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Problematic Peds

Lucus Christoffersen, MSN, RN, CEN, CPEN, CCRN

Assistant Clinical Professor

Idaho State University

Disclaimer

Conflicts of interest: None

Employer: Idaho State University and Bingham Memorial Hospital

Sponsorship/Commerical support: None

Background

Clinical Assistant Professor since Jan 2016

Teach Adult Nursing Health I and II, along with clinical components

House Supervisor at Bingham Memorial Hospital in Blackfoot, Idaho

Utah State Emergency Nurses Association President, 2016-2018

Journal of Emergency Nursing

Reviewer

Emergency Nurses Association

Test Item Writer and Reviewer/Publication Writer and Reviewer

8 years of Critical Care, Emergency, and Trauma Nursing

Level 1 trauma centers to rural community hospitals

ICU, ED, LifeFlight and Trauma Resuscitation

Emergency Department Manager/Educator

Board Certified in Emergency, Pediatric Emergency, and Critical Care

Objectives

Understand normal pathophysiologic changes associated with pediatric

patients

Discuss and understand common complications seen with pediatric patients

Recognize interventions that will improve the care of pediatric patients that

are related to the disease processes

Terminology

Let’s take a few moments to discuss terms:

Neonate – birth to 28 days

Term – 37-40 weeks of pregnancy

Pre-term - <37 weeks pregnant

A pre-term infant is considered a neonate (newborn) until the expected due date plus 28

days

Infant – 1-12 months

Toddler 13 months to 3 years

Preschoolers – 3 – 5 years

School-Aged Child – 5-11 years

Adolescent – 11-18 years

Pediatric Patients Pathophysiology

There are many characteristics that make pediatric patients different than

adults

Remember that pediatric patients are NOT small adults!

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A–Airway and Alertness

B-Breathing

C-Circulation

Obligate nose breathers

Smaller airway diameter

Tongue is larger in proportion

Respiratory rates are faster

Increased metabolic rate

Lower tidal volumes

Alveoli fewer and smaller

Flat diaphragm

Use abdominal muscles for breathing

Largely comprised of water

Myocardium less compliant

Poor tissue perfusion

Tachycardia

Delayed capillary refill

Head proportionately larger

Smaller subarachnoid space

Cranial sutures and open fontanels

Normal intracranial pressures

Larger body surface area to body mass ratio

Limited ability to regulate temperature

Less body fat

Thinner skin

Hypothermia

D-Disability

E-Environment

Assessment of Pediatric Patient

Remember ABCDE’s

A-Airway

B-Breathing

C-Circulation

D-Disability (Neuro Functioning)

E-Environment

S-Safety

PAT – Pediatric Assessment Triangle

Across the room observation, looking at general appearance, work of breathing,

skin color/circulation status

Gives a quick understanding of the pediatric patient’s compensation and risk for

deterioration

General Appearance

Includeso Interactiono Muscle toneo Consolabilityo Look or gazeo Speech or cry

Reflectso Oxygenationo Ventilationo Perfusion of vital

organs

Work of Breathing

More accurate indicator of

oxygenation and ventilation

Look and listen for:

o Abnormal airway sounds

o Coughing

o Abnormal positioning

o Retractions/Nasal

flaring

o Rate and depth

Circulation to the Skin

Adequate circulation to the

skin reflects perfusion

Inspect the skin

o Color

Central areas

Lips

Mucous membranes

o Pallor, mottling, cyanosis

o Flushed, diaphoretic, dry

“Sick, Sicker, Sickest”

If all components of the PAT are stable, consider the child

sick based on concerns of caregiver

o Considered sick until proven otherwise by conducting

the focused assessment

Acute disruption in one component of the PAT, consider to

be sicker

Acute disruption in two or more components of the PAT,

consider sickest and should warrant immediate care by

the team!

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Clinical Red Flags

Airway – apnea, choking, drooling

Breathing – grunting, retractions, tachypnea/bradypnea, absence of

breath sounds, cyanosis

Circulation – cool or clammy skin, tachycardia/bradycardia, delayed

capillary refill, diminished peripheral pulses

Disability – change in level of consciousness (from baseline), sunken or

bulging fontanel

Exposure – petechiae, purpura, signs of potential child maltreatment

Full Set of Vital Signs – hypothermia, fever

Give Comfort – severe pain

History – chronic illness, return visit to ED within 24 hours

History

CIAMPEDS

C Chief complaint P Past medical history and Parent’s impression

I Immunizations and isolation

E Events surrounding illness or injury

A Allergies D Diet and diapers

M Medications S Symptoms associated with illness or injury

Respiratory Emergencies

Upper Airway

Croup

Epiglottitis

Bacterial tracheitis

Foreign bodies

Sleep apnea

Tracheomalacia

Lower Airway

Asthma

Bronchiolitis

Pertussis

Pneumonia

Foreign bodies

Bronchomalacia

Failure secondary to neurological disorder (muscular dystrophy) or anatomical issues (scoliosis/kyphosis)

Respiratory Distress vs.

Respiratory Failure

Respiratory distress o Increased respiratory rate

Tachypneao Increased respiratory effort

Nasal flaring

Use of accessory

muscles

Retractions

Respiratory failure

o Fatigue from excessive work of

breathing

o Inadequate oxygenation and/or

ventilation

Signs and Symptoms

of Respiratory Distress

Increased work of breathing

Tripod position

Paradoxical respirations

Change in skin color

Drooling

Fast respiratory rate

Fast heart rate

Upper airway sounds

Adventitious breath sounds

Signs and Symptoms of

Respiratory Failure

Change in level of consciousness

Decreasing PO2 and/or increasing

PCO2

Can exist with:

o Slow respiratory

rate

o Normal respiratory

rate

o Fast respiratory

rate

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Monitoring

Monitors

o Pulse oximetry

o Capnography

o Cardiopulmonary

monitor Poor perfusion may impede the

monitor’s ability to obtain an

accurate reading

Intubation Tips

Ways to select the size of endotracheal tube:

1. Length-basedresuscitation tape

2. (Age in years +16) / 4

3. Patient’s pinky finger

4. Patient’s naris

5. Half size smaller than the calculated uncuffed ETT diameter

Have both cuffed and uncuffed ETTs available

Alternate Airway

Laryngeal mask airway

Needle cricothyrotomyo When all other options have failed

Surgical cricothryroidotomyo Not recommended for children <12 years

Emergency tracheostomy is rarely indicated

Croup

Upper respiratory disorder- Commonly viral

Barky, seal-like cough – worse at night

Treatment is symptomatic/supportive

o Cool mist/oxygen, as indicated

o Consider corticosteroids

o Consider racemic epinephrine

(typically 2 hours relief)

Concurrent resting stridor

Observe for rebound effect

Epiglottitis

This is an emergency! Symptoms

o Acutely high fevero Muffled voiceo Severe sore throat − difficulty swallowingo Droolingo Stridoro Use of HIB vaccination has decreased the incidence in the pediatric

populationo Causes

o Haemophilus influenzae type Bo Streptococcus pneumoniae and Staphylococcus

o Lateral neck film – thumb signo NO STRESS! Keep the patient calm until airway stabilized

Asthma

Most common chronic childhood illness – 9.3% of children

in the U.S.

Confirmation of diagnosis delayed until the child has had

repeated episodes and is older than one year

A chronic inflammatory disorder of the airways, which is

characterized by:

o Hyperreactiveness of airway

o Widespread inflammatory changes

o Bronchospasm

o Mucous plugging

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Signs/Symptoms of Asthma

Wheezing on inspiration or expiration

Prolonged expiratory phase

Decreased or unequal breath sounds

Tachypnea

Retractions

Coughing, especially at night and in the early morning

Asthma: Interventions

Supplemental O2 & monitoring of O2 saturations

Obtain a peak expiratory flow

Administer medications as ordered

o Inhaled short-acting ß2-agonists and anticholinergic agents

o Steroids

Reassess after dose of inhaled bronchodilator and at least every

60 minutes thereafter

Prepare for hospital admission or transfer if the child’s

condition does not improve

Prepare for discharge only if child’s condition improved and

desired outcomes are achieved

Bronchiolitis

Acute viral infection

Involves the lower respiratory tract and is most commonly

caused by the respiratory syncytial virus (RSV)

Symptoms generally worsen for the first 3-5 days and then

gradually improve

Apnea is one of the most concerning complications of

bronchiolitis in young infants

History of prematurity or cardiac/pulmonary diseases at

greater risk for severe life-threatening manifestations

Signs/Symptoms of Bronchiolitis

Rhinorrhea

Pharyngitis

Coughing/sneezing

Tachypnea

Retractions

Wheezing/prolonged

expiratory phase

Decreased air entry or

exchange

Dehydration secondary to

decreased oral intake

Apnea spells

Low-grade fever

Bronchiolitis: Interventions

The most important intervention is nasal suctioning to decrease

secretions

Place in enhanced contact isolation

Obtain a nasopharyngeal specimen for RSV testing

Administer medications as ordered

Routine use of bronchodilator/corticosteroids controversial

Nebulized saline may reduce length of hospitalizations

Palivizumab (Synagis)

Causes of Pediatric Dysrhythmias

Unrecognized respiratory or

metabolic compromise

Congenital cardiovascular

abnormalities

Long QT syndrome

Marfan syndrome

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Sudden Cardiac Arrest: Causes

Structural defectso Cardiomyopathies

o Arrhythmogenic right ventricular cardiomyopathy

o Myocarditis

o Congenital coronary artery anomalies

o Marfan syndrome

Arrhythmogenic disorderso Congenital long QT syndrome

o Other channelopathies

Marfan Syndrome

Inherited genetic

mutation

Appears at any age

Complications

o Aneurysms

o Mitral valve prolapse

Medical supervision

Long QT Syndrome

Inherited Prolonged QT

o Exercisingo During severe emotionso When startled

Red flagso Chest paino Syncopeo Palpitations

Bradycardia: Interventions

No signs of decreased CO: No treatment needed Ventilate with 100% oxygen Obtain vascular access Begin chest compressions if pulse is <60 BPM or signs of

poor perfusion Lethargy, comatose, pallor, cyanotic, CRT >5 seconds

Look for potential causes Administer pharmacological agents

o Epinephrine (drug of choice in pediatric patients) Consider pacing

Sinus Tachycardia:

Signs and Symptoms

Poor perfusion

o Delayed capillary refill

o Pale cool extremities

o Mottled skin

o Decreased BP

Dry mucous membranes

Decreased number of wet

diapers

Increased stool/diarrhea or

vomiting

Increased work of breathing

Sinus Tachycardia: Interventions

Support ABCs

Look for cause of

tachycardia and treat

If due to hypovolemia:

o Obtain vascular access

o Fluid bolus 20 mL/kg

(unless cardiac cause)

If due to fever:

o Monitor and maintain

normal body

temperature

If due to pain:

o Treat with analgesics

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SVT: History

Previous SVT episode Wolff-Parkinson-White syndrome Congenital heart disease Poor feeding, fussiness Sudden onset of symptoms

SVT: Signs and Symptoms

Pale, cyanotic or mottled Hypotension Poor perfusion Altered level of consciousness Irritability Heart rate too fast to count Signs of congestive heart failure

SVT: Interventions

Vagal stimulation/

maneuvers

Support ABCs

Adenosine (Adenocard) 0.1-0.2 mg/kg

Synchronized

cardioversion 0.5-1 joule/kg

SYNC mode

Ventricular Tachycardia: Assessment

History

Structural heart disease

Myocarditis/ cardiomyopathy

Prolonged QT syndrome

Suspected overdose

Electrolyte imbalance

Signs and Symptoms

Poor perfusion

Ventricular rate > 120 bpm

Wide QRS (> 0.09 seconds)

Pulses may be absent

Palpitations

Increased work of breathing

Ventricular Tachycardia: Treatment

With a Pulse

Obtain immediate cardiology

consult

Support airway and

ventilation

Obtain ECG

Obtain venous access

Consider synchronized

cardioversion

Medications

o Adenosine (Adenocard)

o Amiodarone (Cordarone)

o Procainamide (Pronestyl)

Without a Pulse

• Defibrillate – follow VF

algorithm

Ventricular Fibrillation: Assessment

History

Electrocution

Recent viral illness

History of cardiac

surgery/transplant

Ingestion of toxin

Blunt impact to chest

Signs and Symptoms

Unresponsive child

Absence of palpable pulse

Chaotic, wavy lines

No P or T waves or QRS

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Ventricular Fibrillation: Treatment

Defibrillate at 2 J/kg

Resume CPR for 5 cycles after each shock

Subsequent shocks at 4 J/kg

Vascular access

Medications

Family presence

Used with permission of Physio-Control,

Inc.

Asystole: Assessment

History

Time patient was found pulseless

Events prior to pulselessness

Primary caregiver at time of event

Time of BLS initiation

Time of ALS initiation

Signs and Symptoms

Absent electrical activity

Apnea

Profound shock/poor peripheral

perfusion

Absent heart sounds

No palpable pulses

Asystole: Treatment

Treatment as outlined for PEA

BEST intervention is PREVENTION!

Confirm asystole in two leads

High quality CPR

Family presence with assigned staff

Anticipate need to terminate resuscitative efforts

Fever

Most common complaint

Normal physiologic response

Rectal temperature at least 38°C

(100.4°F)

Degree does not reflect severity

Fever: Diagnostics

and Interventions

Lab studies

Radiographic studies

Antipyretics

Septic work-up

Fluids

Dehydration

Definition and causes

o Fluid loss in excess of intake

o Most common cause is gastrointestinal sources

Pediatric characteristics

o Relatively more body water

o Higher metabolic rate leads to increased insensible fluid loss

o Greater body surface area to weight ratio

o Immature kidney function

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Dehydration: Interventions

Oral rehydration

Subcutaneous fluid replacement

Intravascular fluid replacement

Electrolyte replacement

Monitor weight, intake and output

Consider admission

Gastroenteritis

Definition: GI viral infection

Causes

o Rotavirus, adenovirus, enterovirus

Signs and symptoms

o Fever

o Nausea and vomiting

o Diarrhea

Additional history

Interventions

o Antiemetics

o Rehydration

Meningitis

Inflammation of the meninges Common bacterial organisms

o Neonate Group B streptococcus

o Older child Neisseria meningitidis Haemophilus influenzae (H flu)

Complicationso Seizureso SIADHo Neural damage

Meningitis: Signs and Symptoms

Fever Irritability Mental status changes Poor feeding/vomiting Seizures Bulging fontanel Headache and stiff neck Nonblanching rash

Meningitis: Diagnostics

and Interventions

Septic work-up o CBC with differential

o Electrolytes

o Glucose

o Urinalysis and urine culture

o CSF for cell count, culture,

protein, glucose, and gram stain

Isolation

IV, fluids, antibiotics

Meningococcemia

Definitiono Neisseria meningitidis sepsis

Signs and symptomso Fever

o Mental status changes

o Signs of shock

o Nonblanching rash

Prognosis - Poor

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Meningococcemia Interventions

Isolation

Antibiotic therapy

Monitoring

Clotting factor replacement,

platelet or plasma transfusion

Inotropes/vasopressors

Seizures

• Definition: o CNS dysfunction

• Causes o Fever

o Metabolic disturbance

o Toxin exposure

o Trauma

• Prevalence

• Types o Generalized

o Partial seizures

o Unclassified: febrile, neonatal

• Status epilepticus

Seizures: Diagnostics

and Interventions

Diagnostics

Safe environment

Oxygen and suction

IV access

Monitoring

Medications IV Ativan

Rectal Diazepam

Hydrocephalus

Definitiono Abnormal production, absorption,

or drainage of CSF

o Present with shunt obstruction,

infection

Signs and symptomso Mental status changes

o Signs of increased ICPo Lethargy, agitation, irritable

o Fever

o Bulging Fontanel

Diagnosticso Shunt series, CT, MRI

o CSF analysis, CBC, blood/urine

cultures

Interventionso Surgical repair

Constipation

Definitiono Infrequent or painful defecation

Age groupso Infantso Toddlers

School age Signs and symptoms

o Pain or bleedingo Common withholding behaviors

Squatting Crossed ankles/legs Body stiffening Flushing Sweating Crying

Diagnostics Interventions

Increase fluids, Mag Citrate

Appendicitis

Definitiono Inflammation of the vermiform

appendix

Signs and symptomso Abdominal pain, fever, vomiting,

anorexia

Diagnosticso Clinical exam

o Ultrasound

o CT

Interventions

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Diabetic Ketoacidosis

Presentationo Serum glucose > 300 mg/dLo Dehydrationo Serum pH of < 7.3o Ketonemia/ketonuriao Glycosuria

Signs and symptomso Kussmaul breathingo Mental status changeso Dehydrationo Electrolyte imbalanceo Cardiac dysrhythmiaso Acetone breath

Diabetic Ketoacidosis: Interventions

Correct dehydration

Serial laboratory studies

Correct acidosis

Correct electrolyte imbalances

Monitor neurologic status, vital signs, and ECG

Accurate intake and output

Coagulation Disorders

Hemophilia

von Willebrand

Signs of bleeding and bruising

Treatment

o Replacement of clotting

factor

o Immobilization of affected

joints

o Pain management

Coagulation Disorders

Idiopathic thrombocytopenic

purpura From Viral infections

Signs of bleeding and bruising,

petechiae and purpura

Treatment

o IgG

o Corticosteroids

o Limitation of activity

o Transfusion for severe

blood loss

Apparent Life-Threatening Events

Episode of apnea with o Color changeo Loss of muscle toneo Chokingo Gagging

Historyo Detailedo Infant o Family

Assess for:o Infection

o GERD

o Seizures

o Pulmonary assessment

o Metabolic laboratory

o Neuromuscular

o Assess for signs of child abuse

Burns

Integumentary disruption

Fluid shifts

Vasoconstriction

Tissue necrosis

Electrolyte imbalance

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Burn Assessment

Airway

• Stridor

• Hoarse voice or cough

• Carbonaceous sputum

• Drooling

• Edema

• Blisters

• Singed nasal hairs,

eyebrows, or lashes

Breathing

• Burns to chest

• Inhaled toxins

• Aspiration

Circulation

• Signs of shock

• Urine output

• Laboratory analysis

results

Burn Assessment

Depth o Superficial partial-thicknesso Deep partial-thicknesso Full-thickness

Extento Rule of Nineso Lund and Browdero Rule of Palm

Calculation of fluid needs Only needed for Deep-Partial and Full-thickness burns Parkland Formula Lactated Ringers

2-4 ml/kg X BSA burned 2 ml/kg – Pediatrics 3 ml/kg – Adults 4 ml/kg – All electrical burns

½ of total fluid given in first 8 hours of the initial burn time

Remainder given in next 16 hours Example – 4 year old patient with 50% burns who ways

15 kg from a chemical burn in father’s shop 2 ml of LR X 15 kg X 50% = 1500 ml of LR Fluid 750 ml given in first 8 hours = 94 ml/hr of fluid

Burn Management

Stop the burning process

Wound care

Gastric tube

Laboratory studies

Pain management

Transfer

Head Trauma Assessment

● Neurological assessmento Glasgow Coma Scale

o FOUR Score

o Pupils

● History: o Loss of consciousness

o Nausea and vomiting

o Abnormal behavior

o Seizure activity

● Cushing’s triado Bradycardia

o Hypertension

o Alteration in respiration

Head Trauma Assessment

● Inspect and Palpateo Lacerations

o Abrasions

o Step offs

o Edema

o Hemotympanum

o Periorbital/postauricular

ecchymosis

o Otorrhea/rhinorrhea

o Fontanel

● Assess neurological

functiono Gait

o Grip strength

o Reflexes

Head Trauma Interventions

Elevation of HOB

Oxygenation and ventilation

Sedation and analgesia

Diuretics

Maintain temperature

Trending of vital signs and neurological status

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Dental Trauma

Tooth fracture or avulsion

Interventions Baby tooth – follow up with

dentist

Adult teeth – clean off, stick

tooth back in socket and refer to

dentist If patient unconscious, place

tooth in glass of milk

Vertebral and Spinal Cord Trauma

Mechanism

o MVC

o Sports injuries

Anatomy and physiology

o Larger head

o Weak neck muscles/lax

ligaments

o Anteriorly wedged

vertebral bodies

o Growth plates

SCIWORA

o Spinal cord injury without

radiographic abnormality

Vertebral and Spinal Cord Trauma

Signs and Symptoms:

o Spinal deformity

o Neck pain

o Flaccid extremities

o Altered sensation

o Incontinence

o Absent sphincter tone

o Priapism

Vertebral and Spinal Cord Trauma

Interventions:

o Maintain full spinal

stabilization

o CT with radiologist

interpretation

o Neurosurgical consult

Cardiothoracic Trauma

Often component of multisystem

injury

Blunt vs. penetrating

Rib fractures

Cardiothoracic Trauma

Simple pneumothorax

Open pneumothorax

Tension pneumothorax

Hemothorax

Pulmonary contusion

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Abdominal Trauma

Mechanismo MVC

o Bicycle crashes

o Sports activities

Anatomy and physiologyo Thinner, weaker muscles

o Chest wall pliable

o Ribs horizontal

o Vascular duodenum

Abdominal Trauma Assessment

Location, quality and radiation of pain

Respiratory pattern and depth

Rigidity, guarding and distention

External soft tissue injury

Bloody urinary drainage

Abdominal Trauma Interventions

Cover open wounds with moist,

sterile dressings

FAST exam

Prepare for surgery

Musculoskeletal Trauma

Fracture

Sprain

Subluxation

Dislocation

Fracture Assessment

Deformity, shortening or

rotation

Edema or soft tissue injury

Tenderness

Reluctance or refusal to use

Neurovascular statuso Pallor

o Pain

o Pulselessness

o Paresthesia

o Paralysis

o Poikilothermia

Fracture Interventions

Compare circulation of affected extremity to the unaffected extremity

Proper alignment Immobilization Comparison radiographs Closed reduction Fluid replacement Spiral Fractures

Usually indicate child abuse – should report

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Summary

Pediatric patients have many compensatory mechanisms that may prevent

them form showing deterioration until later than expected

Many pediatric cardiac complications and codes are from respiratory

complications

Oxygen, Glucose, Thermoregulation are top three interventions for pediatric

patients

Immunizations help lower incidence of many childhood illnesses

Patient education and safety training are key to preventing many childhood

and pediatric problems

References

ENPC 4th edition Provider manual – Chapters 3, 4, 5, 7, 10-17