Pediatrics Flashcards
Initial approach to ped patient who “appears well”
Alert, engaged, calm
- 5 Vital signs
- (S) Focused history
- (O) Focused physical
- (A) Assessment and differential
- (P) Order appropriate labs and radio graphics as needed
Initial approach to ped patient who “appears sick”
5 Key Interventions
Act first, talk later
- O2 and ventilation if needed
- Pulse Ox
- Cardiorespiratory monitor
- IV access
- CXR / EKG
Primary Survey, ABCDE
Airway Breathing and ventilation Circulation Disability Exposure / Environmental control
Easiest way to assess patent airway
Ask patient to talk: “What’s your name?”
- able to answer?
- sound of voice? (gargle, muffle, wheezing, stridor)
Conditions that put patients at risk of developing airway compromise
Angioedema / allergy
Inhalation injury / burn
Facial trauma
Neck trauma
GSW or stab to neck
Unique features of pediatric airway
Smaller (more prone to obstruction)
More anterior and cephalad in location
Shorter (right main stem intubation)
Funnel shaped in < 8yrs old (most narrow at sub glottis, just below vocal cords)
Simple trick to help upen airway (esp considering large heads of toddlers)
Rolled towel under shoulders
plus “jaw thrust” to line up airways
Maneuver to ensure sufficient seal in bag mask ventilation
“C” and “E”
Ensure you see this during bag mask ventilation (so yo know it’s working)
Chest rise
Excessive ventilation in bag mask may result in
Excessive ventilation increases risk of gastric air, regurgitation, and aspiration
May result in barotrauma (pneumothorax)
May increase intrathoracic pressure and impair venous return.
This in turn decreases cardiac output, cerebral blood flow, and coronary perfusion.
Three signs to note while assessing work of breathing
Retractions
Nasal flaring
Grunting (ominous - resp failure)
Two common pathways leading to pediatric cardiac arrest
Respiratory failure
Shock
(rarely cardiac origin / sudden)
Three potential causes of respiratory failure, pediatrics
Intrinsic lung disease
Airway obstructions
Inadequate effort
Distress precedes failure
Where do you assess central pulse in infants?
Brachial artery
Where do you assess central pulse in older children?
Femoral artery
Signs of poor perfusion
Mottled, cool skin
Delayed capillary refill
Tachycardia
Pediatric blood pressure and shock: what to be careful of
Normal BP is maintained until over 30% of child’s circulating volume is lost
Hypotension is LATE finding in kids!!
Formula for pediatric BP normal range
Mean systolic BP: 90 mmHg + (2 x age in yrs)
Lower limit: 70 mmHg + (2 x age in yrs)
What is BP like in shock?
Can be normal, low, or high
Fluid resuscitation in pediatrics
Isotonic fluids
20 ml/kg boluses until signs of improved perfusion, resolution of tachycardia
If shock due to hemorrhage, after 2 boluses give PRBC 10 ml/kg
How to assess disability? (in ABCDE)
Quick neuro exam
Engaged?
Pupils?
Moving all 4 extremities?
Symmetric strength and sensation?
AMPLE history
Allergies
Medications
PMH
Last meal
Events surrounding visit
Review: overall assessment in ED
How does the patient look?
If sick → oxygen, pulse ox, monitor, IV access, CXR & EKG
ABCDs intact?
If not, address airway, breathing, circulation, and disability in that order
5 vital signs
AMPLE history
Secondary survey
Review: overall assessment in ED
How does the patient look?
If sick → oxygen, pulse ox, monitor, IV access, CXR & EKG
ABCDs intact?
If not, address airway, breathing, circulation, and disability in that order
5 vital signs
AMPLE history
Secondary survey
Most common cause of death and disability in children
Injury
> 10 million children require care in ED for injuries each year
10,000 children die from serious injuries each year in the US
Injury mortality surpasses deaths from all other childhood illnesses combined
MVC most common cause of death in children
Multisystem injury in pediatric trauma
Rule, rather than exception
Smaller body mass
Less fat and connective tissue
Closer proximity of internal organs
Head injuries in peds: anatomical differences
Leading cause of death in pediatric trauma
Large head relative to body > more torque
Less myelin > more shearing forces, greater neuronal injury
Soft cranium > may have intracranial injury without skull fracture
Types of head injuries in children
Contusions
Diffuse axonal injury
Subdural hemorrhage
Epidural hemorrhage
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
Management of head injuries in children
Maximize Oxygen
Maintain BP
Signs of increased ICP, and what to do
(Pupillary / macular signs)
Elevate head of bed 30 degrees
Hypertonic saline (3%) 5ml/kg
Mannitol 0.5-1 mg/kg
Special considerations about chest injuries in children
Chest injuries serve as marker for other injuries
2/3 of children with chest injury will have other injuries as well
Significant thoracic trauma possible without rib fractures (ribs are very pliable in kids)
Mediastinum very mobile
Increased risk of pneumothorax
Two most vulnerable organs in abdominal injuries
Liver, spleen - lower, below rib cage, in children
If you see a “seatbelt sign” on a child from a MVC, what next step is warranted?
CT of abdomen
seatbelt sign = linear bruising in distribution of seatbelt)
Normal pediatric blood volume
70 ml/kg
Tremendous ability to compensate for blood loss by vasoconstriction
HYPOTENSION IS A LATE FINDING
Treat shock early to avoid sudden deterioration
Due to children having less fat and connective tissue, they are at higher risk of
Hypothermia
Hypothermia puts children at higher risk of
Coagulopathy and Acidosis
Reassuring signs and symptoms in children presenting with abdominal pain
Frequent watery diarrhea
Normal appetite (eating in the exam room)
Fever onset before pain
(fever is late finding in appendicitis, once it’s ruptured)
The “JUMP TEST”
What area should always be checked for male ped presenting w abdominal pain
Groin area - testicles, hernia
What should always be tested in adolescent females w abdominal pain
Urine HCG and pelvic exam (**12 yrs old and up)
Beware of vomiting without diarrhea
May not be stomach virus - could be bowel obstruction, pregnancy, head injury
Two common conditions with referred abdominal pain in pediatrics
Lower lobe pneumonia
Strep pharyngitis (GAS)
Warning signs of abdominal emergencies in pediatrics
Bilious vomiting - obstruction
Vomiting WITH abdominal distention - bowel twist / obstruction
Pain BEFORE vomiting - appendicitis
Blood in stool of ill appearing infant - intussusception
Focal abdominal pain (esp + guarding) - appendicitis
Involuntary guarding
Blood in stool of ill appearing infant
Intussusception
Pain BEFORE vomitting might indicate ___ as opposed to ___
Appendicitis, viral
Neonates abdominal emergency DDX
Slide 6, peds abominal
Malrotation w/ volvulus
NEC
Intestinal atresias/stenosis
Hirschsprung disease
1-2 month abdominal emergency DDX
Pyloric Stenosis
6-10 month abdominal emergency DDX
Intussusception
Pre school / school age abdominal emergency DDX
Appendicitis Intussusception Testicular/ovarian torsion Incarcerated hernia* NAT with blunt abdominal trauma*
Adolescent female abdominal emergency DDX
Ectopic pregnancy Ovarian cyst/torsion Appendicitis STD/PID Tuboovarian abscess
Bilious emesis in a neonate is what kind of surgical emergency until proven otherwise
Intestinal malrotation with midgut volvulus
Risk of midgut volvulus is highest at what age
First month - 50-70%
90% in first year
Why is midgut volvulus a surgical emergency
Bowel necrosis can occur within hours
Study of choice for midgut volvulus
Upper GI series with contrast (CT?)
Findings:
Trace contrast passes in corkscrew configuration
Abnormal position of duodenum
Malrotation / midgut volvulus management review
IV fluid resuscitation NG tube to intermittent suction Call your surgeon Upper GI series Laparotomy
Ultrasund / CT findings for intussusception
“Target sign” or “Crescent sign” of bowel within bowel
Bull’s eye” or “Coiled spring” on ultrasound
Most common abdominal emergency in early childhood
Intussusception
Why is it common for children to have a viral infection before intussusception?
Virus causes inflamed lymphatic tissue in gut - Hypertrophy of Peyer patches in terminal ileum can serve as lead point
Most common area of intestine for intussusception
Ileo-colic
“Classic” presentation of intussusception
sudden onset of intermittent, severe, crampy abdominal pain
Toddlers and infants may “draw up legs” toward abdomen
Episodes occur ~20 min intervals
Classic triad of pain, palpable sausage shaped mass, currant jelly stools occurs < 15% of the time
Management of Intussusception
ABCs
Resuscitate with IVF
If frequent vomiting, decompress stomach with NGT
Consider IV antibiotics if concern for perforation
Notify surgery early
Abdominal xrays (including left lateral decub) to exclude perforation w/ free air prior to air enema reduction (and exclude constipation)
Air enema reduction
Preferred treatment for intussusception
Nonoperative reduction
Air enema or water-soluble contrast enema
Study of choice in typical presentation
Diagnostic and therapeutic
Success rate 75-90% in ileo-colic intussusception
Perforation risk is small, less than 1%
Contraindicatons for nonoperative reduction for intussusception
Prolonged symptoms (> 3 days)
Signs of peritonitis
Evidence of free air on plain x-ray
Indications for surgical treatment of intussusception
when nonoperative reduction fails or is incomplete
Ovarian torsion
Presentation is non-specific
Difficult to differentiate from other causes of abdominal pain in children
Classic presentation in children:
Sudden onset of unilateral lower abdominal pain
Right side > left side (3:2)
Nausea and vomiting (70-80%)
Management of ovarian torsion
Pain control
IVF
US with doppler - STAT!
Emergent operative intervention
Prolonged symptoms does not preclude possible ovarian salvage
May have intermittent torsion
Managing pediatric seizure
Assess ABCs
Place patient on his/her side
O2, O2 sat, monitor, IV access, bedside glucose
Intervene medically if needed for seizure > 3 min
Best medications for seizures
Intervene medically if needed for seizure > 3 min
Lorazepam (0.05-0.1 mg/kg) IV or IM
Diazepam (0.3-0.5 mg/kg) IV or PR
Midazolam (0.2 mg/kg) IV/IM or intranasal
Pre-seizure history questions
Well prior to event History of prior seizures History of fever, recent infections Recent antibiotics Recent trauma Adult Rx medications, toxic ingestions
Seizure history questions
Eye deviation, blank stare, drooling, cyanosis, incontinence
Generalized vs focal
Duration
Responsive or unresponsive
Post Seizure history questions
Single or multiple
Mental status after event
EMS observations at time of arrival
Physical Exam for seizure
Vital signs (rectal temp)
General appearance and mental status
Focused exam:
- Focal neurologic deficits
- Signs of increased ICP (bulging fontanelle, papilledema)
- Skin lesions (Ashleaf spots, shagreen patch, café au lait)
- Nuchal rigidity
- Poor perfusion
- Altered motor tone
- Prolonged post-ictal lethargy
- Generalized petechiae
Categories of febrile seizures
Simple and complex
Qualifications for a Simple Febrile Seizure
Last less than 15 minutes
Generalized
No focal features
Does not recur within 24 hrs
Qualifications for a Complex Febrile Seizure
Last more than 15 minutes
Focal features or postical paresis (Todd’s paralysis)
Recurrence within 24 hrs
Evaluation and Management of Febrile Seizure, Peds
Stabilize the patient
Focused history & physical
Categorize the seizure (simple vs complex)
Determine probability of intracranial infection and acute bacterial meningitis
Determine need for diagnostic studies
Establish disposition
First time simple febrile seizure - labs / imagining?
Not needed - no benefit
Only workup should be for underlying cause of fever (UA, chest X-ray, etc)
Questions to ask in assessing risk of CNS infection
Vaccination status?
Antibiotics taken recently?
- can mask signs of meningitis
Concerning exam findings in pediatric (febrile) seizures
Focal neurological deficits Altered motor tone Nuchal rigidity Poor perfusion Generalized petechiae
Status epilepticus + fever indicates»_space;
Bacterial meningitis
LP indicated
Clear discharge instructions for parents (peds w seizures)
Safe place Place child on his/her side Nothing in mouth Chin lift/jaw thrust When to call EMS
Indications for admission in febrile seizures
Prolonged postictal phase Complex febrile seizure Age < 6 months Social concerns Inability of caretakers to provide appropriate observation Prolonged distance to medical care
Absent staring with/without eyelid flutter
Absence Epilepsy
ethosuximide, valproic acid, lamotrigine, levetiracetam
Myoclonic Jerks (> in AM)
Onset adolescence
Precipitated by stressors
May have tonic-clonic and absence seizures as well
Juvenile Myoclonic Epilepsy
valproic acid, topiramate, levetiracetam
Somatosensory changes (numbness/tingling), speech arrest, facial twitching, drooling, may have tonic clonic seizures at night, often during sleep
Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic)
may not need treatment - may outgrow
Sudden flexion, extension or mixed movements of trunk and proximal muscles
Treated differently and with more urgency
Infantile Spasms **
ACTH, steroids, zonisamide, topiramate, vitamin B-6
Onset at 3-5 years
Mixed seizure types
Most children have severe developmental delay
Lennox Gastaut
Evaluation of Infantile Spasms
Need urgent EEG, MRI, and metabolic evaluation with neurology consultation
Mortality as high as 15-20%
Only 5-10% or children with infantile spasms have normal intelligence
Treatment for Infantile Spasms
ACTH, steroids, zonisamide, topiramate, vitamin B-6
Lab Evaluation of Seizures Without Epilepsy
Electrolytes, glucose, Ca, Mg, Phos Ammonia, Lactic Acid Metabolic syndrome suspected Drug Screen Possible toxin exposure
LP plus Antibiotics
Only if meningeal signs or sustained AMS
Preferred neuroimaging study for seizure
MRI (usually)
EEG
Indication for EEG
All first time, non febrile seizures
When to admit for non febrile seizures
Age (< 6 months) Etiology of seizure Seizure control Social concerns Inability of caretakers to provide appropriate observation Prolonged distance to medical care
Categories of DKA
Mild pH < 7.30, bicarbonate < 15 mmol/L
Mod pH < 7.20, bicarbonate < 10 mmol/L
Severe pH < 7.10, bicarbonate < 5 mmol/L
Symptoms of Hyperglycemia
Polyuria: increased volume and freq of urination Polydipsia: increased thirst New urinary incontinence Weight loss Muscle cramps
Symptoms of Acidosis
Abdominal pain Vomiting Shortness of breath Headache Confusion Altered mental status
PE findings in DKA
Kussmaul respirations
Dehydration (sunken eyes, dry mucous membranes)
Tachycardia
Delayed capillary refill
Abdominal tenderness (nonfocal or epigastric)
Why do kids with DKA have electrolyte imbalances?
Ketoacids bind Na+ and K+ and they are excreted in the urine
Hyponatremia and hypokalemia result
DKA Precipitants (I’s)
Remember the “I”s
Insulin lack
Indiscretion (dietary)
Infection
Impregnation or other stressors
Treatment of DKA
Correct dehydration - IV Fluids
Correct acidosis and reverse ketosis - Insulin, DRIP! not bolus
Restore normoglycemia
Correct electrolyte imbalances - Na, K
Avoid complications of treatment -
Cerebral Edema from rapid fluid resuscitation
Identify and treat precipitating event - infection, etc
ED Management of DKA
ABCs, cardiac monitor, vital signs, accucheck IV access (2 is best, one for fluids, one for insulin drip)
BMP, VBG, UA, +/- CBC
Consider EKG
Accucheck every 1 hr
VBG every 1-2 hr
BMP every 4 hr
Neurologic checks every hr
Consultation with endocrinology & critical care
Step 1 DKA treatment
IV hydration
Initial bolus: NS bolus or LR (Lactate Ringer) bolus 20 ml/kg over 1 hour
Next: LR at 2x MIVF rate
Step 2 DKA treatment
(After initial IVF bolus)
Insulin infusion 0.05-0.1 U/kg/hr regular insulin
No insulin bolus in children!!! (may increase risk of cerebral edema)
Ideally don’t want glucose to fall more than 100 mg/dl per hour
Switch to D5NS when glucose is < 300 mg/dL
Step 3 DKA treatment
Next 4-6 hours
NS with 40 mEq/L K+ (20mEq/L KCl and 20 mEq/L KPhos)
Rate is 2x maintenance rate
After 4-6 hrs: Switch to 0.45% saline with electrolytes
K+ and DKA
Total body K+ is depleted in DKA
It is excreted in the urine when it binds to the ketoacids
Also once you start giving insulin and correct the
acidosis, this drives the K+ into the cells lowering your K+ levels further
Bicarb and DKA?
Multiple downsides
- Paradoxical CNS acidosis
- Rapid correction can worsen hypokalemia
- May increase hepatic ketone production
Selected benefit: Only if arterial pH < 6.9 or if there is hypotension, shock, arrythmia, severe hyperkalemia
Must give cautiously NaHCO3 at 1-2 mEq/kg over 60 minutes
Most serious complication / cause of mortality in children w DKA
Cerebral Edema - 60-90% of all DKA deaths
Signs/Symptoms of cerebral edema
Headache
Gradual decrease in LOC
Slowing of HR inappropriately with increase in BP
Change in pupils
Onset 4-12 hours after treatment initiated, but may be present before tx begins
Cerebral Edema treatment
Reduce rate of IVF infusion
Mannitol 0.5-1 g/kg over 20 min
3% saline 5-10 ml/kg over 30 min
Consider intubation if cannot protect airway
Other complications of DKA
Hyponatremia Hypokalemia Acute renal failure (pre-renal, low perfusion) Rhabdomyolysis Rarely ARDS and pulmonary edema
Cushing’s triad
irregular respirations, decreased heart rate with increased BP
