morgen bernius the pediatric patient 2.3mb

Morgen Bernius, MDNCEMS ConferenceFebruary 24, 2007

The Pediatric Patient

Rule #1: Everyone Loves the Pediatric Patient

Pediatrics in EMS

•

Approximately 10% of all EMS treatment is for children younger than 14 years of age

#1

#2

•

The mnemonic nightmare…

Difficulties in Assessment

Presenter�

Presentation Notes�

PEPP-pediatric education for prehospital providers PAT-Pediatric Assessment Triangle (Appearance, Work of Breathing, Circulation) AVPU-Alert, Responsive to Verbal stimuli, responsive to Painful stimuli, Unresponsive PALS-Pediatric Advanced Life Support ABCDE-Airway Breathing Circulation Disability Exposure SAMPLE-Signs & Symptoms, Allergies, Medications, PMH, Last meal, Events leading up to illness/injury�

•

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

Difficulties in Assessment

They’re just little misshapen adults

The Pediatric Patient

•

General Assessment•

Airway/Breathing

•

Circulation•

Pediatric Pearls

General Assessment

•

Vital Signs–

Respiratory Rate and Quality

–

Pulse Rate and Quality–

Blood Pressure

–

Capillary Refill–

Pulse Oximetry

–

WEIGHT

General Pediatric Assessment

•

Depends on…–

Age

–

Size–

Development

–

Chronic conditions

What is NORMAL?

Presenter�


Tools – broselow tape, pediatric aids PARENTS!!�

•

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

What is NORMAL?

Presenter�


-Use the parents to help with your assessment, and to help communicate with the child .Begin by asking parents or home care provider about the child’s medical problems, normal assessment findings, and medical devices�–ask about limitations affecting growth, neurological development, physical function, or level of education�–ask for Emergency Health Form or card listing normal vital signs If unable to get historical information, base assessment on normal VS for age�

What is NORMAL?

Presenter�


-Use the parents to help with your assessment, and to help communicate with the child .Begin by asking parents or home care provider about the child’s medical problems, normal assessment findings, and medical devices�–ask about limitations affecting growth, neurological development, physical function, or level of education�–ask for Emergency Health Form or card listing normal vital signs If unable to get historical information, base assessment on normal VS for age�

Airway

These are EVERYTHING in the pediatric patient!

Airway/Breathing

•

Most pediatric arrests are of respiratory origin•

Once respiratory arrest progresses to pulseless cardiac arrest, outcome is

poor

Airway/Breathing

80%

10%

10%

RespShockCardiac

Age Distribution of Arrests

05

10152025303540

<7m

o 1 3 5 7 9 11 13 15

# Arrests

•

Occiput•

Airway size

•

Nose•

Tongue

•

Larynx•

Vocal Cords

•

Epiglottis•

Physiology

Anatomic and Physiologic Differences…and the

Consequences

•

The infant has a large occiput•

“sniffing position”

ineffective in

patients < 2yo

Anatomy: Occiput size

Positioning

•

Head Tilt- Chin Lift

•

Jaw thrust

Positioning

•

“Sniffing position”

in children >2years of age

Positioning

•

Shoulder elevation in children <2yo

Positioning

•

Difference #1: It’s SMALLER!

Anatomy: Airway Size

•

Manipulation and visualization•

Peripheral airway contribution to total resistance:–

Adults: 20%

–

Children: 50%



••

PoiseuillePoiseuille’’ss

Law: if the radius is Law: if the radius is halvedhalved, resistance increases , resistance increases 1616--

fold fold (with laminar flow)(with laminar flow)

R =R =8 n l8 n l

ΠΠ

rr44

Presenter�


Relatively small amounts of edema or obstruction can significantly reduce pediatric airway diameter and increase resistance to airflow, and therefore increase the work of breating With turbulent flow, resistance to airflow is inversely proportional to the 5th power of the radius…keep kids calm�

•

The nose is responsible for 50% of airway resistance at all ages

•

In the infant, blockage of the nose = respiratory distress

Anatomy: Nose

•

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

Anatomy: Tongue

•

Relatively cephalad

and anterior in position

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

Anatomy: Larynx

•

Narrowest portion of the airway:–

Adults: glottic

inlet

–

Children <10yo: cricoid

cartilage•

Funnel vs

cylinder shape

Anatomy: Larynx

•

Endotracheal tube size selection

•

Through the cords ≠

home-free•

Cuffed vs

uncuffed

Anatomy: Larynx

Presenter�


ETT size must be selected based on the size of the cricoid ring rather than the glottic opening An air leak at peak inspiratory pressure of 20-30 cm H2O shold be present after intubation if tube size is appropriate�

•

Vocal cords slanted anteriorly vs

perpendicular to trachea

•

Affects visualization•

Can make passage of ETT more difficult

Anatomy: Vocal Cords

•

Short, narrow, and angled away from the long axis of the trachea

•

Floppy (little cartilage)•

Straight laryngoscope

blades

Anatomy: Epiglottis

Breathing

•

High metabolic rate and oxygen demand

•

O2

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

Breathing

•

Weak intercostal muscles, cartilage

•

Tidal volume dependent

on movement of diaphragm

•

Little reserve if movement of

diaphragm is impeded

Breathing

Presenter�


In airway obstruction, forced inspiration will cause sternal and intercostal retractions rather than chest and lung expansion (not just taking big breaths) When diaphragm movement is impeded by high intrathoracicc pressures (pulmonary hyperinflation, e.g. asthma) or by gastric distension (SELLICK EARLY) respiration is compromised, as is tidal volume (less to spare)�

•

General Principles•

Positioning

•

Bag-Valve-Mask ventilation•

Airway Adjuncts

•

Endotracheal intubation

Assisting Ventilation

•

Anticipate and Recognize•

Prepare

•

Oxygen and Humidification•

Position of comfort

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Lessen anxiety•

Be aggressive with secretions

•

Start simple…unobstruct

the airway

General Principles

Presenter�


Somnolent or unconscious child …airway may become obstructed by a combination of neck flexion, jaw relaxation, posterior displacement of the tongue against the posterior wall of the pharynx, and collapse of the hypopharynx Start with noninvasive methods of airway opening�

Signs of Respiratory Distress

RetractionsRetractionsAccessory muscle useAccessory muscle useWheezingWheezingSweatingSweatingProlonged expirationProlonged expirationPulsusPulsus

paradoxusparadoxus

CyanosisCyanosis

TachypneaTachycardiaGrunting StridorHead bobbingFlaringInability to lie downAgitation

Signs of Respiratory Failure

•

Reduced air entry•

Severe work

•

Cyanosis despite O2

•

Irregular breathing / apnea•

Altered Consciousness

•

Diaphoresis

•

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 3rd, 4th, and 5th

fingers

on ramus

of mandible

Bag-Valve-Mask Ventilation

Presenter�


Mask as small as possible to minimize dead space and decrease rebreathing of exhaled gases neutral sniffing positiong, without hypertextension of the head, appropriate for infants and toddlers. Extreme hyperextension should be avoided in infants since it may produce airway obstruction. If cannot ventilate, START OVER. Reposition the head, ensure the mask is fitted, lift the jaw, consider suctioning the airway�

•

May need two providers to get a good seal


Presenter�


Mask as small as possible to minimize dead space and decrease rebreathing of exhaled gases�

•

Don’t forget the Sellick

maneuver!


Presenter�


Occludes the proximal esophagus by displacing the cricoid cartilage posteriorly -one fingertip in infants, thumb and index finger in children�

•

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

Airway Adjuncts

Presenter�


Will stimulate gagging and vomiting in the conscious or semiconscious patient Indicated if procedures to open the airway (head tilt-chin lift, jaw thrust) fail to provide and maintain a clear, unobstructed airway�

Airway Adjuncts

Airway Adjuncts

Presenter�


Too long: may obstruct the larynx, make a tight mask fit difficult, and traumatize laryngeal structures�

Airway Adjuncts

Presenter�


Too small will push the tongue posteriorly into the pharynx, obstructing the airway�

Airway Adjuncts

Just right!!

Airway Adjuncts

Insertion technique:

Presenter�


Too small will push the tongue posteriorly into the pharynx, obstructing the airway�

Airway Adjuncts

•

Nasopharyngeal Airway:•

12F (3mm ETT) to 36F

•

Suction•

Contraindications

Tip of nose to tragus

Presenter�


12F is about size of 3mm ETT, can be used on full-term infant should not blanch nose lubricated suction frequently, too long may irritate vagus nerve, epiglottis, cords _ vomiting, cough, laryngospasm Contraindications: basilar skull fx, csf leak, coagulopathy�

•

Isolates airway•

Reduces potential for aspiration

•

Allows control of inspiratory time and peak inspiratory pressures

•

Allows delivery of PEEP

Endotracheal Intubation

•

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

Endotracheal Intubation: Indications

•

SOAP ME•

Suction

•

Oxygen•

Airway equipment (check it!)

•

Pharmacologic agents•

Monitor, Mechanical

•

Equipment

Endotracheal Intubation: Preparation

•

ETT:–

Uncuffed in children <8yo

–

Cuffed in children >8yo–

Size: Use your CODE CARD!

Endotracheal Intubation: Equipment

ETT size =Age (yrs) + 16

4

•

ETT:


ETT size =Age (yrs)

4 + 4

•

ETT:–

Have other sizes available!

–

Rigid stylet–

Depth of insertion: 3 x internal diameter

(5.0 ETT inserted 15cm)


•

Laryngoscope–

Miller for infants and toddlers

–

Miller or Macintosh for older children


•

Curved vs. Straight blade positioning


•

Confirm tube placement–

Auscultation

–

CO2

detection–

Ability to ventilate


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.

Circulation

•

Tachycardia:•

Hypovolemia

•

Hypoxia•

Anxiety

•

Fever•

Pain

•

Cardiac impairment

•

Bradycardia

Circulation

•

Pulses–

Newborns: Umbilical

artery–

Infants: brachial artery

–

Children: carotid artery

Circulation

•

Pulse quality–

Rate

–

Strength–

Central vs

Peripheral

•

Capillary refill time (CRT)•

Skin color and temperature:–

Warm, cool, pale, or cyanotic?

Circulation

•

Blood Pressure (5th

percentile)–

Infants SBP 60

–

1 year SBP 70–

>1 year SBP (70 + 2 x age)

Circulation

•

Intravenous fluids–

Peripheral IV access

Circulation

•

Intraosseous

(IO) access–

No age restrictions

–

30-90 seconds or 3 attempts–

Can infuse ANYTHING

–

New options: EZ-IO©

Circulation

•

Intraosseous

needle

Circulation

•

Vidacare

EZ-IO

Circulation

•

IO Insertion

Circulation

Pediatric Pearls

Children compensate better than adults

Pediatric Pearls

You cannot remember normal weights, respiratory rates,

blood pressures, heart rates, and calculate drug doses in your head….so don’t try….

Pediatric Pearls

Airway is everything… remember the basics

Pediatric Pearls

Relax…they’re just little (misshapen) adults

Pediatric Pearls

morgen bernius the pediatric patient 2.3mb

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