Quick review of Assessment. Pediatric Medical Assessment Review And Case Studies. Past Medical History. S.A.M.P.L.E. History is a great start.

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1 EMS Live at Night January 12 th, 2010 Pediatric Medical Assessment Review And Case Studies Brian Rogge RN Northwest Medstar Pediatric/Perinatal Team Quick review of Assessment S.A.M.P.L.E. History is a great start. Age and Weight are very important Use Broslow Tape for weight Signs and Symptoms Why was EMS called What is different Allergies Medications Past Medical History If under 1-2 months get brief birth history ANY hospitalizations Immunizations, ask about seasonal flu (or H1N1) Last Meal or oral intake Include last medication and doses Tylenol, Ibuprofen and Cold Remedies Events leading up to the event How long have the symptoms been going on Any siblings sick School or Day Care? 1

2 Assessment Differences Capillary Refill! Central and distal Is temperature dependant especially distal How is the Child Responding to you Age appropriate? Too sick to care? Fontanels Bulging, full, flat, sunken Soft, firm Case #1 5 year old asthmatic, at home, difficulty breathing after playing with friend. What do you want to know? Assessment Meds, when used History What you find What do you want to do? Patient has wheezes throughout Is this good or bad? Patient Speaking in 2-3 word sentences LOOK at work of breathing Retractions, nasal flaring, Accessory Muscles Used inhaler once with no relief Is inhaler empty or outdated Parent states otherwise healthy Child 2

3 Extra Points with Receiving Get more detailed medical history Any ER visits for asthma Any hospitalizations Any intubations (can be very important finding) Parents or Family members smoke? Do not ask if anyone smokes in the home Look at nailbeds Cyanotic? Spoon Shaped? Case #2 2 year old cough, difficulty breathing What do you want to know? Assessment History Meds Any home treatments? Drooling? What you find What do you want to do? Very frightened toddler barking like a seal What do you want to do next? Hint: this may make this a critical incident. Child had a mild fever, was given appropriate Tylenol dose with some relief. Parents have kid bundled up for your arrival, no other Treatments. Is your ambulance warm or cold? Which do you want? 3

4 Difficulties and Pitfalls Keeping the child (and parents) calm is very important. Keep parents close if practical Establishing rapport with parent and child is key How to transport? Cold air may ease symptoms and buy time Slow walk to ambulance? Is ambulance hot? Wheezes versus Stridor Often confused for one another Stridor is audible sound heard from air turbulence through the larger upper airways such as larynx. Wheezes are sounds produced from the turbulent air in the smaller middle airways such as the bronchioles. Case #3 3 month old lethargic, not eating, vomiting What do you want to know? How long and any other symptoms? Fever? What is normal diet? Breastfeeding? Formula? Wet diapers? Diarrhea? What you find 3 month old girl, lethargic, pale, and mottled. Capillary refill is 3 secs central and 5+ seconds distal Nervous yet? Has had Vomiting and diarrhea for 24 hours with mild fever. Patient is bottle fed, with normal formula. 4

5 Fontanel is sunken Patient has shallow respirations Vital Signs: Temp? Feels cool. Heart Rate 176 Resp Rate 12 Unable to get a reliable O2 saturation Blood pressure 62/24» How did you get a blood pressure? What do you want to do? Hint: Now you should be nervous Case #4 7 year old flu like symptoms for 3 days now nearly unresponsive What do you want to know? What is their definition of flu like symptoms? Previous medical history Any Meds or treatments? What you find School age child lying on sofa. Withdraws to nailbed pressure. Deep rhythmic respirations. Very dry skin and mucous membranes No fever, but warm Capillary refill is 4 secs Flu symptoms: not eating and vomiting yesterday 5

6 What do you suspect? Other Assessment points Are you able to do a blood sugar? History of drinking and urinating excessively (polydipsia polyuria) May smell ketones Interesting finding that may lead you faster to problem What do you want to do? Things to consider. Fluids are good to a point Be cautious with >30ml/kg May lead to cerebral edema 6

7 Case #5 10 week old with fever, vomited x1, and occasionally turns blue What do you want to know? Birth History Any treatment for fever Other symptoms What you find? Small 10 week old swaddled in blanket in mother s arms Currently breathing normal, nice and pink Cap refill is brisk, full fontanel Born at 32 weeks Why? Where? How? Do the math Really only 2-3 weeks old Sounds like heading toward sepsis What do you want to do? IV? If yes: Really? Do you need it? How good are you with a 24ga and a 2 week old? Should I just put in an I/O? If No: Why Not? What you observe on way to hospital 30 mins transport time. 5 mins into transport Oxygen sats drop and you recognize apnea Stimulate baby and begins breathing Place O2 on at 1 liter per Nasal Cannula Patient arches back when stimulated Heart rate is all over the place bpm Rhythmic motion intermittently of left hand and wrist Guess I better (re)check pupils No Nystagmus (shaking) and maybe rightward gaze 7

8 You pass on report to hospital Questions or Comments? You have not done any ALS interventions on this child, but you have made a huge impact on their care. Why? CT scan was ordered immediately upon arrival to receiving facility. Good ongoing observation and assessments are essential! Question 1 Which of the following best describes the difference between wheezes and stridor? a. Wheezing is in the large upper airway and stridor is in the smaller middle airway b. Stridor is in large upper airway and wheezing is in smaller middle airways c. They are the same thing d. Wheezing is the sound that people make when they are stridorous Question 2 What is the best method for estimating the weight of a child: a. Estimating based on age of child b. Ask the patient c. Ask a parent d. Use a broslow tape 8

9 Question 3 All of the following are appropriate treatment for seizures, except. a. Placing the patient in rescue position. b. Placing a bite block in the mouth. c. Giving supplemental oxygen. d. Clearing the area around the patient for safety. Question 4 All of the following are symptoms of a new onset of diabetes in a child, except. a. Excessive sweating b. History of lethargy or flu like symptoms c. Very dry skin d. Deep rhythmic breathing Question 5 All of the following are true of vomiting and diarrhea in a child, except. a. It never leads to a medical emergency b. It can last for several days c. It can cause electrolyte abnormalities d. It can cause severe hypovolemic shock Super Secret Question What does RSV stand for? Answer: Respiratory syncytial virus 9

10 Contact: Carolyn Stovall Fax: