recognizing the sick child william beaumont hospital department of emergency medicine

Recognizing the Sick Child

William Beaumont Hospital

Department of Emergency Medicine

Overview

Review of vitals

Who’s sick at a glance

What can babies do?

Rashes: a quick review

History and diagnosis that should raise a red flag

Pediatric fluids and resuscitation

Pediatric fever

Who is sick?

The concept of the “toxic child”The “L” word

Toxic? Sick?

Toxic? Sick?

Nelson: Pediatrics

No Stethoscope Assessment

What can you see, hear and feel right when the patient walks through the door?

Step 1 – EyeballWhat can you see

Retractions Subcostal, intercostal, supraclavicular

TachypneaCyanosis

Nail beds, lips and mucosa Circumoral or facial cyanosis can fool you

Decreased level of consciousnessObvious fracture/deformityRashes

Step 2 - Listen

What can you hearStridor

With Crying At Rest

Abnormal Cry

What don’t you hear- Asthmatics too tight to wheeze- Septic child with weak cry

Step 3 - Feel

Check PulseTachycardia, bradycardiaCap RefillExtremity injuries - fractures and lacerations

Neuro status

What is Normal: Vitals Signs

Vitals vary by ageSimple rules to demystify pediatric vitals


RespiratoryAssess AirwayRespiratory Rate

Newborn 1 year 18 years

Rate <40 24 18


Air EntryChest rise, breath sounds, stridor or wheezing

Quiet versus noisy tachypnea

MechanicsGrunting or retractions

Color


Take home, bottom lineRespiratory rate > 60 is abnormal


CirculationNormal heart rates:

1-3mo 3mo-2yr 2-10yr >10yr

85-200 100-190 60-120 75


AbnormalLess than 5 years >180, <80Greater than 5 years > 160

Anything greater than 220 = SVT


Blood Pressure

Newborn 1 year >1 year

Systolic >60 >70 70+(2 x age)


Blood pressureCap Refill – < 2 Seconds normal

CNS PerfusionRecognize parents, responsive


Take home, bottom linePulse > 220 consider SVTCap refill > 2 seconds not normalBP in kids > 1 year = 70 + (2 x age)

What is Normal: Development

Easy social and motor milestones:2 month olds smile4 month olds roll over6 month olds sit9 month olds cruise12 month olds walk

Review of Rashes

Rashes are visual thingsUsually can’t tell what to do for rashes over the

phone - have to see them

Habif: Clinical Dermatology

Rash 1

Rash 2


Rash 3a


Rash 3b


Rash 4

Nelson: Pediatrics

Rash 5a


Rash 5b


Rash 6a


Rash 6b


Rash 7


Rash 8


Rash 9


Rash 10



Rash 11

Rash 12

Rashes

Take home, bottom lineCheck for blanching – petechiae and purpura do not

blanchToxic vs. nontoxicCheck for oral lesionsCheck the palms and solesMost rashes are benign

Red Flags

Diagnostic categories or history that should heighten your concern and raise your triage class

Mnemonic: CATNITS

Red Flags

CATNITSCongenital problems

Inborn errors of metabolism Neurologic Disease, seizures Vomiting, acidosis, hypoglycemia Liver or cardiac disease

Congenital Heart Disease Chromosomal Abnormalities

Red Flags

CATNITSAllergic

History of anaphylaxis or significant medication reaction History of respiratory distress with previous reactions

Red Flags

CATNITSTrauma

Loss of consciousness > 2 minutes Altered LOC now Limb threatening injury Bleeding not controlled

Red Flags

CATNITSNeoplasm

Recent chemotherapy - Fever and neutropenia Anemia or thrombocytopenia

Red Flags

CATNITS Infectious

Signs and symptoms of septic shock/meningitis, including rash

Any reason to be immune compromised Examples: Immune deficiency, protein loosing

enteropathy, on steroids

Red Flags

CATNITSToxins

Ingestion of dangerous vs. non toxic substance Many interventions are time dependent Patients may deteriorate rapidly

Red Flags

CATNITSSocial/Psychiatric

Patient threat to himself/herself or others Possibility of abuse or neglect

Pediatric Fluids

Bolus10 to 20 cc/kg0.9 NS only, ever, always

Maintenance Fluids 4 – 2 – 1 rule Neonates and infants: D5 0.2 NS Children: D5 0.45 NS

Pediatric Fluid Problem

6 mos old child comes in with 24 hours of n/v/d. Not made urine for 12 hours.

Wt = 8kg

Would you bolus, how much, what fluid?

What is maintenance?

Defibrillation 2J/kg then 4J/kg, 4J/kg

Epinephrine 0.01mg/kg (1:10,000)

Atropine 0.01mg/kg

Glucose D10 2-4ml/kg (not D50)

Drugs you can give through an ET tube (NAVEL) Narcan Atropine Valium Epi Lidocaine

Pediatric Resuscitation Doses

Pediatric Fever = 38 C rectally

Tylenol 15 mg/kg for kids < 6 mos

Tylenol or Motrin 10 mg/kg > 6 mos

0 to 4 weeks of ageAdmit for IV abx and apnea monitoringCBC, BMP, U/A, UCX, BCX, CXR, LPAmpicillin and cefotaxime

Pediatric Fever

4 – 12 weeks of ageLook sick = admitMost of these will be admittedCBC, BMP, U/A, UCX, BCX ? Lumbar punctureAbx ampicillin + cefotaxime or ceftriaxone

If meningitis then add vancomyocin

The EndAny Questions?

recognizing the sick child william beaumont hospital department of emergency medicine

Documents

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clinical dermatologyhabif

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