General Approach to the General Approach to the Pediatric PatientPediatric Patient

Rosen’s Chapt. 164March 29, 2007

Martin Hellman M.D.

Slides byScott Gunderson PGYIII

EpidemiologyEpidemiology

30% of ED visits are pediatrics

Most critically ill patients present to community ED’s not pediatric hospitals

Well established support network for definitive care is essential

EpidemiologyEpidemiology

Fever, Respiratory, & Trauma most common reasons for visits

Trauma is the most common reason for serious morbidity and mortality

PathophysiologyPathophysiology

Anatomic & Physiologic Anatomic & Physiologic DifferencesDifferencesLarge head:body ratio increases head

injuries

Flexible ribs transmit blunt force w/o fractures

Ligaments stronger than physeal plates so fx. more common than sprains

Anatomic & Physiologic Anatomic & Physiologic DifferencesDifferencesSmaller airways more prone to obstruction

Infants often nose breathers and nasal congestion can cause significant distress

Vital SignsVital Signs

60-10012-16>12

70-12018-306-12

80-14022-342-5

90-15024-401-2

100-16030-60<1

Heart RateRespirationsAge

Vital SignsVital Signs

Tachycardia may be shock, but more commonly d/t fever, anxiety, or fear

Blood pressure difficult to obtain without child cooperation

Lower limit of SBP is 70 + (2 x age)

Vital SignsVital Signs

Respiratory rate– Infants may have apnea up to 20 seconds

normally

– Increased by 5/min per degree (C) fever

Developmental MilestonesDevelopmental Milestones

Neonates– Discomfort is nonspecific– Little interaction

Infants– Social smile, tracts lights – 2-3 months– Stranger anxiety – 6 months

Developmental MilestonesDevelopmental Milestones

Toddlers (13 – 36 months)– Walks alone– Language develops

Preschool (4 – 5 yrs)– Many fantasizes may play a role in irrational

thoughts

Developmental MilestonesDevelopmental Milestones

School Age children (6 – 12 yrs)– Reasoning matures– Explain and include child in conversations

Adolescents (13 – 19 yrs)– Independence and autonomy– Peer pressure– Risk taking behaviors

Initial AssessmentInitial Assessment

Hands-off– Appearance– Work of breathing– Circulation

Gives initial assessment of sick or well

AppearanceAppearance

Interaction with environment– CNS Hypoperfusion

Initially irritableProgress to alternating irritability and lethargyProgress to lethargy and coma

Work of BreathingWork of Breathing

Assess from a distance– Once a cry is started difficult to interpret

– Listen from a distance for audible soundsGrunting - self-induced PEEP to open alveoliStridor - upper airway obstructionMuffled voice - larynx trauma or abscessWheezing - airway narrowing, assess degree

Work of BreathingWork of Breathing

Positioning– Sniffing position - trying to overcome

obstruction– Tripoding - maximizes accessory muscles

Effortless tachypnea– Think compensation of shock and metabolic

acidosis

CirculationCirculation

Visual inspection of perfusion– Pallor - shunting to vital organs in shock– Mottling - worsening shock– Cyanosis - late shock and respiratory failure

Clinical InterviewClinical Interview

Remember and respect parents perception that their child has an emergency

Obtain SAMPLE history involving the child as much as possible

Physical ExaminationPhysical Examination

Not stepwise

Painful or frightening components last (ears)

Examine infants mostly in caretakers lap

TraumaTrauma

Attentions to C-spine precautions– Cervical spine injuries without radiographic

abnormalities (SCIWORA)More common in infants due to elasticityDon’t ignore ridiculer symptoms because

radiographs are negativeUp to 36% of traumatic cervical mylopathies in

children are SCIWORA

ABC’s

Intentional TraumaIntentional TraumaChild abuse

– Usually blunt injuries– Consult child protective services– Look for characteristic bruises

Bruise of different agesHand printsBelt/cord marksLinear marksBitesLocation - neck, groin, thigh, wrists and ankles

SeizuresSeizures

Most benign and self-limited

Assess airway and ventilation– Nasal airways can greatly assist

Look for focal findings

Consider fever, CNS infections, and brain injury

Difficult Airway & ObstructionDifficult Airway & Obstruction

Recognition is key

Mallamptai grades not well studied

Clinical croup score and asthma severity scores are very reproducible

Clinical Croup ScoreClinical Croup ScoreStridor None 0Audible with stethoscope (at rest) 1Audible without stethoscope (at rest) 2

RetractionsNone 0Mild 1Moderate 2Severe 3

Air EntryNormal 0Decreased 1Severely decreased 2

CyanosisNone 0With agitation 4At rest 5

Level of ConsciousnessNormal 0Altered 5

Mild disease <3

Moderate dz 3-6

Severe dx >6

Asthma Severity ScoreAsthma Severity ScoreWheezing

None or mild 0Moderate 1Severe 2

Air entryNormal or mild 0Moderately diminished 1Severely diminished 2

Work of BreathingNone or mild 0Moderate 1Severe 2

Prolonged expirationNormal or mild 0Moderate 1Severe 2

TachypneaAbsent 0Present 1

Mental statusNormal 0Depressed 1

Highly reproducible and predictive

Altered Level of ConsciousnessAltered Level of Consciousness Respirations

– Cheyne-Stokes - increased ICP– Regular tachypnea - midbrain dysfunction

Pupils– Fixed - serious CNS pathology– Unilaterally nonreactive - focal increased ICP

causing uncal compression

Posturing

ShockShock

4 organ approach– Heart - tachycardia occurs first, but can be absent in

last stages

– Skin - shunts blood away Assess where extremities go from cool to warm

– Should move peripherally with resuscitation

– Brain Irritability first then decreased mental status

– Lungs Tachypnea to overcome acidosis

Special NeedsSpecial Needs

Utilize guardian to assess baseline mental function

Behavioral changes can be a V-P shunt malfunction

Noninvasive MonitoringNoninvasive Monitoring

Pulse oximetry– Real-time assessment of respiratory status

End-tidal CO2– Real-time assessment of respirations,

peripheral perfusion, and airway– Helps to avoid repeated blood gas analysis

OMTOMT

OMT in children– There are no specific contraindications for

OMT in children

Otitis media– Numerous studies have shown benefit to OMT

in OM course and reoccurrences

SummarySummary

Understand developmental stages and issues

Remember normal vitals for agesInitial “hands-off” observation is keyBeware of the pale child - early shockSCIWORAAssessment of difficult airways