Mod D Tech 25 Recognition and management of the sick child including SUDICA Flashcards
Anatomy and Physiology of infants and children
- Large tongue
- Large head, short neck
- Small face & mandible
- Narrow nostrils
- Loose teeth
- Delicate soft palate
- High horseshoe shaped epiglottis
Breathing
§Lungs are relatively immature in infancy
§Infants rely on diaphragmatic breathing
§Belly breathing normal in the infant
§Infants immature intercostal muscles therefore tire quickly
§Infants have very compliant walls, reducing ability to splint the chest
§Ribs do not fracture easily – possibility of serious underlying damage
Recognition of Potential
Respiratory Failure
Assess the severity of respiratory difficulty in 3 ways:
- Work / effort of breathing
- Effectiveness of breathing
- Effects of respiratory inadequacy on other organs
Work of Breathing
Signs of increased work:
- Respiratory rate (tachypnoea)
- Recession – intercostal, subcostal, sternal
- Inspiratory or expiratory noises
- Wheezing or grunting
- Use of accessory muscles
- Flaring of alae nasi
- Tracheal tug
Breathing – Assessment and Recognition of Potential
Respiratory Impairment
•Rate
•
Rapid breathing in a child at rest indicates that increased ventilation is due to either airway, lung or circulatory / metabolic problems
A falling respiratory rate in the presence of other parameters worsening is suggestive of exhaustion – this indicates imminent respiratory arrest
Normal Respiratory Rates
Abnormal Values
resp above 40 suggest what
•Resps > 40 breaths per minute suggests respiratory distress in all children except newborns
•
Remember (neonates) newborns normal respiratory rate is 40 – 60 bpm
Respiratory Noises
Inspiratory:
stridor
laryngeal / tracheal obstruction
croup, foreign body, epiglottitis
Expiratory:
wheeze
lower airway obstruction
Asthma
Cardiovascular Effects
- Tachycardia – occurs as a result of shock. In small children it may rise in excess of 200 bpm.
- Bradycardia – occurs as a result of hypoxia and acidosis and is a pre-terminal event
- Pulse volume – diminishes in shock
- •Capillary refill – measured on sternum or forehead
- •Blood Pressure – limited pre-hospital value
Normal Heart Rate
Abnormal Values
A weak, rapid pulse >130 beats per minute suggests
•A weak, rapid pulse >130 beats per minute suggests shock in all children but newborns (norm 120-180bpm)
•
BP = 80 + (age in years x 2)
Persistent tachycardia
is most reliable indicator of what in paeds
Persistent tachycardia
is most reliable indicator of shock.
Cardiovascular signs
Capillary refill
•A delay of more than two seconds in association with other signs of shock and in a warm child suggests poor peripheral perfusion
Effects of Circulatory Failure
on other Organs
- Skin Colour – poor tissue perfusion causes pallor
- Respiratory rate – acidosis will lead to tachypnoea
- Mental state – will be disturbed, classically with initial agitation followed by drowsiness
Pathophysiology of cardiac arrest in children
§Children usually have healthy hearts – unlike adults
§They do not stop easily!
§Commonest cause – hypoxia – acidosis
§Respiratory arrest usually precedes cardiac arrest in children
§The most common arrest rhythm - asystole
§ Initial management geared towards early oxygenation rather than defibrillation
Thermoregulation
§Relatively large surface area – cool quickly
§Small babies poorly developed thermoregulation
§May become hypothermic rather than develop a fever when ill
§Particularly important in trauma situations
Recognition of Potential Central Neurological Failure
Can be rapidly assessed by examination of:
- Conscious level – “AVPU”
- Posture – sick babies are often hypotonic, but meningitis may be stiff with arched back or neck. Decerebrate and decorticate rigidity are rare and have very serious significances
3Pupils – size, shape, reactivity
paeds Hypoglycaemia
§Children, particularly babies prone to hypoglycaemia when sick or injured
§
§Rapid exhaustion of glycogen stores
Decerebrate Rigidity
(Abnormal extension)
Decorticate Rigidity
(Abnormal Flexion)
Intra-abdominal organs
§Liver and spleen less well protected by the ribs, may well extend below the costal margin therefore more susceptible to injury
§
§Bladder higher rises higher out of the pelvis increasing the risk to trauma
SUDICA
A child death is one of the most emotionally traumatic and challenging events that an ambulance clinician will encounter
Resuscitation should always be attempted unless there is a condition unequivocally associated with death or a valid advance directive
Ensure that the family are aware where you are taking their infant/child… this should be the nearest appropriate emergency department, not direct to a mortuary
In unexpected deaths, when appropriate explain to the family that the death will be reported to the Coroner and that they will be interviewed by the Coroner’s Officer in due course
Paediatric Trauma
Causes of death in childhood
- SIDS (“Cot death”) – most common between 1 month and 1 year of age
- •Between the ages of 1 and 4 the cause is equally split between congenital abnormality and trauma
- •In the UK Trauma is the most frequent cause of death after 1 year of age
(Advanced Paediatric Life Support, ALSG)
Anatomical Considerations
Anatomical Considerations - Airway
Physiological Considerations
paeds trauma Assessment
•SCENE (“First 5”)
•
•<c>ABCDE</c>
paeds trauma Airway
paeds truama
Breathing
Circulation
- Arrest any significant external bleeding
- Assess skin colour and temperature
- Capillary refill (sternum or forehead)
- Assess pulse rate and volume
- Signs of shock unlikely until at least 25% blood volume is lost
Disability / Level of Consciousness
- Note initial LOC on the “AVPU” scale
- If the patient does not score “A” then consider them time critical
- Assess pupils
- Note any spontaneous limb movements
- Ask the patient to “wiggle” their fingers and toes
- Measure blood glucose level in any child with altered LOC
- Confusion or agitation in the child may arise directly from head injury or secondary to hypoxia from airway impairment, impaired breathing or hypovolaemia.
- After initial AVPU assessment, use revised GCS
- Note any changes no matter how slight
- Children loose heat rapidly – Keep warm!
Paeds Head Injuries
•Children often fall head first
•
•Must prevent secondary injury due to hypoxia by adequate management of:
•
A + B = 100% Oxygen
–
•Vomiting is common with paediatric head injuries so prevent aspiration and monitor GCS regularly
Paeds Head Injuries
- The skull sutures fuse at approx. 12 – 18 months.
- Large intracranial bleeds can be accommodated without obvious abnormal neurological signs
- Deteriorating conscious level or development of unequal pupils mandates urgent removal to hospital
Paeds Chest Injuries
- Fractured ribs and flail segments are rare in children
- Pneumothoraces and pulmonary contusions are more common – Tracheal deviation difficult to see due to chubby necks
- Be aware of the signs and symptoms of respiratory distress
Paeds Spinal Injuries
- Rare, but can be catastrophic if present
- Treat the same as for an adult
- Pad under the shoulders to aid neutral positioning
- Consider manual immobilisation
Paeds Abdominal Injuries
- Blunt trauma is the second leading cause of death in children
- Skeleton protects abdominal organs less well in a child
- Thin abdominal wall transmits forces easily
–internal injuries without external signs
- GENTLE palpation
- Think SHOCK
Extremity Injuries
- Bones are less likely to fracture
- Bones are able to absorb more force so underlying damage may be more severe
- Rapid healing of fractures
- Injuries to the growth plate can result in permanent deformity
Extremity Injuries
- Long bone fractures Significant blood loss
- Open fracture – doubles the blood loss
Thermal Injuries
- Burns and scalds are relatively common in children
- Consider NAI if the mechanism of injury and/or history do not match the sustained injury
- The Rule of Nines does not work in children <14years – use palmar surface
- Burns >10% TBSA = Time Critical
