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Just in Time: Pediatric Assessment for Occasional Peds Providers

Just in Time: Pediatric Assessment for Occasional Peds Providers. Created by Major Jennifer Thomas, RN Pediatric Nurse Manager Elmendorf AFB June 2008 Supported by Federal grant #1HFPEP070008-01-00;

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Just in Time: Pediatric Assessment for Occasional Peds Providers

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  1. Just in Time:Pediatric Assessment for Occasional Peds Providers Created by Major Jennifer Thomas, RN Pediatric Nurse Manager Elmendorf AFB June 2008 Supported by Federal grant #1HFPEP070008-01-00; & Alaska State grant #601-08-156 ‘MEP-Peds’

  2. Lecture Objectives Understand Peds physiology variances Understand the Pediatric Assessment Triangle 3. Understand IV access, fluid maintenance and med admin

  3. Real pics of real situations that we might find ourselves facing….

  4. Tsunami, Indonesia Building collapse, Jerusalem Bus crash, Michigan Tornado, Kansas

  5. Earthquake, Algeria Earthquake, Iran Hurricane Katrina OK City Bombing

  6. Case Scenario

  7. Case Scenario

  8. Case Scenario

  9. Now What? • “How can I help a sick or injured child, or how do I know if a child needs help quickly?” • By reviewing some basic Pediatric assessment information and applying the information to Pediatric Assessment Triangle, you can get a quick idea about the severity of a child’s condition.

  10. A quick vital sign review • Let’s take a quick look at normal vital signs for infants and children. • As you are reading the next few slides, think how these compare to the normal vital signs in adults.

  11. Respiratory Parameters

  12. Heart rate parameters

  13. BP Parameters

  14. A quick Peds refresher • The Pediatric Assessment triangle will address general appearance, work of breathing and circulation • A quick assessment will help determine if the child is sick and needs help quickly, or is not as urgent • The quick assessment is an easy tool to use, even if you do not have a ton of pediatric experience • Usually a more complete primary and secondary survey will follow a quick assessment

  15. General Appearance

  16. Pediatric Cliff notes appearance (TICLS) Level of interactivity/ consolability A child interested in the environment, smiling, happy, or who looks around, cries and can be consoled is good A child not interested in the environment, or not consolable is not good Muscle tone/activity level An active child is grabbing, reaching, or moving A still, floppy or quiet child is not good Look/gaze Babies or children will look at caregivers, items of interest Staring and not engaging in eye movement or contact is bad Speech/cry Cries or speech is good. Moans, grunting, or quiet is not good

  17. Pediatric Cliff NotesAirway refresher • Tongue…takes up a lot of room in a small area -instant obstruction with airway swelling -obligate nose breathers, direct airflow over tongue • Trachea…very pliable, narrow, shorter • Epiglottis…large for area and is “floppy:” -difficult to control during intubation

  18. A comparison Pediatric Airway Adult Airway

  19. Work of breathing A child should be breathing easily Increased work of breathing may include any of the following -Abnormal audible breath sounds Wheezing, rales, ronchi, stridor (like a seal bark) -Increased resp rate/work of breathing “not good” -Retractions (suprasternal, intercostal, subcostal) “bad” -Nasal flaring, grunting “really bad”

  20. Work of Breathing A decreased respiratory effort with decreased neurological status/bad appearance is an emergency Increased work of breathing is compensatory Poor effort or slow breathing is decompensatory

  21. Pediatric Cliff NotesKeep in mind • Pediatric patients have an increased oxygen demand compared to an adult • Pediatric patients are very sensitive to low oxygen levels, and can show subtle/early signs or life threatening/late signs, with a fast transition.

  22. Pediatric Cliff Notes circulation Peripheral pulses/pulse strength Brachial is a great place to check Should be strong Cap refill time 3 seconds or less (check on heels or hands) Skin temperature Pink , warm and dry

  23. Pediatric Cliff NotesCirculation • BP is an unreliable indicator of shock in pediatric patients • Pediatric patients can compensate for up to a 40-45% blood loss • Low blood pressure related to losing blood or fluid is a late sign & may indicate a loss of 25% volume • Cap refill is a good measure in kids • Decreased circulation to the skin is an early sign of compensation for a circulatory problem in kids (not always true in adults)

  24. Pediatric Cliff Notes Keep in mind • Poor perfusion of vital organs leads to compensatory vasoconstriction in less essential areas, especially the skin and kidneys • Therefore circulation to skin and urine output reflects overall good blood flow.

  25. Circulation to SkinOther causes of poor skin perfusion (mottling,  capillary refill time) Fever Hypothermia Medications Normal vasomotor response in infants

  26. Pediatric Cliff NotesCirculation • Fast heart rate is one of the 1st signs of shock… • Can also be caused by anxiety, fear, pain, agitation • Urine Output is an excellent indicator of organ perfusion • Kidneys need good blood flow to filter, and if they are receiving blood flow, so are other organs

  27. Pediatric Cliff NotesCirculation • Urine output: 1cc/kg/hr is normal, • 30cc/hr for older child

  28. Pediatric Cliff NotesOdds n Ends Pediatric Thoracic cavity -Pliable/more horizontal -it limits anterior/posterior diameter and volume -children have a big heart in a small space and less lung reserve -Accessory muscles -Are less developed -And have less reserve to increase ventilation strength or depth -Abdominal cavity -think of a small space with large organs, diaphragm crowding

  29. Pediatric Cliff NotesOdds n Ends Skin/hypothermia -area-to-volume ratio 4x that of adult -muscles not strong enough to shiver to generate heat -thin adipose tissue, poor insulation, core temp drops Liver/hypoglycemic -underdeveloped, poor glycogen stores, increased metabolic rate

  30. Making a quick assessment • The American Academy of Pediatrics has created an ABC approach for quick Peds assessments • Appearance • Work of Breathing • Circulation to skin • This is called the Pediatric assessment triangle • It is used to demonstrate the relationship between 3 assessment areas

  31. Pediatric Assessment Triangle Work of Breathing Appearance Circulation to Skin From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com

  32. Pediatric Assessment Triangle Appearance • Examples of appearance issues

  33. Pediatric Assessment Triangle Work of Breathing • Examples of WOB

  34. Pediatric Assessment Triangle • Examples of Circ to skin Circulation to Skin

  35. Pediatric Assessment Triangle The Triangle is a rapid way to determine physiologic stability.

  36. Pediatric Assessment Triangle • The Triangle focuses on three interdependent aspects of physical assessment that reflect two important pieces of information: • 1. Severity of illness or injury And • 2. Urgency of intervention In other words ...

  37. How quick? How sick?

  38. • Appearance is the single most important factor in assessment. • There are very few false negatives (very few truly sick or injured children that have normal appearance). Pearl

  39. A Good general appearance means Normal to well-compensated oxygenation, ventilation and perfusion “Not sick”“Not quick”

  40. Pediatric Assessment Triangle By looking at general appearance, work of breathing and circulation, provide a quick assessment of Ellie, a 5 month old baby

  41. Pediatric Assessment Triangle • Appearance—Good -Tone is good (able to support self), she is interactive and interested in her environment, smiling, looking at a new object, she appears content and is not crying, nor does she seem to be in pain • Work of Breathing—Good • She does not appear to be working hard to breathe • Circulation—Good • Her skin is pink, and if you felt her, her skin would feel warm and dry, and she doe s not appear mottled (vasoconstricted)

  42. Pediatric Assessment • Based on your assessment, Ellie looks good, and does not appear sickly, nor need medical attention quickly. • What about our next baby, Brandon?

  43. Pediatric Assessment

  44. APoor general appearance meansPoorly compensated physiology (oxygenation, ventilation, perfusion)“Sick!” “Quick!”

  45. Pediatric Assessment • -Increased work of breathing (retractions) • - Does not have a good appearance • -Not interacting • - He looks like he needs some help. • How about our next baby?

  46. Flared nostrils Poor appearance… Sick, Quick!

  47. Triangle: Respiratory Distress Normal Appearance Increased Work of Breathing MEANS RESPIRATORY DISTRESS

  48. Triangle: Respiratory Failure Abnormal Increased or Decreased Work of Breathing Appearance MEANS RESPIRATORY FAILURE

  49. Triangle: Normal Appearance PoorCirculation to Skin MEANS OBSERVE

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