Pediatric CPGs Flashcards
What is the maximum age for which the Broselow tape and associated pediatric calculations are typically designed?
Up to 12 years
What are the criteria under BCEHS CPGs for a patient to be considered pediatric
- Age ≤ 12 years (i.e. 13 years + 1 second = adult)
- No signs of puberty (i.e. signs of puberty = adult)
These criteria do not apply to matters of consent, only clinical practice
Which patients are appropriate for use of the Pedi-Mate
Patients with weight 10-40 lbs. (5-18kg)
Corresponds to children 6mths - 4 yrs
What are the three components of the Pediatric Assessment Triangle (PAT)?
- General Appearance
- Work of Breathing
- Circulation to the Skin
What is the most common precipitating factor in cardiac arrest in the pediatric population?
Respiratory compromise
List up to 12 signs of respiratory distress in pediatrics
- Rapid or slow respirations
- Nasal flaring
- Retractions
- Accessory muscle use
- Pale appearance
- Decreased breath sounds
- Mottled skin
- Grunting
- Stridor
- Wheezing
- Cyanosis
- Bradycardia
A mandatory step in the assessment of any pediatric patient with the potential of respiratory distress is:
expose the chest
Qualitative indicators of shock are _________ (more/less) sensitive than quantitative measures in pediatrics
Qualitative measures include skin color changes, changes in mentation, falcidity, etc.
MORE!
- Hypotension is a LATE and extremely ominous sign of decompensation in chlidren
List up to seven indicators of shock in pediatrics
- Tachycardia/bradycardia
- Pale/cool/mottled skin
- Capillary refill > 2 seconds
- Narrowing pulse pressure
- Tachypnea
- Relative flaccidity
- Change in level of consciousness (LOC) – especially failure to recognize/respond to carer(s)
A child may lose up to _____% of their blood volume before becoming hypotensive in shock
25%
What are three strategies for estimating ETT size in children?
- Compare to child’s little finger
- Compare to child’s nare
- Use formula
- (age/4 + 4) = uncuffed tube size
- (age/4 + 3) = cuffed tube size
What are rough guidelines for laryngoscope blade size in children?
- <1yrs = #1 straight blade (miller)
- 1-4yrs = #2 blade
- >4 yrs = #3 blade
An SBP <90 is often used as a rough indicator of shock/hypoperfusion in adults. What values of SBP are used to indicate shock in pediatrics?
- Neonates (0-28 days)
- <60mmHg
- Infants (1-12 months)
- <70mmHg
- Children (1-10 yrs)
- < 70 mmHg + (2x age in years)
- Ex: 5yr old = 70 + (2 x 5) = 80mmHg
- Children/adolescents (10+ years)
- <90mm Hg
What is the primary cause of cardiac dysfunction in the majority of pediatric cases?
repiratory failure
What are the CPG-accepted age ranges for neonates, infants, and children?
- Neonates (0-28 days)
- Infants (29 days - 1 year) / (1-12 months)
- Children (1 - 12 years)
Sinus arrhythmia is _______ (more/less) pronounced in pediatrics than adults
Sinus arrhythmia is more pronounced
Describe sinus arrhythmia in children
- Marked variation in HR with respiratory cycle
- HR increases with inhalation and decreases with exhalation
- more pronounced in children than adults
What is the significance of a tachycardia >180bpm in a child or >220bpm in an infant/neonate.
tachycardias at these rates are unlikely to be sinus or compensatory in nature. Primary cardiac intervention is likely required
A child with stable WCT ________ (should/shouldn’t) receive cardioversion in the field
shouldn’t
Wide complex tachycardia (QRS > 0.08 seconds) in a conscious pediatric patient with adequate perfusion and a heart rate > 150 bpm is probably in stable ventricular tachycardia and requires support with oxygen, continuous cardiac monitoring, and conveyance to ED, with equipment for electrical cardioversion immediately available
Describe treatment for pediatric patients with bradycardia <60bpm and signs of poor perfusion
(Signs of poor perfusion include cyanosis, mottling, decreased LOC, and lethargy)
- Ensure maximal oxygenation and bag-valve mask ventilation is provided
- If heart rate remains < 60 bpm for 30 seconds of effective oxygenation and ventilation, begin chest compressions
- Epinephrine 0.01 mg/kg IV/IO is indicated for bradycardia unresolved by oxygenation, ventilation, and chest compressions
- Atropine or TC pacing may be appropriate under certain conditions
Is it reasonable to provide chest compressions to an 8-year-old with a pulse?
YES!
In a pediatric patient with a HR < 60 bpm coupled with poor perfusion, CPR is indicated. Ensure maximal oxygenation and bag-valve mask ventilation is provided. If heart rate remains < 60 bpm for 30 seconds of effective oxygenation and ventilation, begin chest compressions. Signs of poor perfusion include cyanosis, mottling, decreased LOC, and lethargy.
When should CPR be initiated in a bradycardic, pediatric patient with a pulse?
- After 30 seconds of attempts to optimize oxygenation/ventilation with no improvement in condition
Describe treatment of unstable NCT in pediatric patients
- Vagal Maneuver
- Adenosine
- (do not use if patient is prescribed carbamazepine or dipyramidole)
- Synchronized Cardioversion
- initial at 1J/kg, repeat at 2 J/k
This differs from management in adults, where unstable NCT is treated with urgent PSA and cardioversion
Describe treatment of unstable WCT in pediatric patients
- Vagal maneuver
- Synchronized cardioversion
- Initial at 0.5 – 1 J/kg, repeat at 2 J/kg
Is atropine indicated for unstable bradycardia in pediatric patients?
Yes!
Only if increased vagal tone suspected
Describe a general approach to the management of Bradycardia in Pediatric patients
- Asymptomatic: no treatment required
- Consider crystalloid bolus if no cardiac history
- Unstable bradycardia
- EPINEPHrine
- Atropine – if increased vagal tone suspected
- CliniCall consultation required prior to repeat dose Q 3-5 min to a maximum total dose of 0.4 mg/kg or 1 mg, whichever is less
- Transcutaneous pacing
- CliniCall consultation required prior to pacing
- In a pediatric patient with a HR < 60 bpm coupled with poor perfusion, CPR is indicated
The sudden, unexplained appearance of respiratory symptoms (such as apnea), change in colour or muscle tone, and/or altered responsiveness in a young child/infant is known as a _________
BRUE (Brief Resolved Unexplained Event)
or
ALTE (Apparent Life Threatening Event)
A BRUE/ALTE is most likely to occur during which period in a child’s life?
Events typically occur in children < 1 year with peak incidence at 10 to 12 weeks.
Describe general principles of IV fluid administration in children
- Fluid may be given in 5-10mL/kg boluses, to a maximum total of 20mL/kg
- Maintenance infusions may be calculated using the 4-2-1 rule:
- 4 mL/kg/hr for the first 10 kg of weight
- 2 mL/kg/hr for the next 10 kg
- 1 mL/kg/hr for each kilogram thereafter
The initial signs of shock are often ________ (subtle/obvious) in children/infants.
The initial signs of shock may be subtle in children and infants as their compensatory mechanisms are very effective.
When is shock considered to be compensated in pediatric patients?
As long as the compensatory mechanisms are able to maintain a systolic BP within an age-appropriate normal range, the shock is considered compensated.
What is the particular significance of classic signs of shock (tachycardia, hypotension, pallor, cold extremities, ALOC) in children?
These are signs of decompensated shock, cardiopulmonary arrest may be imminent
What are the 3 primary components of the pediatric assessment triangle?
- Appearance
- Work of Breathing
- Circulation to Skin
What are the components of the TICLS acronym, and when is this acronym used?
TICLS is an acronym used to systematically assess the “appearance” component of the pediatric assessment triangle.
-
Tone
- Vigorous to limp
- Normal children of all ages, including newborns should have Muscle tone
-
Interactiveness
- Engaged to unintererested
-
Consolability
- Content to unconsolable
-
Look or gaze
- Gaze follows to glassy eyed stare
-
Speech or cry
- Spontaneous speech to wimper
What are the four classic abnormal findings in the “work of breathing” component of the pediatric assessment triangle?
- Abnormal airway sounds
- Grunting
- Stridor
- Wheezing
- Abnormal positioning
- Tripod position
- Sniffing
- Head Tilt (consider Retropharyngeal Abscess, Epiglottitis)
- Intercostal or neck retractions (or head bobbing in infants)
- Nasal Flaring
What are the three classic abnormal findings in the “circulation to skin” component of the pediatric assessment triangle?
- Pallor
- Mottling
- Cyanosis
What are the four major categories of respiratory disorders in children?
- upper airway obstructions
- ex: foreign body, tissue swelling (croup/epiglottitis/anaphylaxis), subglottic stenosis from previous intubation trauma, tumour
- lower airway obstructions
- ex: foreign bodies, bronchial swelling or constriction
- lower airway restrictive pathology
- ex: pulmonary edema, toxic exposure, allergic reactions, infiltration, inflammation, abdominal structures pushing on lung tissue
- disordered control of breathing
- ex: increased intracranial pressure, neuromuscular disease, and some poisonings and overdoses
Continuous salbutamol administration is associated with which electrolyte imbalance?
hypokalemia
Describe pediatric salbutamol dosing by MDI and nebulizer
- MDI
- < 10 kg: not indicated
- 10-20 kg: 5 x 100 mcg per course; may repeat up to 3 times
- > 20 kg: 10 x 100 mcg per course; may repeat up to 3 times
- Nebulizer
- Via nebulizer
- Age < 1 year: 2.5 mg
- Age ≥ 1 year: 5 mg
Describe treatment options for pediatric patients with severe bronchoconstriction and hypoxemia refractory to Salbutamol and supplemental oxygen.
- IM Epinephrine
- 0.01 mg/kg IM to a maximum of 0.5 mg
- MDI Ipratropium
- Dosing not specified, contact clinicall
- Magnesium sulfate
- 50 mg/kg IV/IO infused over 15 minutes
- Procedural Sedation or Anesthesia Induction, in anticipation of;
- Endotracheal Intubation
Nebulized epinephrine is indicated for use in __________ (croup/epiglottitis/both)
Croup only!
Nebulized epinephrine is not indicated for epiglottitis.
The “three Ds” of epiglottitis are:
- Drooling
- Dysphagia
- Distressed breathing
With regards to croup and epiglottitis, which is associated with an abrupt vs a gradual onset?
Epiglottitis generally has an abrupt onset, while the onset of croup is slower and is generally associated with a prodromal history of viral symptoms
Differentiate between classic findings of croup and epiglottitis in terms of onset, common symptoms, infectious agent, and typical age of patients
- Onset
- Croup: gradual with viral prodrome
- Epiglottitis: abrupt
- Common symptoms
- Croup: barking cough +/- stridor, fever, nasal congestion
- Epiglottitis: drooling, dysphagia, and distressed breathing. Coughing is rare. tripod/sniffing is common
- Infectious agent
- Croup: usually viral
- Epiglottitis: usually bacterial, but may be viral or fungal
- Typical age
- Croup: 6 months to 3 years (very uncommon past 6 years)
- Epiglottitis: 2 to 6 years (although increasingly common in adults)
Is the presence or absence of fever an effective tool in differentiating between croup and epiglottitis?
No!
Fever may be present in either, and may be mild or severe in either case!
Inflammation from croup which spreads to the entire respiratory tract is known as:
laryngotracheobronchitis
Epiglottitis is increasingly rare due to routine ___________ vaccination in childhood. Vaccination status should therefore be confirmed when assessing for upper airway disease.
Haemophilus influenzae type B (Hib)
Describe epinephrine dosing in pediatric patients with croup
- 5 mg by nebulizer mask
- If under 1 year of age: 0.5 mg/kg to a maximum of 5 mg
- Total volume of fluid in nebulizer mask should be 5 mL
Is acetaminopohen indicated for antipyresis in croup/epiglottitis? If so, describe dosing
yes!
- < 30 kg: 15 mg/kg PO (use liquid preparation)
- 30-50 kg: 500 mg PO (may use liquid preparation or tablets, depending on patient ability)
- > 50 kg: 500-1,000 mg PO
- May repeat once after 4 hours
- 24 hour maximum: 75 mg/kg or 1 g
- Do not exceed 5 doses in 24 hours in patients < 12 years of age
At what age do children most commonly present with febrile seizures?
between six months and five years
How is status epilepticus defined in children?
As it is in adults – a series of two or more seizures without a recovery of consciousness in between, or a seizure lasting longer than five minutes
Patients who continue to seize on arrival of paramedics or EMRs/FRs should generally be considered as being in status epilepticus.
The leading cause of death in children is:
trauma
children have a _________ (higher/lower) risk of C-spine injury compared to adults
Higher!
Children are at higher risk for cervical spine injury because of their larger, heavier heads, and weakly developed spine and neck muscles.
The preferred choices for analgesia in pediatric trauma are:
opiates/ketamine
Nitrous oxide is less effective but can also be used due to license level, unless contraindications exist.
Children are _______ (more/less) likely to die from isolated pelvic fractures than adults
Less!
Unlike adults, children rarely die from isolated pelvic fractures. If hemodynamic instability exists in what appears to be an isolated pelvic fracture, look for other causes of blood loss.
What are target values for SBP for children requiring fluid resuscitation?
- < 28 days; > 60 mmHg
- 1-12 months; > 70 mmHg
- 1-10 years; > 70 mmHg + (2x age in years)
- 10 years to adulthood; > 90 mmHg
