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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
- Appearance
- Work of Breathing
- Chest rise
- Rocking motions
- Retractions
- Nasal flailing
- Head bobbing
- Grunting
- Snoring
- Stridor
(C)Circulation
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
