Lecture 3: Pediatric Considerations

1. Lecture 3: Pediatric Considerations

2. Objectives On completion of this module, the EMA/Paramedic will be able to: • describe the components of the pediatric acuity assessment • perform an assessment on a pediatric patient and assign an appropriate acuity level using the CTAS acuity scale • discuss the considerations required to assign an acuity level to the pediatric patient

3. Use of EMS by Pediatric Patients • fewer than 10% of requests for medical services are for children • caregivers often choose to transport their critically or seriously ill or injured child to an emergency department by private vehicle rather than waiting for emergency medical services to respond. • Reference: Institute of Medicine, Division of Health Services, National Research Council

4. Unique Attributes of the Pediatric Patient • children are not small adults, (it’s the other way around) • differences include size, thought processes, physical and emotional maturity and social development.

5. Pediatric Considerations • children are less likely to have life threatening conditions • symptoms of life threatening problems may be subtle and progress rapidly,and • frequently involve the respiratory system or central nervous system

6. Pediatric Considerations • accurate assessment is critical due to the potential for rapid deterioration • the child’s diagnosis is not as important as recognition of the potential for rapid deterioration based on history and physical findings

7. Pediatric Considerations • a physiologic assessment of the child will assist in assigning the acuity level • patients with abnormal vital signs- heart rate or respiratory rate, are level 1 or level 2

8. Components of the Pediatric Assessment • pediatric assessment triangle • pediatric history (subjective data) • physical assessment (objective data)

9. Pediatric Assessment Triangle AppearanceWork OfBreathing Circulation

10. Pediatric Assessment Triangle • General appearance • activity level • level of consciousness • Work of breathing • respiratory rate • respiratory effort • Circulation • heart rate • perfusion

14. The “Key Look”: Using sight, hearing, smell, and touch • non verbal cues: facial grimaces, fear, cyanosis • listen for a cough, hoarseness, or labored breathing • touch the patient, assess heart rate, skin temperature and moisture, capillary refill • assess for odors such as ketones, alcohol or infection

15. Pediatric Physical Assessment: • may be limited if patient requires rapid access to care/interventions (Level 1 & Level 2) • all pediatric patients must have their general appearance, respiratory rate, effort and perfusion evaluated initially • Note: age/developmentally appropriate behavior and social interactions indications of child maltreatment (does the story make sense?)

16. Pain Assessment in Children • tachycardia, pallor, sweating and other physiological signs are also used to evaluate pain • pain scales are less helpful (or reliable) at the extremes of age • the parents can give an indication of the severity of pain • pain perception may be influenced by age, past experience and cultural differences

17. Pediatric Vital Signs • abnormal vital signs are often a late finding • tachycardia is an early indication of hypotension or hypovolemia • abnormal VS • level 1 patients have VS- HR or RR > 2 SD • level 2 patients have VS- HR or RR > 1 SD

18. Pediatric Vital Signs

19. CTAS Level 1 Resuscitation

20. CTAS Level I: Explanation • require aggressive treatment • pre and post arrest • unable to speak due to respiratory distress, cyanosis • lethargic/confused • tachycardia/bradycardia • O2 saturation < 90% • VS HR or RR > 2 SD

21. CTAS Level 1: Physiologic Assessment • unresponsive • severe respiratory distress/inadequate breathing • cardiac arrest/shock/cyanosis • respiratory rate greater/less than 2 standard deviations from normal range • heart rate greater/less than 2 standard deviations from normal range

22. CTAS Level 1: Usual Presentations • Severe respiratory distress • airway compromise • near death asthma • anaphylaxis • congestive heart failure • pneumothorax

23. CTAS Level 1: Usual Presentations • Major trauma • head injury with GCS < 10 • severe burns (> 25% TBS or airway problem) • spinal injury with neurologic deficit

24. CTAS Level 1: Usual Presentations Major Trauma: • Chest/abdominal injury with any of: • i) hypotension and tachycardia, usually with severe pain (pain scale 8-10), • ii) respiratory distress with abnormal rate, volume, or decreased air entry, • iii) altered mental state suggesting hypoxemia or hypoperfusion.

25. CTAS Level 1: Usual Presentations • Shock states: • shock/hypotension/ tachycardia • anaphylaxis • septic

26. CTAS Level 1: Usual Presentations • Unconscious/unresponsiveness • active seizures • intoxications/overdoses • hypoglycemia • metabolic disturbances • NB: All patients with altered mental state must have a rapid blood sugar screen test.

27. CTAS Level 2 Emergent

28. CTAS Level 2: Explanation • unstable child with moderate to severe respiratory distress with potential to deteriorate • altered level of consciousness • abnormal vital signs: VS -HR or RR > 1 SD<2 standard deviations • need for rapid treatment on arrival • controlled acts may have been applied in the prehospital setting (ALS)

29. CTAS Level 2: Physiologic Assessment • altered consciousness • altered mental status: lethargic, drowsy, agitated, inconsolable • moderate respiratory distress/marked stridor • capillary refill greater than 4 seconds

30. CTAS Level 2: Usual Presentations • Head injury • GCS < 13 • severe headache, loss of consciousness >5 minutes, confusion, neck symptoms and nausea or vomiting

31. CTAS Level 2: Usual Presentations • Overdose • intentional and unintentional

32. CTAS Level 2: Usual Presentations • Fever • age < 3 months • temperature > 38.0 0 C • immunocompromised • chemotherapy • chronic illness

33. CTAS Level 2: Usual Presentations • Vomiting and/or diarrhea • signs of moderate to severe dehydration • altered level of consciousness • capillary refill > 2 seconds • hypotension

34. Moderate to Severe Dehydration • decreased capillary refill, • tachycardia, • decreased urine production, • decreased skin turgor, • dry oral mucosa, • sunken fontanelle, • and lethargy

35. CTAS Level 2: Usual Presentations • Neonates • less than 7 days of age

36. CTAS Level 2: Usual Presentations • Child Abuse/neglect • afebrile with altered level of consciousness • history of ongoing risk • unexplained trauma

37. CTAS Level 2: Usual Presentations • Serious infections • purpuric skin rashes ( non blanching spots) • history of fever or chills with rigors • temperature instability in neonates • infants less than 3 months temperature < 36 or >38 • immunosuppressed and asplenic children • infants more than 3 months with fever and a toxic appearance

38. Case Presentations

39. A 15 year-old male was hit by a car and fell from his bicycle. He denies loss of consciousness, headache, and neck pain. He complains of severe abdominal pain (8/10) mostly left upper abdomen. He is uncomfortable and grimacing with pain. V/S are pulse 110, B/P 124/68, respirations splinting and 18. GCS 15. He is tender in the LUQ. There are no obvious bony injuries.

40. You have attended a 4 year-old girl who is covered in hives, has stridorous breathing, audible wheezing, and is very anxious and distraught. She appears cyanotic and ashen. The mother states that the child ate a peanut butter cookie prior to the hives appearing. V/S initially, HR 120, RR 30. O2 is applied by NRB. You have given Epinephrine 0.2 ml. SQ with no response and are now en route to hospital.

41. A mother calls the ambulance for her3 year-old son who has had a fever (39º C) for 1 day. The child has leukemia and is on chemotherapy. His last treatment was four days ago. The child has flushed cheeks but otherwise looks well. V/S are pulse 120, BP 100/65 and respirations 20.

42. You arrive and find a 2 month-old infant carried in his mother’s arms. He has had a “high” fever for 2 days and has been given Tylenol with some relief. Yesterday the baby was irritable and today the baby is not feeding well and is lethargic. The baby looks unwell and floppy. VS are pulse 200, RR 36. You apply O2 and transport immediately.

43. CTAS Level 3 Urgent

44. CTAS Level 3: Explanation • normal vital signs • presenting problem suggests a more serious acute process occurring • moderate pain(4-7/10) involving head, chest, abdomen

45. CTAS Level 3: Physiologic Assessment • infant – inconsolable, not feeding or atypical behavior • mild respiratory distress, mild stridor • respiratory rate at the limits of normal range • heart rate at the limits of normal range • capillary refill greater than 2 seconds

46. CTAS Level 3: Usual Presentations • Head injury • alert (GCS 13-15) • moderate pain (4-7/10) • nausea or vomiting

47. CTAS Level 3: Usual Presentations • Moderate Trauma: • head, chest, abdominal pain(4-7/10) • patients extremity trauma - fractures or dislocations pain (8-10/10)

48. CTAS Level 3: Usual Presentations • Asthma, Mild/moderate • short of breath on exertion • frequent cough • O2 Saturation > 92 < 94 %

49. CTAS Level 3: Usual Presentations • Dyspnea Moderate • pneumonia • bronchiolitis • croup

50. CTAS Level 3: Usual Presentations • Seizure: • brief duration (< 5 minutes) • known seizure disorder • new onset • patient stable and alert • able to manage airway • normal vital signs