Paediatrics for Paramedics

8/6/2019 Paediatrics for Paramedics

1/93

Presented by: M Smith


2/93

General Pediatric Assessment Strategies

Pediatric Emergencies

Respiratory Emergencies Dehydration

INCLUDING : Identification of Severity of

Dehydration

INCLUDING : Identification, management andTransportation of the Shocked Paediatric

Intravenous Access and Fluid

Management


3/93


4/93

Newborn (first 6 hours)

Neonate (first 28 days)

Infant (first year) Toddler (1 to 3 years)

Preschooler (3 to 5 years)

School age (6 to 12 years)

Adolescent (12 to adulthood)


5/93


6/93


7/93


8/93


9/93

Parent

Frightened

Guilty Exhausted


10/93

Paramedic

Frightened

May over-empathize


11/93

Who has to control situation?


12/93

Oxygenation, ventilation adequate to

preserve life, CNS function?

Cardiac output sufficient to sustain life,

CNS function?

Oxygenation, ventilation, cardiac output

likely to deteriorate before reaching

hospital? C-spine protected?

Major fractures immobilized?


13/93

If invasive procedure considered, do

benefits outweigh risks?

If parent is not accompanying child, is

history adequate?

Transport expeditiously

Reassess, Reassess, Reassess


14/93

Priorities are similar to adult

Greater emphasis on airway, breathing


15/93

Limit to essentials

Look before you touch


16/93

Circulation


17/93

Initial Assessment (quick assessment that can bedone within seconds of arriving on scene)

AAppearance Mental status (alert, crying, obtunded, no response) Muscle tone (moving, not moving, limp)

BBreathing Respiratory rate (too fast, too slow, irregular)

Respiratory effort (use of accessory muscles, nasal flaring,

retractions, grunting) Check breath sounds

Circulation Skin color (pallor, peripheral cyanosis, central cyanosis)

C

apillary Refill (normal is within 2 seconds) Pulse (too fast, too slow, irregular, normal)


18/93

Detailed assessment With adults this is typically done head to toe, with

pediatrics it is better to do the opposite Why?Why? Take a SAMPLE history (use the parents for

detailed hx if possible)

Determine

Hx of fever or infection Hx of vomitting or fever and check hydration status (skinturgor, check fontanalles in infants, look for xerosis)

Frequency of urination Why are these important questions to ask?Why are these important questions to ask?

Take vitals and measure pulse oximetry


19/93

Detailed assessment (cont.) Try to invent a game you can play or begin a

conversation about something you can talk aboutfor at least several minutes (Batman, SesameStreet, toys, school, etc.).

Explain each step in your assessment (now Imgoing to feel your tummy).

With older patients explain why you are doingeach step (I need to make sure your stomach isOK).

With younger patients, avoid separating themfrom their parents if possible.

Why?Why?


20/93

Detailed assessment (cont.) Explain things as simply as possible avoiding

technical terminology and jargon. Do NOT condescend.

Do NOT lie or make promises you cannot be sureto keep.

Be alert for injuries that seem inconsistent withtheir explanation this is usually a sign of childabuse.

Examples?Examples?

If you suspect child abuse, you must report it by

calling 0800 55555


21/93

Categorize as:

Stable

Potential Respiratory Failure or Shock Definite Respiratory Failure or Shock

Cardiopulmonary Failure


22/93


23/93

Essential elements

Proper equipment

K

nowledge of norms Carry chart of norms for reference


24/93


25/93

Apical auscultation

Peripheral palpation

Tachycardia may result from: Fear

Pain

Fever


26/93

Tachycardia + Quiet, non-febrile patient =

Decrease in cardiac output

Heart rate rises long before BP falls! Bradycardia + Sick child = Premorbid

state

Child < 60

Infant


27/93

Proper cuff size

Width = 2/3 length of upper arm

Bladder encircles arm without overlap


28/93

Children >1 year old

Systolic BP = (Age x 2) +80 Children >1 year old

BP = 70 + 2 x age (in years)


29/93

Evaluate perfusion using:

Level of consciousness Pulse rate

Skin color, temperature

Capillary refill

Do not delay transport to get BP

Hypotension = Late sign ofHypotension = Late sign of

ShockShock


30/93

Before touching

For one full minute

Approximate upper limit of normal =

(40 -Age[yrs])


31/93

> 60/min = Danger!!

Slow = Danger, impending arrest

Rapid, unlabored

Metabolic acidosis

Shock


32/93

Check by using your thumb against to

bottom of the heel (30seconds)

N

ormal < 2 seconds Increase suggests poor perfusion

Increases long before BP begins to fall

Cold exposure may falsely elevate


33/93

Cold = Paediatric Patients Enemy!!!

Large surface : volume ratio

Rapid heat loss Normal = 370C

Do not delay transport to obtain


34/93

Measurement:Measurement:AxillaryAxillary

Hold in skin fold 2 to

3 minutes

Normal = Depends on

peripheral

vasoconstriction/dila

tion

Measurement: OralMeasurement: Oral Glass thermometers

not advised

May be attempted

with school-agedchildren

Measurement: RectalMeasurement: Rectal

Lubricated

thermometer

4cm in rectum, 1 - 2

minutes

Do not attempt if child

Is < 2 months old


35/93

After exposing during primarysurvey, cover child to avoid

hypothermia!


36/93

Head

Anterior fontanel

Remains open until 12 to 18 months

Sinks in volume depletion

Bulges with increased ICP

C

hest Transmitted breath sounds

Listen over mid-axillary lines


37/93

Neurologic

Eye contact

Recognition of parents Silence is NOT golden!


38/93

Best source depends on childs age

Do not underestimate childs ability

as historian

Imagination may interfere with facts

Parents may have to fill gaps, correct

time frames

On scene observations important

Do not judge/accuse parent

Do not delay transport


39/93

Brief, relevant

Allergies

Medications

Past medical history

Last oral intake

Events leading to call

Specifics of present illness


40/93

Children not little adults

Do not forget parents

Do not forget to talk to child

Avoid separating children, parents

unless parent out of control


41/93

Children understand more than they express

Watch non-verbal messages

Get down on childs level Develop, maintain eye contact

Tell child your name

Show respect

Be honest


42/93

Children do not like:

Noise

Cold places Strange equipment


43/93

In emergency do not waste time in

interest of rapport

Do not underestimate childs ability

to hurt you


44/93


45/93

Respiratory distress is the leading cause ofCasualty visits and EMS calls for children

Respiratory compromise is one of the leadingcauses of death in children

Respiratory emergencies can effect children ofall ages

EMS intervention can be life-saving


46/93


47/93

Several key

differences betweenadult and pediatric

airway

Larger floppier

epiglottis

Epiglottitis

More difficult

intubations

Smaller, funnel

shaped trachea

FBAO is more

likely

No blind finger

sweeps


48/93

Foreign Body Airway Obstruction (FBAO) Usual causes are hard candy, nuts, small toys, coins, and

balloons

Recognition Apnea, inspiratory stridor, rales, rhonchi, wheezing, inability

to speak, anxiety, decreased breath sounds, muffled voice

Treatment If the patient is not breathing, open the airway and perform

the AHA approved maneuvers for clearing the obstruction Heimlich, backblows, abdominal or chest compressions.

If properly trained you may use a laryngoscope with Magillsforceps to try and remove the obstruction.

If patient is breathing, be as calming and supportive aspossible. Do not agitate the patient and transport sitting upas comfortably as possible. Be alert for change in status.


49/93

Treatment (cont.)

If patient is not breathing ventilate using a

BVM.

Administer oxygen at 15 LPM by NRB.

If patient is wheezing

Administer Medications through Nebuliser


50/93

Inflammation of theepiglottis andsurrounding structurescaused by bacterialinfection.

This condition is a trueemergency withmortality rates as high

as 10%.

Typically occurs inchildren 3-7 years old.


51/93

Recognition

Rapid onset (6-8 hours) of sore throat,

dysphagia, muffled voice, high fever,drooling, inspiratory stridor or rattle

Child is often found obtunded in tripod

position

Signs of respiratory distress are often

present


52/93

Treatment It is absolutely essential that the patient be

handled as calmly as possible. Anxiety oraggravation can cause increased swelling and

precipitate respiratory arrest. Defer all painful procedures. Transport patient sitting up in position of comfort.

Do not try to visualize the swelling or look in the mouth.

Administer high flow humidified O2 by NRB.

Administer 5 ml of EPINEPHRINE 1:1,000 bynebulizer. This can reduce upper airway swelling.

Have airway equipment (BVM, ET equip) ready incase patients condition deteriorates.

Inform medical control early so preparations canbe made at hospital for treatment.


53/93

Inflammation of theupper airways causedby a viral infection.

Very common (50 per1000 children)

Usually occurs inchildren aged 6 months

to 3 years. (median ageof onset is 18 months).

Sites of inflammation in

paediatric airway infections


54/93

Recognition

Low grade fever, barking cough,

hoarseness, inspiratory stridor, wheezing

Signs of respiratory distress

Often occurs at night

Treatment

Same as for epiglottitis.

The patient is likely to respond well to cool

humidified O2.


55/93

Croup

6 months 3 years

Slow onset

Barking cough

No drooling

Low grade fever (104F)

Very Serious


56/93

In contrast to croup

& epiglottitis,

asthma isinflammation of the

lower airways.

It is very common

(effects 50-100 outof 1000 children

under 10 YO)


57/93

Recognition

Typically it is either exercise, allergy, or

infection induced

S/Sx include wheezing, prolonged

expiration, tachypnea, dyspnea, and

anxiety A silent chest is an especially bad sign.

Why?


58/93


59/93

Bronchiolitis is a viral inflammation of

the lower airways.

It usually effects children under 2 Years

of Age.

Usually presents with symptoms

similar to those of asthma.

Can be very serious in infants.

Why do you think this is?

More common in the winter months.


60/93

Recognition

Wheezing nd t chypnea are ost

commonsymptoms. lsoanxiety,shortnessof reath, andcyanosis.

reatment

ameasasthmaPatient isnot as li ely to respond ell to -

agonists ( PI, L ROL)


61/93

Asthma

Occurs in all ages,

more common in

children > 2 YO

Occurs throughout the

year

Family hx of asthma

Responds well to -

agonists (EPI and

ALBUTEROL)

Bronchiolitis

Usually occurs in

children under 2 YO

Most common in winter,

spring

No family hx

Does NOT respond well

to EPI/ALBUTEROL


62/93

Treat respiratoryemergencies

aggressi ely. eprepared forpatients

todecompensate. Donot hesitate togi eneonates

oxygen ifyoususpect theyneed it.

Remember to treat theparents too.


63/93

An acute complex

pathophysiologic state of

circulatory dysfunction which

results in a failure of the organism

to deliver sufficient amounts of

oxygen and other nutrients to

satisfy the requirements of tissuebeds


64/93

Uncontrolled blood or fluid loss Blood pressure less than 5th

percentile for age

Altered mental status, low urineoutput, poor capillary refill

None of the above


65/93


66/93

Inadequate tissue perfusion to meet

tissue demands

Usually result of inadequate bloodflow and/or oxygen delivery

Shock is not a blood pressure

diagnosis!!


67/93

End organ dysfunction:

reduced urine output

altered mental status

poor peripheral perfusion

Metabolic dysfunction:

acidosis

altered metabolic demands


68/93

Gas exchange capability of lungs

Hemoglobin

Oxygen content

Cardiac output

Tissues to utilize substrate


69/93

Hypovolemic

dehydration,burns,

hemorrhage Distributive

septic, anaphylactic,

spinal

Cardiogenic myocarditis,dysrhythmia

Obstructive

Compensated

organ perfusion

is maintained Uncompensated

Circulatory

failure with end

organdysfunction

Irreversible

Irreparable loss

of essential


70/93

Fluid

Pump

Vessels

Flow


71/93

Inadequate FluidVolume

(decreased preload)


72/93

Fluid

depletion

internal external

Hemorrhage

internal external


73/93

Pump Malfunction

(decreased

contractility)


74/93

Electrical Failure

Mechanical Failure

Cardiomyopathy

metabolic

anatomic

hypoxia/ischemia


75/93

Abnormal Vessel Tone(decreased afterload)


76/93


77/93


78/93

Septic Shock

Decreas

ed

Volume

Decrease

d Pump

Function

Abnorma

l Vessel

Tone


79/93

Heart rateHeart rate

Stroke volume:Stroke volume:PreloadPreload-- volume of blood in ventriclevolume of blood in ventricle

AfterloadAfterload-- resistance toresistance to contractioncontraction

ContractilityContractility-- force appliedforce applied


80/93

Heart rate Peripheral circulation

capillary refill

pulses extremity temperature

Pulmonary

End organ perfusion brain

kidney


81/93

Preload Volume

Contractili

ty

Inotropes

Afterloa

d

Vasodilato

rs


82/93

Early (Warm)

Decreased peripheral vascular

resistanceIncreased cardiac output

Late (Cold)Increased peripheral vascular

resistance

Decreased cardiac output


83/93

OBSTRUCTED

FLOW


84/93


85/93

A: Airway

patent upper airway B: Breathing

adequate ventilation and oxygenation

C: Circulation optimize

cardiac function

oxygenation


86/93


87/93


88/93

Patients in shock have:

O2 delivery

progressive respiratory fatigue/failure energy shunted from vital organs

afterload


89/93

Early intubation provides:

O2 delivery and content

controlled ventilation which: reduces metabolic demand

allows C.O. to vital organs


90/93

Colloid Solutions

Haemacel: Not used in Neonates as they

have a high risk of anaphylaxis.

Voluven (Hydoxy-ethyl starch): Not readilyavailable, but preferred to plasma. It does

not carry viral diseases.


91/93

Crystalloids DD: Frequently used for rehydration and

maintenance in infants and children. (NOTNEONATES).

Ringer-Lactate: Ised for rehydration andvolume expansion. Do not give bicarbonatewith this solution as it contains calcium.

Maintelyte & Paeds maintenance solution:

Used as maintenance solution. Normal Saline: Used as a rehydration fluid,

and for volume expansion.


92/93

Hypotension (state of shock): Colloid

over crystalloid.

Initially give 15-20ml bolus dose: this is

given rapidly. If this does not correct

the hypotension, repeat the bolus up to

3 times.

Failure of the Fluid Bolus correct thehypotension consider Inotropic

Support


93/93

Documents

Paediatrics for Paramedics