Pediatric Slides Flashcards
Research shows that families cope ________ (better/worse) when they are included in resuscitation
better!
Give the age range for neonates, infants, toddlers, and children
- neonates: 28 days or less
- infants: 29 days to 1 year
- Toddlers: 1 to 3 years
- Children: 3 to12 years
The normal average circulating volume of a neonate is:
Is this higher or lower than an adult in proportion to body weight?
75-90ml/kg
Proportionally higher! But still really small…
BGl in neonates is ________ (stable/unstable)
unstable!
A good indicator of fluid status in nenates/infants is:
number of wet diapers.
Ask parents what is normal for the child.
Low for first week, then 6-8/day is normal
The age group most strongly associated with stranger anxiety is:
Toddlers (1-3 years)
In what age group do children start to generally become more verbal and interactive, and are able to voice their chief complaint?
Pre-schoolers (3-6 years)
children aged 6-12 years generally ______ (can/can not) accurately describe and rate their pain
Can!
Describe anatomical differences between childrens’ heads vs. adults
- Relatively larger/more massive
- increased risk for trauma
- tend to fall head first
- More area for heat loss
- Fontanelles open (up to 1-2 months)
Describe differences in the neck and airway structures of children vs. adults
- shorter, fatter necks
- airway is much smaller
- Poiseuille’s law is important, more resistance to airflow
- more at risk of occlusion
- disproprtionately large tongue
- cricoid cartilage is obscured by thyroid
- cric difficult in age <3yrs
- airway is mroe anterior, caudal, and funnel shaped with large, mobile epiglottis
Describe differences in the chest and lung structures of children vs. adults
- Chest wall is thinner - trauma possible
- Less muscle and subcutaneous fat
- Heart sounds dominant on auscultation
- Rib cage is more compliant.
- Belly breathing is normal as diaphragm is a muscle of
- respiration
Cardiac output in children is primarily driven by:
heart rate
Describe differences in the abdominal structures of children vs. adults
- Abdominal distension normal
- Weak abdominal wall muscles
- Up to age 3 some solid organs including liver and spleen extend below the ribcage - increased risk of trauma
What are the 3 main components of the pediatric assessment triangle?
- General Appearance
- Work of Breathing
- Circulation to skin
What are the components of the TICLS mnemonic and when is it used?
TICLS is used to assess the General Appearance of the child as part of the PAT
- Tone
- Interactiveness
- Consolability
- Look/gaze
- Speech/cry
Describe normal and abnormal findings with regards to the “T” component of TICLS
Tone (muscle tone)
- Normal: Good muscle tone with good movement of the extremities. Infants should strongly resist attempts to straighten their limbs.
- Abnormal: Limp, rigid, or absent muscle tone
Describe normal and abnormal findings with regards to the “I” component of TICLS
Interactiveness
- Normal: Strong, normal cry (this is a reliable sign of a
clear airway) - Abnormal: Crying is absent, or abnormal. The child
cannot be stimulated to cry. In addition to indicating
an altered mental status, this may also be a sign of an
occluded airway.
Describe normal and abnormal findings with regards to the “C” component of TICLS
Consolability
- Normal: The child is able to be consoled by usual caregivers. The child responds in his or her usual way to environmental stimuli.
- Abnormal: The child cannot be consoled or comforted by usual caregivers. The child does not respond normally to environmental stimuli, like preferred toys
Describe normal and abnormal findings with regards to the “L” component of TICLS
Look/gaze
- Normal: Child is able to make eye contact
- Abnormal: Vacant stare with lack of eye contact. The child may not seem to recognize normal caregivers.
Describe normal and abnormal findings with regards to the “S” component of TICLS
Speech/cry
- Normal: The child expresses himself or herself age-appropriately. Speech (or crying) is normal (this is a reliable sign of a clear airway).
- Abnormal: The child is unable to express himself or herself age-appropriately. Speech (or crying for babies) is absent or abnormal. As
with lack of crying in infants, this can be a sign of an occluded airway.
What are the 4 classic abnormal findings in the Work of Breathing component of the PAT?
- Abnormal Sounds
- stridor, grunting, and wheezing
- Abnormal Positioning
- Retractions
- Nasal Flaring
What are the three classic signs of impaired Circulation to Skin in the PAT?
- Pallor
- Mottling
- Cyanosis
Also check for dry mucus membranes or reduced urine output
For children with Respiratory Distress (not failure), which categories of the PAT would be normal and which would be abnormal?
Respiratory distress
- General Appearance
- Normal
- Work of Breathing
- Abnormal
- Circulation to Skin
- Normal
For children with Respiratory Failure, which categories of the PAT would be normal and which would be abnormal?
Respiratory Failure
- General Appearance
- Abnormal
- Work of Breathing
- Abnormal
- Circulation to Skin
- Abnormal
For children with Shock, which categories of the PAT would be normal and which would be abnormal?
Shock
- General Appearance
- Normal or Abnormal
- Work of Breathing
- Normal
- Circulation to Skin
- Abnormal
For children with CNS or metabolic disturbance, which categories of the PAT would be normal and which would be abnormal?
CNS or metabolic disturbance
- General Appearance
- Abnormal
- Work of Breathing
- Normal
- Circulation to Skin
- Normal
For children with Cardiopulmonary failure, which categories of the PAT would be normal and which would be abnormal?
Cardiopulmonary Failure
- General Appearance
- Abnormal
- Work of Breathing
- Abnormal
- Circulation to Skin
- Abnormal
What is a normal central capillary refill time in a child?
2-4 seconds
Is SBP or MAP preferred as a metric of perfusion in children?
SBP!
It is a better predictor of clinical course
What formula is used to estimate children’s weight based on their age?
2 x age + 10kg
(also listed as 2 x age + 7,8, or 9 in other sources and CPGs)
Pediatric patients are often ________ (overdosed/underdosed) with regads to pain management
underdosed!
What are non-verbal signs of pain in children?
- Pallor
- Inconsolability
- Tachycardia
- Tachypnea
- Avoiding contact or movement
Gold standard for pain control in children is:
opioids!
Children ______ (do/do not) respond well to NSAIDS
do!
Describe particulare risks for opioid use in children
- more MU receptors means more risk of resp depression
- Less reserve means more likelihood of hypoxia
IM administration of Fentanyl _________(is/is not) recommended in pediatrics
is not!
If vascular access is unavailable, the preferred route of administration for fentaNYL is intranasal – intramuscular absorption rates are inconsistent in children.
Describe Fentanyl dosing for analgesia in pediatric patients
- Loading dose: 1.5-2.0 mcg/kg IN; maximum single dose 100 mcg
- Loading dose: 1-2 mcg/kg IV/IO; maximum single dose 50 mcg every 5 minutes as required; total maximum dose of 200 mcg
- Maintenance dose for long conveyances: 0.75-1.5 mcg/kg IN every 10 minutes as required; maximum total dose of 150 mcg/hour
- Maintenance dose in long conveyances: 0.5 mcg/kg IV/IO every 10 minutes as required; maximum total dose of 150 mcg/hour
- FentaNYL is preferred for pain management over ketamine or methoxyflurane
Describe use of Ketamine, as well as dosing for pain management in children
Analgesia (Aged > 6 months)
Not a first line for pain - but valid second line after opiod use
- Intravenous/Intraosseous
- 0.3 mg/kg slow push
- Maximum single dose 20 mg
- Repeat every 2-3 minutes to a total cumulative dose of 0.6 mg/kg
- Intramuscular
- 0.5 mg/kg
- May repeat 0.3 mg/kg at 45 minutes
- Intranasal
- 1.5 mg/kg
- May repeat 1 mg/kg at 20 minutes
- Maximum single dose 100 mg
A “Load and Go” approach to prehospital pediatric care _____ (is / is not) best practice
is NOT!
stay and play is better
What is the weight range for the Pedi-Mate device?
10-40 lbs (5-18kg)
What is the definition of Status epilepticus in children?
Status epilepticus is defined as a seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures, and can be life threatening requiring emergent treatment
What are the criteria for SIRS in children?
- Temperature >38.5 OR < 36
- Tachypnea greater than 2SD for age
- Tachycardia greater than 2SD for age
- WBC elevated or depressed for age, OR >10 percent neutrophils
Note that SBP is NOT a component of the sirs criteria
How is SIRS differentiated from Sepsis?
Sepsis is SIRS + confirmed or suspected infection
SIRS criteria are:
- Temperature >38.5 OR < 36
- Tachypnea greater than 2SD for age
- Tachycardia greater than 2SD for age
- WBC elevated or depressed for age, OR >10 percent neutrophils
The most common presenting syndrome in pediatric diabetes is:
DKA
What kind of event often precedes the first instance of DKA?
Febrile illness
The most significant life-threatening complication of DKA is:
Cerebral edema
Describe electrolyte changes in early and late DKA
- Early
- Hyperkalemia: lack of insulin prevents potassium uptake into cells and leads to high serum potassium despite overall decrease in total body potassium from diuresis
- Hyponatremia: both due to diuresis and dilution by glucose
- Late
- Hypokalemia AND hyponatremia
- Cells become potassium-depleted, total body potassium is very low. Signals severe disease!
What are the biochemical criteria for DKA?
- Hyperglycemia
- Serum glucose >11 mmol/L
- Acidosis
- Venous pH <7.3 or Bicarbonate <15mmol/L
- Ketosis
- Presence of ketonaemia/ketonuria
Why should fluid administration be done with caution in children with DKA?
to avoid cerebral edema
What are classic signs/symptoms of DKA in children?
- Warm, dry skin
- Recent Hx of increased thirst
- Polyuria
- DLOC or lethargy
- Hyperventilation (kussmaul)
What are three reasons that infants are more susceptible to hypothermia than adults?
- Larger surface area to body mass ratio
- Inability to shiver
- Smaller glycogen stores
Children with sepsis may require up to __________ volume of fluid in the first hour of fluid resuscitation
60mL/kg!
Note that volumes above 20mL/kg are not supported by BCEHS CPGs
What is the key difference between sepsis and septic shock?
Septic shock includes prolonged signs of impired end organ perfusion and hypotension
hypotension is not a component of SIRs Dx
What is the main cause of traumatic death in children?
TBI
Larger, heavier head, with softer bone structure
C-Spine injuries are ________ (more/less) common in children than adults
more!
- C spine injuries more common due to higher fulcrum of head
- Spinal ligaments more lax
How does thoracic trauma in children typically differ from that in adults?
- Structures of chest more flexible, structures larger
- Pulmonary contusions more common
- Tension pneumo much less common
- Rib fx less common with internal injury
Describe anatomical differences of pediatric abdomens that are important in trauma
- Intra-abdominal organs relatively large, diaphragmatic rupture more common
- Less musculature, less space for force to dissipate
- Liver and spleen larger, extend below rib cage
Strains/dislocations are _____(more/less) common in children than adults
less!
ligaments and tendons relatively stronger
What is the most common MOI in pediatric trauma?
Falls
Desccribe key differences between pediatric vs. adult trauma management
- HR/RR and other components of the PAT are better indicators of shock than SBP or MAP
- Temperature management and avoidance of hypothermia are particularly important
- ETI should be avoided unless >15 minutes from trauma hospital
Death from pelvic injury in children is __________(more/less) common than in adults
Less!
If shock is present, other sources of bleeding should be assumed
How is the shock index modified in children?
tolerance for slightly higher shock index in young children
- 1-6 years: >1.2
- 6-12 years: >1.0
- 12+ years: >0.9
What are the pediatric trauma bypass criteria for Vancouver?
Everyone under 17 yrs to BCCH
17yrs+ to VGH
How do pediatric SMR guidelines vary from adults in BC?
simplified SMR is never wrranted! Always use full SMR if spinal injury is suspecrted
Is the KED appropriate for pediatric SMR?
No!
Only for extrication! The KED should be removed for transport with Pt placed on clamshell
What is the highest priority (other than hemorrhage control) in pediatric penetrating traumatic arrest?
Immediate transport!
What amount of BSA burn is considerd severe in pediatrics?
15-20%
Describe the FACADE acronym for pediatric burn management
- First Aid
- Cool for 20 minutes
- Analgesia
- Clean
- Assess
- Dress
- Elevate
How long after a burn is sustained does active cooling remain an effective intervention?
up to 3 hours!
Even if the burn is not brand new, it should be cooled for 20 minutes
Describe the modified rule of nines for pediatric patients
- Head is 18% BSA
- Anterior torso is 18% BSA
- Posterior torso is 18% BSA
- Each arm is 9% BSA
- Each leg is 14% BSA
Describe the 4:2:1 rule for pediatric IV fluid maintenance
- 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
What is the Parkland burn formula and when is it used?
used to calculate fluid resuscitation requirements in burns
4mL x BSA of burn x Weight in kg
(2nd and 3rd degree burns only, first 1/2 given in first 8 hrs, second 1/2 over 16 hrs)
Why do children with respiratory emergencies decompensate more quickly than adults? (6 reasons)
- Airway is small and, with its narrowest point in the subglottic area, big tongue and epiglottis
- A cone-shaped larynx is a likely site for obstruction.
- Thoracic cage in infants is soft, with the ribs positioned horizontally, a mechanical disadvantage for chest expansion.
- Less energy stores in infants, the diaphragm fatigues easily.
- Immature nervous system often triggers bradypnea/apnea.
- Lower airways are small and compliant and easily prone to obstruction.
The risk of respiratory failure ______ (increases/decreases) with age
decreases!
The incidence of respiratory failure in pediatrics is inversely related to age. Two thirds of the cases of respiratory failure in children occur in the first postnatal year, and one half are seen in the neonatal period
What PAT findings may help distinguish respiratory DISTRESS from respiratory FAILURE?
Distress manifests as WOB findings only (abnormal posture, abnormal sounds, retractions, nasal flaring) whereas failure includes adverse findings from general appearance (TICLS) and circulation to skin
What does bradycardia signify in pediatric respiratory distress?
Cardiac arrest is imminent!
The pathogen which most commonly causes croup is:
RSV
Respiratory Syncytial Virus
Croup which spreads to the entire respiratory tract is known as
laryngotracheobronchitis
A common prodrom to croup is:
Signs of viral infection / URI
What is the significance of stridor in croup?
It signifies moderate to severe disease!
mild croup often has no stridor, while stridor may be difficult to hear when cardiorespiratory arrest is imminent
What are the “three D’s” of epiglottitis?
- Drooling
- Dysphagia
- Distressed breathing
Is intubation typically recommended in children with severe epiglottitis?
NO!
Avoid unless absolutely necessary!
While both Croup and Bacterial Tracheitis may present with barking cough, what component of presentation suggests tracheitis?
Toxic appearance
What are normal age ranges for Croup, Epiglottitis, and bacterial tracheitis?
- Croup: 6 months to 3 years (up to 6 years in some sources)
- Bacterial Tracheitis: 3 months to 13 years (more common in 3-5YO)
- Epiglottitis: Any age, but most common in 2 years +
Lower airway obstruction, typically caused by RSV infection in children <2 yrs old is commonly called:
Bronchiolitis
The most common cause of pneumonia in children is
Streptococcus pneumoniae
Give ROUGH age-specific criteria for tachypnea
Roughly….
- Neonates = 60
- Infants = 50
- Toddlers/preschoolers = 40
- Children = 30
In detail….
- <2 months (34–50 = normal)
- 60 = tachypnea
- 2–12 months (25–40 = normal)
- 50 = tachypnea
- 1–5 years (20–30 = normal)
- 40 = tachypnea
- >5 years (15–25 = normal)
- 30 = tachypnea
Describe the BCEHS-endorsed induction strategy for ETI in children
- Fluid bolus (20mL/kg IV/IO)
- Ketamine (1mg/kg IV/IO)
IF signs of hypoperfusion present (SBP
- Push dose Epinephrine (1mcg/kg SLOW IV/IO)
- Reduce ketamine dose by 1/2
Maintenance by 1/2 dose induction of ketamine or midazolam (0.1mg/kg)
What are the suggested definitions for drowning according to the Utstein guidelines?
- primary respiratory impairment from submersion or immersion in a liquid medium
- Classify drowning as “fatal” or “non-fatal”
- Avoid confusing terms like “near drowning” or “dry drowning”
What formula is used to determine the minimum acceptable SBP in children?
SBP = 70mmHg + (2 x age in years)
Only exception is neonates: use 60 mm Hg as cut-off
What are causes of hypovolemic shock in children?
- Whole blood loss
- Plasma Loss
- Fluid/electrolyte loss
What are causes of Distributive shock in cildren?
- Sepsis
- Anaphylaxis
- Spinal injury
- Neurogenic shock
What are causes of cardiogenic shock in children?
- Peri/myocarditis
- Arrhythmia
- metabolic causes
What are causes of obstructive shock in children?
- Tamponade
- Tension pneumothorax
- Pulmonary hypertension
What are signs of decompensated shock in children?
- Progressively more abnormal TICLS findings
- Marked tachycardia or bradycardia (peri-arrest)
- Oliguria or Anuria (wet diapers?)
- Hypotension (SBP < 70 + 2 x age)
- very long cap refill
What is a general treatment strategy for bradycardia in children?
- Correct oxygenation/ventilation FIRST! (MRSOPA)
- If not improvement after 30s with HR<60:
- BEGIN CPR
- Epinephrine preferred over atropine unless increased vagal tone or primary AV block are suspected as the underlying cause
- Epinephrine in 1 mcg/kg IVP q.2-3 minutes
- Consider pacing if complete heart block is discovered on ECG or there is a history of congenital or acquired heart disease
What are the minimum heart rates in neonates or children where a tachycardia should be treaed in the field?
- 220bpm for neonates
- 180bpm for children
When the rate is less than this, the tachycardia is likely compensatory or due to some other cause, and is unlikely to be the cause of the child’s symptoms
Describe treatment of Narrow Complex Tachycardia in Children
Tachycardia should be >180bpm in children or >220bpm in neonates!
- Stable
- Find underlying cause
- Give fluid and transport!
- Unstable
- Vagal maneuver
- Adenosine
- 0.1 mg/kg then 0.2mg/kg (MAX of 6 and 12 mg)
- Synchronized cardioversion
- 1J/kg then 2J/kg
Describe treatment of Wide Complex Tachycardia in children
Tachycardia should be >180bpm in children or >220bpm in neonates!
- Stable
- Find underlying cause
- Give fluid and transport!
- Unstable
- Adenosine
- 0.1 mg/kg then 0.2mg/kg (MAX of 6 and 12 mg)
- Synchronized cardioversion
- 0.5-1J/kg then 2J/kg
What is the compression/breath ratio for CPR in children (not neonates)
- 15:2 with no advanced airway
- Continuous compressions with RR of 20-30bpm if advanced airway in place
Describe Epinephrine dosing in pediatric cardiac arrest
- 0.01mg/kg q.3-5 minutes IV/IO (MAX 1mg)
if no V/IO access
- 0.1mg/kg q. 3-5 minutes ETT (MAX 2.5mg)
What are pediatric defibrillator doses of energy?
2J/kg followed by 4J/kg
Are amiodarone and lidocaine indicated in pediatric cardiac arrest?
YES!
for refractory VF/pVT
Describe major ways in which pediatric cardiac arrest management is different than adult
- Different compression ratio
- 15:2 with BLS airway
- Continuous compressions + 20-30bpm with advanced airway
- Different Epinephrine dosing
- 0.01mg/kg IV/IO
- 0.1mg/kg ETT
- Other drugs are still indicated, but doses may be different
- Amiodarone 5mg/kg
- Lidocaine 1mg/kg
- Bicarb 1meq/kg
- Early transport!
- Minimum of 10 minutes of on-scene optimization
How is toxic exposure in pre-schoolers / toddlers generally different from chldren/adolescents?
- More common in pre-schoolers/toddlers (<6yrs)
- More commonly due to accidental/exploratory ingestion in young kids
- In older children, toxic ingestion is more commonly intentional
- attempts to get high
- suicidality
Describe the classis presentation of anticholinergic/antihistamine poising
- hot as a hare
- red as a beet
- dry as a bone
- blind as a bat
- mad as a hatter
Tachycardia is often present
What special considerations should be made when caring for a child with a CSF shunt?
- Watch for signs of occlusion or infection!
- Look for signs of increased ICP or meningeal signs
- ALOC/DLOC
- Cushing’s triad
- Nuchal rigidity
- N/V
What is SIDS, and when is it most likely to occur? Is field diagnosis of SIDS appropriate?
- A diagnosis of exclusion for an unexpected pediatric death
- In Canada leading cause of death in infants between 1 month and 1 year
- Peak incidence between 2 and 4 months
Field diagnosis of SIDS is not possible and not appropriate!!
What is the likely underlying cause of a call for pediatric arrest in an infant who appears well on arrival? Is transport appropriate?
ALTE (Apparent life threatening event)
transport is indicated, as risk factors for ALTEs and SIDS overlap, and ALTE may be a sentinel event.
If you suspect child maltreatment/abuse, reporting to CPS is ________ (suggested/required)
required by law!
What is concerning about finding a 6 month old infant with injuries from a fall down stairs (beyond cocnerns for trauma)?
- Injuries inconsistent with developmental age!
- 6 month-olds generally do not crawl!
- Not sufficiently mobile to crawl over edge of stairs
- Suspicion of child abuse
What is a SAMPLE Hx?
S-Signs and symptoms
A-Allergies
M-Medications
P-Past medical Hx
L-Last oral intake
E-Events prior
