The Pediatric Patient. Morgen Bernius, MD NCEMS Conference February 24, 2007
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1 The Pediatric Patient Morgen Bernius, MD NCEMS Conference February 24, 2007
2 Rule #1: Everyone Loves the Pediatric Patient
3
4 Pediatrics in EMS Approximately 10% of all EMS treatment is for children younger than 14 years of age #1 #2
5
6
7 Difficulties in Assessment The mnemonic nightmare
8 Difficulties in Assessment PEPP: Pediatric Education for Prehospital Providers PAT: Pediatric Assessment Triangle (appearance, work of breathing, circulation) PALS: Pediatric Advanced Life Support ABCDE: Airway, Breathing, Circulation, Disability, Exposure AVPU: Alert, Responsive to Verbal/Painful stimuli, Unresponsive SAMPLE: Signs/Symptoms, Allergies, Medications, Past medical hx, Last meal, Events leading up to illness/injury
9 They re just little misshapen adults
10 The Pediatric Patient General Assessment Airway/Breathing Circulation Pediatric Pearls
11 General Assessment
12 General Pediatric Assessment Vital Signs Respiratory Rate and Quality Pulse Rate and Quality Blood Pressure Capillary Refill Pulse Oximetry WEIGHT
13 What is NORMAL? Depends on Age Size Development Chronic conditions
14
15 What is NORMAL? USE THE PARENTS!! Ask about: medical problems normal assessment findings medical devices Emergency Health Information Form If unavailable, base assessment on normal VS for age
16 What is NORMAL?
17 Airway
18 Airway/Breathing These are EVERYTHING in the pediatric patient!
19 Airway/Breathing Most pediatric arrests are of respiratory origin Once respiratory arrest progresses to pulseless cardiac arrest, outcome is poor 10% 10% Resp Shock Cardiac 80%
20 Age Distribution of Arrests # Arrests <7mo
21 Anatomic and Physiologic Differences and the Occiput Airway size Nose Tongue Larynx Vocal Cords Epiglottis Physiology Consequences
22 Anatomy: Occiput size The infant has a large occiput sniffing position ineffective in patients < 2yo
23 Positioning
24 Positioning Head Tilt- Chin Lift Jaw thrust
25 Positioning Sniffing position in children >2years of age
26 Positioning Shoulder elevation in children <2yo
27 Positioning Shoulder elevation in children <2yo
28 Positioning Shoulder elevation in children <2yo
29 Anatomy: Airway Size Difference #1: It s SMALLER!
30 Anatomy: Airway Size Manipulation and visualization Peripheral airway contribution to total resistance: Adults: 20% Children: 50%
31 Anatomy: Airway Size 8 R = n l Π r 4 Poiseuille s Law: if the radius is halved,, resistance increases 16- fold (with laminar flow)
32 Anatomy: Nose The nose is responsible for 50% of airway resistance at all ages In the infant, blockage of the nose = respiratory distress
33 Anatomy: Tongue The infant s tongue is larger relative to the oropharynx Loss of tone with sleep, sedation, CNS dysfunction Frequent cause of upper airway obstruction May be difficult to control with the laryngoscope blade
34 Anatomy: Larynx Relatively cephalad and anterior in position
35 Anatomy: Larynx More acute angle between the base of the tongue and glottic opening Straight blade more useful to create a direct visual plane Positioning
36 Anatomy: Larynx Narrowest portion of the airway: Adults: glottic inlet Children <10yo: cricoid cartilage Funnel vs cylinder shape
37 Anatomy: Larynx Endotracheal tube size selection Through the cords home-free Cuffed vs uncuffed
38 Anatomy: Vocal Cords Vocal cords slanted anteriorly vs perpendicular to trachea Affects visualization Can make passage of ETT more difficult
39 Anatomy: Epiglottis Short, narrow, and angled away from the long axis of the trachea Floppy (little cartilage) Straight laryngoscope blades
40 Breathing
41 Breathing High metabolic rate and oxygen demand O 2 consumption: infants 6-8 ml/kg/min adults 3-4 ml/kg/min Hypoxemia develops more rapidly in presence of apnea or inadequate alveolar ventilation
42 Weak intercostal muscles, cartilage Tidal volume dependent on movement of diaphragm Little reserve if movement of diaphragm is impeded Breathing
43 Assisting Ventilation General Principles Positioning Bag-Valve-Mask ventilation Airway Adjuncts Endotracheal intubation
44 General Principles Anticipate and Recognize Prepare Oxygen and Humidification Position of comfort Lessen anxiety Be aggressive with secretions Start simple unobstruct the airway
45 Signs of Respiratory Distress Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie down Agitation Retractions Accessory muscle use Wheezing Sweating Prolonged expiration Pulsus paradoxus Cyanosis
46 Signs of Respiratory Reduced air entry Severe work Failure Cyanosis despite O 2 Irregular breathing / apnea Altered Consciousness Diaphoresis
47 Bag-Valve-Mask Ventilation Mask: bridge of nose to cleft of chin, as small as possible Infants and toddlers: jaw supported with base of the middle or ring finger Older children: fingertips of 3 rd, 4 th, and 5 th fingers on ramus of mandible
48 Bag-Valve-Mask Ventilation May need two providers to get a good seal
49 Bag-Valve-Mask Ventilation Don t forget the Sellick maneuver!
50 Airway Adjuncts Oropharyngeal airway holds tongue and soft hypopharyngeal structures away from posterior pharyngeal wall unconscious patients only 4-10cm length Estimate length: corner of mouth to angle of jaw
51 Airway Adjuncts
52 Airway Adjuncts
53 Airway Adjuncts
54 Airway Adjuncts
55 Just right!! Airway Adjuncts
56 Airway Adjuncts Insertion technique:
57 Airway Adjuncts Nasopharyngeal Airway: 12F (3mm ETT) to 36F Suction Contraindications Tip of nose to tragus
58 Endotracheal Intubation Isolates airway Reduces potential for aspiration Allows control of inspiratory time and peak inspiratory pressures Allows delivery of PEEP
59 Endotracheal Intubation: Indications Inadequate CNS control of ventilation Functional or anatomic airway obstruction Excessive work of breathing Need for high peak inspiratory pressures or PEEP to maintain effective alveolar gas exchange Need for mechanical ventilatory support Inability to protect airway
60 Endotracheal Intubation: Preparation SOAP ME Suction Oxygen Airway equipment (check it!) Pharmacologic agents Monitor, Mechanical Equipment
61 Endotracheal Intubation: Equipment ETT: Uncuffed in children <8yo Cuffed in children >8yo Size: Use your CODE CARD! ETT size = Age (yrs)
62 Endotracheal Intubation: Equipment ETT: ETT size = Age (yrs) + 4 4
63 Endotracheal Intubation: Equipment ETT: Have other sizes available! Rigid stylet Depth of insertion: 3 x internal diameter (5.0 ETT inserted 15cm)
64 Endotracheal Intubation: Laryngoscope Equipment Miller for infants and toddlers Miller or Macintosh for older children
65 Endotracheal Intubation Curved vs. Straight blade positioning
66 Endotracheal Intubation Confirm tube placement Auscultation CO 2 detection Ability to ventilate
67 Circulation
68 Circulation Cardiac monitor Pediatric electrodes for infants and young children. Adult electrodes may be used for larger children and adolescents. Make sure pediatric paddles are available for defibrillation if necessary.
69 Circulation Tachycardia: Hypovolemia Hypoxia Anxiety Fever Pain Cardiac impairment Bradycardia
70 Circulation Pulses Newborns: Umbilical artery Infants: brachial artery Children: carotid artery
71 Circulation Pulse quality Rate Strength Central vs Peripheral Capillary refill time (CRT) Skin color and temperature: Warm, cool, pale, or cyanotic?
72 Circulation Blood Pressure (5 th percentile) Infants SBP 60 1 year SBP 70 >1 year SBP ( x age)
73 Circulation Intravenous fluids Peripheral IV access
74
75 Circulation Intraosseous (IO) access No age restrictions seconds or 3 attempts Can infuse ANYTHING New options: EZ-IO
76 Circulation Intraosseous needle
77 Circulation Vidacare EZ-IO
78 IO Insertion Circulation
79 Pediatric Pearls
80 Pediatric Pearls Children compensate better than adults
81 Pediatric Pearls You cannot remember normal weights, respiratory rates, blood pressures, heart rates, and calculate drug doses in your head.so don t try.
82 Pediatric Pearls Airway is everything remember the basics
83
84 Pediatric Pearls Relax they re just little (misshapen) adults
85
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