General Approach to the Pediatric Patient Rosen’s Chapt. 164 March 29, 2007 Martin Hellman M.D. Slides by Scott Gunderson PGYIII

Epidemiology 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

Epidemiology Fever, Respiratory, & Trauma most common reasons for visits Trauma is the most common reason for serious morbidity and mortality

Pathophysiology

Anatomic & Physiologic Differences Large 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 Differences Smaller airways more prone to obstruction Infants often nose breathers and nasal congestion can cause significant distress

Vital Signs > <1 Heart RateRespirationsAge

Vital 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 Signs Respiratory rate –Infants may have apnea up to 20 seconds normally –Increased by 5/min per degree (C) fever

Developmental Milestones Neonates –Discomfort is nonspecific –Little interaction Infants –Social smile, tracts lights – 2-3 months –Stranger anxiety – 6 months

Developmental Milestones Toddlers (13 – 36 months) –Walks alone –Language develops Preschool (4 – 5 yrs) –Many fantasizes may play a role in irrational thoughts

Developmental 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 Assessment Hands-off –Appearance –Work of breathing –Circulation Gives initial assessment of sick or well

Appearance Interaction with environment –CNS Hypoperfusion Initially irritable Progress to alternating irritability and lethargy Progress to lethargy and coma

Work of Breathing Assess from a distance –Once a cry is started difficult to interpret –Listen from a distance for audible sounds Grunting - self-induced PEEP to open alveoli Stridor - upper airway obstruction Muffled voice - larynx trauma or abscess Wheezing - airway narrowing, assess degree

Work of Breathing Positioning –Sniffing position - trying to overcome obstruction –Tripoding - maximizes accessory muscles Effortless tachypnea –Think compensation of shock and metabolic acidosis

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

Clinical Interview Remember and respect parents perception that their child has an emergency Obtain SAMPLE history involving the child as much as possible

Physical Examination Not stepwise Painful or frightening components last (ears) Examine infants mostly in caretakers lap

Trauma Attentions to C-spine precautions –Cervical spine injuries without radiographic abnormalities (SCIWORA) More common in infants due to elasticity Don’t ignore ridiculer symptoms because radiographs are negative Up to 36% of traumatic cervical mylopathies in children are SCIWORA ABC’s

Intentional Trauma Child abuse –Usually blunt injuries –Consult child protective services –Look for characteristic bruises Bruise of different ages Hand prints Belt/cord marks Linear marks Bites Location - neck, groin, thigh, wrists and ankles

Seizures 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 & Obstruction Recognition is key Mallamptai grades not well studied Clinical croup score and asthma severity scores are very reproducible

Clinical Croup Score Stridor None 0 Audible with stethoscope (at rest) 1 Audible without stethoscope (at rest)2 Retractions None0 Mild1 Moderate2 Severe3 Air Entry Normal0 Decreased1 Severely decreased2 Cyanosis None0 With agitation4 At rest5 Level of Consciousness Normal0 Altered5 Mild disease <3 Moderate dz 3-6 Severe dx >6

Asthma Severity Score Wheezing None or mild 0 Moderate 1 Severe 2 Air entry Normal or mild 0 Moderately diminished 1 Severely diminished 2 Work of Breathing None or mild 0 Moderate 1 Severe 2 Prolonged expiration Normal or mild 0 Moderate 1 Severe 2 Tachypnea Absent 0 Present 1 Mental status Normal 0 Depressed 1 Highly reproducible and predictive

Altered 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

Shock 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 Needs Utilize guardian to assess baseline mental function Behavioral changes can be a V-P shunt malfunction

Noninvasive 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

OMT 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

Summary Understand developmental stages and issues Remember normal vitals for ages Initial “hands-off” observation is key Beware of the pale child - early shock SCIWORA Assessment of difficult airways