Created July 2008 by Major Jennifer Thomas, USAF, RN, BSN, CPN Pediatric Clinic Nurse Manager

1. Created July 2008 by Major Jennifer Thomas, USAF, RN, BSN, CPN Pediatric Clinic Nurse Manager Elmendorf AFB And Linda Oxley, MSN, RN, CPN Inpatient Pediatric Nursing Educator Alaska Native Medical Center Anchorage, AK Supported by Federal grant #1HFPEP070008-01-00; & Alaska State grant #601-08-156

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

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 Michael is a 5 year old who’s just been pulled out of a day care center after the roof caved in.

7. Case Scenario Michael’s initial vital signs: Temperature: 97.0 orally Heart rate:140 beats per minute Respirations: 45 breaths per minute Estimated weight: 45 pounds Are these normal or is he sick? Does he need help right now or can he wait? How can I figure this out quickly?

8. Case Scenario You can see his left thigh is obviously becoming more distended; The right side of his face, scalp and abdomen are badly abraded; His color is pink, his hands are just a little cool to the touch and his arms warm; He is crying loudly, trying to crawl away from you and yelling for his Mom. Is this assessment data important?

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 the Pediatric Assessment Triangle, you can get a quick idea about the severity of Michael’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 Hazinski, M.F. 1992

12. Heart rate parameters Hazinski, M.F. 1992

13. The 4th Vital Sign: Blood Pressure Blood pressures in children often make people nervous. They seem so different for kids than for adults.

14. The 4th Vital Sign: Blood Pressure Blood pressure in children behaves differently than in adults. Measurements will stay in the same range in the face of decreasing circulating volume for a long time. Acute intravascular losses of 20-25% will finally cause BP numbers that define hypotension. Other forms of fluid loss such as dehydration will cause hypotension at varying percentages based upon the clinical issue, age, etc. Range of these losses 5-15% before BP falls. Once hypotension has developed, cardiovascular collapse is a significant risk. This is called decompensated shock.

15. Measuring blood pressure in kids Cuff size is critical. Too small and blood pressure will be falsely elevated. Too big and blood pressure will be falsely lowered. If the bladder does not reach at least 2/3 the way around the limb, the numbers obtained are likely inaccurate. Cuffs bladders should be at least 2/3 the limb’s circumference; fully around is better. Cuff length should cover 2/3 of the distance of the limb between joints.

16. Blood Pressure Sites Forearms Upper arms Thighs Calves Any of these are acceptable. Leg BPs are normally the same as arm BPs until about age 1. Leg pressures may be slightly higher after age 1. Avoid sites proximal to IV insertion sites. Avoid limbs that appear to be fractured or badly damaged. If one site seems better tolerated by the child, use that. Manual method - upper arms are easiest; machine measurements - often easiest on calves or thighs. Set upper limit for inflation pressure on machines to 100 for babies and 120 for kids. These are also good upper numbers to aim for in manually collected BPs.

17. Machine versus manual BP’s Both methods have pros and cons. Machines are easier to use as the BP cuff can be placed and left, with repeating cycles providing information without touching the child. (Decreases effect of fear) Manually collected BPs allow direct ‘listening’ to the changes in blood flow versus the machine interpreting the sensation of movement past the bladder. (Also often a more familiar technique to providers)

18. Machine versus manual BP: when is the data corrupted? Machines may overestimate blood pressure if child is actually becoming hypotensive. Manual readings with sphygmomanometer, bulb and stethoscope may underestimate blood pressure if the child is hypotensive. And the younger the child, the more difficult it is to obtain an accurate reading. Luckily, signs of inadequate perfusion are going to show themselves before the child becomes hypotensive: pulse, consistency of pulse central to peripheral; capillary refill in warm environment, behavior/neurologic changes, etc.

19. Which should I use, machine or manual? The method with which you are most comfortable and confident. Practice makes perfect. And the reference numbers:

20. BP Parameters Hazinski, M.F. 1992 Rule of Thumb: The diastolic number should be about 2/3 of the systolic number

21. Are Michael’s numbers ok? Normal? What now? Keep going to find out…

22. Pediatric Assessment Triangle A tool to quickly determine “How Sick?” and “How Quick?” Work of Breathing Appearance Circulation to Skin From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com

23. A quick Peds refresher • The Pediatric Assessment Triangle (PAT) 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 • The next section goes into detail on the 3 sides of the PAT

24. General Appearance

25. Pediatric Cliff notes appearance (TICLS) muscle Tone/activity level An active child is grabbing, reaching, or moving A still, floppy or quiet child is not good 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 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

26. Michael’s T.I.C.L.E.? Normal? Abnormal?

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

28. A comparison Pediatric Airway Adult Airway

29. 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”

30. 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

31. Is Michael’s breathing (45 breaths/min) normal? Abnormal?

32. 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.

33. 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

34. 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)

35. 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.

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

37. Michael’s BP is 105/60,his heart rate is 140 bpm Is his circulatory status normal? Abnormal?

38. 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 (The 5th Vital Sign) 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 • Urine output: 1cc/kg/hr is normal, • 30cc/hr for older child

39. 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

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

41. Pediatric Assessment Triangle The Triangle is a rapid way to determine physiologic stability. Return to the

42. 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 ...

43. How quick? How sick?

44. • Appearance is the single most important factor in assessment. • There are very few false negatives, i.e. very few truly sick or injured children that have a normal appearance. • Counter to intuition, a screaming child in obvious distress is often less in need of attention than a quiet, listless child. Pearl

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

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

48. 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 does not appear mottled (vasoconstricted)

49. 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?

50. Pediatric Assessment