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Recognizing the Sick Child

Recognizing the Sick Child. William Beaumont Hospital Department of Emergency Medicine. Overview. Review of vitals Who’s sick at a glance What can babies do? Rashes: a quick review History and diagnosis that should raise a red flag Pediatric fluids and resuscitation Pediatric fever.

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Recognizing the Sick Child

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  1. Recognizing the Sick Child William Beaumont Hospital Department of Emergency Medicine

  2. Overview • Review of vitals • Who’s sick at a glance • What can babies do? • Rashes: a quick review • History and diagnosis that should raise a red flag • Pediatric fluids and resuscitation • Pediatric fever

  3. Who is sick? • The concept of the “toxic child” • The “L” word

  4. Toxic? Sick?

  5. Toxic? Sick? Nelson: Pediatrics

  6. No Stethoscope Assessment • What can you see, hear and feel right when the patient walks through the door?

  7. Step 1 – Eyeball • What can you see • Retractions • Subcostal, intercostal, supraclavicular • Tachypnea • Cyanosis • Nail beds, lips and mucosa • Circumoral or facial cyanosis can fool you • Decreased level of consciousness • Obvious fracture/deformity • Rashes

  8. Step 2 - Listen • What can you hear • Stridor • With Crying • At Rest • Abnormal Cry • What don’t you hear • Asthmatics too tight to wheeze • Septic child with weak cry

  9. Step 3 - Feel • Check Pulse • Tachycardia, bradycardia • Cap Refill • Extremity injuries - fractures and lacerations • Neuro status

  10. What is Normal: Vitals Signs • Vitals vary by age • Simple rules to demystify pediatric vitals

  11. What is Normal: Vitals Signs • Respiratory • Assess Airway • Respiratory Rate Newborn 1 year 18 years Rate <40 24 18

  12. What is Normal: Vitals Signs • Air Entry • Chest rise, breath sounds, stridor or wheezing • Quiet versus noisy tachypnea • Mechanics • Grunting or retractions • Color

  13. What is Normal: Vitals Signs • Take home, bottom line • Respiratory rate > 60 is abnormal

  14. What is Normal: Vitals Signs • Circulation • Normal heart rates: 1-3mo 3mo-2yr 2-10yr >10yr 85-200 100-190 60-120 75

  15. What is Normal: Vitals Signs • Abnormal • Less than 5 years >180, <80 • Greater than 5 years > 160 • Anything greater than 220 = SVT

  16. What is Normal: Vitals Signs • Blood Pressure Newborn 1 year >1 year Systolic >60 >70 70+(2 x age)

  17. What is Normal: Vitals Signs • Blood pressure • Cap Refill – < 2 Seconds normal • CNS Perfusion • Recognize parents, responsive

  18. What is Normal: Vitals Signs • Take home, bottom line • Pulse > 220 consider SVT • Cap refill > 2 seconds not normal • BP in kids > 1 year = 70 + (2 x age)

  19. What is Normal: Development • Easy social and motor milestones: • 2 month olds smile • 4 month olds roll over • 6 month olds sit • 9 month olds cruise • 12 month olds walk

  20. Review of Rashes • Rashes are visual things • Usually can’t tell what to do for rashes over the phone - have to see them

  21. Rash 1 Habif: Clinical Dermatology

  22. Rash 2 Habif: Clinical Dermatology

  23. Rash 3a Habif: Clinical Dermatology

  24. Rash 3b Habif: Clinical Dermatology

  25. Rash 4 Nelson: Pediatrics

  26. Rash 5a Habif: Clinical Dermatology

  27. Rash 5b Habif: Clinical Dermatology

  28. Rash 6a Habif: Clinical Dermatology

  29. Rash 6b Habif: Clinical Dermatology

  30. Rash 7 Habif: Clinical Dermatology

  31. Rash 8 Habif: Clinical Dermatology

  32. Rash 9 Habif: Clinical Dermatology

  33. Rash 10 Habif: Clinical Dermatology

  34. Rash 11 Habif: Clinical Dermatology

  35. Rash 12

  36. Rashes • Take home, bottom line • Check for blanching – petechiae and purpura do not blanch • Toxic vs. nontoxic • Check for oral lesions • Check the palms and soles • Most rashes are benign

  37. Red Flags • Diagnostic categories or history that should heighten your concern and raise your triage class • Mnemonic: CATNITS

  38. Red Flags • CATNITS • Congenital problems • Inborn errors of metabolism • Neurologic Disease, seizures • Vomiting, acidosis, hypoglycemia • Liver or cardiac disease • Congenital Heart Disease • Chromosomal Abnormalities

  39. Red Flags • CATNITS • Allergic • History of anaphylaxis or significant medication reaction • History of respiratory distress with previous reactions

  40. Red Flags • CATNITS • Trauma • Loss of consciousness > 2 minutes • Altered LOC now • Limb threatening injury • Bleeding not controlled

  41. Red Flags • CATNITS • Neoplasm • Recent chemotherapy - Fever and neutropenia • Anemia or thrombocytopenia

  42. Red Flags • CATNITS • Infectious • Signs and symptoms of septic shock/meningitis, including rash • Any reason to be immune compromised • Examples: Immune deficiency, protein loosing enteropathy, on steroids

  43. Red Flags • CATNITS • Toxins • Ingestion of dangerous vs. non toxic substance • Many interventions are time dependent • Patients may deteriorate rapidly

  44. Red Flags • CATNITS • Social/Psychiatric • Patient threat to himself/herself or others • Possibility of abuse or neglect

  45. Pediatric Fluids • Bolus • 10 to 20 cc/kg • 0.9 NS only, ever, always • Maintenance Fluids • 4 – 2 – 1 rule • Neonates and infants: D5 0.2 NS • Children: D5 0.45 NS

  46. Pediatric Fluid Problem 6 mos old child comes in with 24 hours of n/v/d. Not made urine for 12 hours. Wt = 8kg Would you bolus, how much, what fluid? What is maintenance?

  47. Defibrillation 2J/kg then 4J/kg, 4J/kg Epinephrine 0.01mg/kg (1:10,000) Atropine 0.01mg/kg Glucose D10 2-4ml/kg (not D50) Drugs you can give through an ET tube (NAVEL) Narcan Atropine Valium Epi Lidocaine Pediatric Resuscitation Doses

  48. Pediatric Fever = 38 C rectally • Tylenol 15 mg/kg for kids < 6 mos • Tylenol or Motrin 10 mg/kg > 6 mos • 0 to 4 weeks of age • Admit for IV abx and apnea monitoring • CBC, BMP, U/A, UCX, BCX, CXR, LP • Ampicillin and cefotaxime

  49. Pediatric Fever • 4 – 12 weeks of age • Look sick = admit • Most of these will be admitted • CBC, BMP, U/A, UCX, BCX • ? Lumbar puncture • Abx  ampicillin + cefotaxime or ceftriaxone • If meningitis then add vancomyocin

  50. The End Any Questions?

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