Caring for Kids vs. Adults Flashcards
Why do children deterioate rapidly
they have less of a phsyiological reserve
This is why early recongnition of a child in distress is essential
Anatomical differences in children vs adults
These differences are most pronounced in infancy
- In summary, infants and toddlers (younger than 2 years) have higher anterior airways. Children older than 8 years have airways similar to adults. The age range of 2 to 8 years old marks a transition period, when the above-mentioned anatomical differences may have varying effects on airway management.
What kind of breathing do infants do
Infants are considered to be obligated nose breather, meaning that they prefer to breath through their nose
Anatomy of the Tongue in Children
- In children the tongue is large compared to the oral cavity especially in infancy making the tongue a natural airway obstructer
- An oral airway should be a first line of defense when beginning bag-mask ventilation on an unconscious child to avoid tissue airway obstruction.
Tonsils and Adenoids in Children
- Children also have large tonsils and adenoids and large amounts of lymphoid tissue
- All of these are potential areas for swelling and can result in upper airway obstruction
- These can also be sources for bleeding during trauma or intubation, which will obstruct views and risk aspiration
Epiglottitis of a Child
- Larger
- Less flexible
- Omega or U shaped
- Lies more horizontally compared to adults
- More susceptible to trauma
Can make visulization more difficult during intubation
angle between the epiglottis and laryngeal opening in children
- The angle between the epiglottis and laryngeal opening is more acute in infants than in an adult, which makes blind nasal intubation difficult.
- Can make direct visualization difficult during intubation and blind nasal intubation
The Glottis in Infancy
- In infancy, the glottis begins at the first cervical vertebrae (C1)
- As the thorax and trachea grow, the glottis moves to C3 to C4 by age 7 and is located at C5 to C6 in adulthood.
- This makes the glottis in children higher and more anterior than in adults.
- This will make visulization more difficult with intubation
Cricoid Cartilage in Children
- The cricoid ring is the smallest portion of a child’s airway, whereas in adults the vocal cords are the smallest portion of the airway.
- An uncuffed endotracheal tube (ETT) provides an adequate seal in a small child because it fits snugly at the level of the cricoid ring.
- When using an uncuffed ETT, correct tube size is imperative because air can leak around an ETT that is too small, and tracheal damage can result from an ETT that is too large.
- Children have small cricothyroid membranes, and, in children younger than 3 years, it is virtually nonexistent. This means emergency surgical airway techniques such as needle cricothyrotomy and surgical cricothyrotomy are extremely difficult, if not impossible, in infants and small children.
Trachea in a child
- Smaller and shorter making extubation easier
- More malleable meaning it is more susceptible to change in shape when under pressure making it easier to collapse
- Smaller diameter which will increase resistacne as well as easier to obstruct
- Increased inspiratory pressure during respiratory distress causes increased negative intrathoracic pressure and can lead to collapse of the extrathoracic trachea.
Sniffing Position for Children
- With both adults and children, an effective way of opening the airway is to place the patient in the sniffing position, in which the patient’s head and chin are thrust slightly forward to keep the airway open.
- However, the occiput (back part of the skull) is larger in children and may cause flexion of the neck and inadvertent obstruction of the airway. To align the airway in an adult, a roll can be placed under the head. In children this is not needed, and infants may need a shoulder roll to achieve sniffing position.
Cricothyroid Membrane in Children
Smaller, virtually non-existant in children, younger than 3 years old
Needle cricothyroid and surgical cricothyroid are difficult in infants and small children
Thoracic Cage in Children
- An infant’s ribs and sternum are mostly cartilage, and the ribs lay more horizontally than do those of an adult. The thoracic cage thus offers little stability, and the chest wall will collapse with negative pressures.
- This makes retractions more pronounced in infants and most obvious in preterm infants. The cartilaginous ribs do, however, mean that closed-chest compressions from cardiopulmonary resuscitation do not usually cause rib fractures in children
- Ribs and sternum are mostly cartilage (infants)
Ribs lay more horizontal
* The thoracic cage offer little stability; the chest wall will collapse with negative pressure; retractions are more pronounced in infants
Belly Breathers in Children
- Breathing for infants is mostly diaphragmatic, making them abdominal or “belly breathers.”
- Instability of the thoracic cage makes it difficult to increase minute ventilation by increasing thoracic volume. Infants must drop the diaphragm more to increase tidal volume, which increases WOB.
- To avoid increased WOB, infants usually increase respiratory rate to increase minute ventilation.
Diaphragm in children
Main action for breathing in infants
Infants known as belly breather increase WOB when increasing tidal volume
Mainstem Bronchus in Children
Right mainstem angle lower
Right mainstem intubation and right foreign body obstruction are more frequent
Conducting Airway in Children
- At birth, the number of conducting airways is completely developed. However, airway diameter increases with lung growth.
- This explains the phenomenon of children “outgrowing” reactive airways disease. It is less likely that the swelling and smooth muscles are no longer reactive; rather, the degree of airway obstruction is less pronounced as a result of the increased airway diameter.
Alveoli in Children
Fewer at birth increase in number during childhood
No pores of Kohn (infants)
Infants decompensate more rapidly during airway obstruction
More respiratory distress during alveolar disease
Reasons for decreased FRC in Children
Larger heart in relation to thoracic cavity
Less elastic recoil
Abdomincal contents are larger and push up against diapgragm
Higher compliance
basal oxygen consumption of children
- Furthermore, the basal oxygen consumption of children is twice that of adults: 6 mL O2/kg for children versus 3 mL O2/kg for adults.
- The clinical implication of lower pulmonary reserve and increased oxygen consumption is that children will desaturate more rapidly than will adults.
- Recommendations for airway management suggest that clinicians should be prepared to provide bag-mask ventilation with 1.0 FIO2 if a child’s oxygen saturation falls below 90%
MAP in children
- Once blood pressure is obtained, the calculation to determine mean arterial blood pressure (MAP) is:
MAP = 1/3 systolic pressure + 2/3 diastolic pressure
- MAP is often used in the pediatric setting to evaluate blood pressure stability and effectiveness of cardiac inotropic and sympathomimetic therapies.
Crying in Infants
- Crying can also increase WOB in an infant up to 32-fold (5), so it is imperative to try to keep young children in respiratory distress as calm as possible. Keeping them in a quiet, comfortable environment with familiar people will help alleviate anxiety and minimize additional respiratory distress.
Breath Sounds in Infants
- Breath sounds may be more difficult to distinguish in very young children, and vocal noise transmissions are more common as a result of whining and crying during auscultation.
Contraindication to ABG in Children
- These include a modified Allen’s test result indicating lack of collateral circulation (another extremity should be chosen) or a lesion or surgical shunt proximal to the patient on the same limb.
- If there is evidence of infection or peripheral vascular disease involving the selected limb, an alternate site should be selected.
- A coagulopathy or high-dose anticoagulation therapy such as heparin or Coumadin may be a relative contraindication for arterial puncture.
ABG in Children
Heparin Dilution
- Because of the smaller sample size, neonatal and pediatric samples are more susceptible to liquid heparin dilution errors.
- Heparin has a lower pH than blood, so heparin will lower pH without affecting PaCO2. This will make the ABG results trend toward a metabolic acidosis.
- This is most common in umbilical line sampling in neonates if all heparin is not removed from the line prior to collecting the ABG sample.
- Comparing the current values of pH and calculated bicarbonate with previous ABG results should help reveal this error should it occur
ABG in Children
Air in Sample
- An air bubble consists of room air, which has a PO2of158 mmHg and a PCO2 of approximately 0 mm Hg.
- PaCO2 in the blood will decrease as CO2 travels into the air bubble in an equilibrating manner because gases travel from areas of high pressure to areas of low pressure until they are equal.
- Room air will change the PaO2 in the arterial sample in an attempt to equilibrate but will raise it or lower it based on the blood sample’s starting PaO2.
- If the sample PaO2 is greater than 158 mm Hg, then oxygen will travel from the blood into the air sample and lower the PaO2 of the blood sample.
- If the sample PaO2 is less than 158 mm Hg, then addi- tional oxygen molecules will travel into the blood sample and increase measured PaO2.
- To avoid this, all air bubbles should be tapped to the end of the syringe and pushed out of the sample immediately after the sample is drawn.
ABG in Children
Venous Admixture
- This is an error that will occur with puncture sampling, not with arterial line sampling.
- Peripheral venous blood has different PvO2, PvCO2, and pH values based on local metabolism, perfusion, and tissue and organ function.
- So there is no direct correlation between any venous sample and an arterial one.
- In general, however, lower PO2 and higher PCO2 values should be expected.
- A mixed venous blood sample taken from the right atrium or ventricle of the heart can be correlated with an ABG and then subsequent samples used to trend changes in acid-base status.
- Normal mixed venous blood gas values are pH = 7.38, PvCO2 = 48 mm Hg, and PvO2 = 40 mm Hg.
ABG in Children
Temperature
- Patient hypothermia or hyperthermia will cause the measured blood gas results to be less accurate.
- This is because the electrodes in a blood gas analyzer are heated to normal body temperature.
- In general, every 2°C decrease in body temperature will cause a drop in PaCO2, causing a subsequent increase in pH of 0.03.
- Decrease in temperature will also cause a decrease in measured PaO2. The reverse is true for increases in body temperature.
ABG in Children
Metabolism
- Blood continues to metabolize when it is outside of the body.
- If a sample is left at room temperature, pH will decrease, CO2 will increase, and PaO2 will decrease.
- Icing samples have been used historically but are not effective when samples are stored in plastic syringes; therefore, the current recommendation is to run a sample immediately after it is obtained
Transcutaneous Monitoring
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Transcutaneous monitoring electrochemically measures skin-surface PO2 and PCO2 by heating localized areas of the skin to induce hyper-perfusion.
- This provides a non-invasive estimate of arterial oxygen and carbon dioxide.
- To validate transcutaneous measurements, an arterial blood sample should be drawn and compared with transcutaneous readings taken at the same time.
- Validation should occur at initiation of monitoring and at regular intervals.
- Though transcutaneous monitoring is non-invasive, it is not without complications.
- In patients with poor skin integrity (e.g., extremely premature infants), tissue injury such as erythema, blisters, burns, and skin tears may occur at the measuring site
- Patients with adhesive allergies can also be at risk for complications from the electrodes.
Capillary Blood Gas Sampling
- Arterialized capillary blood can provide a rough estimate of arterial blood values.
- The physiological principle is that there is little time for oxygen and carbon dioxide exchange in blood flowing through a dilated capillary bed, so the sample drawn has approximately the same acid-base balance as that in the arteries.
False reading from a capillary blood sample can be the result of
- Inadequate warming of the site
- Clots within the sample tubing
- Excessive squeezing or “milking,” which causes contamination with venous blood and interstitial fluid
- Exposure of blood to air during sampling
Why use a Miller Blade
- Because of the higher and more anterior glottic opening, floppy epiglottis, and large tongue in children younger than 3 years old, a straight (Miller) laryngoscope blade is recommended for these patients. It elevates the distensible airway and provides direct control of the epiglottis.
Miller Blade Chosen By Wieght
- Size 0 Miller (straight): less than 3 kg
- Size 1 Miller: 6 to 11 kg
- Size 2 Miller: 12 to 31 kg
- Size 2 Macintosh (curved): 19 to 31 kg
- Size 3 Miller or Macintosh: greater than 31 kg
for selecting ETT sizes for pediatric patients
- In neonates, ETTs are selected by either gestational age (when intubating at birth) or weight (once weight is known).
- Cuffless ETTs are preferred in infants.
- In children older than 1 year, selection of an ETT size should be based on the following calculation:
ETT size (mm) = (16 + age in years)/4
determining depth placement of an ETT in child
- For any age child, depth can be calculated by multiplying the internal diameter of the ETT by 3. This gives the provider the desired depth of the ETT, measured at the lip.
- For infants, depth can be calculated by adding 6 to the weight in kilograms. This gives the provider the desired depth of the ETT, measured at the lip.
- During intubation, the provider passes the ETT through the vocal cords until one of the vocal cord markers is visualized at the level of the cords. The provider reads the number at the lip after intubation to document the correct depth.
What protects the airway?
Epiglottitis
What is the part of the body of an infant that can be lifted with a towel for good airway positioning?
Shoulders
In infants, the ribs and sternum are mostly composed of what?
Cartilage
What type of breathers are infants because their diaphragm drops?
Belly breathers.
What occurs during the first 3 years?
Large portion of lung proliferating (growth).
What is missing in alveoli for newborns which is structurally different?
Pores of Kohn (small openings).
What is basal oxygen consumption in infant?
Twice that of adults.
What can we give when the heart is under stress?
Oxygen
What can we give to the infant during bradycardia?
Caffeine, oxygen, and ventilator/BIPAP.
What is the normal pulse SpO2?
Greater than 97.
TMC doesn’t work on what parts of the body?
An injury or over bone.
What will happen when having excessive squeezing or milking during CBG?
Contamination with venous blood and interstitial fluid.
What is the smallest portion of the airway in children?
Cricoid ring.
What is the best indicator that an infants is seriously ill
Mental status is the best indicator of whether an infant is seriously ill
Altered mental status is frequently due to inadequate oxygenated blood flow to the brain
What might what a frighten child harder to treat
A frightened or injured child may regress to an earlier developmental stage
This will make it hard to assess
Take note on whether the child can be comforted by parents
What are most cardiac arrests caused by in children
Most cardiac arrests in children and infants will be a result from respiratory failure, shock, or both
Less common is a sudden collapse due to an arrhythmia (VF, VT)
Once Cardiac Arrest Occurs
Low survival rates
Outside the hospital survival rates are (4-13%)
In hospital survival rates (~33%)
Even though there is low survival rates children will have better survival rates than adults due to the fact that when they have cardiac arrest they tend to not have all the co-morbidities that adults have
Quick Initial Impression
Quick (<5 sec) visual and auditory
- What do you see
- Is the child interacting
- Is the child conscious
- Is there any signs of circulatory problems?
- Mottling is a sign of circulatory probelms
- What do you hear
- Is the child breathing normally and if not what is different about their breathing?
- Remember that emotion and anxiety will change RR
- Can you hear stridor
- How does the child look
- Is the child’s color good, how has it changed, is there any bleeding
Assessing Neurological State
Alert
Responsiveness, interacts with surrounding without assistance
Irritable
Unresponsive
Poor tone
Assessing Respiratory
Observable chest or abdominal Movement
Abnormal pattern
Audible sounds
Accessory muscle use
Assessing Cardiac
Pale
Mottled-Signals a cardiac problem
Cyanosis
Jaundice
Flushed (fever)
Initial Impression and Interventing
It is during the initial impression when you make the call on whether or not you need to intervene
You have to act sooner with kids than with adults
As soon as you feel that something is wrong you should call for help
Never hesitate to call for help
If not breathing adequately
- Life saving intervention is needed
- Call for help (emergency response)
- Has pulse but not breathing
- Ventilate patient
- Heart rate of less than 60 bpm with poor perfusion
- Chest compressions and ventilation
- Pulseless
- Pediatric arrest algorithm
If child is breathing adequately
Asses/evaluate
Identify
intervent
Types of Respiratory Problems
Upper Airway Obstruction
Lower Airway Obstruction
Lung Tissue Disease
Disordered Control of Breathing
Will lead to respirtory distress or failure
Types of Circulatory Problems
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Obstructive Shock
Airway
Breathing
Rate
Effort with chest expansion
Breath sounds
Oxygenatation saturation
Clear-Unobstructed
Oxygen Saturation in Neonates Versus Pediatric
We can have high saturation goals in pediatric than in neonates
Maintainable Airway
Obstructed but relieved with head tilt chin lift
Airway Not Maintainable
- FBAO
- <1 year
- Back slaps and 5 chest thrust
- > 1 year old
- abdominal thrusts
- <1 year
- Advanced Interventions
- ETT
- LMA
- NIV
- Laryngoscoppy
- Cricothyrotomy
Respiratory Distress in Infants
- Accessory Muscle use (PALS)
- Retractions
- Head Bob
- Head bobbing is a sign of respiratory failure
Uncuffed ETT Tube Size in Peds
Formula for uncuffed tube: 1 x ETT= (age/4) + 3.5
Cuffed ETT Tube Size in Peds
Formula for Cuffed tube: 1 x ETT= (age/4) + 4
Remember that you can used cuffed tubes in any child with the exception of neonates
NG/OG/Foley Size in Peds
2 x ETT
Depth of ETT Insertion in Peds
3 x ETT
Chest Tube Size in Peds
Chest Tube Size= 4 x ETT
*This is for the biggest chest tube size
No Life Threatening Condition
- Proceed with systemic approach
- Assess/evaluate -> Identify -> intervene (PALS)Repeat as needed and continue until stable
- Primary assessment: Identify and intrevee
- Secondary Assessment: Focused history and exam
- Diagnostic test
- Blood WorkLabs
- (CBC, arterial blood gas)
- We will not put arterial lines in kids
- Blood WorkLabs
- Radiographic
- Xray, CT, MRI, other
- Advanced
Secondary Assessment
- Expand on History
- Normal delivery
- Prenatal care
- Growth pattern
- Immunization
- Activities over last few days
- Normal response to illness and injury
- SAMPLE
- Focused physical exam
- A detailed exam must not distract from the ongoing management of ABG for rapid intervention
- Physical head to tow assessment of the patient that is performed only after urgent or life threatening circumstances have been managed
- If necessary may be performed from tow to head to help build trust
- Is possible have parent hold the child
SAMPLE Questions
- Signs and Symptoms
- Allergies
- Meds
- Prescribed, OTC, supplements
- Past Pertinent History
- Last oral intake
- We don’t want them to vomit if we intubate
- Events proceeding incident
Extra Membrane Oxygenation
- Used to offload the heart, lungs, or both
- Run by the perfusionist
- Seen with ARDS, open heart surgery, or the patient is very sick
- Offloading the Lung
- VV ECMO
- Blood is taken by the vein to oxygenate the pump through the heart
- VV ECMO
NOVA Lung
Less invasive and heart will still be the pump
May help in weaning for extubation
Can be used as a bridge when waiting for lung transplant or for the antibiotics to work
Can only be used for 20-29 days
When Dealing with an infant or pediatric patient keep in mind
–Sound, touch, skin sensitivity
–Comprehension
–Fear of abandonment, the unknown, punishment, getting hurt, death
–The parents
Respiratory Assessment
IPPA has to be modified to fit the patient’s size, understanding, and ability to cooperate
Smaller patients will have more noticeable cyanosis, WOB, accessory muscle use, shortness of breath, heart sounds, breath sounds, and defects
Position of the lungs and heart will approximate adult landmarks with the exception of the heart being slightly larger in the body of a child in comparison to an adult and PMI is more noticeable in a child
Smaller patients will be less tolerant of a long exam, handling, loud voices, and testing
Smaller patients have less respiratory reserve and will tire quickly
Inspection
–General appearance – ill, cyanosis, LOC/responsiveness, lethargy, etc
–WOB- acc. muscle use, tracheal tug, nasal flaring, stridor, head bob, etc.
–V/S, I/E ratio, breathing pattern
–Capillary refill
Palpatation
Pain
Sub Q E
Perfusion
Fremitus
Percussion
Resonance
Increased resonances can be noted either due to lung distention as seen in asthma, emphysema, bullous disease or due to Pneumothorax.
Decreased resonance is noted with pleural effusion and all other lung diseases.
Auscultation
–Breath Sounds – normal, harsh, decreased, increased, =
–Adventitious sounds – wheezes, crackles, rubs
Heart Sounds – lubb, dubb, murmu
Signs of Respiratory Distress
Nasal Flaring
Inspiratory Retraction
Increased RR
Increased depth of breathing
Head bobbing
Seesaw Respiration
Restlessnes
Tachycardia
Grunting
Stridor
Signs of Repirtaory Failure
Cyanosis
Diminished Breaht Sounds
Decreased Level of Responsiveness
Poor skeletal muscle tone
Inadeuqtae RR, effort, or chest rise
Tachycardia
Use of accessory muscle
What is the epiglottis?
It is a flexible flap at the superior end of the larynx in the throat. It acts as a switch between the larynx and the esophagus to permit air to enter the airway to the lungs and food to pass into the gastrointestinal tract.
What is the anatomy of the thoracic cavity in children?
An infant’s ribs and sternum are mostly cartilage. Ribs lay more horizontal in infants than in an adult horizontal. Breathing in infants is mostly diaphragmatic (making them abdominal or belly breathers). Right main stem angle at the carina is lower in children than in adults. The diameter increases with lung growth. Alveoli stops proliferating when the body growth stops. A large portion of lung proliferation occurs within the first 3 years of life.
What is the anatomy of the thoracic cavity in infants and children compared to adults?
Alveolar sacs are structurally different in a newborn. Alveoli in newborn also do not have Force of Kohn which is the small openings thought to exist between adjacent alveoli. Infants and children have a lower functional residual capacity which is the amount of air remaining in the lungs after a normal expiration. Also, infants and children have larger hearts in proportion to the thoracic diameter, which decreases lung capacity. Infants have more compliant chest walls. A child’s lungs have less elastic recoil than an adult. Children have a larger abdomen which pushes up against the diaphragm. The basal oxygen consumption is twice that of adults.
Children have a lower what?
Pulmonary reserve but have an increased oxygen consumption.
basal oxygen consumption in adults an children
Adult is 3
children is 6
