Systematic Approach to Pediatric Assessment. Learning Objectives Master “Assess – Categorize...
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Transcript of Systematic Approach to Pediatric Assessment. Learning Objectives Master “Assess – Categorize...
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Systematic Approach to Pediatric Assessment
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Learning ObjectivesLearning Objectives
Master “Assess – Categorize – Decide – Act ” approach at every
stage of assessment
Purpose & components of General Assessment
Summarize ABCDE of Primary Assessment
Evaluate problems- respiratory / circulatory
Categorize clinical condition by type & severity
Summarize life-saving interventions to be instituted if life-threatening
condition identified
Recall components of Secondary & Tertiary assessments
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Respiratory Distress
Respiratory Failure Shock
Cardiopulmonary Failure
Cardiac Arrest
Precipitating Conditions
Respiratory Circulatory Sudden Cardiac(Arrhythmia)
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Survival Following Respiratory Arrest vs Cardiopulmonary Arrest in Children
100%
50%
0%Respiratory
arrestCardiopulmonary
arrest
Survivalrate
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Approach to Pediatric AssessmentApproach to Pediatric Assessment
At any point life-threatening problem life-saving interventions
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ASSESSMENTASSESSMENT
Clinical Assessment Description
General Assessment(Pediatric Assessment Triangle)
Visual & auditory assessment of Appearance, Work of Breathing & Circulation (within 1st few seconds of seeing patient)
Primary AssessmentHands on A-B-C-D-E approach to evaluate (includes vital signs & pulse oximetry)
Secondary AssessmentFocused Medical History (S-A-M-P-L-E) Thorough Physical exam
Tertiary Assessment Investigations
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Respiratory Circulatory
Type
Upper airway obstructionLower airway obstructionLung tissue diseaseDisordered control of breathing
Hypovolemic shockDistributive shockCardiogenic shockObstructive shock
Severity Respiratory distressRespiratory failure
Compensated ShockHypovolemic shock
Respiratory + CirculatoryIncluding cardiopulmonary failure
CATEGORIZECATEGORIZE
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DECIDE Action based on initial assessment & categorization of clinical condition
Decisions based on scope of practice
ACTACT Actions appropriate for clinical condition & severity
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REASSESSMENTREASSESSMENT
Process of A - C - D - A is ongoing Reassess after interventions
Ex: Is patient’s breathing better after oxygen?Is child’s perfusion better after IV bolus?
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REMEMBERREMEMBER
At any time during Assessment and Categorization process
if a life threatening condition is identified
initiate life saving interventions
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GENERAL ASSESSMENTGENERAL ASSESSMENT
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PAT (Pediatric Assessment Triangle) Using Visual & Auditory clues
APPEARANCE WORK OF
BREATHING
CIRCULATION
Pediatric Assessment Triangle General Assessment
AppearanceMuscle tone, Interaction, Consolability, Look/gaze or Speech/cry
Work of breathing Work of breathing or absent respiratory effort, Abnormal sounds
Circulation Abnormal skin color, Bleeding
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PRIMARY ASSESSMENTPRIMARY ASSESSMENT
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Primary AssessmentPrimary Assessment
Hands-on evaluation (in contrast to PAT)
- Airway- Breathing- Circulation- Disability- Exposure
A B
C
D
E
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AIRWAYAIRWAY
For Airway Patency, use look, listen, feel
Status Description
Clear Open & unobstructed
Maintainable Maintained by simple measures
Not maintainable Needs advanced measures
A
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BREATHINGBREATHING
Evaluation of:• Respiratory rate• Respiratory effort• Tidal volume• Airway & lung sounds• Pulse oximetry
B
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CIRCULATIONCIRCULATION
Assessment includes evaluation of:
Cardiovascular function End-organ function
Heart rateBlood pressureSkin color, temperatureCapillary refill time (CRT)Peripheral & central pulses
Brain perfusion (Mental status) Skin perfusion Renal perfusion (urine output)
C
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Cardiovascular functionCardiovascular function
Normal Heart Rate by AgeNormal Heart Rate by Age
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Blood PressureBlood Pressure
Definition by Systolic BP & Age (< 5th centile)
Age Systolic BP (mm Hg)
Term Neonates (0-28 days) < 60
Infants (1-12 months) < 70
Children 1-10 yrs 70 + (age x 2)
Children > 10 yrs < 90
Hypotension with hemorrhage: > 20-25% acute blood loss
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Capillary RefillCapillary RefillCapillary RefillCapillary Refill
Prolonged capillary refill (10 seconds) in a 3-month-old with cardiogenic shock
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Brain perfusion (Mental status)Brain perfusion (Mental status)
S/S in sudden, severe cerebral hypoxia: loss of muscle tone, gen. seizures,
dilated pupils, unconsciousness
S/S in gradual development of hypoxia: altered consciousness with
confusion, irritability, lethargy, agitation
Pupillary response & AVPU scale used to characterize neurologic condition
Drugs, metabolic conditions & raised ICP can also cause neurologic s/s
End Organ PerfusionEnd Organ Perfusion
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Evaluate
Pallor
Mottling
Central cyanosis
Petechiae
Purpura
Skin perfusionSkin perfusion
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Normal urine output:
Age Normal Urine Output
Infants & young children 1.5 – 2 ml / kg / hr
Older children & adolescents 1 ml / kg / hr
Renal perfusionRenal perfusion
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DISABILITYDISABILITY
Quick evaluation of cerebral cortex & brainstem Evaluate during Primary as well as Secondary Assessment
– to monitor changes in neurologic status: AVPU GCS Pupillary response to light
D
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AVPU ScaleAVPU Scale For rapid evaluation of cerebral cortical function
A - Alert V - Responsive to Voice P - Responds to Painful stimulus U - Unresponsive
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EXPOSUREEXPOSURE
Undress child to facilitate focused physical examination - look for evidence of trauma - unusual markings suggestive of abuse
Warm the child, if hypothermia detected
E
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LIFE-THREATENING CONDITIONSLIFE-THREATENING CONDITIONSwarranting immediate life-saving measureswarranting immediate life-saving measures
Signs include:
Airway Complete / severe airway obstruction
Breathing Apnea / significant work of breathing / bradypnea
Circulation No detectable pulse / poor perfusion / hypotension / bradycardia
Disability Unresponsiveness / depressed consciousness
Exposure Hypothermia / bleeding / petechiae / purpura / abdominal distension
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Categorization by Severity
RESPIRATORY
DISTRESS FAILURE
Tachypnoea
Tachycardia
Increased respiratory effort
Abnormal airway sounds
Pale cool skin
Changes in mental status
(Early) Marked tachypnoea/Tachycardia
(Late) Bradypnea, Apnea/ Bradycardia
Increased / decreased / no respiratory effort
Cyanosis
Stupor / coma
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Categorization by Severity
SHOCK
COMPENSATED HYPOTENSIVE
Tachycardia
Cool pale diaphoretic skin
Delayed CRT
Weak peripheral pulses
Narrow pulse pressure
Oliguria
In addition:
BP BELOW THE 5th percentile
Change in mental status
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SECONDARY ASSESSMENTSECONDARY ASSESSMENT
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ComponentsComponents Focused History Focused physical examination
S
A
MP
L
E
Aim: to gain information that explains impaired respiratory, cardiovascular or neurologic function
Signs & symptoms
Allergies
Medications
Past medical history
Last meal
Events
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TERTIARY ASSESSMENTTERTIARY ASSESSMENT
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Investigations to detect & identify presence & severity of
respiratory & circulatory abnormalities
Tertiary does not mean 3rd in order – dictated by clinical
situation. e.g. RBS may be done early
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SUMMARY SUMMARY
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General Assessment
Appearance - Work of Breathing - Circulation
Primary Assessment
Airway Breathing Circulation Disability Exposure
Secondary Assessment
(SAMPLE History, Focused Physical Exam, glucose)
Tertiary Assessment
(Lab studies, x-rays, other tests)
Pediatric Assessment Flowchart
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Respiratory Circulatory
Type
Upper airway obstructionLower airway obstruction
Lung tissue diseaseDisordered control of breathing
Hypovolemic shockDistributive shockCardiogenic shockObstructive shock
Severity Respiratory distressRespiratory failure
Compensated ShockHypovolemic shock
Respiratory + CirculatoryIncluding cardiopulmonary failure
Categorize illness by type & severityCategorize illness by type & severity