Assessment of the Hospitalized Pediatric Patient

1. Assessment of the Hospitalized Pediatric Patient Ken Graham MD, F.A.A.P. Angie Ostrowski MD, F.A.A.P. Rocky Mountain Children’s Clinic & St. James Healthcare

2. Objectives • Describe normal pediatric vital signs. • Describe abnormal pediatric vital signs and exam findings. • Identify interventions in the care of ill children based on physical exam findings. • Interpret laboratory findings as they relate to ill children. • Identify findings that would be important to report to MD’s and describe treatments based on laboratory findings.

3. 1ST – Lets Review Normal • PALS and NB STABLE course. • Start with the basics – the assessment of NB’s and Children using the ABC’s. • Remember, we want you to be able to look at a child and in 1-2 minutes you should have some idea of the child’s clinical status (is this child “sick” or “toxic”).

4. A - Airway/ B - Breathing Here, we are looking at the respiratory system. What do we evaluate on P.E.? 1) Vital signs a) Respiratory Rate (RR) – What’s normal? Infant : 30-60 Toddler : 24-40 Preschooler : 22-34 School-aged : 18-30 Adolescent : 12-16 b) O2 Saturation : > 90% is normal at this altitude What else do we evaluate in addition to RR and O2 Sat?

5. Airway/Breathing 2) Color Pink – what we want to see. Blue – with cyanosis – face/body – need to look at the mouth, lips and tongue. Ashen – “deadly pale” – the color nobody wants to see – usually represents more than respiratory compromise. 3) Respiratory Effort What are we looking for here?

6. Respiratory Effort • GFR Grunting – patient is generating his/her own PEEP to keep airways open. Flaring – nasal flaring – sign of increase respiratory pull. Retracting – can be a sign of difficulty on inspiration and expiration. – can be simple intercostal, to profound supraclavicular and subcostal retractions. * When one sees supraclavicular retractions, the child is using less than 50% of his/her lung volume to breathe! This kid needs help. 4) Respiratory sounds

7. Respiratory Sounds Inspiratory Noises Nasal congestion/secretions can give NB’s great difficulty with breathing. – frequent flushing and suctioning may be needed. Inspiratory Stridor usually signifies croup and is a high pitch noise secondary to swelling near the vocal cords/upper airway. Rhonchi/Rales/Crackles usually signifies air passing thru a bronchus that contains secretions or exudates – Pneumonia. Can often be heard on expiration as well. Expiratory Noises Wheezes are noises usually signifying airway obstruction/bronchospasm. Commonly seen in asthmatics and NB’s/children with Bronchiolitis (RSV&FLU). When the asthmatic is in real trouble one can hear wheezes on inspiration as well.

8. C - Circulation Here we are looking at the cardiovascular system. What do we evaluate on P.E.? 1) Vital Signs a) Heart Rate (HR) - What’s normal? Age Awake Sleeping NB’s to 3 mon. 85 – 205 80 – 160 3 mon. to 2 yrs 100 – 190 75 – 160 2 yrs to 10 yrs 60 – 140 60 – 90 > 10 years 60 – 100 50 – 90 I like to remember 3 numbers having to do with HR’s – >160,180, and 220 – this deals with Sinus Tach and SVT.

9. Circulation – VS 1) Vital signs b) Blood Pressure (BP) – What is normal? Age Minimum Systolic Blood Pressure Term NB (0-28d) 60 mm Hg Infants ( 1- 12mon.) 70 mm Hg Children (1-10yrs) 70 + (age yrs x 2) mm Hg Children > 10 yrs 90 mm Hg What else do we evaluate in addition to HR & BP?

10. Circulation 2) Color a) Pink – again to color we want to see b) Mottled – a sign of poor skin perfusion, the skin has a checkerboard appearance and refill is generally delayed. c) Ashen – as discussed before under respiratory findings – describes poor circulation and poor oxygenation. 3) Capillary Refill – should be < 2 seconds and correlates with skin perfusion and good BP. Most often we test this 1st on the chest and then in the extremities. What else do we evaluate?

11. Circulation continued 4) Pulses – are they present and if so where? a) Central – carotid and femoral b) Peripheral – radial/brachial, Post. Tibial and Dorsalis Pedis. *Palpating the pulse can be one of the most important parts of the physical exam. The most important is simply to use your eyes to see if the patient is alert and how they are breathing. If they aren’t alert, but are breathing – check the pulse. – By touching you can tell temperature, BP ( is pulse strong and where is it present), and HR (tachycardia, bradycardia, or normal). Other Vital Signs/Physical Exam findings to think about?

12. Temperature • Normal Temperature – 98.7 F, 37.0 C • In Peds we consider Fever to be a Temp > 100.5/38.0 a) In NB’s and Infants under 6 weeks of life a temp this high reqs a R/O sepsis work-up. b) After 2 months of age we are not as worried about bacterial sepsis– esp. in an immunized infant. * Remember Fever is our Friend! Should we treat fever? Why? Why not?

13. What Does Grandma Think? Grandma thinks if your fever is too high – you will get brain damage! Is this true or false? FALSE – even temperatures as high as 106 don’t cause injury – in fact – in order to produce a fever higher than this you must have a brain injury (head injury/damage to the Thalamus). We do have to mention heat stroke here – because you can get deregulation of body temp. controls when you get overheated. Grandma thinks high fever will cause a seizure? T or F? FALSE – it isn’t the height of fever that causes a seizure, it is how fast the temp rises from normal– so you can have a seizure at a relatively low temp. Febrile seizures usually occur b/t ages 6 mo-2 yrs

14. Fever - When do We Treat and WHY? Treatments: a) Tylenol (acetaminophen) 10-15mg/kg/dose q 4-6hrs b) Motrin (ibuprofen) 10mg/kg/dose q 6-8hrs > 6mon of age When: a) Fussy infants, and children b) Infants and Children with febrile seizures c) Children with Respiratory distress and/or tachycardia who have fever. d) Children that are febrile and in pain, i.e. headaches, sore throat, body aches and for post-op pain relief.

15. Case #1 • 16 mo female, resp arrest in ED, fever and poor PO intake x5 days • T103.6, HR 185, RR 28, Sats 96% RA • What else do you want to know? • What do I want to know? • What are you concerned about? • What’s on your differential?

16. BP 98/56 • Pink mucosa, no mottling, brisk pulses • Distal CR 3 secs • Sucking on a bottle but appears sick • IV fluids running • Labs mostly reassuring; CXR, head CT nl • What now?

17. Fever control • NS bolus • Monitor UOP, perfusion and HR/BP closely • Consider antibiotics if worsens • Am labs

18. Case #2 • 3 yo male, h/o RAD • Admitted last night for hypoxia, stable on 1L with Q4hr nebs • Tonight is working harder to breath, difficult to hear BS and O2 req up to 4L • First steps and important vitals?

19. Albuterol + Atrovent ASAP- listen before and after • Steroids? • Check and recheck and then recheck! • Update MD

20. Case #3 • 2 mo female, RSV + • Admitted today with hypoxia, poor PO intake and fever (Tmax 100.2F) • DOI #2 • Important vitals? • Important treatments? • How will you know if there is clinical change?

21. Treatment 1) Antipyretics – Tylenol and Motrin discussed. 2) Fluids a) Bolus fluids – Normal Saline (NS) Volume –> 10 to 20ml/kg b) Maintenance fluids – D5W ¼ NS / D5W 1/2NS with 20 meq K/L Rate calculated based on weight in kg’s.

22. Treatment continued c) Glucose containing fluids for hypoglycemia D10W –> 2-4ml/kg given as bolus over 3-5 min. for Blood Glucose < 40. 3) Antibiotics (IV) Ampicillin and Gentamicin are common for Neonates. Cefotaxime and Ceftriaxone are common for Kids. Cefuroxime is common for community acquired pneumonia. Vancomycin and Zyvox common for MRSA and Strep/Staph Sepsis.

23. Treatment Continued 4) Antiemetic Meds Zofran, Phenergan, Compazine, Reglan, Benadryl, Dramamine, and Scopolamine 5) Steroids Decadron for Croup – IM,IV, and P.O. 0.6mg/kg/dose once up to 6 doses – given q6hrs Solumedrol for severe Asthma (RAD) exacerbations 1-2mg/kg/dose q 6-8hrs -> 60-120mg q6hrs Max Oral Methyprednisolone can be used much the same way as Solumedrol.

24. Treatment continued 6) Inhaled Meds (common to RAD treatment) a) Albuterol – common for RAD and Bronchiolitis Dose 2.5-5.0mg q 1-6hrs b) Xopenex L-albuterol – used like regular albuterol Dose 0.31-1.25mg q1-6hrs c) Ipratopium Bromide (Atrovent) adjunct with albuterol and xopenex Dose 0.5mg q6-8hrs d) Pulmicort (budesonide) – inhaled steroids Dose 0.25-1.0mg once to twice/day e) Multiple other Meds – MDI’s – Advair, Flovent etc...

25. Laboratory Evaluation • What are the common Labs ordered for the inpatient ill NB/Child and what information do they provide? Basic / Comprehensive metabolic Panels CBC – Complete Blood Count (Manual Diff) Urinalysis (culture if indicated) CRP and Sed Rate (ESR) Blood and other Cultures Blood Gases

26. Basic / Comprehensive Panels These metabolic panels give information regarding electrolytes, kidney and liver functions. * The purpose for discussing these laboratory values is to use our thinking caps with regards to the values that are presented. Lab values on the print-out may look normal, but in the face of disease, may in fact be abnormal and vise versa. * In general, with the Basic – we want to know all the values all the time! – not just the labs that have “L” or a “H” after the value. What info does the Basic provide?

27. Basic and Comprehensive Panel Na+, K+, Cl-, and Ca++ are electrolytes and these help us evaluate hydration status. Creatinine (Cr) - provides information about kidney function and is often low in children. It is most often the 1st concern reported by nurses – its generally o.k. if it is low, we worry much more if it is high. BUN – another lab to assess kidneys and hydration status CO2 – gives info on acid/base status as well as hydration. – How does it tell us about hydration? Glucose (Glu) – obviously we look to see if Glu is in the correct range – Glucose is the main energy source our body uses. We commonly get calls for mildly elevated Glu levels. – Why would they be mildly elevated?

28. Basic and Comprehensive The Comprehensive Panel adds in LFT’s and other factor that tell us about liver function and other body functions –i.e. nutritional status. We generally want to know that the ALT and AST are normal. – The Alk. Phos. is almost always high in the growing child because of Bone Alk. Phos. We like to know the T.P. and Alb. as well – especially in the face of Liver and kidney disease.

29. CBC • The three main components CBC we look at are: a) WBC with manual differential – this tells us about the cells that fight infection – what types are elevated and depressed? We make a big deal about the Band Neutrophils; these are the cells the bone marrow pumps out to fight severe infections – typically bacterial. We sometime want to know the ANC – the Absolute Neutrophil Count. – What does the info provide? If it is low, one might not be able to fight off infection – i.e. cancer patients on Chemo.

30. CBC continued b) H&H - Hematocrit (HCT) and Hemoglobin (Hbg) we evaluate these indices to look for anemia and the body’s oxygen carrying capacity. Normal values vary greatly with age. The CBC can be the most difficult for nurses to evaluate. There are many values reported on the CBC that pertain to the H&H, but are only important during certain disease states. – i.e. RDW, MCV, MCHC. – We can usually evaluate these later or we might specifically ask for them based on the H&H info provided by you. c) PLT – Plateletcount – tells about the cells responsible for clotting our blood. We like to see at least a count of 20. Can go to surgery if > than 50.

31. Urinalysis (UA) • The UA is one of the cheapest and most informative tests we can order. Why???? It can tell us about hydration status – looking at the Spec. Grav. and Ketones. It can be informative about acid/base status looking at urine pH. We can R/O infection (UTI’s) looking at Leuk. Esterase and if Nitrite is positive we have an idea on the type of infection present. If these are positive we send a culture. Can R/O liver disease with ICTO test. can R/O Diabetes looking at the Glu.

32. CRP & Sed Rate (ESR) • These are inflammatory markers and we evaluate them to help decide the seriousness of the infection / disease process. They can be elevated in serious bacterial infections/sepsis, cancers and inflammatory diseases; like JRA, Crohn’s disease, Ulcerative Colitis (UC) etc…. CRP is normally < 1.0 ESR is normally < 20.0 We generally will follow these markers throughout the course of treatment to help decide on length on treatment needed and to confirm adequate treatment when followed with clinical improvement.

33. Blood and other Cultures Blood cultures are commonly ordered in the evaluation of a NB/child with high fever and suspected sepsis/bacteremia. We would all like to get cultures from 2 separate sites, but with kids, that is not always possible. In general, we want to obtain at least 2ml into 1 culture – if 2 cultures are indicated – this will be emphasized. Other Bacterial cultures that are common – abscesses, i.e. MRSA, eye infections etc… CSF/Urine * We generally want to obtain all of our cultures as quickly as possible before initiating the start of antibiotics. WHY?????

34. Blood Gases • This is the challenging and anxiety provoking part of our laboratory evaluation. We use Blood gases (Arterial if possible) to evaluate: a) Acid/Base status b) Respiratory vs. Metabolic compromise c) Oxygenation Status Only Arterial samples are useful for evaluating pH, PCO2, PO2, and HCO3. Capillary samples are not useful in evaluating PO2. Venous blood pH values are usually 0.02-0.04 lower and PCO2 6-10mm Hg higher than the arterial sample.

35. Blood Gases Normal Values Arterial: Capillary: pH 7.30-7.40 7.30-7.40 PCO2 35-45 mmHg 35-50 mmHg PO2 (on RA) 50-80 mmHg 35-45 mmHg Bicarb (HCO3-) 19-22 mEq/L 19-22 mEq/L Base Excess -2 to +2 -2 to +2 Pulse Ox reading on Room Air – 90-95%

36. THANK YOU FOR TAKING CARE OF PEDIATRIC PATIENTS!

37. Blood Gases • Let’s use the S.T.A.B.L.E. programs blood gas rules (1-7) and evaluate some blood gases. pH PCO2 PO2 HCO3 • 7.1 38 58 11 • 7.35 25 45 14 • 7.0 55 38 13 • 6.9 80 28 15 • 7.4 35 75 22 • 7.35 33 50 20