Special Populations Flashcards
Newborn age range
0-1 month
Infant age range
1 month- 12 months
Toddler age range
1-3 years
Preschool age range
4-5 years
Adolescent age range
13-17 years
Adult age range
18+ years
How does an infant respiratory system differ from adults?
breathe via diaphragm (belly breathers) larger tongue narrow and shorter airway obligate nose breathers
Infant reflexes- 4
Moro or startle reflex Suckle reflex Rooting reflex Palmar reflex
What age do the fontanels close?
18 months
School age children and the three types of reasoning
Preconventional-make choices to avoid punishment Conventional- decisions made via peer approval Postconventional- decisions made via own beliefs and conscience
Major anatomic differences with Peds
- higher surface to area to volume area ratio
- less fatty insulation
- prone to hypothermia
- smaller absolute circulating blood volume
- can compensate longer than adults
- head larger (kids lead with head with falls)
- occiput bigger (pad shoulders if C spine maintained)
- airway shorter and narrower
- larger tongue
- airway narrowest at cricoid cartilage
- obligate nose breathers
- higher basal metabolic rate
- decreased functional reserve capacity
- chest wall pliable –> organ damage more likely
- abdominal organs less protected by rib cage
Respiratory distress S/S
Retractions nasal retractions sniffing position tripoding
Respiratory distress Tx
High flow O2 nebulized albuterol with wheezing
Respiratory Failure S/S
See saw breathing
ALOC
head bobbing
cyanosis
bradycardia
slowing respirations
Respiratory Arrest S/S
No breathing Severe bradycardia cyanosis
Respiratory Failure Tx
High flow O2 PPV
Respiratory Arrest Tx
PPV Intubation CPR for HR<60
Cystic fibrosis tx
dependent on symptoms may include bronchodilators, humidified O2, PPV
Bronchiolitis tx
albuterol or racemic epi PPV for failure or arrest
When do you initiate PPV in peds?
First sign of decreased respiratory effort or decreased LOC
When do we intubate peds?
Poor seal of mask on face
need for extended resuscitation times
cardiac arrest
respiratory arrest
head or facial injury
unable to protect airway
ETT equation for children under 8
16 + age divided by 4 for UNcuffed tubes subtract 0.5mm for cuffed tube
Infant ETT uncuffed size
3.5mm
Volume resuscitation Ped amount
20mL/kg, repeated up to 3x
DOPE
Displacement Obstruction Pneumo Equipment
Newborn VS
Pulse 100-180 SBP 50-70 RR 30-60
Infant VS
Pulse 100-160 SBP 70-90 RR 25-50
Toddler VS
Pulse 90-150 SBP 80-100 RR 20-40
Preschool VS
Pulse 80-120 SBP 80-100 RR 20-30
School Age VS
Pulse 70-120 SBP 80-110 RR 15-25
Adolescent VS
Pulse 60-100 SBP 90-120 RR 12-20
Adult VS
Pulse 60-100 SBP 100-140 RR 12-20
TICLS
PAT Appearance Characteristics
Abnormal tone
Abnormal position
Abnormal gaze
decreased interactions
unconsolable
Abnormal cry
PAT Work of Breathing Characteristics
Retractions
Grunting
Flaring
Gasps
Apnea
PAT Circulation
Temperature
pallor
cyanosis
mottling
Difference bw Neuro Shock and Hypovoloemic Shock Hypotension
Neuro= wide pulse pressure
Hypo= narrow pulse pressure
Difference bw Cardiogenic Shock and Hypovoloemic Shock Hypotension
Hypo= quiet tachypnea
Cardio= grunting, loud tachypnea with accessory muscle use
Indications of progression from compensated shock to hypotensive shock
Increased tachycardia
Diminished or absent peripheral pulses
Weakening central pulses
Narrowing pulse pressures
Cold distal extremeties with dec cap refill
ALOC
Hypotension (LATE finding)
PALS shock management
optimize O2 and SpO2
Improve volume
Correct metabolic derangements
Reduce O2 demands
-fever, px, anxiety, WOB
Positioning
Support ABCs
Fluids/IV
Monitor
Frequent reassessment
Peds Fluid Bolus
20mL/kg over 5-20mins
5-10mL/kg if compromised (cardiac)
repeat up to 2 more times
What vitals should we be monitoring in ped emergencies for improvement if interventions are working?
O2 sats
HR
Peripheral pulses
cap refill
Skin temp/color
BP
LOC
Ongoing fluid loss (diarrhea, blood, etc)
Fluid bolus for peds with overdose risk (ie calcium channel or beta blocker)
5-10mL/kg over 10-20mins
S/S of Septic Shock per PALS
ALOC- irritable or dec ALOC
Altered HR- tachycardia
Altered Temp- fever or hypothermia
Altered perfusion- long cap refill, mottling, pallor ecchymosis
Hypotension
PALS Peds Sepsis Initial Stabilization
ABCs
Monitor vitals
IV/IO
BGL
Fluid bolus
Antipyretics if needed
**If symptoms persist beyond fluid boluses, consider pressor
Pressor choices for Cold vs Warm Shock in Peds
Warm= norepi or epi
Cold= epi
**cold shock give epi infusion at 0.3mcg/kg/min stimulates predominantly alpha effects
What do we give if ped is refractory to fluids and pressors?
Consider adrenal insufficiency and give 1-2mg/kg hydrocortisone bolus early
PALS Anaphylaxis Tx
Position Pt
Maintain Airway
Epi if bad
Fluids
Albuterol for bronchospasm
Antihistamine
Solumedrol
*may need epi infusion at 10-15 min mark if severe, dose at 0.05mcg/kg/min
PALS Neurogenic Shock Tx
Position pt flat to improve CO
Fluids and observe response
If refractory, give pressor trial
Provide warming or cooling as needed
PALS Cardiogenic Shock Tx
Supplementary O2
May need PPV
5-10mL/kg fluid bolus
watch for pulmonary edema
consider pressors
PALS Cardiac Tamponade Txp
Fluids to help compressed heart squeeze better —>better perfusion
Rapid Txp
What are the two routes to cardiac arrest in peds?
hypoxia
sudden cardiac arrest (usually VF/VT)
Signs of hypertrophic cardiomyopathy in ped EKG
high QRS voltage
Q wave in lateral leads
narrow QRS
sudden syncope
Predisposing factors for Sudden cardiac arrest in peds
hypertrophic cardiomyopathy
anomalous coronary syndrome
long QT
Brugadas
Myocarditis
Drug intoxication
Commotio cordis
normal QRS width in kids
<0.09ms
compression depth in kids (1yo-puberty)
1/3 AP diameter
about 2 inches
compression depth in infants
1.5 inches
about 1/3 AP diameter
Compression to Ventilation ratio with 1 vs 2 rescuers for Child and Infants
15: 2 for 2
30: 2 for 1
Unwitnessed vs witnessed arrest for when to call 911
Unwitnessed- 1 round of CPR
Witnessed- call 911
Once advanced airway placed, provide ventilations at rate of
1:6s aka asynchronous
If ETCO2 is 10-15 during CPR what does that indicate
poor CPR
change hand position or provider
Priority Routes for Drug Admin in Ped CPR
IV
IO
ETT
LEAN for Ped CPR Drugs
Lidocaine
Epi
Atropine
Naloxone
Recommended ET dose for epi
10x normal IV/IO dose
Recommended ET dose for other meds
2-3x normal IV/IO dose
How do we give drugs down ETT?
Prep drug amount
instill drug down ETT, briefly pausing compressions to do so
follow with 5mL flush
rapidly give 5 PPV after
Defib joules for peds CPR
1st- 2J/kg
2nd- 4J/kg
3rd- >4J, usually 6J, 8J
Max of 10J/kg
Epinephrine dose for peds in CPR
0.01 mg/kg q 3-5 mins
Amiodarone peds dose for CPR
5mg/kg repeated 2 more times
Lidocaine dose for peds CPR Initial
1mg/kg loading dose
Lidocaine dose for peds CPR Infusion
20-50mcg/kg/min
*repeat bolus initial dose if infusion >15mins after initial bolus therapy
Max Amiodarone dose
15mg/kg aka 3 doses
Traumatic Arrest Causes for Peds
hypoxia via FBAO, resp arrest, traumatic injury
injury to vital structures
severe brain injury causing cardio collapse
upper cervical spinal cord injury
tension pneumo
cardiac tamponade
massive hemorrhage
Steps to Cardiac arrest for Trauma Peds
CPR
ABCs
Anticipate airway obstruction via teeth, blood, etc
Minimize C spine motion
Control bleeding
Txp to adequate facility
Establish IV IO
Early s/s of hypoxia with peds
anger irritable
nasal flaring
retractions
tachypnea
tachycardia
mottling
pallor
cyanosis
Late s/s of hypoxia in peds
ALOC
bradycardia
tachypnea
grunting
positioning
head bobbing
severe retractions
pallor
cyanosis
mottling
Signs of U Airway Obstruction
Increased rate, effort of breathing
Increased inspiratory effort
stridor
hoarsness
barking cough
drooling
snoring
gurgling
poor chest rise
poor auscultation
Signs of L Airway Obstruction
Increased rate and effort
Increased expiration effort
wheezing
cough
Causes of Mobitz Type I in peds
drugs- Ca and B blockers
conditions that stimulate vagal tone
MI
Causes of Mobitz Type II in Peds
Intrinsic conduction issue
cardiac surgery
MI
Causes of Third Degree Block in Peds
Extensive conduction issues
cardiac surgery
Congenital
MI
Toxic drugs
acidosis
severe hypoxia
2 most common reversible causes of bradycardia
hypoxia
increased vagal tone
Atropine dose in peds
0.02 mg/kg may repeat 1x
Atropine minimum and maximum dose
- 1mg/kg minimum
- 5mg single max dose
S/S of Advanced tacharrythmias in Peds/Infants
(s/s of cardiac compromise)
irritability
s/s of pulmonary edema
poor feeding
tachypnea- loud
“sudden” collapse
s/s of shock
JVD
Narrow Tachycardias in Peds
sinus tach
SVT
Atrial flutter
Wide Tachycardia in Peds
>.09ms
VT
SVT with aberrancy
Sinus Tach HR for Peds and Infants
SVT vs Sinus tach PALS
Synchronized Cardioversion Initial Joules
0.5-1 J/kg
Synchronized Cardioversion Subsequent Doses
2J/kg
PALS Tachycardia with Pulse
If pt is in SVT or VT with Pulse AND is hemodynamically stable and refractory to meds…
consider expert consult before SCV
If wide complex tachycardia is refractory to SCV…
consider expert consult before administration of amiodarone or procainamide (give slow!)
ROSC Care for Peds
EPI infusion dose Peds
0.1-1mcg/kg/min
lower doses have beta effects
higher doses (0.3mcg) have alpha effects
Norepi Infusion dose in Peds
0.1-0.2 mcg/kg/min
Tx of Mild Croup
Consider decadron
blow by O2
Moderate to Severe Croup Tx
Nebulized epi
decadron
blow by O2
Impending respiratory failure for Croup Tx
NRB or BVM if sats below 90
decadron IV or IM
Consider ETT or Cric
go with a size smaller tube
Moderate to Severe Anaphylaxis Tx
IM epi
Albuterol for wheezing
Decadron or Solumedrol
Fluids for hypotension
Benadryl
FBAO in peds Tx
If kid can cough forcefully and make noise, all them to continue to clear airway
if they can’t, abdominal thrusts
if they become unresponsive, CPR with airway clearing before ventilations
Complications of Hyperventilation
Gastric distention- aspiration
Pneumo
Severe air trapping- decreases preload
What is hypoglycemia in infants vs peds?
45 infants
60 peds
