Neonate and paediatric physiology and resuscitation Flashcards
What age range does paediatric medicine usually cover?
Birth to 14 years (sometimes 18 years)
What is the average weight of a neonate between birth and 1 month?
3.5kg
What is the normal HR range for a neonate between birth and 1 month old?
100 - 160bpm
What is the normal RR range for a neonate between birth and 1 month old?
25 - 50
A neonate’s head is __/__ the total length of its body
1/4
A neonate’s head is __/__ of its body weight
1/3
List some physiological features of a neonate (birth to 1 month)
- Large occiput
- Open fontanelles and unfused sutures
- Soft cranial bones
- Cartilaginous ribs
- Diaphragmatic breathers
- Nasal breathers
- Apnoea and bradycardia occurs under stress (including cold stress and physiological stress)
- Predisposed to hypothermia
What is the significance of the large occiput of a neonate?
Easily hyperextends or hyperflexes and can occlude the airway (sniffing position).
Hormonal changes which instigate onset of labour also commence…
Reabsorption of foetal lung fluid.
Crying of a just-birthed neonate is evidence of…
Significant inspiration and expiration on closed glottis (-ve pressure)
What instigates the closing of the ductus arteriosus and the foramen ovale (foetal valves) and allows pulmonary circulation after birth?
Pressure changes (reduced to pulmonary blood supply); inflates lungs and displaces fluid into lymphatics.
What is triggered by cord clamping/spontaneous umbilical vein constriction?
An increase in systematic blood pressure; the ductus venousus starts to close.
What are some keys to successful interaction when assessing a neonate?
- Likes to be held and kept warm
- Avoid loud noises, bright lights
- May be soothed if allowed to feed
- Warm your stethoscope and hands before touching infant
List the characteristics typical of a neonate during assessment.
- Normally alert, looking around
- Focuses well on the face of the person holding them
- Flexed extremities and responsive to stimulus
- Intact neurology demonstrated by reflexes (Moro, Rooting, Palmar Grasp)
What is the weight range of an infant between 1 and 12 months?
3.5 to 10kg
What is the normal HR range for an infant between 1 and 12 months?
90 to 150bpm
What is the normal RR range for an infant between 1 and 12 months old?
25 to 50
How long does it take for an infant’s birth weight to double?
6 months
How long does it take for an infant’s birth weight to triple?
1 year
List some physiological features of an infant (1 to 12 months old)
- Obligatory nose breathers
- Diaphragmatic breathers
- Cartilaginous vocal chords (easily damaged)
- Thin and pliable chest wall
- Underdeveloped cervical structures
The posterior fontanelle of an infant is closed by…
8 to 10 weeks
The anterior fontanelle of an infant is closed by…
10 to 14 months
When does an infant usually begin crawling?
5 to 12 months
When does an infant usually begin walking?
10 to 18 months
What might a sunken fontanelle indicate?
Poor hydration
What might a bulging fontanelle indicate?
Raised ICP
Is a fontanelle an accurate measure of pulse?
List some keys to successful interactions when assessing an infant.
- Likes to be held by parents
- Place older infants in sitting position
- Examine from toes to head
- Have parent remove one clothing item at a time, then replace
- Distract with a toy, penlight, or stethoscope
- Speak continuously in soft tones
- Perform painful procedures last (only take BGL if absolutely necessary - taken on the sole of the foot in pts <1)
List the characteristics typical of an infant during assessment.
- Normally alert
- Eyes follow examiner
- Slightly flexed extremities
- Rolling over by 4 to 6 months
- Can sit unaided by 4 to 8 months
The term ‘toddler’ spans what age range?
1 to 3 years
What is the normal HR range for a toddler (1 to 3 years)?
80 - 140bpm
What is the normal RR range for a toddler (1 to 3 years)?
25 - 30
List some physiological features of a toddler (1 to 3 years)
- Small and short trachea
- Thin chest walls (breath sound transmission - may hear obstruction in lower lobes when it’s located near the epiglottis, etc)
- High centre of gravity (prone to falls and TBI)
- Larger percentage of fat and cartilage (less likely to suffer serious injury than older children - energy sustained from trauma will dissipate)
- Poor thermoregulation
List some keys to assessing a toddler (1 to 3 years).
- Have parent remove clothing as necessary
- Use appropriate language (“ouchie”)
- Distract with a toy or penlight if necessary
- Avoid needles is possible
- Consider using assessment equipment on parents or other sibling
- Consider early analgesia where injuries are obvious
What are the characteristics typical of a toddler during assessment?
- Normally alert/active
- Does not like to sit still
- May grab at penlight or push hands away
- Can walk by 18 months
What is the age range of a pre-schooler?
4 - 5 years
What is the normal HR range for a pre-schooler?
80 - 140bpm
What is the normal RR range for a pre-schooler?
20 - 30
Pre-schoolers cannot sustain rapid RR for extended periods due to…
Immature intercostal muscles.
What is the difference in oxygen requirement between pre-schoolers and adults/adolescents?
Pre-schoolers have twice the oxygen requirement as adults/adolescents.
Do children have a larger or smaller functional residual capacity (FRC)?
Smaller
Why do children have smaller oxygen reserves?
They have a smaller functional reserve capacity (FRC).
What is the risk of smaller functional reserve capacity (FRC) and therefore smaller oxygen capacity in children?
Hypoxia can develop rapidly.
List some keys to interaction when assessing pre-school children.
- Be honest
- Tell child just before procedure if it will hurt
- Avoid needles if possible
- Keep wounds covered
- Allow child to hide their face
- Distract child with a story (discuss TV show/daycare/school/friends/activities)
- Praise good behaviour and bravery
What are some characteristics typical of pre-school children during assessment?
- Normally alert/active
- Can sit still on request
- Can cooperate with examination
- Understands speech
- Will make up own explanations for anything not understood
What is the age range of primary school children?
6 - 12
What is the normal HR range for primary school age children?
70 - 120bpm
What is the normal RR range for primary school age children?
15 - 25
Around what age do bones lose cartilaginous flexibility?
6
At what age is a child’s airway size and flexibility equal to that of an adult?
10
List some keys to interaction when assessing primary school age children (6 - 12)
- Speak directly to the child
- Explain in simple terms what is wrong
- Always be truthful
- Allow child to participate in examination
- Explain procedures immediately before performing them
What is the age range of an adolescent?
13 - 18
What is the normal HR range of an adolescent?
60 - 100bpm
What is the normal RR range of an adolescent?
15 - 20
At what age is cardiac output equal to that of an adult?
15
List some keys to interaction when assessing adolescents.
- Speak directly to the pt
- Obtain hx from the pt
- Explain the process as to an adult and gain consent
- Interview privately when appropriate
- Be honest
- Encourage questions
- Reassure pt regarding disfiguring injury when possible
- Respect modesty
- Ask friends to comfort pt when needed
What are some characteristics typical of adolescents during assessment?
- Has clear concepts of the future
- Responds positively to respectful attitude
- Can make decisions about care
What is the Luscombe formula?
(age x 3) + 7 = estimated weight
List some considerations for paediatric airway assessment.
- Larger head (prone to flexion)
- Larger tongue
- Nasal breathers <6 months
- Narrow nasal passages
- Lack of hyaline cartilage (easily obstructed)
- Epiglottis more horizontal
- Larynx is higher and more anterior
- Cricoid ring is narrowest part of the airway
- Trachea is short and soft
- Smaller airway diameter (lower threshold for obstruction; airway is ~the size of their pinky finger)
Due to the small diameter of a paed’s airway, minor swelling/oedema can be catastrophic. List four causes of airway swelling in paeds.
- Croup
- Epiglottitis
- Burns
- Inhalational injuries
List some reasons for paed-specific airway adjucts.
- Size of oropharynx
- Large tongue
- Possibility of trauma when turning an OPA
- Tonsils
List four OPA considerations in paeds.
- Proper sizing
- Proper positioning
- If too large, epiglottis becomes obstruction
- If too small, may push tongue into hypopharynx
List some features of paed respiration.
- Increased RR
- Comparitively poor muscle tone (tire easily)
- Increased metabolism and oxygen consumption
- Decreased functional residual capacity
- Increased chest wall compliance
- Decreased lung elastic recoil
What is the significance of decreased functional residual capacity in paeds?
- More prone to hypoxia
- Oxyhaemoglobin desaturation occurs quickly
- Fewer alveoli per surface area
What is the significance of increased chest wall compliance in paeds?
Leads to prominent sternal recession and rib space indrawing when airway is obstructed or lung compliance decreases.
What is the significance of decreased lung elastic recoil in paeds?
Allows intrathoracic pressure to be less negative - reduces small airway patency
List signs of paediatric respiratory distress.
- Rate (first sign)
- Increased effort
- Recession
- See-saw breathing (severe chest retractions on inspiration with expansion of abdomen - serious sign, fatigues quickly)
- Inspiratory/expiratory noises
- Grunting (heard when trying to expire against a closed glottis - increases pulmonary pressure)
- Accessory muscle use
- Head bobbing (using neck muscle to assist breathing - neck muscles not strong enough to hold the head)
- Nasal flaring
- Efficacy of breathing
- Pulse oximetry (may be inaccurate as paeds have reduced peripheral circulation)
List some provisional diagnoses for expiratory wheezing (lower airway obstruction/bronchoconstriction) in paeds.
- Bronchiolitis
- “Reactive airways”
- Asthma in older children
- Note that inspiratory and expiratory wheeze indicates worsening condition
What is a provisional diagnosis for inspiratory wheeze or stridor in paeds?
Airway obstruction
List the signs of imminent respiratory arrest.
- Bradypnoea
- Bradycardia
- Periodic apnoea
- Diminished air movement/silent chest
- Low SpO2
- Decreasing LOC/stupor/coma
- Poor skeletal muscle tone/extreme lethargy
- Cyanosis (central and peripheral)
What are some anatomical features of paed hearts?
Higher in the chest wall with smaller pericardial sack.
A smaller pericardial sack in paeds means they are more prone to what two things?
Cardiac contusion and cardiac tamponade
What is the stroke volume in paeds (mL/kg/beat/min)?
1.5mL/kg/beat/min
What is the stroke volume in adults?
75-90mL/beat
What is the circulating blood volume of a neonate?
90mL/kg
What is the circulating blood volume of a child?
80mL/kg
What is the circulating blood volume of an adult?
70mL/kg
List some signs of poor circulation in paeds.
- Tachycardia
- Bradycardia (late response to hypoxia - pre-terminal)
- Dysrhythmias (uncommon)
- Hypotension (very late sign)
Should BP be relied upon as an indicator of shock in paeds?
What is the significance of an increased surface area and a relatively small body mass in paeds?
Increased potential for dehydration.
Are distal pulses an accurate indicator of shock in paeds?
No; inaccurate due to the ability to vasoconstrict.
True or false: poor capillary refill is an accurate sign of hypovolaemia/hypoperfusion.
What are the signs of hypoperfusion/shock in paeds?
- Tachypnoea
- Mottled/cold/pale skin
- Agitation
- Inconsolable or lethargic
What visual things are checked when assessing cardiovascular state?
- Skin colour
- Muscle tone
- EBL (estimated blood loss)
Where should the pulse be checked when assessing cardiovascular state of a newborn?
Base of the umbilical cord.
How should the pulse be checked when assessing cardiovascular state of a neonate?
Auscultate
Where should the pulse be checked when assessing cardiovascular state of a infant and a toddler?
Brachial
Where should the pulse be checked when assessing cardiovascular state of a toddler/older child?
Radial
What is the equation used to calculate the normal BP of a 1 - 10 year old?
70mmHg + (age x 2) - systolic BP
Are central pulses a good indicator of perfusion in paeds?
List the components of a paediatric CNS assessment.
- Conscious level
- Mental status
- Hypoxic/hypercapnic will be agitated/drowsy
- Posturing
- Painful stimulus may be necessary to stimulate posturing
- Pupils
- Check dilation, reactivity, and equality
- Sensation
- Difficult to assess unless child is verbal
What are the three age ranges of the modified GCS?
- Infant (<1)
- Child (1 - 4)
- Adult (4+)
Is AVPU used in paeds?
Yes, used as per adults except may need to make a judgement call for assessing ‘alertness’ in very young paeds.
List the values of the infant (<1) GCS.
- Eyes
- 4 - open
- 3 - to voice
- 2 - to pain
- 1 - no response
- Verbal
- 5 - coos, babbles
- 4 - irritable cry, consolable
- 3 - cries persistently to pain
- 2 - moans to pain
- 1 - no response
- Motor
- 6 - normal, spontaneous movement
- 5 - withdraws to touch
- 4 - withdraws to pain
- 3 - decorticate flexion
- 2 - decerebrate extension
- 1 - no response
List the values of the child (1 - 4) GCS.
- Eyes
- 4 - open
- 3 - to voice
- 2 - to pain
- 1 - no response
- Verbal
- 5 - oriented, speaks, interacts, social
- 4 - confused speech, disordered, consolable
- 3 - inappropriate words, inconsolable
- 2 - incomprehensible, agitated
- 1 - no response
- Motor
- 6 - normal, spontaneous movement
- 5 - localises pain
- 4 - withdraws to pain
- 3 - decorticate flexion
- 2 - decerebrate extension
- 1 - no response
List the values of the adult (4+) GCS.
- Eyes
- 4 - open
- 3 - to voice
- 2 - to pain
- 1 - no response
- Verbal
- 5 - oriented and alert
- 4 - disoriented
- 3 - nonsensical speech
- 2 - moans, unintelligible
- 1 - no response
- Motor
- 6 - follows commands
- 5 - localises pain
- 4 - withdraws to pain
- 3 - decorticate flexion
- 2 - decerebrate extension
- 1 - no response
What is the significance of paed’s large volume of cerebral blood?
Can lead to cerebral oedema developing rapidly.
What is the implication of unfused sutures and patent fontanelles (<18 months) with regard to ICP?
May accommodate gradual increase in ICP and delay symptoms.
Poor musculature in the neck and back of paeds makes them prone to ____ and ____ injuries.
Flexion and extension.
What is the significance of the thin-walled abdomen in paeds?
Internal organs are not as well protected and prone to injury.
What is the significance of paed bones being soft and pliable?
Less likely to #
Weaker epiphyseal plates of paed bones means…
If # occur, they usually occur along these plates.
True or false: paeds have underdeveloped renal function.
List the manifestations of pain in paeds.
- Vocalisations
- Facial expressions
- Grimace
- Protecting
- Vital sign changes
- Changes in activity/behaviour
True or false: paeds are often under-treated for pain.
Describe the paediatric assessment triangle.
What is the paediatric assessment triangle and what are the main components?
A 30 second initial assessment of a paed to assess criticality; main components are appearance, work of breathing, and circulation [to skin].
Describe the deciphering of the paediatric assessment table.
____% of term babies breathe spontaneously within 10 - 30 seconds of birth.
85%
____% of newborns will require stimulation to breathe.
10%
____% of newborns will require ventilations.
3%
____% of newborns will require longer term respiratory support.
1.9%
____% of newborns will require CPR.
0.1%
How can ventilations encourage newborns to breathe?
Ventilations can cause pressure changes which assist with transition from maternal to neonatal circulation.
What two things should infants in CA secondary to hypoxaemia be initially rx with?
Positive pressure ventilation and oxygen.
When should suction be used in neonate resuscitation?
When there are signs of obvious obstruction.
True or false: high flow O2 should be given before CPR is commenced in neonates.
When is neonatal CPR commenced?
When HR is recognised as being below 60bpm.
What is the compression to ventilation ratio for neonatal CPR?
3:1
How many compressions per minute should be given in neonatal CPR?
90
List the benefits of delayed cord clamping.
- Increased placental transfusion
- Increased cardiac output
- Higher/more stable BP
- Improved pulmonary vascular perfusion and closure of DA
- Improved benefits in pre-term birth
If possible, leave the umbilical cord uncut for ____ ____ to ensure passage of oxygenated blood and reduce the risk of hypovolaemia.
60 seconds
When should only ventilations be given in newborn resuscitation?
If not breathing adequately and/or HR is >100
Describe the pattern in which ventilations should be given if only ventilations are being provided.
Waltz pattern (breath two three, breath two three)
After commencement of newborn CPR, do not cease until…
HR is >60bpm
Note: ? >100bpm in W4S
Should ventilations be continued after newborn CPR has stopped because HR was >60bpm?
Yes - maintain ventilations until good respiratory effort is noted.
What effects does placing babies prone on their mother’s chest been shown to have?
- Increased oxygenation
- Improves tidal volume
- Promotes self soothing
- Contributes to positive neurobehavioural development
At what point should infants be managed as per paediatric CPR guidelines (15:2)?
When they are more than a few hours post birth.
List some common causes of arrest in paeds.
- Hypoxaemia and/or hypotension
- Drowning
- Septicaemia
- SIDS
- Asthma
- UAO (upper airway obstruction)
- Congenital abnormalities of heart/lungs
True or false: VF is a common paed arrest rhythm.
Incidence of VF is 10%, though it often occurs initially with congenital heart conditions.
What is the minimal age for an LMA according to QAS guidelines?
8 years
What is the compression rate of paediatric CPR?
100 - 120bpm
What is the energy level used for paed defibrillation?
4j/kg
What is the paed dosage of IV adrenaline for CA?
10mcg/kg
What is the max dosage of adrenaline for paed CA?
1mg
What is the dose interval for adrenaline in paed resus according to QAS guidelines?
Every 3 to 5 minutes.
What can be given under consult if hypovolaemia is suspected and at what dosage, according to QAS guidelines?
NaCl; 10-20mL/kg, repeated twice according to pts response, max of 60mL/kg.
What are the cares provided after ROSC?
- Continue supportive therapy until there is recovery of function of vital organs/arrival at hospital
- Regular monitoring
- Notification
- Avoid further hypoxaemia
- Maintain normothermia
- Consider glucose control
- Assist parents
What is the formula for dose in volume drug calculations?
What is the most common underlying cause of death of children <1 in Australia?
Perinatal and congenital issues.
What is the most common underlying cause of death for children aged 1 - 14 in Australia?
Land transport accidents.
What is the most common underlying cause of death for those aged 15 - 24 in Australia?
Suicide.
