Pediatric Assessment and PALS Overview

Infant chest compressions for 2 person CPR way and ratio with breaths?

- 2 thumbs circling chest -15:2

Infant chest compressions for 1 person CPR way and ratio with breaths?

-2 finger traditional chest compressions - 30:2

What are emperic ABX given to 0-6 day olds?

-Ampicillin (listeria) PLUS -Cefotaxime or Gentamicin -Vancomycin if MRSA risk -Acyclovir for HSV coverage

infant chest compression depth

-Compress 1/3 to ½ the depth of chest

•Child (Age 1-8) CPR way, ratio and depth

-Heel of one hand over lower half of sternum -Compress 1/3 to ½ the depth of chest -30:2 (one rescuer) - 15:2 (two rescuer) Ratio

What is uncompensated shock?

-Hypotension - SBP less than 5th percentile for age -Progresses to CV collapse and cardiac arrest rapidly

H's

-Hypoxemia -Hypovolemia -Hypothermia -Hyper/Hypokalemia -Hydrogen Ion -Hypoglycemia

•If work-up negative in 29-60 days, do what?

-Recommendations: •Can hold LP •Can hold admission •Can discharge home with next day outpatient follow-up

What is the difference between respiratory distress and failure?

-Respiratory Distress: Increased work/effort -Respiratory Failure: Inadequate oxygenation/ventilation

In intubating, use what blade for <3 YO?

-Straight blade (Miller) <3 years old

T's

-Tamponade -Tension Pneumo -Toxins/Poisons/Drugs -Thromboembolism -Trauma

•Child (Age 8 +) CPR way, ratio, and depth

-Use adult 2 hand method -Compress 1 ½ to 2 inches -Ratio 30:2 (both 1 & 2 rescuer)

•AAP recommendations for treatment for UTI if what on UA?

-WBC 5 or greater -Bacteria and/or +leuk esterase

Fluid resuscitation! ! ! -_____ ml/kg bolus of isotonic crystalloids

20ml/kg for 2-3 liters

•Blind nasotracheal intubation/Surgical Cricothyroidotomy-contraindicated in children <______YO

< 10yo

Age-specific obstructed airway support: <1 year: >1 year:

<1 year: Back blow/chest thrust >1 year: Abdominal thrust

•Antiarrhythmic Medications for Shock-Refractory VF or Pulseless VT •2015 (Updated): ____________ or ________ is equally acceptable for the treatment of shock refractory VF or pVT in children.

Amiodarone or lidocaine - but peds cards doesn't like amiodarone

What is the Pediatric Assessment Triangle- General Assessment?

Appearance Work of Breathing Circulation

PEDS breathing notes: •________ breathers- rely on their diaphragm •Watch out for _______ distention- OG tube easier to ventilate •Mediastinum shifts _______ •Compliant rib cage- post rib fractures never accidental ______ breathing is 1st sign of respiratory distress

Diaphragmatic Gastric easily Belly breathing

-___________: Poor oxygenation; pneumonia, drowning, pulmonary contusion -_________: Fluid, mucus, blood in airway (small airways) -Decreased/absent breath sounds: __________

Grunting Crackles Obstruction

Do you have to do CT b4 LP in infants?

NO....

What airway aid can be used in the conscious, semiconscious, and unconscious patient?

NPO

-___________ most common SBI

Pyelonephritis

Why is suction so important for kids?

Respiratory is main cause of desating babies •Can result in dramatic improvement in infants

Why is a little bit of airway swelling a worse priblem for babies than adults?

THE SIZE/DIAMETER IS SMALLER - Smaller lumen same amount of swelling sig decrease in lumen

-Stridor: ________ airway obstruction -Wheezing: ________ airway obstruction

Upper Lower

•0-28 day neonate is hx of fever enough to work up?

YES - if they are acting weird, hypothermic, BRUE, isolated bacterial infection think sepsis

Check for what in semiconscious patient before inserting OPA?

a Gag Reflex

•Targeted Temperature Management •2015 (Updated): For children who are comatose in the first several days after cardiac arrest (in-hospital or out-ofhospital), temperature should be monitored continuously and fever should be treated ___________. •For comatose children resuscitated from OHCA, it is reasonable for caretakers to maintain either 5 days of normothermia (36°C to 37.5°C) or _____ days of initial continuous hypothermia (32°C to 34°C) followed by 3 days of normothermia. •For children remaining comatose after IHCA, there are insufficient data to recommend hypothermia over ________.

aggressively 2 normothermia

Metabolic dysfunction- many present how?

as lethargy

Tachycardia- early or late compensating?

early

•Vasopressors for Resuscitation •2015 (Updated): It is reasonable to give __________during cardiac arrest.

epinephrine

•Vasoactive pressors - not for _______

hypovolemia!

PEDS airway notes: •Tongue is _________ in proportion to mouth •Pharynx is _______ •Epiglottis is __________/________ •Larnyx is more ________ and _____ •Narrowest at _________ •Trachea is narrow, less _________ and short

larger smaller larger/floppier anterior and superior cricoid rigid

Hypotension- early or late compensating?

late

MC IO site in peds?

proximal tibia (humural head is good too)

Majority of brady is a ____ issue

respiratory

T/F OPA should NOT be used in a conscious or semiconscious patient

true

In intubating use what kind of tubes <8yo, now usually <2yo?

uncuffed

What is compensated Shock?

when the patient is developing shock but the body is still able to maintain perfusion -Infants increase HR to increase CO -Pronounced compensatory vasoconstriction -Normal BP

How are meds in peds?

wt based

How is disability assessed in peds?

•AVPU scale: -Alert -Verbal: Responds to verbal commands -Painful: Responds to painful stimulus -Unresponsive Pediatric Glasgow Score

What are you looking for in Work of Breathing?

•Abnormal airway sounds •Abnormal positioning •Retractions •Nasal flaring •Head bobbing

•If work-up negative in 7-28 days then do what?

•Ampicillin PLUS Cefotaxime or Gentamicin •Can hold LP -Real world: •If you give antibiotics perform LP •ADMIT for culture results

_______ shock will need less and slower administration of fluids

•Cardiogenic

What are some common Isolated Bacterial infections in 0-28 days?

•Conjunctivitis •Omphalitis- infected umbilical stump •Acute Otitis Media •Mastitis •Cellulitis

7 - 28 Day Olds work up

•Full Sepsis work-up -CBC, Bcx, UA, Ucx -RVP if viral symptoms -CRP/Procalcitonin (bacterial or viral) -CXR ONLY if respiratory symptoms

0- 6 Day Olds in work up requires what?

•Full sepsis work-up -LP -CBC, Blood culture -UA, Urine culture -RVP- rapid viral panel -HSV testing -CXR

•6-month-old girl brought to ED by mother after "falling from the bed" onto carpeted floor. •Mother states infant is "sleepy," was worried when there was no improvement in mental status after three hours of observation. Appearance Lethargic, poorly responsive to environment Breathing and Circulation Normal •General impression? •Management priorities?

•General impression: Primary CNS or metabolic dysfunction •Management priorities: -Provide oxygen, closely monitor ventilation. -Obtain vascular access, rapid glucose screen. -Perform further physical assessment. -Obtain blood for labs, cultures, metabolic studies. -Obtain CT of head, radiographs.

•3-month-old girl presents with severe difficulty breathing. •Seen in ED two days earlier; sent home with a diagnosis of bronchiolitis •Her difficulty breathing has increased. Appearance Lethargic, glassy stare, poor muscle tone Breathing Marked sternal and intercostal retractions, rapid and shallow respirations Circulation Pale with circumoral cyanosis •General impression? •Management priorities?

•General impression: Respiratory failure or cardiopulmonary failure •Management priorities: -Support oxygenation and ventilation with bag mask; prepare for endotracheal intubation. -Assess cardiac function, vascular access. -Continually reassess after each intervention.

•One-year-old boy presents with complaint of cough, difficulty breathing. •Past history is unremarkable. He has had nasal congestion, low grade fever for 2 days. Notably on PE he has Audible inspiratory stridor at rest Initial assessment? Initial treatment priorities?

•Initial assessment: Respiratory distress with upper airway obstruction •Initial treatment priorities: -Leave in a position of comfort. -Obtain oxygen saturation. -Provide oxygen as needed. -Begin specific therapy.

•15-month-old boy with 24-hour history of vomiting, diarrhea. •Diarrhea is watery with blood and pus. •Attempts at oral rehydration by mom were unsuccessful. •Called ambulance when child became listless and refused feedings. Appearance Listless, responds poorly to environment Breathing Effortless tachypnea, no retractions Circulation Pale face and trunk, mottled extremities •General impression? •Management priorities?

•Initial impression: Shock •Management considerations -Provide oxygen by mask. -Obtain quick vascular access, FSBS -Administer volume-expanding crystalloid (NS or LR) in 20 mL/kg increments. -Continuous reassessment and complete exam.

What is proper Airway Positioning?

•Large occiput - naturally has passive flexion so must bring back •1-inch padding under infant or toddlers entire torso •Keep plane of midface parallel to spine board = "sniffing position" •Maintain cervical spine control - appropriate sized collar -So head does move and pop tube out

Where in PEDS is it important to listen for breath sounds?

•Listen with stethoscope over midaxillary line and above sternal notch

What is Minimum BP formula in PEDS?

•Minimum BP = 70 + (2 X age in years) -gives 5th percentile (if below then bad) •< 60 mmHg in term neonates •< 70 mmHg in infants (1 mo - 12 mos)

What should be used if absolutely needed in kid <10 that cannot have Surgical Cricothyroidotomy

•Needle Cricothyroidotomy

What are you looking for in Circulation?

•Pallor •Mottling •Cyanosis

29 - 60 Day Olds work up

•Partial Sepsis work-up -CBC, Bcx, UA, Ucx -RVP if viral symptoms -CRP/Procalcitonin -CXR ONLY if respiratory symptoms

What does SAMPLE stand for? in secondary assessment?

•Signs and Symptoms •Allergies •Medications •Past medical history •Last Meal •Events leading to presentation

How do you measure size for OPA?

•Size is determined by distance from corner of the mouth to the angle of the mandible

What does TICLS stand for with appearance?

•Tone •Interactiveness •Consolability •Look/Gaze •Speech/Cry

61 - 90 Day Olds workup

•UTI work-up -UA, Ucx

How is an NPO measured?

•distance from tip of nose to the tragus of the ear •Diameter should be no large than size of nare