Pediatrics Bailey Burge, BSN, RN Burn Intensive Care Unit September 26, 2012

1. PediatricsBailey Burge, BSN, RNBurn Intensive Care UnitSeptember 26, 2012

2. Objectives List anatomical and physiological differences in pediatric patients Discuss why it may be necessary to vary your approach based on age Identify normal ranges for pediatric vital signs Identify differences in medication administration

3. Anatomical Differences • NOT LITTLE ADULTS • Body Proportions • Head larger • Greater body surface area to total body weight • Thinner skin

4. Rule of Nines

5. Anatomical Differences • Airway: • Large Tongue • Trachea shorter & narrower • Cartilage is more elastic • Larger portion of soft tissue in airway • Airways smaller & narrower • Musculoskeletal: • Fontanels • Chest wall softer & more compliant • Weaker abdominal muscles • Abdominal breathers till around 8 yr old

6. Physiological Differences Higher metabolic rate Higher fluid requirements Limited glycogen stores Total circulating blood volume per kg greater than adult

7. Assessment • Approach to physical exam: • Consider age and developmental level • Infants: Calm, soothing voices, warm hands • Toddlers: Incorporate play, give limited choices, positive reinforcement • Preschoolers: Use concrete words, let them help & play with equipment • School-Age: Explain, allow questions, participate in care, ask if want caregiver present • Adolescents: Treat as adult, be honest, give concrete info

8. Assessment • Approach to physical exam: • Always observe first • Eye level • Vary the sequence with activity level • Auscultate if calm and quiet • Begin with least invasive, end with most invasive

9. Assessment Special Points • Head • Anterior Fontanel: • Remains open for 12-18 months • Sinks in dehydration • Bulges with increased intracranial pressure

10. Assessment Special Points • Chest • Transmitted breath sounds • Listen mid-axillary • Red flags: • Grunting • Nasal flaring • Stridor • Neurological • Silence is not golden • Recognizes parents • AVPU • Modified Glasgow Coma Scale

11. Assessment Pain • Difficult & Challenging • Control • Constant background pain + exacerbation • Assess • Behavioral, physiologic and self-report • Scales: FACES, Numeric, FLACC • Harmful effects with unrelieved pain • Meds for pain, meds for burn care

12. Vascular Access SPECIAL POINTS • Peripheral • Supplies: • EMLA cream, heat packs • IV: 22-24 G • Explain • Don’t use parent to restrain • Papoose • Look distally if non-emergent

13. Vascular Access • Visualize vein • Light • Vein finder • Provodine for darker skin • Change when • Insert with bevel down for flashback • Location: • Hands • Good site for chubby kids • Make fist, flex wrist • Feet • Antecubitalfossa • Secure • Visualize insertion site • Tape • Arm board

14. Vascular Access • Intraosseous • Emergency • Tibia preferred site • Distal femur, medial malleolus, iliac crest • Avoid growth plate • Advance till no resistance • Aspirate bone marrow • Flush • Observe for swelling

15. Vascular Access • Intraosseous • Stabilize • Flush with 5ml after med administration • Only good for 24 hours • Discontinue: • Twist and pull • Pressure for several mins • Apply dressing with date and time

16. Vascular Access • Central Venous Line • More complications than adults • Femoral, internal jugular, subclavian • Advocate • Large burn • Frequent laboratory data • Prolonged venous access • Heparin

17. Medication Administration • Caution • Flushes • Mixing meds with juices/milk • Too much diluent • Oral Medications • Syringe for accurate dosage • Give when head raised • Place syringe between gum & cheek • Gastric tubes • Pulsate piston syringe

18. Medication Administration • Intramuscular • Infants • 0.5 ml – 1 ml per site • Older children • Max 2ml per site • Sites: • Vastuslateralis: <3 years old • Ventrogluteal: >3 years old • Deltoid

19. Medication Administration • Dextrose: • >8 yo (D50) 1-2ml/kg/IV • 1-8 yo (D25) 2-4ml/kg/IV • 0-1 yo (D10) 5-10ml/kg/IV • Newborn (D10) 2ml/kg/IV

20. Nutrition Enteral Feedings Weight Initial volume (ml/hr) Advancement <10 kg 1ml/kg 5ml every 4 hours <50 10 10ml every 4 hours • Residuals: > than previous hour’s feeding volume, inform physician • Zantac

21. Vital Signs MAP?? No Foley? Weigh diapers: 1g = 1ml Urine output: <10 years 1ml/kg/hr >10 years 0.5ml/kg/hr

22. Vital Signs • Abnormal causes: • Hypotension: sign of late shock • Tachycardia: fever, hypoxia, anxiety, early sign of shock • Bradycardia: critical hypoxia, ischemia • Hyperventilation: hypoxia, pain, fever, excitement • Hypoventilation: severe head injury, exhaustion from hyperventilation

23. Review of Shock Early signs (compensated) Late signs (decompensated) • Increased rate • Poor perfusion • Altered mental status • Agitation • Widened pulse pressure • Weak central pulses • Decreased mental status • Decreased urine output • Hypotension

24. Hypovolemic Shock • Most common • Hypotension is late sign • 20ml/kg fluid bolus (LR or NS) • Albumin (5%, 25%): 0.5 – 1G/kg • PRBC: 10-20ml/kg

25. Burns • Third leading cause of death • Thermal most common • Child abuse • Lines of demarcation • Listen to story • Thinner skin • Takes less than 10 seconds at 130 • Takes less than 5 seconds at 140

26. Abuse

27. Admission to BICU Weight (kg) & measurements Pedi team consult Medication Code Sheet Pictures: head to toe Child Life consult Parent allowed 24 hours Family is patient Education

28. Burn Care • Coordinate with PI physicians • No painful procedures in room • Explain procedure few minutes before • Be truthful • Topicals: • Silver dressings • Santyl • Praise afterwards no matter what the reaction

29. References American Burn Association. 2007. Advanced Burn Life Support Course: Provider Manual. Chicago, IL.: American Burn Association. Emergency Nursing Pediatric Course (2004). Provider Manual. (3rd ed.). Des Plaines, IL. Herndon, D. N. (2007). Total Burn Care. Galveston, TX: Elsevier Health Sciences.