BP

Hypovolemic shock most common is peds, then septic, then cardiogenic

Hypovolemic – mostly dehydration, then hemorrhagic, GI

Septic –more common endotoxin vs extotoxin – (results in inability for cells to extract o2)

Cardiogenic – usually electrical (SVT VFIB)

Kids don’t usually get clammy unless cardiogenic, mottled in Hypovolemic

Simultaneous palpation of proximal and distal pulses (eg. femoral vs Pedal) big diff indicates compensated shock

Fluid Doses 20ml/kg of NS or LR – does it help? See study…Bottom line – maybe not be effective in short transport times. Focus on maintaining airway.

2 attempts or 90 sec, AC or saphenous at ankle. Then try IO. IO must be injected under pressure, gravity drip will not work

Pediatric Trauma

• Immature anatomy
• Different mechanisms
• Long term sequela
• Age specific equipment

• Larger heads, softer skulls – will fall head first, will decompensate quickly due to head trauma, soft tissue obstruction due to decrease tone leading to hypoxemia, ICP, cerebral edema,
• Proportionally smaller torso yet larger organs
• Impact – smaller total body mass
• More often hit by cars than unrestrained passengers (abdomen and L spine from improper seat belt position)
  • Waddell’s Triad
  • 1. Femur fracture
    2. Intra-abdominal or intrathoracic injury
    3. Head injury
• Falls from height
• Fall from bike – head – unhelmeted bike riders 2^nd leading cause of head injury death in US kids (#1 MVA)

Normoventilate(30) for resp failure, decomp shock, traumatic coma

Hyperventilate (35)– single dilated pupil, fixed dilated, apneic spells

SCIWORA Syndrome: (Spinal Cord Injury w/o Radiologic Abnormality)

Head Trauma – ….

Neck Trauma ……

Chest Trauma – soft bone structure –

Abdominal Trauma – upper organs are lower, lower organs are higher (liver not well protected), thinner walled, abdominal viscera less protected

MSK Trauma, lose less blood, growth plate involvement, incomplete fractures, vascular injury common

ABCDEF – Airway Breathing Circulation Disability (pupils and GCS), E exposure, (but keep warm) F (focused physical on stable patient)

El Physiocontrol Lifepak 12, así como muchos otros tipos de equipos médicos usados se pueden comprar en línea por mucho más barato que comprar nuevos.

3/25/09 Dr Cooper

Pediatric Airway Management

Bag and drag, get control of lungs and heart will follow – get control of airway and move

Start with PAT – Appearance – example, seesaw respirations – upper airway obstruction. Snoring; soft tissue, gurgling; secretions, stridor; croup FBAO, epiglottis. Hoarseness; laryngeal trauma

• Mandibular block, needs to be moved forward– use OPA or Jaw thrust
• Larynx, higher and more forward in the throat, airway is funnel shaped, particulate matter can get wedged below cords but above cricoid ring.
• Size of Infant airway= drinking straw. Adult=Garden hose

Management

• Non- rebreather
  Pulse Oximeter of 90-95%, GCS 14, AVPU of V , compensated shcok – SBP 70-90 + 2x age
• BVM, Spo2 <90%, SBP <70 + 2x age (decompensated shock), Traumatic Coma, AVPU P or U, GCS 8 or less – disable pop-off valve, watch the chest just rise,
  • Size the mask, completely cover nose and mouth, face mask cannot press against eye, causes profound vagal response in baby
  • EC Clamp
• OPA – teeth to angle of mandible
• NPA – nares to tip of earlobe
• Positioning
  • Medical – Sniffing plus
  • Trauma – Neutral airway position
  • Squeeze – relax, 20 times per minute
  • Do not hyperextend neck in either case
  • Infant – pad entire body (or use a backboard with a hole for head). Head is too high and padding aligns plane of face to be parallel with stretcher. Disproportion ends around 8 years of age. Older child may need a shoulder roll.
  • Steeles rule of three, spinal cord is only one third of spinal canal. Hard to add further injury as long as you keep some degree of caution, a little movement won’t injure,
  • May have to remove C collar in order to intubate

Technique for high pressure ventilation- Sniff plus, jaw thrust up into mask, two thumbs on side of mask

ETT – respiratory failure decompensated shock, traumatic coma

• Miller Blade to lift floppy epiglottis (less than 8 years)
• Uncuffed tube – allows for larger diameter tube, and cuff pressure may cause pressure on tracheal mucosa
• Pass tube just below where black mark disappears
• 4 Ps
  • Prepare – suction o2 scope and tube
  • Position patent and operator – eye level of airway –
  • Preoxygenate
  • Perform intubation _ don’t persist longer than you can hold your own breath
    • Smaller mouth, developing dentition, etc avoid levering, suction avoid prying
  • RSI where used – GCS 5-9
  • Confirm placement primarily and secondary (wave form capnography)
• Neonatal Intubation – very delicate maneuver
• DOPE for common ETT problems
  
  • Displacement – re-auscultate
    
  • Obstruction – suction
    
  • Pneumothorax – absent sounds on one side
  • Equipment failure –
  • Don’t screw around, bad tube – remove
• Nasogastric Intubation
  • Straight back into nares will follow curve of throat, measure from nares, around ears down to xyphoid process

ETT vs BVM – No significant mortality differences, true for medical and trauma patients.

BVM the single most important skill to master

(TUBE TOOLS – CD Rom)

The Physiocontrol Lifepak 12 as well as many other types of used medical equipment can be purchased online for much cheaper than buying new.

___________________

Respiratory Problems

• Respiratory distress – increased effort but enough to compensate for tissue hypoxia – due to mild hypoxemia (days)
• Respiratory failure increased or decreased effort not enough to compensate for tissue hypoxia – due to sever hypoxemia (hours)
• Respiratory arrest – if uncorrected leads to cardiopulmonary arrest (2 minutes)

• Upper airway obstruction – extrathoracic
• Lower airway disease – intrathoracic

Grunting = PEEPing

Peripheral mottling – circulatory problem; central mottling- respiratory problem

Sniffing and tripod – severe distress, head bobbing or grunting – respiratory failure

Oxyhemoglobin dissociation curve – kid won’t turn blue until o2 is dangerously low

Pediatric Respiratory volumes -Kids have smaller oxygen cushion than adults, will deteriorate more quickly. Higher o2 requiements

Upper Airway Obstructions

• Croup
• FBAO
• Bacterial Tracheitis
• Least common.epiglottitis rare due to vaccine

Lower Airway

• Asthma –reactive airway disease
• Bronchiolitis – caused by RSV
• Pneumonia – lung tissue disease
• FB – small FB lodged in lower airway – generally caused resorbtion atelectasis

Pediatric Airway Assessment – determine degree of problem – altered mental status very worrying sign, indicates respiratory failure – BVM – if the baby accepts the mask he needs the mask.

Treatment – o2 always primary – everything else is adjunct

Pediatric Assessment, Dr Cooper

3/23/09

See www.cpem.org

• Planning: Triage & transport – Needs vs. resources – enroute, review and plan
• Arrival: General Impression: Pediatric Assessment Triangle (PAT) – Hands off assessment – ABC Appearance, Work of Breathing, Circulation to skin
• Initial Assessment: Rapid cardiopulmonary assessment – Hands on
• Focused History: pertinent negatives, relevant findings

Pediatric Assessment Triangle

1. Appearance
   

• Alertness
• Distractibility
• Consolibility
• Eye contact
• Quality of cry
• Spontaneous movement
• (All critical to whether brain is perfused properly)

   

1. Work of Breathing
   

• Chest rise
• Rocking motions
• Retractions
• Nasal flailing
• Head bobbing
• Grunting
• Snoring
• Stridor

(C)Circulation

• Pallor
• Mottled
• Blue
• Grey

Initial Assessment: Rapid cardiopulmonary assessment – Hands on

• Airway –clear? Maintainable?, stable?
• Breathing – ventilation, oxygenating, stable? In peds rates and effort are not necessarily related like adults, effort much more important!
• Circulation: Shock? Cardiogenic?, stable? Shock: inability of blood to meet metabolic needs of the tissues- Mental status, pulse rate and character; distal vs. proximal, skin color, BP. Cardiogenic shock: Dysrhythmias, other , compensated, decompensated, cardiopulmonary failure (cardiogenic shock not initially treated with fluid)

Focused History: pertinent negatives, relevant findings

Why peds don’t have heart attacks: no CAD, atherosclerosis, etc –congenital heart diseases are rare. Adults drop dead, kids droop dead (secondary to respiratory arrest, etc)

Anatomic & Physiologic differences

Child airway – funnel shaped, narrowest part is at crichoid ring- adult s cylinder, narrowest at glottis

• Small jaw, large tongue, prone t soft tissue obstruction – reposition
• Immature immune system. lack of specific antibodies, protective mucus layer
• Infants are nasal breathers, keep clear
• Floppy omega shaped epiglottis
• Narrow subglottic area

Remember if suspected C spine injury, stabilize c spine before/while maintaining airway

Breathing anatomy

• Adult – diagonal ribs, stiff cartilage, stronger muscles
• Ped – horizontal ribs, soft cartilage, weaker muscles – diaphragmatic breathers, much less alveoli – faster o2 depletion. Susceptible to barotraumas, high risk of Pneumothorax, bag until chest rise, no more. (head bobbing grunting – near end resp failure)young tissue – high elastin content– shift mediastinum -easily

Breathing assessment requires an open Airway! – ASSESS A, THEN FIX A! THEN GO ON TO B!

• Is ventilation adequate – inspect chest rise – capability    
• Auscultation – air entry
• (Missed slide)

Always consider hypoxia first as cause for AMS

• Auscultate in armpits, small chest, sounds travel
• ETT only of BVM ineffective
• Consider NG/OG if abdominal distention

Circulation

• Adults, big hearts large chambers and thin walls, Starlings Law (like a spring, recoil helps CO)
• peds – small chambers thick walls – can’t vary CO well with heart walls, CO depends only on HR
• Adults – stiff vessels – vigorous response to hypovolemia and hypothermia
• Peds – soft vessels – more compliant vessels
• Smaller blood volume, lose lager percentage compared to adult
• Smaller fat mass – larger relative blood volume

Bleeding control – direct pressure – retain systemic o2

Shock assessment – cause assessment – cardiogenic etc – Simultaneous palpation of central and peripheral pulses – strong central weak peripheral – compensated – everything weak; decompensated shock

• Tachycardia = 150 – 5x age in year
• Kids get mottled – not clammy
• Cap refill – use warm extremities
• Minimum systolic BP: 80 + 2x age

Adrenaline makes you stupid – use a Broselow Tape

• Alcohol, ingested toxins
• Epilepsy, endocrine, exocrine, electrolytes
• Infection, insulin
• Overdose, opiates, oxygen deprived (hypoxia, hypercarbia)
• Uremia (renal failure)
• Trauma, temperature
• Insulin, infection
• Psychosis, porphyria
• Stroke, shock, space occupying lesions

Metabolic causes

• Glycemic emergencies
• hypoxia
• hypercarbia
• Thiamine deficiency
• Acidosis
• Electrolytes, incl. sodium, calcium, magnesium

Structural causes

• stroke, thrombotic, embolic, hemorrhagic
• Tumor or other space occupying lesions
• Trauma, Brain edema

Drug related causes

• alcohol
• opiates
• hallucinogens
• etc.

Infections

• Meningitis
• Encephalitis
• Sepsis

Endocrine causes

• hypo/hyperthyroidism
• Graves’s disease
• Addison’s disease
• Cushing’s disease
• diabetic emergencies

Last but not least – Psychiatric causes

• Psychosis
• Conversion reactions
• Catatonia
• Munchausen’s Syndrome

Updated 11/18/09