An approach to Acute Paediatrics Flashcards
Why are children different?
- Anatomical differences
- Physiological differences
- Compensate well and decompensate quickly
- Communication challenges
- Parents usually present (and anxious)
Anatomy - how are childrens airways different?
- Large head to body size
- Short necks
- Large tongue
- Obligate nasal breathers - Nasal passages easily obstructed
- Compressible floor of mouth and trachea
- High anterior larynx
Anatomy - how are childrens breathing different?
- Small total surface area for air tissue interface
- Lower airways small - easily obstructed
- Diaphragmatic breathing
- Fewer type I (slow twitch) fibres - easy fatigue
- Soft non-calcified bones- v. compliant chest wall - recession and in-drawing
- Horizontal ribs - less expansion
Physiology - how is respiratory different in children?
- Higher metabolic rate/oxygen consumption - Respiratory rate higher and gradually falls
- Oxygen dissociation curve shifted left in neonates (HbF predominance) - Neonates tolerate slightly lower saturations
- Immature lung vulnerable to insult
- Apnoea may occur in babies
Physiology - how is a childs cardiovascular system different?
- Circulating blood volume- 70-80 ml/kg - Small loss can make a big difference
- Circulation changes from in-utero to ex-utero (In utero you are bypassing lungs) - PDAs/ PFO may remain open for several months
- ECG features vary with age
- Stroke volume increases with size - Heart rate higher and gradually falls
- Systemic vascular resistance progressively rises from birth - Blood pressure lower and rises
- Falling blood pressure is a late sign
- Bradycardia (<60) indicates life threatening pathology (but may be seen in anorexia)
•Manage as arrest if no response/poor perfusion
what are some other considerations in a child?
- Huge variation in shape and size - Calculations are done by weight/age
- Large surface area:weight ratio - Rapid heat loss/hypothermia
- Immature immune system at birth - Babies are more susceptible to infections
- Huge spectrum of intellectual ability and emotional response - Child development knowledge v. helpful
how is communication different with children?
- Babies have no or limited language - Can’t describe their symptoms
- Talkative children can be quiet - Look for non verbal clues (colour, activity, play), Age appropriate discussion
- Fear - emergency care is scary! - Affects physiological parameters (can push BP and HR up), Parental anxiety- must be able to stay with child
- Clear communication (+/- play) needed
Scenario Part 1: Assessment
How do you interpret his heart rate (140) and respiratory rate (35)?
A.Within normal range for age
B.Only heart rate elevated
C.Only respiratory rate elevated
D.Both significantly elevated
E.Peri-arrest state- 2222 call the registrar
A
How do you interpret his sats (94%) and BP (90/50)?
A.Both acceptable for age
B.Sats are low BP is normal
C.Sats acceptable BP is low
D.Both sats and BP are low
E.Peri-arrest state- 2222 call the registrar
A
Saturations for a young baby will be sitting at around 92/93
If you saw these numbers in an adult then it would be abnormal
What is the likely diagnosis?
A.Acute asthma
B.Bronchiolitis
C.Lower respiratory tract infection
D.Upper respiratory tract infection
E.Viral induced wheeze
E
Little bit old for bronchiolitis (condition of infancy)
Only wheeze and no creps then bronchiolitis less likely
Normal values by age - what are the trends of HR, BP and RR?
what is PEWS?
The Paediatric Early Warning Score (PEWS) is a specialised tool that measures the infant/ child’s clinical status and recommends an appropriate response. This procedure is to be adhered to for all infants and children admitted to all areas within the trust
Specific charts for ages
What management(s) would be appropriate?
A.Apply oxygen
B.Obtain IV access
C.Start back to back nebulisers
D.Start IV antibiotics
E.Start multi-dose salbutamol
E
Scenario Part 2: Action
- Sats monitoring applied
- Consider oxygen if sats dropping
- Start salbutamol MDI
- Observe in PAU
- Repeat observations in 60 mins
- Senior review
- Any parental questions?
The next day: Call from the ward
- “Please come and review Hamish SIM”
- “I’m a bit worried about his observations”
- “He’s not feeding that well”
- “He’s sounding more wheezy”
Scenario Part 3: Progress on the ward
Nursing concerns:
- Feeding has reduced from yesterday evening
- ust seems unsettled
- Oxygen requirements up to 5 lpm
- I’m worried about him
Mum says:
- “He doesn’t seem as bright and active”
- “He is working hard with his breathing”
- “We just can’t get him to feed at all”
