Diagnostic Categories Of
Children Transported
Pediatric Emergencies:
Assessment and Transport
Carroll King JD, MD
St Vincent Healthcare
Medical Director/PICU
Pediatric Assessment Triangle
Pediatric Assessment Triangle
• Alertness
Appearance • Distractibility
• Consolability
Work of • Eye contact
Appearance • Speech/cry
Breathing • Spontaneous motor
activity
• Color
Circulation to Skin
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Pediatric Respiratory System Pediatric Assessment Triangle
Large head, small • Abnormal position
mandible, small Appearance • Abnormal breath sounds
neck • Retractions
• Nasal flaring
Large, posteriorly- Work of
placed tongue breathing
High glottic opening
Small airways
Presence of tonsils,
adenoids
Pediatric Respiratory System Pediatric Assessment Triangle
• Color
Poor accessory muscle development Appearance • Temperature
• Capillary refill time
Mobile thoracic cage • Pulse quality
Horizontal ribs, primarily diaphragm Work of
breathing
breathers
Increased metabolic rate, increased O2
consumption Circulation
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Anatomical Differences Anatomical Differences
A child’s anatomy differs in four • Large tongue in relation to
significant ways from an adult’s. smaller airway a small oropharynx
• Distal airways are
Smaller airway markedly smaller.
• Trachea is not rigid and
Less blood will collapse easily
Bigger head • Back of the head is
rounder and requires
Vulnerable internal organs careful positioning to keep
airway open
Anatomical Differences, Anatomical Differences
• Relatively smaller blood • Head size is proportionally
smaller airway volume smaller airway larger
• Approximately 70 cc of • Prominent occiput and a
less blood blood for every 1kg (2 lbs) less blood relatively straight cervical
of body weight spine
• A 20 lb child has about • Neck and associated
700cc of blood—about the bigger head support structures aren’t
volume of a medium sized well developed
soda cup • Infants and small children
are prone to falling
because they are top
heavy
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Anatomical Differences Kids Don’t Tolerate
• Internal organs are not
smaller airway well protected Hypoxia
• Soft bones and cartilage
and lack of fat in the rib
Hypovolemia
less blood
cage make internal organs Hypoperfusion Acidosis
susceptible to significant
bigger head internal injuries Hypotension
• Injury can occur with very Hypothermia
internal organs little mechanism or
obvious signs
Respiratory Distress
Early Shock
Tachycardia (May be bradycardia in neonate)
tachycardia
Head bobbing, stridor, prolonged expiration
Abdominal breathing delayed capillary refill > 3 seconds
Grunting—maintains end expiratory volume tachypnea
anxiousness, combativeness, agitation
peripheral constriction, cold clammy
extremities
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Late Shock Debunking the Myths
Weak or absent pulses Kids don’t get sick
Diminished LOC “He’s young, he will heal better”
Hypotension It’s a kid, less is best
LATE LATE LATE shock “He fell off the couch.”
VERY VERY VERY bad sign It’s a kid, use D5 .2NS
It’s nap time or he has been up all night-
maybe he is just tired.
Assessment Evaluation
Listen to the parents- they are trying to Various conditions may lead to
tell you something respiratory failure and/or shock
LOOK FIRST! Allow assessment and evaluation to
Never trust a neonate! quickly direct intervention
Zebras occur in the first year of life Avoid progression to cardiopulmonary
Difficult parts of the physical exam failure and arrest
Heart exam, palpation of the liver Survival markedly better with respiratory
Nuchal rigidity? arrest vs. cardiopulmonary arrest
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Cardiopulmonary assessment General Appearance
Evaluation of general appearance “Looks bad”
Mental status, tone, sick or not sick
Mental status, responsiveness
Physical exam- ABC’s
Tone and activity
Classification of physiologic status
Age-appropriate response
Reaction to painful procedures
Adapted from PALS
Physical Exam- Airway Physical exam- Breathing
Clear Respiratory rate- fast and slow
Maintainable- positioning, suctioning, Effort and mechanics- retractions and
nasal airway, bag mask grunting
Not maintainable without intubation Breath sounds- wheezing and stridor
Avoid respiratory arrest Skin color- red is good, blue is bad,
gray is worse
Pulse oximetry- reliable. Don’t blame
the probe- use with CBG
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Physical Exam- Circulation Cardiovascular Function
Cardiovascular function Heart rate- tachycardia is the first and most
consistent response to inadequate cardiac
Heart rate output.
Pulses, capillary refill Don’t ignore tachycardia- fever, pain, fear
Blood pressure Shock is much more common than SVT
Use heart rate to gauge progress or decline
End-organ perfusion
Pulses- everyone has them
Brain Capillary refill- 6 seconds and reassess
3 stools during the exam Pulses diminished, slightly warmer, still
lethargic
What do you do? What is the likely DX? What do you do?
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Scenario 1 continued Scenario 2
Repeat crystalloid boluses of 20 ml/kg 5 year old with history of frequent
Use pulses, extremity temp, capillary impetigo presents with a 1 day history
refill, level of alertness to guide therapy of fever and lethargy and cough for 3
Place foley catheter days. This morning had to be
awakened and has remained drowsy
Reassess and re-examine and at times acts “goofy.”
Lethargic child, VS: HR 190, RR 70, BP
65/30, temp 38.8
Scenario 2 Scenario 2
Airway- patent Presumed septic shock (compensated?)
Breathing- Tachypniec, grunting, Apply oxygen, bag mask, prepare intubation
retractions, poor BS on right Obtain IV access and begin aggressive fluid
resuscitation with isotonic fluids
Circulation- Tachycardic, no peripheral
Use physical exam to guide therapy
pulses, cool to elbows and knees,
Obtain labs
clammy skin, capillary refill > 5 seconds
Antibiotics, fever therapy, foley catheter,
transport
What do you do? What is the likely DX?
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Scenario 3 Scenario 3
2 month old, former 35 week premature infant Airway- patent
with cold symptoms now having difficulty
Breathing- moderate retractions,
breathing. Parents relate toddler in house
with “bad cold.” Infant has felt warm and not expiratory wheeze throughout all fields
eating well. Brought to clinic because she is Circulation- warm and well perfused,
breathing funny. capillary refill Females
Subglottic edema; Air flow obstruction Fall, early winter
Croup: Signs/Symptoms Croup: Management
“Cold” progressing to hoarseness, Mild Croup
cough Reassurance
Low grade fever Moist, cool air
Night-time increase in edema with:
Stridor
“Seal bark” cough
Recurs on several nights
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Croup: Management
Severe Croup
Humidified high concentration oxygen Epiglottitis
Monitor EKG
IV tko if tolerated
Nebulized racemic epinephrine
Anticipate need to intubate, assist
ventilations
Epiglottitis: Pathophysiology
Epiglottitis: Incidence
Bacterial infection (Hemophilus influenza)
Affects epiglottis, adjacent pharyngeal tissue Children > 4 years old
Supraglottic edema Common in ages 4 - 7
Pedi incidence falling due to HiB vaccination
Can occur in adults, particularly elderly
Incidence in adults is increasing
Complete Airway
Obstruction
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Epiglottitis: Signs/Symptoms Epiglottitis
Rapid onset, severe distress in hours
High fever
Intense sore throat, difficulty swallowing Respiratory distress+
Drooling Sore throat+Drooling =
Stridor Epiglottitis
Sits up, leans forward, extends neck slightly
One-third present unconscious, in shock
Epiglottitis: Management
High concentration oxygen
IV not advisable The less you do… the better
Keep IO handy and OUT OF SIGHT
Keep IM meds handy
Immediate Life Threat
Rapid transport
Possible Complete Airway
Do not attempt to visualize airway
Obstruction
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Asthma: Pathophysiology
Lower airway is hypersensitive to:
Asthma Allergies
Infection
Irritants
Emotional stress
Cold
Exercise
Asthma: Pathophysiology
Asthma: Pathophysiology
Bronchospasm
Bronchial Edema Increased Mucus
Production
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Asthma: Pathophysiology
Asthma: Signs/Symptoms
Cast of airway
produced by
asthmatic mucus Dyspnea
plugs
Signs of respiratory distress
Nasal flaring
Tracheal tugging
Accessory muscle use
Suprasternal, intercostal, epigastric
retractions
Asthma: Signs/Symptoms Asthma: Prolonged Attacks
Coughing Increased evaporative water loss
Expiratory wheezing Decreased fluid intake
Tachypnea Dehydration
Cyanosis
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Asthma: History Asthma: Physical Exam
How long has patient been wheezing? Patient position?
How much fluid has patient had? Drowsy or stuporous?
Recent respiratory tract infection? Signs/symptoms of dehydration?
Medications? When? How much? Chest movement?
Allergies? Quality of breath sounds?
Previous hospitalizations?
Asthma: Risk Assessment
Prior ICU admissions Asthma
Prior intubation
>3 emergency department visits in past year
>2 hospital admissions in past year
>1 bronchodilator canister used in past month
Use of bronchodilators > every 4 hours Silent Chest = Danger
Chronic use of steroids
Progressive symptoms in spite of aggressive Rx
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Golden Rule
Asthma: Management
ALL THAT WHEEZES IS NOT ASTHMA
Airway
Pulmonary edema Breathing
Allergic reactions Sitting position
Pneumonia Humidified O2 by NRB mask
Foreign body aspiration Dry O2 dries mucus, worsens plugs
Encourage coughing
Medications
Asthma: Management Asthma: Management
Nebulized Beta-2 agents Nebulized anticholinergics
Albuterol Atropine
Terbutaline Ipatropium
Metaproterenol
Isoetharine
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Asthma: Management Asthma: Management
Subcutaneous beta agents Use EXTREME caution in giving two
Epinephrine 1:1000--0.1 to 0.3 mg SQ sympathomimetics to same patient
Terbutaline--0.25 mg SQ Monitor ECG
POSSIBLE BENEFIT IN PATIENTS
WITH VENTILATORY FAILURE
Asthma: Management
Avoid
Sedatives Status Asthmaticus
Depress respiratory drive
Antihistamines
Asthma attack unresponsive to β-
Decrease LOC, dry secretions 2 adrenergic agents
Aspirin
High incidence of allergy
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Status Asthmaticus Status Asthmaticus
Humidified oxygen Intubation is a LAST RESORT
Rehydration
Continuous nebulized beta-2 agents Mechanical ventilation
Atrovent SLOW rate
Corticosteroids
Magnesium sulfate (controversial)
Heliox (controversial)
Asthma: Management
Circulation
IV TKO Bronchiolitis
Assess for dehydration
Titrate fluid administration to severity of
dehydration
Monitor ECG
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Bronchiolitis: Pathophysiology Bronchiolitis: Incidence
Viral infection (RSV) Children 2 years Age - 90% of deaths from FBAO: children <
child with sudden onset of:
5 years old
Respiratory distress
Choking
65% of deaths from FBAO: infants Coughing
Stridor
Wheezing
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FBAO: Management FBAO: Management
Minimize intervention if child conscious, Inadequate ventilation
maintaining own airway Infant: 5 back blows/5 chest thrusts
100% oxygen as tolerated Child: Abdominal thrusts
No blind sweeps of oral cavity
Wheezing
Object in small airway
Avoid trying to extract in field
BPD: Pathophysiology
Complication of infant respiratory distress
syndrome
Bronchopulmonary Dysplasia
Seen in infants with Hx of prematurity
Results from prolonged exposure to high
BPD concentration O2 , and mechanical ventilation
of the immature lung.
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BPD: Prognosis
BPD: Signs/Symptoms
Medically fragile, decompensate quickly
Require supplemental O2 to prevent cyanosis
Chronic respiratory distress Prone to recurrent respiratory infections
Retractions
Rales About 2/3 gradually recover
Wheezing
Possible cor pulmonale with peripheral
edema
BPD: Treatment
Supplemental O2
Assisted ventilations, as needed
Diuretic therapy, as needed
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