1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10: The Critically Ill Pediatric Patient

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiologic Differences in the Vital Signs of the Infant and Child Respiratory rate and heart rate are elevated to increase cardiac output because of the smaller stroke volume and increased basal metabolic rate. Tachycardia causes fever, anxiety, shock, hypoxemia. Bradycardia causes hypoxemia, vagal nerve stimuli; it is tolerated poorly if bradycardia is persistent. Tachypnea is the first sign of respiratory distress. A slow respiratory rate indicates impending respiratory arrest. Blood pressure is the last parameter to fall in shock.

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pediatric Vital Signs

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurological Considerations of the Critically Ill Infant or Child Measure circumference of head for child under age 2 Fontanels are used to assess hydration status or presence of increased intracranial pressure. Newborn reflexes to assess in addition to cough and gag include Moro, rooting, grasp, and Babinski. Mental status assessment is the same as for adults. Can the child be comforted by normal comfort measures? Infant and child: ineffective thermoregulation

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiratory Considerations of the Critically Ill Infant or Child Infants until 6 months of age are nose breathers, so any obstruction can lead to respiratory distress. The narrowest part of child’s airway until age 8 is at the cricoid ring. Airway is small because of anatomic structures, so a mucus plug can compromise the airway. Unequal rise/fall of chest may be a sign of pneumothorax, atelectasis, or endotracheal tube displacement. Accessory muscle retractions are a sign of respiratory distress.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Neutral Head Position

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Gastrointestinal Considerations in the Critically Ill Infant and Child Abdomen is protuberant. Distention can interfere with breathing and lead to respiratory arrest. Measure abdominal girth; consider NG tube placement. Consider age-related stomach capacity and gastric emptying times when planning times for checking residuals or doing chest physiotherapy to avoid reflux and aspiration.

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Renal Considerations in the Critically Ill Infant and Child Infant and child are less able to concentrate urine –Infant urine output = 2 mL/kg/hour –Child urine output = 1 mL/kg/hour –Adult urine output = 0.5 mL/kg/hour

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Calculation of Maintenance Fluid

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Assessment of Severity of Dehydration See Table 10-3.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Signs and Symptoms of Fluid Overload Bulging fontanels Skin that is taut Periorbital and sacral edema Hepatomegaly Symptoms of congestive heart failure

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Monitoring the Critically Ill Infant or Child for Hypoglycemia Small glycogen stores Increased glucose demand because of large ratio of brain to body size Increased risk for hypoglycemia

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Immune System Considerations in the Critically Ill Infant or Child Infant: Skin is thin, less protective barrier Infant/child: Fewer stored neutrophils, lower complement levels, deficiency in immunoglobulins; increased risk for viruses, Candida, inflammatory bacteria Infants: may not have a fever or leukocytosis with an infection –Observe for changes in feeding, hypothermia, or altered glucose metabolism.

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Recommended Resuscitation Equipment for Infants and Children See Table 10-5.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Tools for Assessing Pain in Children

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Contrasting Nonverbal Behavioral Cues of the Healthy and the Critically Ill Child See Table 10-6.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is an early sign of respiratory distress in a critically ill child? A. Unequal rise and fall of the chest B. Accessory muscle retractions C. Bradypnea D. Tachypnea

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Tachypnea Rationale: The first sign of respiratory distress in the critically ill child is tachypnea. Unequal rise and fall of the chest may be due to a pneumothorax or atelectasis. Accessory muscle retractions is a later sign of respiratory distress. Bradypnea is a later sign of respiratory distress and impending respiratory arrest.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about assessing the hydration status in a critically ill 8-month-old is correct? A. Assess the posterior fontanel to determine the infant’s fluid status. B. Assess the anterior fontanel to determine the infant’s fluid status. C. Sunken fontanels are seen with fluid overload. D. Bulging fontanels are seen with fluid deficit.

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Assess the anterior fontanel to determine the infant’s fluid status. Rationale: The anterior fontanel can be used to assess fluid status in an infant until the fontanel closes by 9 to 18 months of age. The posterior fontanel closes by 3 months of age and can no longer be used to assess fluid status once closed. Bulging fontanels are seen with fluid overload. Sunken fontanels are seen with fluid deficit, such as dehydration.

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements reflects the stomach capacity and gastric emptying time for a 12-month-old? The stomach capacity is ___ and the gastric emptying time is _______. A. 90 mL; 2.5 to 3 hours B. 1,000 mL; 2.5 hours C. 360 mL; 2.5 to 3 hours D. 150 mL; 3 to 6 hours

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. 360 mL; 2.5 to 3 hours Rationale: The stomach capacity for a 12-month-old is 360 mL and the gastric emptying time is 2.5 to 3 hours. The stomach capacity for a newborn is 90 mL and the gastric emptying time is 2.5 to 3 hours. The stomach capacity for a 1-month-old is 150 mL and the gastric emptying time is 2.5 to 3 hours. The older child would have a gastric emptying time of 3 to 6 hours, and as an adolescent nears adulthood, the stomach capacity would approach the adult size of 2 to 3 L.