acutely ill child Flashcards
upon arrival at the scene of a compromised child, a caregiver’s first task is a
quick survey of the scene itself
any child with a heart rate below 60 beats/min or without a pulse requires
immediate CPR
brief, hands on assessment of cardiopulmonary and neurologic function and stability
primary assessment
most common precipitating event for cardiac instability in infants and children
respiratory insufficiency
first priority in resuscitation of a child
rapid assessment of respiratory failure and immediate restoration of adequate ventilation and oxygenation
earliest and most reliable sign of shock
tachycardia
components of secondary assessment
SAMPLE
Signs and symptoms Allergies Medications Past Medical History Last meal Events leading to situation
tertiary assessment
occurs in hospital setting where ancillary laboratory and radiographic assessments contribute to thorough understanding of child’s condition
sequential approach in airway obstruction
head tilt/chin lift maneuver
inspection of foreign body
finger sweep clearance or suctioning once visualized
most common cause of distributive shock
sepsis and burn injuries
most common pre-arrest rhythm
bradyarrhythmias
6 Hs that causes bradycardia
hypoxia hypovolemia hydrogen ions hypokalemia or hyperkalemia hypoglycemia hypothermia
4 T’s
toxins
tamponade
tension pneumothorax
trauma
for narrow complex tachycardia, we should distinguish between
sinus tachycardia and SVT
history and onset consistent with a known cause if tachycardia; P waves consistently present and of normal morphology
Sinus tachycardia
onset abrupt without prodrome; P waves absent or polymorphic; if present rate is often fairly steady at or above 220 beats/min
SVT
management for SVT with poor perfusion
convert child’s heart rhythm back to sinus rhythm
Adenosine can be given with rapid “push”
If no IV access or adenosine failed–> synchronized cardioversion using 0.5-1 joule/kg
management of wide complex tachycardia
Ventricular tachycardia
cardioversion and increase dose to 2 joules/kg if
1 joule/kg is not effective
most important treatment of cardiac arrest
anticipation and prevention
most important component of CPR
adequate chest compressions those that circulate blood around the body with a good pulse pressure
lone rescuer for unwitnessed pedia cardiac arrest should treat arrest as
asphyxial; immediately inititiate CPR
lone rescuer for witnessed pedia cardiac arrest should treat arrest as
primary arrhythmia; immediately activate EMS and obtain AED
pulseless VT or VF
emergency defibrillation
inotrope, vasodilator
Dobutamine
inortrope, chronotrope, renal and splanchnic vasodilator
Dopamine
inodilator
Milrinone
inotrope; vasopressor
Norepinephrine
most common cannulated artery
radial artery
intracranial dynamics in the setting of an expanding mass lesion
Munro-Kellie doctrine
hallmark of severe TBI
coma
3 key components of clinical brain death diagnosis
demonstration of irreversible coma/unresponsiveness
absence of brainstem reflexes
apnea
extension of upper extremities followed by flexion of arms with the hands reaching to midsternal level
Lazarus sign
to establish diagnosis of brain death, findings must remain consistent over a period of observation:
7 days to 2 months: 2 examinations separated by at least 48hr
2months to 1yr: 2 examinations separated by 24hr
older than 1yr: 12 hour observation
to establish diagnosis of brain death, findings must remain consistent over a period of observation:
7 days to 2 months: 2 examinations separated by at least 48hr
2months to 1yr: 2 examinations separated by 24hr
older than 1yr: 12 hour observation
confirmatory testing of brain death should be performed on
all children less than 1 yr old using EEG and studies to confirm absence of cerebral blood flow such as nuclear medicine cerebral flow scans
supports diagnosis of brain death
electrocerebral silence for 30 min recording
most common cause of shock in children worldwide
hypovolemic shock
seen in patients with CHD, or with congenital or acquired cardiomyopathies including acute myocarditis
Cardiogenic shock
stems from any lesion that creates mechanical barrier that impedes adequate cardiac output
obstructive shock
inadequate vasomotor tone which leads to capillary leak and maldistribution of fluid into the interstitium
Distributive shock
type of distributive shock but the septic process usually involves a more complex interaction of distributive, hypovolemic and cardiogenic shock
septic shock
fluid loss and decrease preload
hypovolemic shock
state of abnormal vasodilation
distributive shock
hallmark of uncompensated shock
imbalance between oxygen delivery and oxygen consumption
should be initiated in an attempt to reverse shock
20ml/kg Isotonic saline up to 60-80ml/kg
associated with reduction in mortality in septic shock
early administration of broad spectrum antibiotics
may improve systolic function and decrease SVR without causing significant increase in HR with added benefit of enhancing diastolic relaxation in cases of cardiogenic shock
Milrinone therapy
may be beneficial in pediatric shock with up to 50% of critically ill patients having absolute or relative adrenal insufficiency
Hydrocortisone replacement
simplified consensus definition of acute lung injury
acute onset (<7days)
severe hypoxemia (PaO2/FiO2 <300 for ALI or <200 for ARDS)
diffuse bilateral pulmonary infiltrates on frontal radiograph
absence of left atrial hypertension (pulmonary artery wedge pressure <18mmHg)
both ventilation and perfusion are lower in nondependent areas of the lung and higher in dependent areas of lung
estimation of FiO2 during use of nasal cannula
FiO2- 21% (nasal cannula flow (L/min) x 2)
high flow nasal cannula delivers gas flow at
4-16 L/min providing significant CPAP
formula for proper internal diameter for tracheal tube
Age (yr) /4 + 4
volume of gas left in the alveoli at the end of expiration
Functional residual capacity
In intrathoracic airway obstruction, airway narrowing is much more pronounced during
expiration therefore expiratory time is much more prolonged than inspiratory time
most common type of shock in trauma
hypovolemic shock due to hemorrhage
more common after bicycle handle impact or direct blow to abdomen
pancreatic and duodenal injuries
most important step to reducing impact of drowning injury
Prevention followed by early initiation of CPR at the scene
highest drowning rates seen in
1-4 yr and 15-19 yo
most common cause of mortality and long-term morbidity in drowning
CNS injury
pediatric drowning patients should be observed in ED for ___ hours even if aymptomatic
6-8 hours
In drowning, death or severe neurologic sequalae are quite likely in patients with the ff:
deep coma apnea absence of pupillary responses hyperglycemia in ED submersion duration >10min failure of response to CPR given for 25 min
most critical and and effective neurologic intensive care measures after drowning are
rapid restoration and maintenance of adequate oxygenation, ventilation and perfusion
In drowning, what should be instituted asap after resuscitation and sustained for 12-24hr?
hypothermia (32-34C)
burns in young children that should raise the suspicion of child abuse
“glove and stocking” burns of hands and feet
single-area deep burns on trunk, buttocks or back
small, full-thickness burns (cigarette burns)
burns in patients that will warrant admission
BSA >10-15%
associated with smoke inhalation
burns from high-tension (voltage) electrical injuries
burns associated with child abuse or neglect
children with burns __% require IV fluid resuscitation
> 15% BSA
involve only epidermis characterized by erythema, swelling and pain; no blistering
1st degree burn
injury to entire epidermis and variable portion of dermal layer; vesicle and blister formation
2nd degree burn
destruction of entire epidermis and dermis leaving no residual epidermal cells
Full thickness
Rule of nines must only be used in
children older than 14 years old
In small burns, <10% what should be used to estimate BSA
rule of palm
area from wrist crease to finger crease(palm) in child equals 1% of child’s BSA
appropriate starting guideline for fluid resuscitation in burns
Parkland formula
(4ml LR/kg/%BSA) half of fluid given over 1st 8 hours from onset of injury
remaining fluid to be given at an even rate over the next 16 hours
chest compression depth
1.5in (4cm) in infants
2in (5cm) in children
chest compression rate
100-120/min
A case regarding a 5 year old boy who got reprimanded by his parents. Suddenly, he stops breathing and turns blue in color
*Nelson 21st: These are reflexive events in which the crying child becomes apneic, pale, or cyanotic, may lose consciousness, and occasionally will have a brief seizure.
Nelson 21st: Breath-Holding Spell (Chapter 612) …It is important also to educate parents on how to handle more severe spells with first-aid measures or even basic cardiopulmonary resuscitation when needed.
2 types of breathholding spells
A cyanotic spell is caused by a change in the child’s usual breathing pattern, usually in response to feeling angry or frustrated. It’s the most common type.
A pallid spell is caused by a slowing of the child’s heart rate, usually in response to pain.
Some children may have both types of spells at one time or another.
Breath-holding spells can occur in children 6 months through 6 years of age. They are most common from 1 to 3 years of age. Some children have them every day, and some have them only once in a while.
