CCP 341 Paediatric Anatomy and Physiology 🧒 Flashcards
Focused SAMPLE History In critically ill or injured peds
Signs and symptoms Allergies Medications Past medical problems Last food or liquid Events leading to injury or illness
TICLS mnemonic for assessing the components of “appearance” in paediatric assessment triangle (PAT)
Tone Irritable/interactive Consolable Look/gaze Speech/cry
simple method of determining urine output/hydration status in infants and toddlers
urine output can be quantified by the number of
wet diapers over past day/24hrs
The three components of the Pediatric Assessment Triangle
appearance
work of breathing
circulation to skin
Key components of “work of breathing” in the paediatric assessment triangle (PAT)
- Abnormal sounds: stridor, grunting, snoring, wheezing
- Abnormal positioning: sniffing, tripoding, refusal to lie
down - Retractions
- Head bobbing
- Nasal flaring
Key components of “circulation to skin” in the paediatric assessment triangle (PAT)
- Pallor
- Delayed capillary refill time (>2 s)
- Mottling
- Cyanosis
- Petechiae
Historical Features Concerning for Child Abuse
- History lacking in details
- Inconsistency—details change with repeated questioning
- History inconsistent with child’s developmental status
- Reported mechanism inconsistent with injury
Physical Examination and Radiologic Findings
Concerning for Abuse
- Any bruises in young pre-cruising infants
- Patterned ecchymosis, burns, or skin marks (abrasions, lacerations)
- Bruises on the ears, trunk, inner thighs, neck, or groin
- Posterior oropharynx bruising or lacerations
- Posterior rib fractures
- Classic metaphyseal fractures
- Any fracture in a non-ambulatory child
- Fractures in different stages of healing
Anatomic Differences (and their complications) in Pediatric Airway Management
💵💵💵MONEY SLIDE💵💵💵
- Large occiput and head → Neck position flexed when laying supine and flat on stretcher
- Large tongue → May occlude airway in the unconscious or obtunded child
- High, anterior airway → Visualization of the vocal cords may be difficult
- Upper airway anatomy and narrow subglottic region → Upper airway prone to dynamic collapse and inflammation (eg, croup)
- Large tonsils and adenoids → Prone to bleeding with manipulation
- Small cricothyroid membrane → Surgical cricothyrotomy difficult
- Large stomach, dependence on diaphragmatic excursion for ventilation → Insufflation of the stomach during BMV can compromise ventilation
Solutions/modifications to airway management necessary to manage the Anatomic Differences in Pediatric Airway Management
💵💵💵MONEY SLIDE💵💵💵
- Large occiput and head → Shoulder roll required for optimal positioning of young infant
- Large tongue → Jaw thrust and oral or nasopharyngeal airway useful adjuncts during airway management
- High, anterior airway → Correct positioning prior to laryngoscopy critical
- Upper airway anatomy and narrow subglottic region → Utilization of uncuffed tubes. (Cuffed tubes safe as long as cuff pressure monitored)
- Large tonsils and adenoids → Blind nasotracheal intubation relatively contraindicated younger than 10 years old
- Small cricothyroid membrane → Needle cricothyrotomy recommended in infants and young children
- Large stomach, dependence on diaphragmatic excursion for ventilation → Use orogastric or nasogastric tube for decompression
discuss the epiglottis and its implications to airway in infants/small children
- Infants and children have large tongues relative to the size of their mouths + a large, floppy epiglottis → obstruction when sedated or obtunded
- manipulation of the epiglottis during laryngoscopy is frequently required to achieve intubation
- straight (Miller) laryngoscope blade may better manipulate the floppy epiglottis
discuss physiologic changes in infants/small children which leads to difficult intubation
- ↑ basal metabolic rate and ↓ FRC → rapid desaturation
- ↑ extracellular fluid volume vs adults → RSI drugs (sedatives and paralytics) need higher per kilogram
doses; their duration of action may be shorter when compared with adults
RSI NODESAT flow levels for infants and children respectively
5 L/min for infants
15 L/min for older children
Age specific changes to Positioning req’d to optimize laryngoscopy view
- neonates and infants → shoulder roll
- toddlers and school age children → flat/no roll
- adolescents → elevation of head similar to adults
discuss needle cricothyrotomy versus surgical cricothyrotomy in infants/children
- needle cricothyrotomy recommended in small children d/t lack of anatomical landmarks in infants and young children
- needle cric should be performed in infants/children (<6 years of age) when landmarks for Open surgical cric cannot be found
- Needle cric is considered an “oxygenation” strategy rather than a “ventilation” strategy. progressive hypercarbia will ensue
- needle cric will provide ~30 to 45 minutes of adequate oxygenation
HOUNDS mnemonic for assessing WOB as part of the pediatric assessment triangle
- Head position
- bObbing: Head bobbing
- Uncooperative
- Nasal flaring
- Drawing/retractions: suprasternal, supraclavicular, intercostal, and subcostal areas
- Snoring / Seesaw respiratory patterns
Gross motor developmental milestones
1 mo → Lifts head 3 mo → Rolls over 6 mo → Sits independently 9 mo → Cruises 12 mo → Walks 15 mo → Goes up stairs 18 mo → Runs 24 mo → Goes down stairs
Fine, social, language developmental milestones
1 mo → Alert to sound and face 3 mo → Smiles, and recognises voices 6 mo → babbles 9 mo → Single words 12 mo → Two words 15 mo → Four words 18 mo → 8 words 24 mo → Sentences (2 word)
discuss and describe issues of “consent” in pediatric patients
- Age of consent — The legal age of majority has become largely irrelevant in determining when a young person may consent to his or her medical treatment. The concept of maturity has replaced chronological age, except in Québec, where the age of consent is 14 years and older
- the child should understand the nature of the proposed treatment and its anticipated effect. The child should also understand the consequences of refusing treatment.
- One way to gauge this capacity is to use the teach-back technique: ask the child to re-phrase what they have just been told and invite the child to ask questions.
- More complex medical situations may require more rigour in determining whether the child understands. It is prudent for providers to also encourage the child to invite a family member to attend the discussion
- The Canadian Paediatric Society requires that the minor demonstrate comprehension of the magnitude of the intervention, the probabilities of harm and benefit, and the consequences of consent or refusal – Royal College of Canada
What’s the 4-2-1 rule for fluids maintenance?
💵💵💵MONEY SLIDE💵💵💵
Maintenance Fluids per hour:
4 mL/kg/hr for first 10 kg body weight
2 mL/kg/hr for second 10 kg body weight
1 mL/kg/hr for each additional kg body weight
ml/kg/min for minute ventilation
100-200mL/kg/min for minute ventilation
Maintenance fluid volume for a 24-hour period based on body weight
- <10 kg — 100 mL/kg
- > 10 kg to 20 kg — 1000 mL for first 10 kg of body weight plus 50 mL/kg for any increment of weight over 10 kg
- > 20 kg to 80 kg — 1500 mL for first 20 kg of body weight plus 20 mL/kg for any increment of weight over 20 kg, up to a maximum of 2400 mL daily
