–http://www.realclearscience.com/blog/2011/09/science-of-the-hitchhikers-guide-to-the-galaxy.html
Objectives• Know how children are different from adults• Discuss methods for dealing with children• Be aware of vital sign differences in children• Discuss the anatomic differences between adults and children
• Discuss common pediatric problems and demonstrate knowledge through case studies.
• Review problems of pregnancy and how to assist with a precipitous delivery
Dealing with children
• Check yourself• Be polite to the parents• Infants (0-1)• Toddlers (1-3)• Preschoolers (3-6)• School age (6-12)• Adolescents (12-18)
Anatomical differences
• Infants have proportionately large tongues, small (4mm) tracheas
• Children’s heads are proportionately larger, Infants - fontanel (soft spot)
• Larger body surface area per mass (2.5X)• Ribs are more pliable, less developed abdominal wall muscle
• Faster metabolic rate
Normal vital signs
Age Heart Rate RespiratoryRate
Infant 80-200 30-60Pre schooler 75-190 22-40School age 60-140 18-30adolescent 50-100 12-16
Airway obstruction
• Partial airway Obstruction– S/S: Stridor, noisy breathing, retractions but alert
– Tx.: Position of Comfort, O2, transport, do not agitate
–http://www.accessmedicine.ca/search/searchAMResultImg.aspx?rootterm=chest+wall+retraction&rootID=45319&searchType=1
Airway
• Complete obstruction– S/S: not speaking, cyanosis, no crying, increased resp effort, LOC, AMS
– Tx.: Clear airway (backblows, chest thrust, abdominal thrust), Attempt BVM
Case
• A frantic mother runs over to you while you are checking for contraband in a campground, shoves a 4 month old, cyanotic baby into your hands while saying “I was feeding him peanuts and he stopped breathing!”
• Now what?
Upper Airway Disease
Croup:• When: fall, winter, 3mo-3yr, largely viral • S/S: Barky cough, stridor, low fever, if more severe: stridor, retractions
• Tx.: Cool mist/air, racemic Epi, steroids
Upper Airway disease
Epiglottitis: • S/S: hoarse, stridor, fever, drooling• Tx: This is an emergency!, transport quickly in position of comfort. Do not disturb, get advanced airway capabilities headed your way.
–http://voicedoctor.net/media/structural-injury-inflammation-bacterial/acute/supraglottitis-or-epiglottitis
Lower airway disease
Asthma and Bronchiolitis-S/S: - Wheezing and breathing effort on exhalation- Rapid breathing (tachypnea) without stridor -Tx.: Calm, reassure, Assist with personal MDI
Case
• 13 yo male is brought to you by worried parents at the sled dog kennel. They think he may be allergic to dogs and he is having trouble breathing. He appears short of breath and has wheezing.
• Now what?
Cardiac Arrest• C-A-B• start with 30 chest compression (single rescuer, 15 for two rescuer)
• Then Airway/two rescue breaths• Push >100 times per minute, 1/3 depth of chest
• Don’t check pulse for >10 seconds• Defibrillation – Preferred manual at 2-4 jules/Kg, 2nd would be AED with pedsattenuator, last choice is “adult” AED.
• Just remember COMPRESSIONS
Dehydration, Diarrhea, Vomiting
• S/S – lots of poop or vomitMild – irritable, decreased urineModerate – more tachycardic,
compensated BP, dry membranes• Severe – low BP, tachycardic, dry mucous Membranes, sunken eyes, lethargy, cool mottled extremities, threadypulse
Dehydration, Diarrhea, Vomiting
• Causes – gastroenteritis – virus, bacterial, giardia;; intestinal maladies, etc
• Tx.: – mild and moderate can be treated with oral rehydration – small amounts (5-10ml) frequently (Q5 min) (pedialyte, Gatorade, WHO: 1L water, 1 tsp salt, 8 tspsugar)
• Tender abd, rebound or bloody stool is concerning
Poisoning
• Try to determine what was taken, when, and how much
• Tx: medical command, supportive care, O2, transport, rarely consider charcoal
Fever
• Temp greater than 100.4• Often in response to infection to decrease bacterial/viral replication
• Assess hydration status• Cool quickly if >105: shade, AC, fan, cool water. (APAP)
Seizure
• S/S: Tonic, clonic, spasms, unresponsive• Caused by fever, infections, poisoning, hypoglycemia, trauma, decreased levels of oxygen, head injury or could be idiopathic in children.
• Ask: Prior episodes? Similar pattern? Taking anitseizure meds?
Seizure
• Tx.: Asses for injury, prevent injury (but don’t restrain), Asses airway, place on side, suction as needed, provide O2, transport, BVM if needed
• Seizures lasting more than 15 minutes is an Emergency! – status epilepticus
Case
• 11 yo female is having a clonic seizure, laying on top of a low stone wall and is unresponsive. The parents report this started about 30 seconds ago.
• Now what?
Shock (hypoperfusion)
• Causes: Diarrhea and dehydration, Trauma, Vomiting, Blood loss, Infection, Abdominal injuries
Shock• a) Mental status changes • b) Rapid respiratory rate • c) Pale, cool, clammy skin • d) Weak or absent peripheral pulses • e) Delayed capillary refill• f) Decreased urine output. Measured by asking parents about diaper wetting and looking at diaper.
• g) Absence of tears, even when crying
ShockTx:a) Assure airway/oxygen.b) Be prepared to artificially ventilate. c) Manage bleeding if present. d) Elevate legs. e) Keep warm.f) Transport.
Trauma#1 cause of Deaths in pediatricsBlunt is common• MVC: unrestrained: head and neck– Restrained: abdomen, lower spine
• Pedestrian Struck: head, LE, abomen• Falls• Burns• Sports• Child abuse
–http://learnpediatrics.com/body-systems/musculoskeletal-system/approach-to-non-accidental-injuries/
TraumaHead• Concerns: Bobble heads, resp arrest• S/S: N/V, AMS, contusions, blood from ears/nose
• Tx: keep calm, Manage airway and C-Spine (jaw thrust)
TraumaChest• Concerns: Ribs are Pliable• S/S: Contusion, flail chest, crepitus, sucking chest wound, decreased breath sounds, tracheal deviation
• Tx: keep calm, Manage airway, splint, Occlusive dressing, (needle decompression)
–http://www.tactical-life.com/tactical-weapons/seal-a-sucking-chest-wound/
–http://t3.gstatic.com/images?q=tbn:ANd9GcQ2-dVH7FbpMHCsnhbh7XyfNR7Qw6oQsVgxIXwopthYXRT1-XpVww
TraumaAbdomen• Concerns: internal injury (Spleen, liver)• S/S: N/V, pain, contusion, rigid abdomen• Tx: keep calm, transport quicklyExtremities: same as Adults
Obstetrics• Expectant mother: best thing for unborn child? (and not flat on back)
• Precipitous Delivery: • 1st Stage – cervical dilatation• 2nd Stage – fetal expulsion• 3rd Stage – expulsion of placenta
Obstetrics - problems• Breech• Shoulder Dystocia• Prolapsed umbilical Cord• Uterine atony and hemorrhage
–http://www.google.com/imgres?q=shoulder+dystocia&safe=off&client=safari&rls=en&biw=1244&bih=611&tbm=isch&tbnid=Hx0CHu6GxE02yM:&imgrefurl=http://www.aafp.org/afp/2004/0401/p1707.html&docid=ZI6EMijBRmaPGM&imgurl=http://www.aafp.org/afp/2004/0401/afp20040401p1707-f1.jpg&w=310&h=307&ei=3SWnUf38KeKdiQKYsoC4BA&zoom=1&ved=1t:3588,r:1,s:0,i:162&iact=rc&dur=981&page=1&tbnh=181&tbnw=204&start=0&ndsp=11&tx=99&ty=57
Case
• 34 yo female waddles over to you at Wonder Lake campground and says “I am 39 weeks pregnant, I am feeling contractions, and I think my water just broke.”
• What stuff would you try to find and what are you going to do?
Hypothermia - Treatment• Prevention• Passive re-warming• Active External re-warming
• Active Core re-warming
Passive
• Remove from cold
• Prevent further loss
• Be proactive and reverse if not too late
• Limited by ability to heat self
Active External
• 108ºF (42C) is the magic Temperature
• Warm water• Bair Hugger• Radiant heat• Down side: rewarming shock
Active Core Rewarming• Inhalation• Heated IVF• GI tract lavage• Bladder Lavage• Peritoneal lavage• Pleural Lavage• Extracorporeal• Mediastinal via thoracostomy
Conservative
• Or Heated IV, warm O2 and forced air• 36 pt.s with severe hypo and pulse present:– Rewarming rate of 1.09C/hr– 92% rewarmed but 42% in hospital mortality
• Time intensive, large amounts of fluid
Gastric/bladder lavage
• Less invasive• Slower due to less mucosal area than more invasive methods
• Rewarming rate: ~1C/hr
Thoracic Lavage
• Can be preformed with equipment available in most EDs
• Quick, rewarming rate:3C/hr (reported up to 6c/20 min with 40L of tap water)
• In review of 14 pt.s had 28% mortality
Venovenous
• Must have pulse to use• Easier and less invasive than some forms of ACR
• Rewarming rates of 2-3C/hr
Hemodialysis/filtration
• Advantages: may be easier to establish and equipment availability in smaller hospitals compared to CPB
• Especially useful if renal failure or hyperkalemia is present
• Rewarming rate: 2-3C/hr
Hypothermia ACLS AlgorithmInitial Therapy of all Patients
-remove wet clothing-Protect against heat loss and wind
-Maintain horizontal position-Avoid rough movement and excess activity
-Monitor core Temp-Monitor cardiac rhythm
Asses responsiveness, breathing, pulse
Pulse and Breathing – next slidePulse or Breathing absent
Start CPR
Give one shock then resume CPR
Secure airway, ventilate with warm humid O2 (108-115F or 42-46C)
Establish IV, infuse warm NS (109F/43C)
Core T <86F (30C)
-continue CPR
-withhold IV meds
-limit to one shock
-transport to hospital for Tx of severe hypo
Core T >86F (30C)-Continue CPR
-Give IV meds as indicated, but increase time intervals
-repeat defib for VT/VF as core T rises
-transport for AIR
What is core Temp?
93.2-96.8F (34-36C)
Mild hypothermia-passive rewarming
-Active external rewarming
86-93.2F (30-34C)
Moderate hypothermia-Passive rewarming
-Active external rewarming of trunc only
<86F (30C)
Severe hypothermia-Active Internal rewarming sequence
Active internal rewarming-Warm IV Fluids (109F [43C])
-Warm humid O2
-Peritoneal lavage (KCl free fluid)
-Extracorporeal rewarming
-Esophageal rewarming tubes
Continue internal rewarming until
-core temp >95F (35C) or
-return of spontaneous circulation or
-Resuscitative efforts cease
Hypothermia extras• Check pulse for full minute• Transcutaneous pacing not recomended, but have been case reports of success in humans, and in dogs it decreased rewarming time by 50%
• In one swine model, EtOH did not have affect on cooling/rewarming, but did lead to increase hemodynamic instability with/after rewarming
• Avoid hyperventilation – hypocapnic ventricular irritability• Avoid rough handling – in dog model, rough handling/manipulation lead to arrhythmia in over 50%
• Consider transport to more advanced care for Severe hypothermia
• Not DEAD until WARM AND DEAD
Summary• Children are not just small adults• They tend to have higher pulse and respiratory rates and lower blood pressures
• Anatomic differences• Common problems• Review problems of pregnancy and how to assist with a precipitous delivery
Questions?Richard Trierweiler, MD, MPH, [email protected]
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