Paediatric presentations

[John]

Paediatric presentations

Children are not little adults

Vital signs, behaviour and physiology differ with age.

Talk to the child and listen to the parents.

Document what you see and your recordings.

Focus on the child not the complaint.

Observe parent / child interactions.

What is the child doing now?

            Playing, happy, sociable, talking or unhappy, anxious crying

What are the parents concerns?

            What does the parent think the problem is?

            How does the child differ from its usual behaviour / condition

            Describe the onset of signs and symptoms

Is the child’s behavior consistent with its age and development?

Does the child look sick?

Danger signs

            Floppy, lethargic, decreased LOC, unusual cry

            No response to parent, flushed, pale

            Paradixical behaviour

            Any neck stiffness / photophobia

            Any rash associated with any of the above

Vital signs

Airway and Breathing

Absent, decreased or noisy breathing

Rate

Effort, use of accessory muscles, indrawing below diaphragm

Breath sounds, is the chest quiet, noisy or normal?

Oxygen saturation

Cough – productive / dry

Is the child drooling?

(Airway)

A child airway is smaller in diameter

Can easily become blocked by secretions, edema and foreign bodies

The Larynx is more cartilaginous and soft

Can be occluded if neck is hyper-extended

The tongue is larger

            Can cause obstruction in the unconscious child

Infants under 4-6 weeks are obligatory nose breathers

            Mucous can cause respiratory distress

A child airway is shorter

            ETT is only inserted 2-3 cm past the vocal cords and can be easily dislodged

Narrowest part of the airway is the cricoids cartilage,

which provides a natural seal for the ETT

therefore, uncuffed tubes are used until approximately 8 years of age

(Breathing)

Lungs are immature at birth

Infants rely on diaphragmatic breathing

            Any thing that impedes movement will cause respiratory distress

(distended abdominal)

The respiratory muscles tire easily

            Can lead to respiratory distress

Ribs lie more horizontal, are softer and the intercostal muscles are immature

            In respiratory distress the intercostal muscles retract (recession)

In the injured child serious injury can occur to underlying lung tissue

without the presence of rib fractures

The Alveoli and smaller and fewer in number and tidal volume is smaller

            Over bagging can lead to pneumothorax

Children in respiratory distress need supplemental oxygen

Circulation

Heart rate – bradycardia is uncommon in children and is usually secondary to hypoxia

Does the child look well perfused?

Check capillary return?

Bleeding or estimated blood loss

Hydration

            Drinking (and eating), passing urine

            Diarrhoea, vomiting

            Skin turgor, fontanelle

(Circulation)

Infants and children have a larger surface area

to volume ratio and a higher metabolic rate

rapid heat loss and increased insensible water loss

Less total circulating blood volume

            small losses can be critical

Stroke volume is smaller

            Bradycardia causes drop in cardiac output

Tachycardia causes increased cardiac output

Children have higher glucose needs

            Any stress can cause depletion of glycogen stores

Children’s cardiovascular system is generally healthier than adults

            Able to maintain adequate pressure despite volume loss

(Disability)

Cranial sutures remain open to approx 18 months of age

            Bulging fontenelle can indicate raised intracranial pressure

Sunken fontenelle indicates dehydration

During childhood there is rapid changes

in a child’s cognitive, language and motor skills

            knowledge of normal milestones is imperative for accurate assessment

use a modified Glascow Coma Scale for eval‎uating a Childs neurological status

Paradoxical Irritability is a danger sign in children

            Where a child is irritable and not consolable but when left alone falls asleep

Most common causes of changes in neurological function in children are

            Trauma, poisonings, seizures, infections and hypoxaemia

Temperature

Rectal temperature is preferred and most accurate

Tympanic temperature is not suitable in children under six months of age

Any fever in a baby under 3 months is significant

A child is easier to eval‎uate once the temperature is lowered

Do not cover cool infants

Pediatric             Vital signs

Age                  HR                   BP                   R                      W

New born             100-160      50-70               30-60               3 kg

1-6 weeks             100-160      70-95               30-60               4 kg

6 months          90 -120            80-100             25-40               7 kg

1 year               90 -120            80-100             20-30                10 kg

3 years             80 -120            80-110             20-30                15 kg

6 years             70- 100            80-110             18-25               20 kg

10 years            60-120 90-120             15-20               30 kg

Initial rapid assessment

Initial impression

Does the child look well or unwell?

Respiratory

Wok of breathing

Skin color – pallor, mottling, cyanosis

Response to the environment

Primary assessment – eval‎uation of ABCDE

Are ABCs within normal limits?

Assessment of D (disability – neurologic status)

Assessment of E (exposure to environment)

Look for injury

Check body temperature

A full set of vital signs may be taken

If ABCs do not require immediate intervention

Secondary assessment – brief history

Are there any underlying illnesses or psychological issues

that may alter your initial triage impression?

Are there cultural issues

that require special attention during your assessment?

Neurologic Assessment

Rapid paediatric assessment includes observation / eval‎uation of the following

Age appropriate response to the environment and level of activity

Rousability and response to comforting measures

Recognition of and response to parents

Condition of the anterior fontanelle – under 14-18 months of age

Quality of cry, high pitched, moaning or whimpering cries are abnormal

Pupillary size and reaction

Muscle tone, gait and posture

N.B. Paradoxical irritability occurs

when a child cries when comforted, and is quiet when left alone.

This may be seen in children with meningitis.

Children showing paradoxical irritability

and children who seem unaware or unconcerned with the hospital environment

may be very ill and require immediate intervention.

Paediatric ABCDE’s

ABCDE’s	Assessment Parameters	Abnormal findings
Airway	Patency Posture	Audible airway sounds such as stridor, wheezing. Positioning for best air entry
Breeding	Respiratory pattern Respiratory rate Respiratory effort	Grunting respirations Abnormal resting respiratory rate for age Retraction, nasal flaring, anxious facial expression‎
Circulation	Skin color and turgor Peripheral pulses Capillary refill	Pale, mottled or cyanotic skin Presence of skin tenting Weak or absent Capillary refill time > 2 sec
Disability	Rousability Consolability Response to environment Fontanelle (infants)	Slow to rouse or unusually irritable Unable to console yet quiet when left alone Unaware or unconcerned with surroundings Bulging tense fontanelle when upright and not crying Sunken, in the presence of other signs of dehydration
Exposure	Skin temperature	Cool / clammy / cold skin
Environment	Skin colour Skin abnormalities	Pallor, mottling, cyanosis Injuries, wounds, bruises

Paediatric assessment guidelines

Critical signs and symptoms

Cardio-vascular

Decreased peripheral pulses, slow capillary refill, mottled or pale skin, cool limbs

Tachycardia                          Hypotension                        Bradycardia

Respiratory

Stridor / wheeze                 Retractions                                            Dyspnoea                            Cough

Cyanosis / apnoea   Chest pain                        Tachypnoea                          Aspiration

Neurological

Any unexplained change in mental status    

Seizures                                                                                 Ataxia                                     Syncope               

Abnormal neurological findings                                                 Headache

Use the modified GCS to assess children

Any loss of consciousness in a child

who has sustained a head injury and / or any vomiting,

must be considered significant until proven otherwise.

Head / Eyes / ENT

Stiff neck                                                                               Facial cellulitis – cellulitis leads to rapid sepsis

Periobital cellulitis                                                                 Drooling

Sore throat / dysphagia                                                             Severe epistaxis

Gastro-intestinal

GI bleeding                                                                            Frequent vomiting               

Abdominal pain                 Diarrhoea                                              Abdominal distention

Abodmen

GIT takes 2 years to develop                                             More rapid emptying and peristalsis

Neonate stomach capacity 10-20 mls (adults 2000-3000 mls)

Kidneys comparatively larger                                      Abdomen normally pot bellied

Peritonitis – abdomen won’t move

Genito-urinary

Straddle injury                                                                      Painful testes / scrotum   

PV bleeding                                                                           Haematuria                           

Penile or vaginal trauma

Musculo-skeletal

Arthritis                                                                                 Bone pain                       

Torticoli’s                                                                              Limp

Refusal to use extremity

Dehydration

Subjective

Symptoms. Eg. vomiting, reduced fluid intake, fever fail to P. U. > 6 hours

Objective                               Tearless cry                          Dry mucosa                 Sunken fontanelles

Poor skin turgor                 Irritability / lethargy

Diarrhoea

Consider                                Sepsis                                    Appendicitis                         Obstruction / intussusecuption                 Poisoning                                              Side effect of medication

Syncope

Arrhythmias                          Aortic stenosis                                 Hypovolaemia                      Seizures

Hypoglycaemia                    Intracranial lesions                 Inner ear infection               

Apnoea

Cessation of breathing for > 20 seconds or

< 20 seconds with bradycardia, pallor, limpness or cyanosis

Infants may have irregular breathing patterns

Central apnoea, ie, nil respirations

Obstructive apnoea, ie nil airflow

Mental Status Changes

Consider

Infectious causes eg. sepsis, meningitis, pneumonia, encephalitis

Traumatic causes eg. head trauma, occult fracture, poisoning, abuse

Metabolic causes eg. hypoglyaemia, acidosis, post ictal

Other causes eg. arrhythmias, torsion intra-abdoinal

Coma

Especially if due to hypoxia or hypoglycaemia, or direct tissue trauma

Obtain history –notingchanges in mental status, past medical history,

symptoms and localizing signs

Record GCS and blood glucose

Anatomical / Physiological Differences in Kids

Most children do not die of the same things that adults do 

The leading causes of death in childhood are

                Respiratory failure

                                Airway obstruction, suffocation, drowning, overdose, epiglottitis

                Shock

                                Hypovolaemia, (trauma / dehydration), sepsis

Respiratory

Small jaw                                                                                Large tongue

Soft cricoid                                                                            Anterior larynx

Small thorax                                                                           Horizontal ribs

Underdeveloped intercostals

Diaphragmatic breathing

                Decrease tolerance to increase intra-abdominal pressure

                Increase chest wall compliance >retraction during distress >decrease efficiency

Narrow airway                                                                      Increase resistance

Small alveoli with little collateral ventilation                 Increase collapse

Tidal volume 7mls / kg                                                         Increase dead space

Obligatory nose breathers until 4 months of age

Glottis narrow                                                                       Seal achieved with uncuffed ETT

A child’s initial response to hypoxia is bradycardia

Cardiovascular

Decrease myocardial compliance

                Increase cardiac output only by increase heart rate

Hypotension is a late sign of shock in children

                There vascular system can compensate dramatically for blood volume losses

up to 30%.

Increase sensitivity to vagal stimulation

Bradycardia is the most common arrhythmia

                Progressing to a systole if ignored

Primary cardiac arrest is rare

Other

Immature liver – limited energy stores

                Increase susceptibility to hypoglycaemia

Increase basal metabolic rate & O2 demand

                Breath & beat faster > increase susceptibility to hypoxia

Immature kidneys until 12 months of age > decrease to cope with fluid & salt overload

Decrease surface area > increase susceptibility to hypothermia

Patent fontanelle

Paediatric urine specimens

Non toilet trained children

                All children that fit into this category need to have urine bags put on.

                Clean the area first as creams

etc will mean that the bag will not stick and will leak

                Once collected, the urine needs to be tested with dipstix.

                Bag urine specimens CANNOT be sent to the lab for analysis.

                If the sample is positive, a definitive sample needs to be collected

and is the policy of this hospital

that an in-out catheter sample be collected form the child and sent to the lab.

                If you are not confident in doing this procedure

                Please seek assistance form colleagues

Or ask the doctor to perform the procedure.

Toilet trained children

                These children need  clean catches attended.

                This can be done be by instructing the parents on how to obtain the specimen.

These samples can be tested on dipstix

and if positive can then be sent on to the lab.

Do not put the dipstix into the same specimen jar

that you will be sending to the lab as this will contaminate the sample.

Pour some urine into another container for testing.

Intranasal Fentanyl

                The new pain relief kids in ECC

Why use the nose

                Rich vascular supply                                    easy to give

                Works fast                                                         short procedure

                Small volume                                                   no need for IV

Why use fantanyl

                Achieves therapeutic levels in 2-10mg                 duration 30 mins

                No haemodynacim instability                              no respiratory compromise

                Appears to be better tolerated than morphine

               So quick, safe and effective

For What

                Children older than 2 yrs with severe pain from burns, fractures

where they are unlikely to need an IV

What is Fentanyl

                Opoid analgesic used for the management of acute pain

Dose

                1.5 micrograms / kg (up to 70kg)                 Use IV preparation – 100 mcg /  2ml

                Min dose 20 mcg                                          Max dose 100 mcg

                Second dose after 10 mins if pain persists of 0.5 mcg / kg

Contraindications

                Child less than 2 yrs                                      Head trauma                    Chest trauma                    Abdominal trauma                                              Hypovolaemia

Preparation

                IV fentanyl 100 mcg / 2 ml                       1 ml tuberculin syringe

                Mucosal atomizer device (MAD)

How to get it

                Pt should be reclined at 45 degrees                 Hold syringe horizontally

                Push plunger to expel as a mist into nose in 1 rapid dose

                If volume greater that 1 ml or more give in divided doses between nostrils

Observations

                Observe for 20 minutes post dose                              O2 sats, pulse and resp

                Can be D/C 1 hour after dose if pt well                 Give caregivers D/C advise

Adverse effects

                Nausea, vomiting, sedation – uncommon

                Respiratory depression and muscle rigidity reported with fentanyl

But not with intranasal

Paediatric Triage

Initial Assessment

Airway, breathing and circulation

All life threatening problems need to be addressee at this point

Vital signs, head to toe and obtaining a history.

This may be limited due to the area, lack of privacy etc..

Therefore, some aspects can be completed with the child is in a treatment area.

Adequate data is needed from the assessment for an accurate triage decision to be made.

Hx

Obtaining a good hx is a vital part in the triage process

Information sources (parents, care givers, bystanders, ambulance crew and the child).

CIAMPEDS

Chief complaint

                Why was the child brought in?

                What is the primary problem?

                What is the duration of the complaint?

Immunizations and isolation

                Are they up to date?

                When were the last given

                Has the child recently been exposed to any communicable diseases?

Allergies

                Any known allergies?

                Any allergies to medications?

                And if so what reaction did they have?

Medications

                Is the child taking any medications?

                When was the last dose and how much?

Past medical history / Parents impressions of child’s condition

                Any significant past medical history or chronic illness?

                What is different about the child’s condition that concerns the caregiver?

Events surrounding the illness or injury

                How long has the child been ill?

                Was the onset fast or slow?

                Has any one else in the family been sick?

                If problem is an injury when did it occur,

was there any witness and how did it happen?

Diet / diapers

                How much has the child been eating and drinking?

                When was the last time they ate or drank?

                When did the child last void or number of wet nappies?

                When was the last bowel motion and was it normal?

Symptoms associated with the illness or injury

                Are there any other symptoms and if so when did they begin?

                Has the condition gotten better or worse?

Paediatric assessment triangle

Appearance

                                Tone

                                Interactiveness

                                Consolability

                                Look or gaze

                                Speech or cry

Breathing

                                Nasal flaring

                                Retractions

                                Abnormal airway sounds

                                Position of comfort

                                Altered respiratory rate

Circulation to skin

                                Pallor

                                Mottling

                                Cyanosis

Paediatric patient assessment

Patient presentation

                                Airway

                                Breathing

                                Cardiovascular     pulse present, capillary refill

Paediatric considerations

                                The use of play and distraction therapy

                                Appropriate posturing

                                Always family presence

                                The use of appropriate age related gestures and communication

Subjective data (Hx)

                                Why has the child come into hospital and why today?

                                How long the child has been unwell?

                                Has this happened before?

                                What precipitated the illness / trauma/

                                Does the child have any pain? (location, quality, severity)

                                Have they given them anything for it?

                                Is the problem getting better / worse / staying the same?

                                Are there any other symptoms?

                                How much have they been eating / drinking?

                                Is the child’s vaccinations up to date? tetanus, childhood immunization

                                Have they seen GP?

                                Any allergies

                                Any medication

                                Any other medical conditions

                                MRSA risk / need for interpreter?

Objective data

                                Vital signs

                                Respiratory – work of breathing

                                Circulation

                                Rash

                                Hydration status (color, warmth, turgour)

                                GCS

                                Activity level

                                BSL, Peak flow

                                Activity level

                                ECG if appropriate

                                Head to Toe examination

                                (Neuro, Respiratory, Cardiovascular, GI, Genitourinary, Musculoskeletal, skin)