Head Is there a history of injury, headaches, or infection? Eyes \200 \200 How good is visual acuity \200\224are glasses needed? Is there a history of infection, inju ry, or surgery? Ear, nose, and throat \200 \200 \200 \200 \200 \200 Is there a problem with hearing or balance? Is there a history of ear infection or discharg e? Is there any dif \201 culty with breathing? Is there a history of nasal discharge, snor ing, or bleeding? Are there any enlarged lumps or glands? Is there a history of sore throat , dental problems, or mouth ulcers? Chest \200 \200 \200 \200 \200 \200 Is there any limitation to exercise? Is there a history of cough, wheeze, chest pain, or ha emoptysis? Has there been any exposure to tuberculosis? Has the child ever had a chest X-ra y (CXR)? Are there any smokers in the family? Are there any smoke-free zones in the family accommodation? Heart \200 Is there a history of heart murmur or rheumatic fever in the patient or family? Is there a history of dyspnoea, orthopnoea, chest pain, or cyanosis? Gastrointestinal \200 \200 How good is the child \200\231s appetite? Have there been any recent changes in weight, foo d tolerance, or bowel movements? Has there been any rectal bleeding? 03_McClure_03.indd 26 11/14/2012 7:04:54 PM SYMPTOM REVIEW 27 Genitourinary \200 \200 \200 \200 \200 Is there a history of infection? How frequent is urination? Is there any dysuria, or haemat uria, or discharge? Is there a history of bedwetting? What was the age of menarche? Joints, limbs, and tissue \200 \200 \200 \200 Is there any pain? Is there swelling or limitation in movement? Is there muscle weakness? I s there any dif \201 culty walking or a limp? Nervous system \200 \200 \200 \200 Is there a history of \201 ts, faints, or funny turns? Is there a history of febrile seiz ures? Are there any abnormal involuntary movements or tremors? How has the child being doin g at school \200\224has there been a recent change that has concerned the teachers or the f amily? Is there a history of hyperactivity? Skin \200 \200 Is there a rash? Are there any birthmarks or unusual marks on the skin? 03_McClure_03.indd 27 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 28 Family history In pediatrics, the family history is one of the most important components of the history: \200 Ages tree. Include the whole extended family with ages. Illness in the family: does anyone have a history of seizures, asthma, cancer, heart disease, tuberculosis, or any other medic al condition? What was the age of onset and the medical advice so far? Death in the family: have there been any deaths in the family? What was the cause and age at death? Were any in infancy or childhood? Social occupations of the family members? Are there any pets? of parents and siblings: you will need to be able to draw the family history: where and how does the family live? What are the Practice point Draw a family tree to assist your note-taking, and identi \201 cation of key family and so cial history information Examining a child: introduction The physical examination of a child is one of the hardest p arts of the doctor \200\223patient interaction. You will need to have gained the con \201 dence of the family and the child if you are to get the information that you require. How y ou approach the family (and how you communicate with them) throughout the interaction will be picked up by the child. In fact, a child may decide very early into the interview whethe r you \200\231ve gained their con \201 dence, and whether or not they will let you examine them. No amount of coercing will improve the situation \200\224the parent will often be yo ur advocate and do the convincing for you. It is therefore very worth- while investing in t he art of communication \200\224how to talk with toddlers to teenagers and how to speak eff ectively with parents of sick children. The following description is not meant to be prescriptive. There is much overlap between th e different systems and you will have to decide on when, and in what order, you do things. For example, the tongue is assessed in the respiratory, cardiovascular, and GI systems \200 \224just look at it once! 03_McClure_03.indd 28 11/14/2012 7:04:54 PM GENERAL CONDITION 29 General condition \200 State any evidence of chronic illness? Make an assessment of their mental state: is their b ehavior appropriate. Does the child interact with the parents? Is the child alert, tired, l ethargic, or uncomfortable? Height , weight, and head circumference: these measurements are often made before you see the child. Acquaint yourself with how they are done in the clini c or on the pediatric ward. Certain measurements, e.g. the head occipitofrontal circumferen ce (OFC), you will want to do yourself. In a growth clinic, length or height measurements a re best done by the auxologist. Hydration: sunken eyes, skin turgor, and pulse. of health: make a note of the child \200\231s general appearance. Is there capillary re \201 ll, mucous membranes, anterior fontanelle, Practice point \200 In those under 2yrs old, obtain a length measurement using a table stadiometer. In older ch ildren, height can be measured standing Weigh the child unclothed Measure the head OFC at t he maximum point of the occipital protuberance posteriorly and at the mid-forehead anterior ly Each of these measurements should be plotted on standard charts and the centiles recorde d with the raw data \200 03_McClure_03.indd 29 11/14/2012 7:04:54 PM CHAPTER 3 Clinical assessment 30 Vital signs See also b p.37. See Tables 3.1 and 3.2 for normal values of respiratory rate, heart rate (HR), and BP at different ages. \200 Temperature can be measured. Different units use different methods: \200 \200 \200 A sick child could have a high, or abnormally low, temperature. Pulse rate: the pulse rate sh ould be assessed from the radial pulse. (In the younger child you may \201 nd it easier t o use brachial pulse.) Assess the rate, character, and rhythm at the radial pulse. Respirat ory count the number of breaths/min. Breaks or pauses in breathing that last longer than 15 s are abnormal. In the infant, count abdominal movements over 1min, if you \201 nd it is easier to see diaphragmatic, rather than chest wall movement. BP: method with BP displayed on-screen. It is important that the size and width of the cuff is appropriate for the size of limb in which pressure is being measured. It should cover 50 \200\22375% of the upper ar m or thigh. A single measurement is required in most cases, but if heart disease is suspect ed, 4-limb measurements are needed. If considering hypertension, a standard technique is re quired; plot observations on BP centile charts. : there are various ways in which the body temperature an electronic thermometer in the axilla; a chemical dot thermometer in the axilla; an infra red tympanic thermometer or b p.696. \200 rate: in the older child you can observe the chest and measurement is commonly performed using an automated Table 3.1 Normal values of respiratory rate and heart rate at different ages Age Respiratory rate (breaths/min) Heart rate (beats/min) 0 \200\2236mths 30 \200\22350 120 \200\223140 6 \200\22312mths 20 \200\22340 95 \200\223120 1 \200\2235yrs 0 \200\22330 90 \200\223110 6 \200\22310yrs 18 \200\22325 80 \200\223100 >10yrs 12 \200\22325 60 \200\223100 Table 3.2 Normal values of blood pressure at different ages Age BP, mean (mmHg) BP range, 90% (mmHg) 0 \200\2236yrs 95/65 80/50 \200\223115/80 10yrs 110/70 90/55 \200\223130/85 15yrs 120/75 110/60 \200\223145/90 03_McClure_03.indd 30 11/14/2012 7:04:54 PM RESPIRATORY SYSTEM 31 Respiratory system See also b p.254. \200 Lips and buccal mucosa: what is the color of the mucous membranes and lips? Is the tongue i n good condition? What is its color? Are there any plaques, white patches, or spots? Oropha rynx: exudate? What is the shape of the palate, uvula, and posterior pharynx? Chest: What i s the position of the trachea? What is the chest like on percussion? (hyperresonant or dull ? Where?) Breathing: \202 aring, intercostals, subcostal, and sternal recession, use of a ccessory muscles, forced expiration, grunting, or tracheal tug? Is there an audible noise d uring inspiration or expiration? Auscultation of the lungs: listen for breath sounds in all regions of the chest. Evaluate inspiration and expiration. In the crying child you will st ill be able to listen during inspiration. Are there any \201 ne crackles, rhonchi, or whe ezes? Is there a pleural friction rub? Ears: the child will need to be positioned correctly for this part of the examination. It is often easier to have the child sitting on the moth er \200\231s lap; one of her arms should be held around the upper body, and with the other arm she should place her hand against the side of the child \200\231s head so that it is he ld \201 rm against her. Is there evidence of otitis externa? Is there a rash in the post- auricular area (a feature of dermatitis, measles, and rubella)? On otoscopy, check the stat e of the tympanic membrane. What is its color and degree of lucency? Is it perforated, or i s there a myringotomy tube present? Nose: what is the color and size of the tonsils? Is there an what is the shape of the chest? Are there scars or deformity? are there any signs of respiratory distress. Is there nasal is there discharge? Can the child breathe through each nostril? Practice point You should also consider the following as additional features essential to the respiratory examination: \200 \200 \200 \200 Sputum pot contents Peak \202 ow rate measurement and assessment in relation to height In haler technique in those using such devices Evidence of previous tracheotomy or use of curr ent one You should be able to recognize the following patterns of abnormal signs: \200 \200 \200 \200 \200 \200 Consolidation Collapse or removal of a lung Pleural effusion Pneumothorax Air \202 ow obst ruction Bronchiectasis 03_McClure_03.indd 31 11/14/2012 7:04:55 PM CHAPTER 3 Clinical assessment 32 Cardiovascular system \200 and cyanosis (see b respiratory system, pp.55, 60, 254): Color examine the color of the sclerae and conjunctivae. Teeth: assess the number and condi tion of the teeth. Clubbing: Pulses brachial pulse. Pulse rate varies with the phase of res piration. It increases with inspiration and decreases with expiration. Chest: identify the position of the apex beat and consider whether it is displaced. In young children (<7yrs) i t will be in the 4th intercostal space, to the left of the mid-clavicular line, on the left . In the child older than 7yrs, it will be in the 5th to 6th intercostal spaces. If it is n ot palpable, check the right side to exclude dextrocardia. Can you feel any other pulsation s, heaves, or vibrations in the chest wall? Murmurs: positions. Listen over the whole preco rdium \200\224the apex, the 2nd intercostal space to the left of the sternum (pulmonary val ve area), the 2nd intercostal space to the right of the sternum (aortic valve area), and th e 4th intercostal space over the sternum (tricuspid valve area). Listen to the heart sounds in each of these areas. Are the sounds muf \202 ed and suggestive of pericardial \202 u id? In the pulmonary valve area, is the second heart sound split during inspiration? (Fixed splitting is found with atrial septal defect.) At the apex, is a third heart sound present , indicating mitral valve prolapse or atrial septal defect? Is there a gallop rhythm of con gestive heart failure? \200 \200 assess \201 ngers and toes. Is there any peripheral oedema? and rhythm: compare the stren gth of the femoral and right auscultate the heart with the child in the sitting and supine Murmurs (see b pp.228 \200\223231) Now listen for added noises during the cardiac cycle. If there is one, then it should be described according to: \200 \200 Loudness Timing in the cardiac cycle: \200 diastolic or systolic early, mid, or late \200 Pitch: high or low Quality: Location where best heard: Radiation: chest? Listen to th e back : grade I to VI \200 \200 \200 blowing, musical, or rough apex, pulmonary, aortic, or left sternal where, if anywhere, does the noise transmit across the 03_McClure_03.indd 32 11/14/2012 7:04:55 PM GASTROINTESTINAL SYSTEM 33 Gastrointestinal system For hands, mouth, tongue, and eyes see respiratory and cardiovascul ar systems (b pp.50, 254). Assess whether the child is jaundiced. Abdomen The child needs to be relaxed and positioned supine, with the knees bent and hands by the sides. \200 Look everted? the abdominal wall move? Is the child in pain? Is peristalsis visible? Does t he child know that you are going to touch the abdomen: they should Let be free to tell you if it hurts. Do not hurt the child. First auscultate for bowel sounds, and then percuss in your assessment of hepatomegaly and ascites. In the right mid-clavicular line an enlarged l iver extends more than 2cm below the costal margin. The normal span of the liver \200\224be tween its upper and lower margins \200\224is shown in Table 3.3. Palpate rebound: palpate f or masses during inspiration and deep expiration. Can you feel an abnormal spleen, liver, o r kidney? Watch at the shape of the abdomen: is it distended? Is the umbilicus \200 the abdomen and check for any tenderness before assessing the child feeding. Rectum and anus In most instances you will only need to observe the patency of the anus and to look for \201 ssures and rectal prolapse. However, if the child has abdominal symptom s, a digital examination may be required to check for sphincter tone, masses, and tendernes s. \200 This examination should only be done once and you will need to decide whether this test sho uld be performed by a senior colleague, or by the surgeon should the child have an acute ab domen. Never perform a rectal examination as a senior house of \201 cer. Table 3.3 Normal span of liver (between its upper and lower margins) Age Normal span of liver At 6mths 2cm below costal margin At 3yrs 4cm span At 10yrs 6cm span In adults 10cm span 03_McClure_03.indd 33 11/14/2012 7:04:55 PM CHAPTER 3 Clinical assessment 34 Genitourinary system See also b p.484, 868. For hands, mouth, tongue, abdomen, and eyes see b Respiratory system, Cardiovascular system, and Gastrointestinal system. The external gen italia are examined for any evidence of ambiguity, congenital abnormality, and size. For th is examination you should have a chaperone present for both sexes. In the older child you m ust ensure privacy and preserve the child \200\231s dignity with the appropriate use of cov ers and gowns. Examine once only. In \200 boys: development of the penis, testes, scrotum, and pubic hair can be staged using a stand ardized system (Tanner scale). Look at the state of the foreskin. Is there evidence of infe ction or discharge. Locate the position of the penile meatus. Have both testes descended? In \200 girls: Tanner stage the pubic hair. Is there evidence of fused labia, enlarged clitoris, or infection with discharge or bleeding? Musculoskeletal system See also b p.732. \200 Congenital and arms. Look at the shape of the bones. Deformities: limbs of equal length? Wh at is the range of motion of each joint? Are the skin folds in the upper thigh normal? In t he infant under 6mths check for congenital hip dislocation. Inspect the full length of the spine looking for tufts of hair, dimples, masses, or cysts at the base. Check for torticoll is in the neck. Observe for any abnormal curvature or posture with the child standing and b ending over touching their toes. Gait: anomalies: examine the \201 ngers, toes, hands and feet, legs are there deformities due to fracture? Are the lower watch the child walk and describe it in light of your other \201 ndings. Practice point See also b pp.496 \200\223499, 557 You should be able to recognize the gaits associated with: \200 \200 \200 \200 \200 \200 \200 Myopathy (waddling) Hemiplegia Spastic diplegia Cerebellar ataxia Painful limb (antalgic ga it) Foot drop Trendelenburg gait 03_McClure_03.indd 34 11/14/2012 7:04:55 PM 35 Chapter 4 Resuscitation Cardiopulmonary arrest 36 Rapid cardiopulmonary assessment 36 Pediatric basic life support 38 Choking children 39 Pediatric advanced life support 40 Rhythm disturbances 42 Treating s upraventricular tachycardia 43 Following unsuccessful resuscitation 44 04_McClure_04.indd 35 11/14/2012 7:06:55 PM CHAPTER 4 Resuscitation 36 Cardiopulmonary arrest Cardiopulmonary arrest in children often develops as a progression o f res- piratory failure and shock. The outcome of out-of-hospital arrest is poor, but respi ratory arrest alone is associated with a rate of survival of 80%. In hospital, even though unexpected cardiac arrest is now a rare event (1 per 5000 pediatri c admissions), it is important that events or signs that may lead to arrest are recognized early. Children with any of the features in Table 4.1 warrant urgent medical review (see b p.30 for normal values of vital signs). Rapid cardiopulmonary assessment The rapid cardiopulmonary assessment should take less than 1min. Airway Is it patent? Breathing \200 What are the effort and work of breathing? Is there recession, nasal \202 aring, grunting , use of accessory muscles, stridor, or wheeze? What is the air entry like in the chest? Wh at is the respiratory rate: is it fast or slow? What is the skin color? \200 \200 Circulation \200 \200 What is the heart rate? What is the systemic perfusion? Check pulse volume, capillary re \201 ll, skin temperature, level of consciousness, and urine output. What is the BP? Disability \200 \200 What is the level of consciousness? What are the pupils like: size and reaction? 04_McClure_04.indd 36 11/14/2012 7:06:56 PM RAPID CARDIOPULMONARY ASSESSMENT 37 Table 4.1 Warning signs for acute deterioration Threatened airway obstruction Tachypnoea Age Action respiratory rate (breaths/min) Term to 3mths >60 4 \200\22312mths >50 1 \200\2234yrs >40 5 \200\22312yrs >30 >12yrs >30 Bradycardia or tachycardia Age Bradycardia (beats/min) Tachycardia (beats/min) Term to 3mths <100 >180 4 \200\22312mths <100 >180 1 \200\2234yrs <90 >160 5 \200\22312yrs <80 >140 >12yrs <60 >130 Hypotension Age Action systolic pressure (mmHg) Term to 3mths <60 4 \200\22312mths <65 1 \200\2234yrs <70 5 \200\22312yrs <80 >12yrs <90 Altered mental state or convulsion Low pulse oximetry values: <90% in any supplemental oxygen (<60% if cyanotic heart disease) 04_McClure_04.indd 37 11/14/2012 7:06:56 PM CHAPTER 4 Resuscitation 38 Pediatric basic life support Cardiopulmonary arrest in children usually results from hypoxi a due to respiratory or neurological failure or shock. If it occurs, irrespective of the ca use, basic life support (BLS) must be started immediately. Pediatric basic life support algorithm 1 First things \200 \200 Assess the safety of the situation. Stimulate the child and check responsiveness. 2 Shout for help 3 Open the airway Give head tilt and chin lift, or jaw thrust 4 Assess breathing Look, listen, and feel 5 If no breathing: rescue breaths \200 \200 Child Infant : 5 breaths mouth to mouth : 5 breaths mouth to mouth and nose 6 Assess the pulse \200 \200 Child Infant : at the carotid artery : at the brachial or femoral artery 7 If HR <60/min and poor perfusion: chest compressions \200 >8yrs: use two-handed method for rate of 100/min and ratio of Child 15 compressions to 2 breaths Child rate of 100/min and ratio of 15 compressions to 2 breaths Infant help at rate of 100/min and ratio of 15 compressions to 2 breaths 1 \200\2238yrs: use heel of hand on the lower third of the sternum for : use two \201 ngers or the encircling chest technique if you have 8 Provide 1min of life support 9 Contact emergency medical services 04_McClure_04.indd 38 11/14/2012 7:06:56 PM CHOKING CHILDREN 39 Choking children The algorithm for emergency management of choking children using the Resus citation Council (UK) protocol is as follows (Fig. 4.1): Assess severity Ineffective cough Effective cough Unconscious Conscious Encourage cough Continue to check for deterioration to ineffective cough or until obstruction relieved Open airway 5 breaths Start CPR 5 back blows 5 thrusts (chest for infant) (abdominal for child >1 yr) Fig. 4.1 Resuscitation Council Guidelines, Pediatric FBAO treatment algorithm 2010. Reprodu ced with permission. 04_McClure_04.indd 39 11/14/2012 7:06:56 PM CHAPTER 4 Resuscitation 40 Pediatric advanced life support Pediatric advanced life support (ALS) algorithm 1 Basic life support 2 Ventilate and oxygenate 3 Attach de \201 brillator and monitor 4 Assess cardiac rhythm and check pulse \200 If ventricular \201 brillation (VF) or pulseless tachycardia (VT): \200 \200 \200 I f not VF or VT: \200 \200 de \201 brillate as necessary: 4J/kg for initial and all subsequent shocks then then give cardiopulmonary resuscitation (CPR) for 2min reassess rhythm and pulse and respond asystole or pulseless electrical activity: give CPR for 4min then reassess rhythm and pulse, and respond 5 During CPR \200 Attempt and verify: \200 \200 Check: electrode or paddle placement: the position and co ntact. Give: e pinephrine every 3 \200\2235min (0.1mL/kg IV (1:10,000)) Consider: \200 \200 tracheal intubation IV or IO access \200 \200 giving anti-arrhythmics and alkalizing agents potentially reversible causes \200\224hypoxia ; hypovolaemia; hypokalaemia; hyperkalaemia; hypocalcaemia; tension pneumothorax; cardiac t amponade; toxins; thromboemboli 6 Are there dif \201 culties in ventilation? Rule out the following potential problems \200 \200 \200 \200 \200 displaced? Is the endotracheal tube Is there an obstruction? Does the child have a Is there Is there a ir in the pneumothorax? equipment failure? stomach causing diaphragmatic splinting? Useful formulas in children \200 Estimation of weight \200 0 \200\22312 months \200\224 \200 1 \200\2235yrs \200\224 \200 6 \200\22312yrs \200\224 Endotracheal tube \200 \200 \200 Weight (kg) = (0.5 x Age (mths)) + 4 Weight (kg) = (2 x Age (yrs)) + 8 Weight (kg) = (3 x Age (yrs)) + 7 Size Length Length = (Age (yrs)/4 + 4) for oral tube = (Age (yrs)/2 + 12) cm if nasal tube = (Age (yrs)/2 + 15) cm 04_McClure_04.indd 40 11/14/2012 7:06:56 PM pediatric ADVANCED LIFE SUPPORT 41 The algorithm for ALS using the Resuscitation Council (UK) protocol is shown in Fig. 4.2. Unresponsive? Not breathing or only occasional gasps CPR Call (5 initial breaths then 15:2) Attach defibrillator / monitor Minimize interruptions resuscitation team (1 min CPR first, if alone) Assess rhythm Shockable Non-Shockable (VF / Pulseless VT) (PEA / Asystole) Return of spontaneous circulation 1 Shock 4J / kg Immediate post cardiac arrest treatment Immediately resume CPR for 2 min Minimize interruptions Immediately resume CPR for 2 min Minimize interruptions Use ABCDE approach \200 Controlled oxygenation and ventilation \200 Investigations \200 Treat precipitating cause \200 Temperature control \200 Therapeutic hypothermia? During CPR Reversible Causes Ensure high-quality CPR: rate, depth, recoil \200 Plan actions before interrupting CPR \200 Give oxygen \200 Vascular access (intravenous, intraosseous) \200 Give adrenaline every 3-5 min \200 Consider advanced airway and capnography \200 Continuous chest comp ressions when advanced airway in place \200 Correct reversible causes Hypoxia \200 Hypovolaemia \200 Hypo-/hyperkalaemia/metabolic \200 Hypothermia Tension pneumothorax \200 Toxins \200 Tamponade - cardiac \200 Thromboembolism Fig. 4.2 Resuscitation council guidelines 2010. Pediatric Advanced Life Support algorithm. Reproduced with permission. 04_McClure_04.indd 41 11/14/2012 7:06:56 PM CHAPTER 4 Resuscitation 42 Rhythm disturbances See b pp.55 \200\22357, 250 \200\223251. Bradycardia \200 \200 Bradycardia is often the \201 nal response to hypoxia. A preterminal rhythm leading to as ystole. Treatment \200 \200 \200 Oxygen, with attention to airway and in \202 ation. Epinephrine 10 micrograms/kg IV May re quire atropine 20 micrograms/kg IV (minimum 100 micrograms; maximum 1mg) if triggered by va gal stimulation. Sinus tachycardia \200 \200 Heart rate can be as high as 220/min in an infant, but not higher. Caused by fever, pain, a nd shock. Treatment Treat the cause. Supraventricular tachycardia \200 \200 The most common primary arrhythmia in infancy and childhood. Onset sudden. Heart rate: >220 /min in infants; >180/min in children over 3yrs. Rhythm is regular and P waves may not be v isible. Infants may present with shock, sweatiness, and poor feeding. \200 Treatment See algorithms opposite, b pp.57, 250. Ventricular tachycardia \200 \200 \200 Rare in children; caused by primary cardiac problem or overdose. Heart rate: between 120 an d 250/min. Rhythm is almost regular, but QRS is wide (>2 small squares). Treatment \200 \200 Pulse present: Pulseless: amiodarone 5mg/kg; synchronized shock. treat as for VF. Ventricular \201 brillation \200 \200 Treatment See algorithm on b p.41. Mainly caused by hypothermia and drug overdose. Found in 27% of all pediatric in-hospital a rrests. Asystole \200 \200 Treatment See algorithm on b p.41. Mainly caused by hypoxia and acidosis. 60% of all pediatric arrests. Pulseless electrical activity See algorithm on b p.41. 04_McClure_04.indd 42 11/14/2012 7:06:57 PM TREATING SUPRAVENTRICULAR TACHYCARDIA 43 Treating supraventricular tachycardia Attach cardiac monitor and check BP. Algorithm for treating patient with supraventricular tachycardia, but not in shock 1 Trial of vagal maneuvers 2 Adenosine \200 50 \200\223100microgram/kg given as a rapid IV push into the most central IV access availab le followed by fast IV \202 ush If no response, then 100 \200\223200microgram/kg If no re sponse, then increase at increments of 50 \200\223100microgram/kg to a maximum single dose of 500microgram/kg \200 3 Consider \200 \200 \200 Synchronous DC shock Amiodarone (IV bolus over 10min) 5mg/kg Procainamide (IV loading dose of 15mg/kg over 30 \200\22360min). Stop infusion if QRS widens or hypotension occurs Flecai nide (IV 2mg/kg bolus over 20min) Seek advice \200 Algorithm for treating patient with SVT who is in shock 1a Attempt vagal maneuvers but do not delay progress to step 2 1b If IV access is available give adenosine (see preceding algorithm) but do not delay prog ress to step 2 2 Synchronous DC shock \200 \200 \200 1J/kg If no response, then 2J/kg If no response, then 2J/kg 3 Consider using anti-arrhythmics (amiodarone) 4 Synchronous DC shock \200 Return to step 2 in the algorithm at 2J/kg 04_McClure_04.indd 43 11/14/2012 7:06:57 PM CHAPTER 4 Resuscitation 44 Following unsuccessful resuscitation The death of a child is distressing. The family should be spoken to sympa- thetically and in private. Most parents will want to see and hold thei r dead child and they should be offered this opportunity. Report to the coroner (UK) \200 b Sudden unexpected death in an infant Unexpected deaths (see (SUDI)). Infants brought in dead to the emergency department or who die soon after arrival. Deaths where there has been recent surgery or an accident. Deaths w here there are suspicious circumstances. \200 Sudden unexpected death in an infant (SUDI) Parents or carers \200 \200 Take and record a detailed clinical history. Explain that a referral has been made to the c oroner. Explain the role of the police and warn the family that they may visit the house. Child After failed resuscitation the endotracheal tube and IO needle can be removed, but ve nous access should be retained. Retain the child \200\231s cloth- ing/bedding and nappy for the police. Take the following samples: \200 \200 \200 \200 Nasopharyngeal Urine Blood Lumbar indicated. aspirate: virology and bacteriology. : biochemistry and freeze immediately. : toxicology, cultures, metabolic and coagulation sc reen. puncture (cerebrospinal \202 uid (CSF) for virology and culture): if Other professionals Inform the following: \200 Senior clinical staff: in the UK a designated SUDI team will investigate these deaths and a home visit will be made by the pediatrician and police within 24hr. Family general practit ioner. Health visitor (or community midwife). Neonatologist (if a neonate). \200 \200 Follow-up \200 Arrangements should be made for the family to discuss the results of the coroner \200\231s post-mortem. Genetic counseling may be needed. Bereavement counseling should be offered: th is may be provided by the family practitioner, the pediatric team, or from other agencies ( e.g. Foundation for the Study of Infant Deaths, Child Death Helpline, and CRUSE). \200 04_McClure_04.indd 44 11/14/2012 7:06:57 PM 45 Chapter 5 Emergency and high dependency care The ABC of high dependency 46 Respiratory distress 48 Respiratory distress: management 50 F oreign-body inhalation 51 Drowning 52 Circulation: cardiovascular dif \201 culty 53 Cardio vascular system dif \201 culty: assessment 54 Cardiovascular system dif \201 culty: thera py \200\2241 56 Cardiovascular system dif \201 culty: therapy \200\2242 58 Cyanosis: asses sment 60 Cyanosis: management 62 Anaphylaxis 64 Hypovolaemic shock 65 Burns 66 Burns: treat ment 68 Sepsis 70 Altered level of consciousness 72 Altered level of consciousness: clinica l assessment 74 Altered level of consciousness:Glasgow coma scale 76 Altered level of consc iousness: management 78 Status epilepticus 80 Poisoning 82 Poisoning: management 84 Poisoni ng: antidotes and substrates 86 Fluid and electrolytes 89 Fluid and electrolytes: dehydrati on 90 Fluid and electrolytes: abnormalities 92 Renal insuf \201 ciency 94 Glucose: hypogly caemia 96 Diabetic ketoacidosis 98 Diabetic ketoacidosis: treatment 100 Inborn error of met abolism 102 Other acid \200\223base problems 104 Further reading 106 05_McClure_05.indd 45 11/15/2012 12:18:56 AM CHAPTER 5 Emergency and high dependency care 46 The ABC of high dependency Emergency and high-dependency care is about providing the right care and support in a timely manner. Practicing pediatrics under these condi- tions means t hat you will need to anticipate what could happen next, which can be very dif \201 cult. T herefore, we shall start with an emphasis on patient safety \200\224the ABC \200\224the ass essment of Airway, Breathing, and Circulation. Then, we shall cover most of what is needed next for acute care \200\224knowledge, assessments, and treatments. A \200\224establish an airway Provide oxygen Use fractional inspired oxygen (FiO2) 100%; us e the optimum method for patient size and monitor. \200 \200 Neonates, infants: Infants, toddlers: tidal volume (7mL/kg) and NC \202 ow rate is shown in the following example. head-box oxygen with in situ FiO2 monitor. nasal cannulae (NC). The ideal estimate of FiO2 from Consider a 6kg infant on 0.25L/min NC oxygen (tidal volume = 42mL; NC \202 ow = 250mL/min , 4mL/s; inspiratory time = 1s). FiO2 value is: 4mL \227 1.0 = 4mL oxygen, plus 38mL \227 0.21 = 8mL oxygen. FiO2 = (4 + 8)/42 = 0.29. \200 Toddler, pre-school: School-age child: NC, face mask. non-rebreathing mask. Maintain airway and air movement \200 airway when needed with jaw lift: suction nasopharynx and Support mouth as needed. Provide oral or nasopharyngeal airway. Maintain lie down. Minimize discomfort. patient in upright position: do not force a distressed patient to B \200\224use respiratory support for breathing \200 Identify appropriately (e.g. bronchodilators). Assist achieved with nasopharyngeal continuo us +ve airway pressure (see bronchiolitis, b p.288), or \200\223ve pressure ventilation. I ntubation the level of respiratory involvement: treat speci \201 c problems work of breathing with non-invasive support: this can be and mechanical ventilation. C \200\224assess circulation; establish IV access \200 \200 Start Provide \202 uid intake to an amount ranging from restricted to just below maintena nce. pulse oximetry and cardiac monitoring. IV \202 uids: when the circulation is good it is advisable to limit 05_McClure_05.indd 46 11/15/2012 12:18:57 AM THE ABC OF HIGH DEPENDENCY 47 05_McClure_05.indd 47 11/15/2012 12:18:57 AM CHAPTER 5 Emergency and high dependency care 48 Respiratory distress Respiratory distress is de \201 ned as increased work of breathing th at causes a sense of altered well-being. The hallmarks are use of accessory muscles and tac hypnoea. Distress can be caused by disorders of gas exchange (O2 absorption, or CO2 elimina tion), respiratory drive, neuromuscular disease, and infection (see Box 5.1). Box 5.1 Differential diagnosis of respiratory distress Nasopharynx \200 \200 \200 \200 Nose: Oropharynx: Tongue: Pharynx: choanal atresia, stenosis tonsillar hypertrophy glossomegaly peritonsillar abscess, retropharyngeal abscess, diphtheria Upper airway obstruction \200 Larynx: haemangioma, croup Epiglottis: vocal cord dysfunction, laryngomalacia, papilloma, epiglottitis, foreign body Lower airway disorder \200 Trachea: artery sling Bronchi: Bronchioles: tracheitis, tracheobronchomalacia, foreign body, pulmonary \200 bronchitis, bronchomalacia asthma, bronchiolitis, pertussis Disordered gas exchange \200 carbon monoxide poisoning, methaemoglobinaemia, Hemoglobin: acidosis Shunt: Dead Other: \200 \200 pulmonary oedema, hemorrhage, atelectasis, or embolism space ventilation: asthma, bronchiol itis, pulmonary hypertension sickle chest syndrome, pneumonia, pneumothorax Respiratory drive \200 \200 Hyperventilation: Hypoventilation: psychogenic, brainstem tumor apnoea, drugs Neuromuscular \200 Respiratory muscle atrophy, central nervous system (CNS) depression muscle weakness: Duchenne muscular dystrophy, spinal Other \200 Pleural: empyema Chest pneumothorax, chylothorax, haemothorax, pleural effusion, wall: \202 ail chest, rib fractures 05_McClure_05.indd 48 11/15/2012 12:18:57 AM RESPIRATORY DISTRESS 49 De \201 nitions Broadly, we can de \201 ne the two major causes of respiratory distress a s follows. Respiratory failure \200 Hypoxaemia previously well child. Acidosis: since the child may have a chronic \200\230compensated \200\231 problem. Increasing your observations on child \200\231s breathing and mental state. despite high FiO2: arterial oxygen tension (PaO2) <8kPa in pH <7.25; no speci \201 c arterial carbon dioxide tension (PaCO2) fatigue, or absence of improvement with therapy: based on Neuromuscular weakness \200 Clinical: chest wall weakness of neurological or muscular origin. Physiological: manometry to assess maximum inspiratory force < \200\22320mmHg. bulbar dysfunction with poor or absent cough, gag, swallow, or use spirometry to assess vital capacity <12mL/kg, or 05_McClure_05.indd 49 11/15/2012 12:18:57 AM CHAPTER 5 Emergency and high dependency care 50 Respiratory distress: management Clinical assessment Assess the patient for the following: \200 pallor or cyanosis. \200 Color: Respiratory or brainstem cause. Inspiration obstruction produces stridor; lower airw ay obstruction leads to cough, wheeze, and a prolonged expiratory phase. Chest \202 ail-c hest, diaphragmatic palsy, pneumothorax, or foreign body inhalation. Position Mental Heart drive: pattern and timing of breathing may re \202 ect a central and expiration of air at the mouth and nose: upper airway wall movement: chest and abdominal wall dynamics may indicate \200 \200 and level of agitation. state. rate and perfusion: these may re \202 ect impending arrest. Investigations \200 Non-invasive: saturation, pulse oximetry measurement of oxyhaemoglobi n saturation (SpO2). Arterial blood gas: assessment of acid \200\223base, PaO2, PaCO2. A ca pillary blood sample is a good alternative (for pH, PCO2) if the extremity is warm and the blood \202 ows freely. Blood CXR complications (e.g. pulmonary oedema, pneumothorax). pulse oximetry measurement of oxyhaemoglobin \200 tests: full blood count (FBC), electrolytes, glucose, and cultures. : for diagnosis (e.g. s evere pneumonia); for assessment of Monitoring \200 \200 \200 \200 \200 \200 Pulse oximetry. Continuous ECG. BP. Temperature. Fluid balance. Conscious level. Therapy There are speci \201 c therapies for each condition listed in the \200\230Differe ntial diagnoses \200\231 on b p.48 (see individual sections). With regard to \202 uid the r- apy, we generally restrict total volume to 80% maintenance for the fol- lowing reasons. \200 with retraction: high \200\223ve intrathoracic pressure will pull \202 uid Distress out of capillaries into the interstitial space and will aggravate breathing with p ulmonary oedema. Syndrome common problem in moderate to severe respiratory distress. Diures is is limited: in the hydrated patient consider using furosemide (0.5 \200\2231mg/kg, IV). It may help the patient with extra-interstitial water without overt oedema. of inappropriate antidiuretic hormone (SIADH): this is a 05_McClure_05.indd 50 11/15/2012 12:18:57 AM FOREIGN-BODY INHALATION 51 Foreign-body inhalation Foreign-body (FB) aspiration is more common in toddlers and infants , who tend to put objects in their mouths. FBs can be inhaled into the airway, or they may get caught in the esophagus and compress the trachea. Symptoms The symptoms of a FB in the aerodigestive tract range from no symptoms to complete airway obstruction. \200 Larynx: usually causes hoarseness, cough, dysphonia, haemoptysis, stridor, wheezing, dyspno ea, cyanosis, or apnoea due to complete obstruction. Trachea there may be an asymptomatic p eriod followed by features of pneumonia (see b p.290). Esophagus: trachea is compressed, ma y produce dyspnoea, stridor, respiratory failure, or apnoea (see b pp.256, 258). and bronchus: can cause chest pain. After initial symptoms, will produce drooling, dysphagia, or vomiting and, if the Etiology Inhaled FB should be considered in all patients with a history of choking or gaggi ng. Diagnosis \200 A monophonic chest may be noted on examination. Chest and neck identifying the location of an object. Inspiratory and expiratory \201 lms may show an area of hyperin \202 ation. A rterial blood gas distress. wheeze or absent breath sounds on one side of the radiographs, with lateral views, may be helpful in analysis is indicated when the patient is in severe Initial treatment Follow a standard protocol. \200 FB \200 ABC . removal: if the child is calm with good air exchange, removal of the FB should take place under controlled circumstances; manipulation may change the pos ition of the object, inducing more severe obstruction. If the child is in distress, but mai ntaining good air exchange, back blows and chest thrusts may be performed as per the standa rd technique for pediatric advanced life support (ALS). An unconscious child with poor air entry should be given oxygen (FiO 2 100%) via a face mask until rigid bronchoscopy and obje ct removal can be performed. 05_McClure_05.indd 51 11/15/2012 12:18:57 AM CHAPTER 5 Emergency and high dependency care 52