Introduction to Pediatrics by Deb Martin Lightfoot RN MSN 12/16/2017

Author: Colleen Maxwell

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2 copyright 2006 www.brainybetty.comObjectives: 1. Assess: Review the General and Pediatric Primary Assessments 2. Review Pediatric Anatomical and Physiological features as relate to the Pediatric Primary Assessment 3. Differentiate pediatric airway and respiratory findings into specific upper airway, lower airway and lung tissue disease problems in the pediatric population 4. Relate Pediatric Primary Assessment findings to specific interventions 5. Differentiate shock states in the pediatric population 6. Review of VS per PALS 12/16/2017 copyright 2006

3 copyright 2006 www.brainybetty.comReminders: Children are not small adults. Children differ anatomically, physiologically and emotionally from adults. Types of illnesses, injuries, and their responses, vary across the age span. 12/16/2017 copyright 2006

6 copyright 2006 www.brainybetty.comDeb’s list: 1. Big heads 2. Weak Neck 3. Large tongues 4. Large tonsils and adenoids 5. Small diameter of airways 6. Larynx is anterior and funnel shaped 7. Larynx is soft and cartilaginous 8. Epiglottis is u-shaped, floppy 9. Short neck, short trachea 10. Tracheal rings are C shaped 11. Lots of soft tissue 12. Lots of secretions 13. Immature cardiac sphincter 14. Obligate nose breathers until 4-6 months 15. Nares very cartilagionous 16. Narrow cricoid ring 12/16/2017 copyright 2006

7 Basic Pediatric Airway Maintenance:Big heavy heads Important concept for maintaining airway positioning Weak neck muscles Large tongue A common cause of airway obstruction, relieved by simple repositioning 12/16/2017 copyright 2006

8 copyright 2006 www.brainybetty.comSmall airways The very small diameter of a very young pediatric airway leaves no room for foreign materials without causing an airway obstruction. only a small amount of edema or mucous or other secretions can increase airway resistance. Narrow cricoid ring which is the narrowest part of the child's airway and therefore dictates the ETT size. Due to this narrow passage this area is vulnerable to traumatic intubation 12/16/2017 copyright 2006

9 Airway considerations:Small diameter of airways with increased secretions, increased soft tissue, floppy cardiac sphincter = set up for airway disaster? Larynx is soft and cartilaginous Larynx is anterior and funnel shaped susceptible to tracheal aspiration Large tonsils and adenoids Short neck - short trachea Lots of secretions 12/16/2017 copyright 2006

10 Basic Pediatric Airway Maintenance:Obligate nose breathers until 4-6 months Nares very cartilaginous Infants can breathe and swallow at the same time. Infants are obligatory nose breathers. They only breathe through their mouths when crying. Nasal congestion can be life threatening. 12/16/2017 copyright 2006

11 Pediatric airway positioning considerations:Larynx is soft and cartilaginous There is an increased risk for compression of airway with either hyperflexion or hyperextension, leading to airway obstruction. Tracheal rings are C shaped collapsible 12/16/2017 copyright 2006

12 copyright 2006 www.brainybetty.comPediatric airway considerations: The epiglottis is U-shaped and floppy: susceptible to edema and inflammation long narrowed and angled away from the trachea control of the epiglottis may be more difficult The pediatric airway has an increase proportion of soft tissue therefore susceptible to edema and inflammation . 12/16/2017 copyright 2006

13 Pediatric Airway AssessmentYou can note all of these symptoms during your “across the room assessment” What can they mean? What can you do? Airway Assessment 1. LOC 2. AbnormalSounds Stridor Wheeze Grunting 3. Preferred posture Head bobbing 12/16/2017 copyright 2006

14 Respiratory System ReminderThe lower airways of children are smaller and are more prone to obstruction and collapse. Smaller airways cause greater resistance to flow. Mucosa is less adherent to the airways and more prone to the development of edema. 12/16/2017 copyright 2006

16 copyright 2006 www.brainybetty.comDeb’s list: 1. Thin chest wall 2. Chest wall, ribs and sternum are cartilaginous 3. Ribs are horizontal 4. Poorly developed intercostals muscles 5. Diaphragm dependant 6. High metabolic rate 7. High metabolic need for O2 8. Small number of aveoli 9. Diminished TV 12/16/2017 copyright 2006

17 copyright 2006 www.brainybetty.comRespiratory System Ribs are horizontal cannot expand during respiratory distress. Intercostal muscles are poorly developed will retract with distress 12/16/2017 copyright 2006

18 copyright 2006 www.brainybetty.comRespiratory System Chest wall, ribs and sternum are cartilaginous, soft and more compliant Retractions are common in respiratory distress ad compromise the ability to generate adequate tidal volume 12/16/2017 copyright 2006

20 copyright 2006 www.brainybetty.comRespiratory System The infant relies on the diaphragm for breathing Keep up right and avoid pressure from above (asthma) or below – abdomen (gastric distention) 12/16/2017 copyright 2006

21 copyright 2006 www.brainybetty.comRespiratory System Less alveoli for gas exchange 20 million compared to 300 million in adults Small lung volumes 10mgs /kg Less compensatory reserve 12/16/2017 copyright 2006

22 copyright 2006 www.brainybetty.comRespiratory System The resting metabolic rate in a young infant or child is increased compared to that of an older child or adult. Conditions can boost the already accelerated metabolic rate: fever, hypothermia, illness, and hypoxia 12/16/2017 copyright 2006

25 copyright 2006 www.brainybetty.comBreathing Assessment Cyanosis: a late sign of hypoxia approximately 30% of the child’s blood is deoxygenated by the time cyanosis becomes evident 12/16/2017 copyright 2006

27 copyright 2006 www.brainybetty.comBreathing Assessment Cues used to assess the work of breathing in children include: Stridor Snoring Restrictions Head bobbing and accessory muscle use Tripoding and nasal flaring Wheezing and grunting 12/16/2017 copyright 2006

28 copyright 2006 www.brainybetty.comBreathing Note that: Children with lower airway obstruction may have end-expiratory breathing. Grunting occurs when a child tries to exhale against a partially closed glottis. This is a physiologic positive end-expiratory pressure (PEEP) when they are trying to pop open their alveoli. 12/16/2017 copyright 2006

29 copyright 2006 www.brainybetty.comBreathing Children often tripod themselves when they are having difficulty breathing. The same factors that increase heart rate can also increase respiratory rate, including pain, fear, and fever. As respiratory distress progresses, the respiratory rate may become slower and more irregular. 12/16/2017 copyright 2006

30 copyright 2006 www.brainybetty.comBreathing monitor respiratory rate, pattern, oxygen saturations, and electrocardiographic waveform for any changes in heart rate or function. assess respiratory function by watching for chest excursion and by listening to a child’s breathing. 12/16/2017 copyright 2006

31 copyright 2006 www.brainybetty.comBreathing Measurements commonly used to help determine breathing adequacy include oxygen saturation as measured by pulse oximetry (SpO2) and end-tidal carbon dioxide (ETCO2) values. Arterial blood gas (ABG) 12/16/2017 copyright 2006

35 copyright 2006 www.brainybetty.comPediatric Respiratory Problems : Is this an Upper airway or Lower airway problem? Anaphylaxis Asthma Croup Epiglottitis Foreign body obstruction Pertussis Pneumonia RSV Anaphylaxis Croup Epiglottitis Foreign body obstruction all of these can be considered upper airway problems 12/16/2017 copyright 2006

41 copyright 2006 www.brainybetty.comCroup A common infection of the upper airway that affects the larynx but may extend into the trachea and bronchi Most common in children younger than 3 years Symptoms include a low grade fever and “barking seal” cough Anticipate humidified oxygen and?? 12/16/2017 copyright 2006

42 copyright 2006 www.brainybetty.comEpiglottitis A bacterial infection caused by Haemophilus influenzae that most commonly occurs in children aged 3–5 years Symptoms include rapid onset of fever, stridor, and pronounced signs of toxicity. Children are at risk of acute and complete airway obstruction. Invasive measures should be kept to a minimum. How common is this? 12/16/2017 copyright 2006

44 copyright 2006 www.brainybetty.comAsthma A chronic inflammatory disorder of the lower airways, resulting in inflammation, bronchospasm, and edema May be triggered by allergens, exercise, emotions, infections, or cold air Reactive airway disease (RAD) is a term commonly used synonymously with asthma. 12/16/2017 copyright 2006

45 copyright 2006 www.brainybetty.comAsthma RAD is most common in children younger than 3 years and may progress to asthma. Management includes use of oxygen therapy and bronchodilators. Corticosteroids are often used in conjunction with other therapies. Assessment? Interventions? 12/16/2017 copyright 2006

46 copyright 2006 www.brainybetty.comPneumonia A parenchymal disease that occurs in the lung itself The younger the child is, the less tolerance he/she has for the condition. Assessment? Interventions? 12/16/2017 copyright 2006

48 The Pediatric Cardiovascular SystemThe hall mark of the pediatric cardiovascular system: Strong compensatory mechanisms But sudden and rapid deterioration occurs when these mechanisms become exhausted 12/16/2017 copyright 2006

49 Pediatric Cardiovascular SystemPediatric hearts are stiff Have less contractility cannot increase the amount of blood pumped - SV but can increase the heart rate to increase CO 12/16/2017 copyright 2006

50 copyright 2006 www.brainybetty.comStroke Volume The younger the child, the higher the pulse rate. Stroke volume is smaller in children than in adults. An increase in heart rate is the chief compensatory mechanism in children to increase end-organ perfusion and maintain blood pressure. 12/16/2017 copyright 2006

51 The Pediatric Cardiovascular SystemThe hall mark of the pediatric cardiovascular system: Strong compensatory mechanisms But sudden and rapid deterioration occurs when these mechanisms become exhausted 12/16/2017 copyright 2006

55 copyright 2006 www.brainybetty.comYeah- Math!!!! You have assumed the care of a 2 year old child involved in a MVC. It was estimated that this child has lost 300 mls of blood. What % of this child's circulating volume is this? 15kg x 80mls /kg = 1200mls total 300mls is 25% of this child’s total circulating volume! What do you think the assessment findings would look like for this child? 12/16/2017 copyright 2006

56 Cardiovascular SystemBlood pressure?? Really?? Why bother?? Hypotension can be the last sign of circulatory collapse Children can maintain a BP within the “normal” range until a child has lost 25-45% of their total circulating blood volume You are transporting a post trauma 2 year old whose BP is in a 2 year old “normal” range. However your patient is pale and cool with delayed cap refill and a decrease in LOC. What is happening with this child? 12/16/2017 copyright 2006

57 copyright 2006 www.brainybetty.comPeds Cardiovascular System Assessment: 1. Skin color and temp 2. CRT 3. Pulse strength- peripheral vs. central 4. Pulse rate- bradycardia in children is most often cause by hypoxia Fontanel-flat or bulging Skin tugor Mucous membranes-dry or moist 8. Obvious signs of fluid loss? Vomiting, diarrhea, blood loss 12/16/2017 copyright 2006

58 Across the room assessment:Observe the child’s general appearance and level of consciousness. A well-perfused child will be watching the activity in the room. The heart can be observed beating through the skin. Clubbing is the broadening of a child’s fingers and toes in response to low oxygen levels. 12/16/2017 copyright 2006

60 copyright 2006 www.brainybetty.comSkin Condition An assessment of the child’s skin is a good indicator of circulation and of whether hypoperfusion exists. Early compensatory mechanisms shunt blood from the skin to the vital organs. As a child becomes hypoperfused, the skin becomes cool, pale, mottled, or cyanotic. 12/16/2017 copyright 2006

61 copyright 2006 www.brainybetty.comShock A child in early or moderate stages of shock will be able to maintain perfusion. Once the child’s compensatory systems fail, the child will fail quickly. 12/16/2017 copyright 2006

62 The Pediatric Cardiovascular SystemThe hall mark of the pediatric cardiovascular system: Strong compensatory mechanisms But sudden and rapid deterioration occurs when these mechanisms become exhausted 12/16/2017 copyright 2006

63 copyright 2006 www.brainybetty.comHypovolemic Shock Most common form of shock in children? True or false? Characterized by inadequate intravascular volume Mostly caused by trauma Regardless of cause, fluid replacement is the top priority. 12/16/2017 copyright 2006

64 copyright 2006 www.brainybetty.comHypovolemic Shock Stages of hypovolemic shock Stage 1: Child appears asymptomatic. Stage 2: Child attempts to compensate for fluid losses, but compensatory mechanisms are maximized. Stage 3: Child is no longer able to compensate. Hypotension occurs. Stage 4: Death is imminent if volume is not replaced. 12/16/2017 copyright 2006

65 Fluid Volume and AccessAny trauma or medical condition that causes fluid loss required IV access for volume replacement. How many mls/kg? How many times? The use of intraosseus (IO) access has become more common for patients needing immediate intervention. Urine output is an objective guide. 12/16/2017 copyright 2006

66 copyright 2006 www.brainybetty.comIndicators of Shock Blood pressure- Again- Really?? Level of consciousness Heart rate – Really? What about pulses? Skin temperature, (CRT?) Respiratory rate and pattern Urinary output 12/16/2017 copyright 2006

67 copyright 2006 www.brainybetty.comBlood Pressure A child initially compensates well during hypoperfusion. Child may maintain normal blood pressure until compensatory mechanisms are depleted. And this is the reason to focus on Assessment and not the numbers!!!!! The biggest challenge in assessing blood pressure is getting the cuff to fit??? 12/16/2017 copyright 2006

69 copyright 2006 www.brainybetty.comCardiogenic Shock Child will present with traditional signs of shock including: Tachycardia Tachypnea Hypoxia Mental status changes Changes in skin condition How would the CCTP monitor this child during transport?? 12/16/2017 copyright 2006

70 copyright 2006 www.brainybetty.comCardiogenic Shock Child often has pulmonary congestion resulting in rales and venous distension. Transport principles focus on improving cardiac function with fluid resuscitation and inotropic agents. 12/16/2017 copyright 2006

71 copyright 2006 www.brainybetty.comDistributive Shock Major treatment goals include stopping vasodilation, returning volume to the intravascular space and improving tissue perfusion. Neurogenic shock- Volume replacement and vasoactive medications are the primary treatments. 12/16/2017 copyright 2006

72 copyright 2006 www.brainybetty.comDistributive Shock Anaphylactic shock Children will often present with general body edema, hypotension, rash, urticaria, anxiety, and warm, flushed skin. Treatment modalities involve removing the allergen, volume replacement, and epinephrine. Other treatments??? 12/16/2017 copyright 2006

73 copyright 2006 www.brainybetty.comDistributive Shock Dissociative shock Caused by the hemoglobin molecule being unable to give up oxygen to the tissues. Tissue perfusion is normal, and the release of oxygen is abnormal. Causes include carbon monoxide poisoning and cyanide poisoning. Treatment includes removing the cause, oxygen administration, and support. 12/16/2017 copyright 2006

74 copyright 2006 www.brainybetty.comDistributive Shock Septic shock Caused by an overwhelming release of proinflammatory mediators The response is so large that it causes more tissue injury. Treatment focuses on managing hypovolemia and removing the infectious agent. 12/16/2017 copyright 2006

75 copyright 2006 www.brainybetty.comDistributive Shock Warm phase Patient presents with vasodilation, diminished kidney function, metabolic acidosis, and changes in mental status. Cold phase This results from continually falling cardiac output. Patient feels cold to the touch. 12/16/2017 copyright 2006

76 Pediatric Neurologic System-Disability AssessmentBasic anatomy and perfusion are similar to adults There is room for the brain to move around in the skull The anterior fontanelle closes at 16–18 months. The posterior fontanelle closes at 2 months. 12/16/2017 copyright 2006

77 copyright 2006 www.brainybetty.comNeurologic System A normal fontanelle is soft and flat and has a feeling of fullness. A newborn might have a cephalohematoma from forceps or vacuum-assisted delivery—it usually resolves on its own. 12/16/2017 copyright 2006

79 Neurologic AssessmentEvaluate the child’s general appearance. How is the child responding to the environment? Is the child awake and responsive, or unresponsive and lethargic? A sunken fontanelle may indicate dehydration. 12/16/2017 copyright 2006

81 Neurologic AssessmentPedatric Glasgow Coma Scale (GCS) What is AVPU? Check the size of the child’s pupils and their response to light. Very constricted pupils could indicate a narcotics overdose. Dilated pupils could indicate a brain injury. 12/16/2017 copyright 2006

82 Neurologic AssessmentMuscle tone Children normally have flexed elbows and knees. Completely flaccid extremities are an abnormal finding. Moro reflex: Child jumps or is startled by loud noise Stepping reflex: Infant moves legs up and down when held in the air 12/16/2017 copyright 2006

87 copyright 2006 www.brainybetty.comGlucose Requirements Children are predisposed to developing hypoglycemia due to secondary factors. Children have decreased glycogen reserves and an immature liver that is not capable of stimulating glycogen stores. Management of hypoglycemia depends on the age and weight of the child. 12/16/2017 copyright 2006

88 Exposure ConsiderationsInfants are not able to shiver. Resuscitation efforts must include maintenance of body temperature. Be careful not to overwarm the patient. Heat loss can be minimized by replacing blankets on areas of the child that have already been assessed. 12/16/2017 copyright 2006

89 copyright 2006 www.brainybetty.comThermoregulation Children are more susceptible to hypothermia. Thinner skin and no subcutaneous layer of fat Large body surface area to volume ratio They dissipate heat quickly. They react poorly in extremes of heat or cold. 12/16/2017 copyright 2006

92 copyright 2006 www.brainybetty.comWhat about Vital Signs? For infants it may be easier to listen for the heart by placing the stethoscope over the second intercostal space at the midclavicular line. Using the fourth intercostal space may be better for older children. Cardiac sounds should be absent of rubs, murmurs, gallops, or secondary sounds. 12/16/2017 copyright 2006

93 copyright 2006 www.brainybetty.comVital Signs Doppler ultrasound may be a useful assessment tool if the pulse cannot be felt. In children, assess the pulse using the cardiac, radial, femoral, or dorsalis pedis arteries. In infants, assess the pulse using the brachial or femoral arteries. 12/16/2017 copyright 2006

98 copyright 2006 www.brainybetty.comGlucose Requirements Children are predisposed to developing hypoglycemia due to secondary factors. Children have decreased glycogen reserves and an immature liver that is not capable of stimulating glycogen stores. Management of hypoglycemia depends on the age and weight of the child. 12/16/2017 copyright 2006

100 copyright 2006 www.brainybetty.comPediatric Equipment ECG monitoring with SpO2 and ETCO2 is the standard of care for all intubated children. It is important to carry various sizes of ECG leads, pulse oximetry probes, and blood pressure cuffs to ensure accurate vital sign values. 12/16/2017 copyright 2006

101 Pediatric Assessment TriangleCredit line: Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2006. 12/16/2017 copyright 2006

104 Musculoskeletal SystemChildren have fewer calcified bones. Children’s bones are more porous and tend to buckle rather than to fracture. Epiphyseal-metaphyseal growth plate injuries account for 10%–15% of all fractures in children. 12/16/2017 copyright 2006

105 Musculoskeletal SystemA child’s thorax is pliable, so it can withstand greater kinetic forces without fracturing. If there is a fracture, there was a large amount of force. Observe for severe pulmonary contusion. 12/16/2017 copyright 2006

106 Musculoskeletal SystemLigaments in children are stronger and more resistant to tensile forces. Dislocations are rare. The pediatric spine has incomplete ossification, epiphyseal growth plates, and hypermobility. The cervical spine is flexible, so children tend to have avulsions rather than fractures. 12/16/2017 copyright 2006

107 Gastrointestinal SystemPhysiologic differences lead to increased risk of aspiration. Children have a smaller stomach capacity, which leads to more frequent meals. Chances of encountering a child with a full stomach are high. 12/16/2017 copyright 2006

109 copyright 2006 www.brainybetty.comRenal System Children are more prone to dehydration than adults are. Children are unable to concentrate urine as effectively as adults. Children are more prone to electrolyte loss because they have a higher clearance for blood urea nitrogen (BUN), creatine, and electrolytes. 12/16/2017 copyright 2006

110 copyright 2006 www.brainybetty.comRenal Assessment Get information from parents/caregivers on fluid intake, wet diapers, stools, frequency of vomiting, etc. weigh diapers to determine fluid loss. Physical assessment may include fontanelles, skin turgor, and presence or absence of tears. 12/16/2017 copyright 2006

111 copyright 2006 www.brainybetty.comMetabolism Children have a higher metabolic rate than adults. An infant’s consumption of oxygen is twice that of an adult. Rate of hypercapnia and hypoxemia is accelerated in children. 12/16/2017 copyright 2006

112 Physical Growth and DevelopmentChildren often regress during an illness or when recovering from an injury. Failure to meet developmental milestones may indicate an illness, family crisis, or neurologic injury. Parents are the best source of information. 12/16/2017 copyright 2006

113 copyright 2006 www.brainybetty.comPsychosocial All children fear separation from their parents. Children also fear loss of control. Preschoolers fear loss of control, bodily injury, the dark, and the unknown. Adolescents and teenagers fear loss of control and changes in body image. 12/16/2017 copyright 2006

114 copyright 2006 www.brainybetty.comPsychosocial Adolescents are more compliant if they are allowed to help in decision making. Foster trust by: Speaking at eye level Using first names Explaining medical procedures using age-appropriate words 12/16/2017 copyright 2006

115 Approach to Parents and CaregiversBe sensitive to the needs of parents and caregivers. Whenever, possible, provide written information and involve parents and caregivers in the plan of care. 12/16/2017 copyright 2006

116 copyright 2006 www.brainybetty.comHistory Parents/caregivers can provide history. Eating, sleeping, input and output, activity level Compare current information with normal patterns. History for infants and chronically ill children should include perinatal history, delivery history, gestational age and weight. 12/16/2017 copyright 2006

117 Accompanying Parents and CaregiversPresence of parent/caregiver often reduces child’s anxiety Assess parent/caregiver’s comfort level and the potential for disruption of care 12/16/2017 copyright 2006

118 Bronchopulmonary Dysplasia (BPD)Chronic lung disease that develops in preterm neonates who have been treated with oxygen and positive-pressure ventilation (PPV) Neonates at risk include those born before 30 weeks of gestation and weighing less than 1,200 g at birth. 12/16/2017 copyright 2006

121 Near-Sudden Infant Death SyndromeA life-threatening, acute episode of apnea Often accompanied by choking, gagging, skin color change, and a change in muscle tone Causes are unknown, but they can include gastroesophageal reflux disease, viral lower respiratory infections, and meningitis. Requires supportive care and immediate transport 12/16/2017 copyright 2006

122 Sudden Infant Death SyndromeSudden death of an infant younger than 1 year that remains unexplained even after autopsy and investigation Incidence is highest in first 4 months Incidence has decreased with campaign to have babies sleep on their backs 12/16/2017 copyright 2006

123 Sudden Infant Death SyndromeIf the baby dies during transport, the parent/caregiver may become the patient. CCTP should attempt to provide emotional support to the parent and make sure support is available at the medical center upon arrival. 12/16/2017 copyright 2006

126 Mechanical VentilationVolume-cycled ventilation Evaluates the peak inspiratory pressures (PIP) to assess lung compliance. The initial PIP settings should be the lowest possible value that results in adequate chest excursion. Most children can be adequately ventilated with a PIP of 20–30 cm. 12/16/2017 copyright 2006

127 Mechanical VentilationPhysiologic PEEP for infants and children is 3–5 cm. Many critical care practitioners will consider an alternative type of ventilator if the patient requires PEEP values greater than 12 cm. 12/16/2017 copyright 2006

128 Mechanical VentilationIn infants and children with severe lung disease, an oscillator may be more appropriate. An oscillator delivers smaller tidal values with rapid respiratory rates. 12/16/2017 copyright 2006

130 Ventilator Setting ChangesIn both types of ventilation, increasing FIO2 inspiratory time and PEEP will improve oxygenation. Increasing PIP and tidal volume within the target range will also improve oxygenation. The strategies to improve ventilation depend on the patient’s initial rate. 12/16/2017 copyright 2006

131 Ventilator Setting ChangesIn patients with a rate of 20 breaths/min or less, increasing the rate will improve ventilation and lower the carbon dioxide value. In patients with a higher respiratory rate, increasing the rate may actually worsen ventilation because the expiratory time will be decreased. 12/16/2017 copyright 2006

133 Cardiac Defects That Do Not Cause Cyanosis (1 of 3)Ventricular septal defect (VSD) A hole in the septum between the ventricles. Blood in the left ventricle flows into the right ventricle. Arterioventricular canal defect A hole in the atrial septal wall that allows blood to flow from the left side of the heart to the right side of the heart 12/16/2017 copyright 2006

134 Cardiac Defects That Do Not Cause Cyanosis (2 of 3)Atrial septal defects A hole in the septal wall that allows blood to flow from the left atrium into the right atrium. Aortic stenosis A narrowing of the aortic valve 12/16/2017 copyright 2006

135 Cardiac Defects That Do Not Cause Cyanosis (3 of 3)Pulmonary stenosis A narrowing of the pulmonary valve Patent ductus arteriosis The ductus arteriosis does not transition after birth. 12/16/2017 copyright 2006

136 Left Heart Obstruction DefectsPersistent pulmonary hypertension (PPHN) Caused by abnormally elevated pulmonary resistance, resulting in hypoxia Presentation includes low APGAR scores, hypoclycemia, and congenital diaphragmatic hernia. 12/16/2017 copyright 2006

137 Left Heart Obstruction DefectsPersistent pulmonary hypertension (PPHN) (continued) Extracorporeal membrane oxygenation (ECMO) is a short-term intervention in which the patient’s blood is pushed through a heart-lung machine and then returned to the patient. 12/16/2017 copyright 2006

138 Left Heart Obstruction Defects (3 of 3)Hyperplastic left heart system (HLHS) Underdevelopment of the aorta, aortic valve, left ventricle, and mitral valve Coarctation of the aorta (CoA) A pinching or narrowing of the aorta that obstructs blood flow from the heart to the systemic circulation 12/16/2017 copyright 2006

139 Cardiac Defects With Cyanosis (1 of 2)Tetralogy of Fallot (TOF) Ventricular septal defect Pulmonary stenosis Right ventricular hypertrophy Overriding aorta Most common defect seen beyond infancy 12/16/2017 copyright 2006

140 Cardiac Defects With Cyanosis (2 of 2)Transposition of the great arteries (TGA) The aorta is connected to the right ventricle, perfusing the body with deoxygenated blood. The pulmonary artery is connected to the left ventricle, carrying oxygenated blood to the lungs. 12/16/2017 copyright 2006

141 General Management PrioritiesAll pediatric patients with congestive heart failure require diuretics. A vasopressor may be used if diuretics do not work. Any cardiac lesion that is dependent on the ductus arteriosis requires the administration of a prostaglandin E1 infusion. 12/16/2017 copyright 2006

142 Pediatric ECG Interpretation (1 of 2)Avoid placing the ECG leads at the level of the diaphragm. Leads may be placed on the lower abdomen or on the patient’s thighs. A 12-lead ECG is not as common in children, but it is used for some. 12/16/2017 copyright 2006

143 Pediatric ECG Interpretation (2 of 2)Assess whether the rate is appropriate for the child’s age. Evaluate the components of the rhythm, including the PR interval and the width of the QRS complex. A PR interval of 0.16 or less and a QRS complex of 0.08 or less is considered normal. 12/16/2017 copyright 2006

144 copyright 2006 www.brainybetty.comPrerenal Disorders Most common renal disorders in children Caused by dehydration or decreased renal perfusion Patients may present with nausea, vomiting, diarrhea, diabetic ketoacidosis, shock, and burns. 12/16/2017 copyright 2006

145 copyright 2006 www.brainybetty.comIntrarenal Disorders The proximal cells of the kidneys have high metabolic demands that make them susceptible to ischemic insults. Occlusion of the renal arteries causes infarction as a result of decreased renal blood flow. 12/16/2017 copyright 2006

146 Hemolytic Uremic Syndrome (HUS) (1 of 2)Patient develops acute renal failure (ARF) Caused by several bacterial and viral organisms Follows gastroenteritis-type illness Symptoms include vomiting, abdominal pain, and bloody diarrhea. 12/16/2017 copyright 2006

147 Hemolytic Uremic Syndrome (HUS) (2 of 2)As gastrointestinal symptoms subside, the child becomes acutely ill. Treatment includes: Maintaining fluid and metabolic balance Control of hypertension Transfusion of packaged RBCs and platelets Aggressive treatment of renal failure 12/16/2017 copyright 2006

148 Acute Glomerulonephritis (AGN)Condition is associated with edema, hypertension, and hematuria Results from deposits of circulating immune complexes in the kidney basement membrane Can be caused by many organisms, the most common of which is group A beta-hemolytic streptococci. 12/16/2017 copyright 2006

149 Acute Poststreptococcal GlomerulonephritisThis condition follows an infection by streptococci, either as a skin or pharyngeal infection. It occurs most commonly in school-age children and more often in males. The most prominent symptom is urine that looks like cola or tea. 12/16/2017 copyright 2006

150 Acute Poststreptococcal Glomerulonephritis (2 of 2)Treatment is primarily supportive and includes fluid restriction of IV solution to avoid promoting peripheral or pulmonary edema. 12/16/2017 copyright 2006

151 Acute Tubular Necrosis (ATN) (1 of 2)Results in damage to the tissue in the kidney’s tubules Most common cause is renal ischemia precipitated by hypovolemia Tubular damage can also occur following heavy metal poisoning or after a severe crush injury, burn, or hemolytic crisis. 12/16/2017 copyright 2006

152 Acute Tubular Necrosis (ATN) (2 of 2)Three phases Oliguric phase: Decrease in urine volume Diuretic phase: Passage of large volumes of isothenuric urine Recovery phase: Signs and symptoms resolve 12/16/2017 copyright 2006

153 copyright 2006 www.brainybetty.comPostrenal Disorders Flank and abdominal pain is often present Prolonged, unrelieved obstruction causes irreversible damage Patient suffers a decrease in glomerular filtration and renal function 12/16/2017 copyright 2006

154 copyright 2006 www.brainybetty.comComplications (1 of 2) Hyponatremia Caused by low sodium levels and is often treated with fluid restrictions Hypocalcemia Not usually treated unless more severe symptoms are present 12/16/2017 copyright 2006

155 copyright 2006 www.brainybetty.comComplications (2 of 2) Hyperkalemia This condition can cause life threatening arrhythmias by producing membrane excitability. Management includes careful monitoring and removal of potassium chloride from IV fluids, pharmacologic treatments, and dialysis. 12/16/2017 copyright 2006

156 Meningococcal Infections (1 of 2)Presentation of symptoms depends on the age of the child, the type of organism, and the child’s state of health. Presenting symptoms include fever, chills, nuchal rigidity, vomiting, photophobia, headache, back pain, and seizures. 12/16/2017 copyright 2006 156

157 Meningococcal Infections (2 of 2)Younger children may also experience poor feeding, marked irritability, and agitation. Standard precautions should be taken with all suspected infections. 12/16/2017 copyright 2006 157

158 copyright 2006 www.brainybetty.comHead Injuries (1 of 2) Leading cause of death for children Main causes of head injuries include: Motor vehicle accidents Sports Falls Abuse 12/16/2017 copyright 2006

159 copyright 2006 www.brainybetty.comHead Injuries (2 of 2) Primary injuries occur at the moment of impact and cause physical and mechanical destruction. Secondary head injuries involve a cascade of cellular destruction. If secondary trauma is not addressed, it can result in irreversible brain damage and death. 12/16/2017 copyright 2006

160 Increased Intracranial Pressure (ICP)Most common causes are trauma or a failed cerebral spinal fluid shunt Signs and symptoms include: Irritability Projectile vomiting Fever and seizures Lethargy and visual changes Papillary dilation Cushing’s triad 12/16/2017 copyright 2006

161 copyright 2006 www.brainybetty.comConcussion Most commonly seen head injury There may be a brief loss of consciousness and posttraumatic injury. The role of the CCTP is to provide support en route to the medical center. Document the patient’s pain level and tolerance of the transport process. 12/16/2017 copyright 2006

163 copyright 2006 www.brainybetty.comEpidural Hematoma Typically includes arterial bleeding from contusions or lacerations, most commonly of the middle meningeal artery The accumulation of blood in these injuries does not touch the brain tissue. There is usually a lucid period followed by a rapid neurologic deterioration. 12/16/2017 copyright 2006

164 copyright 2006 www.brainybetty.comSubdural Hematoma Caused by shearing forces that slide the brain tissue over the base of the skull Blood comes into contact with the brain tissue. Can be the result of child abuse such as shaken baby syndrome 12/16/2017 copyright 2006

165 Risk Assessment and Management (1 of 4)Children with low-risk injuries may be fine with supervision at home. Children with moderate-risk injuries may have an associated injury. They will need x-rays, basic trauma care, and cervical immobilization. 12/16/2017 copyright 2006

166 Risk Assessment and Management (2 of 4)Children with high-risk injuries may present with a depressed level of consciousness, possible neurologic deficits, and signs of increased ICP. These children often need immediate surgical interventions. 12/16/2017 copyright 2006

167 Risk Assessment and Management (3 of 4)CCTP should stabilize the cervical spine and attend to the ABCs. Proper analgesia and sedation should be administered to prevent a spike in ICP. Hypovolemia is a big concern, especially with younger children. 12/16/2017 copyright 2006

168 Risk Assessment and Management (4 of 4)The most life-threatening situation involves herniation syndromes in which increased cranial pressure causes the brain to shift. The brain can shift laterally or down through the foramen magnum. 12/16/2017 copyright 2006

169 Spinal Cord Injuries (1 of 3)Mortality from spinal injuries is twice that of adults. The top priority is immobilizing the head and spine. Frequent assessments must be made to identify ascending lesions. 12/16/2017 copyright 2006

170 Spinal Cord Injuries (2 of 3)Children have weak spine ligaments and increased spinal mobility. They can sustain damage to the spinal cord and ligaments without sustaining damage to the vertebrae. This damage is called spinal cord injury without radiographic abnormalities (SCIWORA). 12/16/2017 copyright 2006

172 Breathing AbnormalitiesFacial trauma and soft-tissue swelling can block the upper airway. Hanging injuries can occur in toddlers or in teenagers who are attempting suicide or playing a “choking game.” A head injury may cause a decrease in consciousness and result in the tongue obstructing the airway. 12/16/2017 copyright 2006

173 copyright 2006 www.brainybetty.comTension Pneumothorax Can be resolved by inserting a 14–16-gauge needle in the second or third intercostal space For infants, a 22–23-gauge butterfly needle is used anterior to the fourth intercostal space. The chest is emptied of air or fluid until the condition improves. 12/16/2017 copyright 2006

174 copyright 2006 www.brainybetty.comHemothorax Treatment involves inserting a chest tube and removing the blood. Ideally, the blood can be collected and autotransfused back to the patient. Fluid resuscitation should be maintained to keep the patient from going into hypovolemic shock. 12/16/2017 copyright 2006

175 Circulation AbnormalitiesPatients should be assessed for bleeding, hypovolemia, arrhythmias, and pericardial tamponade. Pericardial tamponade is an emergency condition in which fluid accumulates in the pericardium. The appropriate treatment during transport is a rapid IV fluid bolus. 12/16/2017 copyright 2006

176 copyright 2006 www.brainybetty.comFractures (1 of 3) Children have less calcified bones. Bones tend to respond to force by buckling rather than breaking. If a break is evident, look for organ injury. Children tend to suffer from avulsions (tendon pulling away from the bone) rather than fractures. 12/16/2017 copyright 2006

177 copyright 2006 www.brainybetty.comFractures (2 of 3) Pelvic fractures can be responsible for massive internal hemorrhaging, which can lead to profound deterioration. CCTP can stabilize the pelvis by wrapping a sheet around it or by using a SAM splint. 12/16/2017 copyright 2006

178 copyright 2006 www.brainybetty.comFractures (3 of 3) Femur fractures are rare in children. They can result in significant blood loss. Older children and adolescents are at the greatest risk for these types of fractures. The injury should be splinted until the child is transported to the hospital. 12/16/2017 copyright 2006 178

179 copyright 2006 www.brainybetty.comAbuse and Neglect (1 of 3) Transport crew members must attend to their own safety first. Types of abuse include: Psychologic Physical Economic Sexual Neglect 12/16/2017 copyright 2006

180 copyright 2006 www.brainybetty.comAbuse and Neglect (2 of 3) CCTP should pay close attention to the child’s behavior. Children younger than 6 years who have experienced neglect usually appear markedly passive to their environment. Children 6 years or older may seem aggressive on initial evaluation. 12/16/2017 copyright 2006

181 copyright 2006 www.brainybetty.comAbuse and Neglect (3 of 3) CCTP must adhere to agency protocol regarding the reporting of suspected abuse or neglect. Efforts should be made to preserve evidence. It is important to keep accurate records of everything. 12/16/2017 copyright 2006

182 Environmental Emergencies (1 of 2)Hypothermia Exists when the patient’s body core temperature is 95°F (35°C) or less Pediatric population is at an increased risk. Management is the same as with adults. 12/16/2017 copyright 2006

183 Environmental Emergencies (2 of 2)Heat stroke Life-threatening emergency in the field with morbidity rates ranging from 17%–70% Pediatric population acclimates more slowly to heat production from exercise. Management is the same as with adults. 12/16/2017 copyright 2006

184 copyright 2006 www.brainybetty.comDrowning (1 of 3) Top cause of death for the pediatric population between the ages of 1 and 14 The less time the child spends submerged, and the more quickly he or she is resuscitated, the better the outcome. 12/16/2017 copyright 2006

185 copyright 2006 www.brainybetty.comDrowning (2 of 3) CCTP should secure the airway early, provide PPV, and add PEEP early. Rewarm the patient as quickly as possible and work to reverse metabolic acidosis. 12/16/2017 copyright 2006

186 copyright 2006 www.brainybetty.comDrowning (3 of 3) Dry drowning occurs when a patient has a laryngospasm that prevents water from entering the lungs. The duration of the laryngospasm determines the extent of the hypoxemia. Death from dry drowning is the result of asphyxiation instead of aspiration. 12/16/2017 copyright 2006

187 Pediatric ConsiderationsChildren are not small adults. be familiar with age-specific development and deviations from the norm. The parent or caregiver should be allowed to ride with the patient whenever possible. As with adults, never lie to children. 12/16/2017 copyright 2006

190 Pediatric Assessment TriangleCirculation is assessed by observing the child for pallor, mottling, or cyanosis. After using PAT, perform a primary assessment. All children should be assessed for pain using the FLACC scale. 12/16/2017 copyright 2006

Introduction to Pediatrics by Deb Martin Lightfoot RN MSN 12/16/2017

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