1. Recognizing the Sick Child William Beaumont Hospital Department of Emergency Medicine

2. 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

3. Who is sick? The concept of the “toxic child” The “L” word

4. Toxic? Sick?

5. Nelson: Pediatrics

6. No Stethoscope Assessment What can you see, hear and feel right when the patient walks through the door?

7. Step 1 – Eyeball What can you see Retractions Subcostal, intercostal, supraclavicular Tachypnea Cyanosis Nail beds, lips and mucosa Circumoral or facial cyanosis can fool you Decreased level of consciousness Obvious fracture/deformity Rashes

8. Step 2 - Listen What can you hear Stridor With Crying At Rest Abnormal Cry What don’t you hear -Asthmatics too tight to wheeze -Septic child with weak cry

9. Step 3 - Feel Check Pulse Tachycardia, bradycardia Cap Refill Extremity injuries - fractures and lacerations Neuro status

10. What is Normal: Vitals Signs Vitals vary by age Simple rules to demystify pediatric vitals

11. What is Normal: Vitals Signs Respiratory Assess Airway Respiratory Rate Newborn1 year18 years Rate<402418

12. What is Normal: Vitals Signs Air Entry Chest rise, breath sounds, stridor or wheezing Quiet versus noisy tachypnea Mechanics Grunting or retractions Color

13. What is Normal: Vitals Signs Take home, bottom line Respiratory rate > 60 is abnormal

14. What is Normal: Vitals Signs Circulation Normal heart rates: 1-3mo3mo-2yr2-10yr>10yr 85-200100-19060-12075

15. What is Normal: Vitals Signs Abnormal Less than 5 years >180, <80 Greater than 5 years > 160 Anything greater than 220 = SVT

16. What is Normal: Vitals Signs Blood Pressure Newborn1 year>1 year Systolic>60>7070+(2 x age)

17. What is Normal: Vitals Signs Blood pressure Cap Refill – < 2 Seconds normal CNS Perfusion Recognize parents, responsive

18. What is Normal: Vitals Signs Take home, bottom line Pulse > 220 consider SVT Cap refill > 2 seconds not normal BP in kids > 1 year = 70 + (2 x age)

19. What is Normal: Development Easy social and motor milestones: 2 month olds smile 4 month olds roll over 6 month olds sit 9 month olds cruise 12 month olds walk

20. Review of Rashes Rashes are visual things Usually can’t tell what to do for rashes over the phone - have to see them

21. Habif: Clinical Dermatology Rash 1

22. Rash 2 Habif: Clinical Dermatology

23. Rash 3a Habif: Clinical Dermatology

24. Rash 3b Habif: Clinical Dermatology

25. Rash 4 Nelson: Pediatrics

26. Rash 5a Habif: Clinical Dermatology

27. Rash 5b Habif: Clinical Dermatology

28. Rash 6a Habif: Clinical Dermatology

29. Rash 6b Habif: Clinical Dermatology

30. Rash 7 Habif: Clinical Dermatology

31. Rash 8 Habif: Clinical Dermatology

32. Rash 9 Habif: Clinical Dermatology

33. Rash 10 Habif: Clinical Dermatology

34. Rash 11

35. Rash 12

36. Rashes Take home, bottom line Check for blanching – petechiae and purpura do not blanch Toxic vs. nontoxic Check for oral lesions Check the palms and soles Most rashes are benign

37. Red Flags Diagnostic categories or history that should heighten your concern and raise your triage class Mnemonic: CATNITS

38. Red Flags CATNITS Congenital problems Inborn errors of metabolism Neurologic Disease, seizures Vomiting, acidosis, hypoglycemia Liver or cardiac disease Congenital Heart Disease Chromosomal Abnormalities

39. Red Flags CATNITS Allergic History of anaphylaxis or significant medication reaction History of respiratory distress with previous reactions

40. Red Flags CATNITS Trauma Loss of consciousness > 2 minutes Altered LOC now Limb threatening injury Bleeding not controlled

41. Red Flags CATNITS Neoplasm Recent chemotherapy - Fever and neutropenia Anemia or thrombocytopenia

42. 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

43. Red Flags CATNITS Toxins Ingestion of dangerous vs. non toxic substance Many interventions are time dependent Patients may deteriorate rapidly

44. Red Flags CATNITS Social/Psychiatric Patient threat to himself/herself or others Possibility of abuse or neglect

45. Pediatric Fluids Bolus 10 to 20 cc/kg 0.9 NS only, ever, always Maintenance Fluids  4 – 2 – 1 rule  Neonates and infants: D5 0.2 NS  Children: D5 0.45 NS

46. 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?

47. Defibrillation2J/kg then 4J/kg, 4J/kg Epinephrine0.01mg/kg (1:10,000) Atropine0.01mg/kg GlucoseD10 2-4ml/kg (not D50) Drugs you can give through an ET tube (NAVEL) Narcan Atropine Valium Epi Lidocaine Pediatric Resuscitation Doses

48. 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 age Admit for IV abx and apnea monitoring CBC, BMP, U/A, UCX, BCX, CXR, LP Ampicillin and cefotaxime

49. Pediatric Fever 4 – 12 weeks of age Look sick = admit Most of these will be admitted CBC, BMP, U/A, UCX, BCX ? Lumbar puncture Abx  ampicillin + cefotaxime or ceftriaxone If meningitis then add vancomyocin

50. The End Any Questions?