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Recognizing the Sick Child. William Beaumont Hospital Department of Emergency Medicine. Overview. Review of vitals Who’s sick at a glance What can babies do? Rashes: a quick review History and diagnosis that should raise a red flag Pediatric fluids and resuscitation Pediatric fever.

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recognizing the sick child

Recognizing the Sick Child

William Beaumont Hospital

Department of Emergency Medicine

overview
Overview
  • Review of vitals
  • Who’s sick at a glance
  • What can babies do?
  • Rashes: a quick review
  • History and diagnosis that should raise a red flag
  • Pediatric fluids and resuscitation
  • Pediatric fever
who is sick
Who is sick?
  • The concept of the “toxic child”
    • The “L” word
slide5

Toxic? Sick?

Nelson: Pediatrics

no stethoscope assessment
No Stethoscope Assessment
  • What can you see, hear and feel right when the patient walks through the door?
step 1 eyeball
Step 1 – Eyeball
  • What can you see
    • Retractions
      • Subcostal, intercostal, supraclavicular
    • Tachypnea
    • Cyanosis
      • Nail beds, lips and mucosa
        • Circumoral or facial cyanosis can fool you
    • Decreased level of consciousness
    • Obvious fracture/deformity
    • Rashes
step 2 listen
Step 2 - Listen
  • What can you hear
    • Stridor
      • With Crying
      • At Rest
    • Abnormal Cry
  • What don’t you hear
    • Asthmatics too tight to wheeze
    • Septic child with weak cry
step 3 feel
Step 3 - Feel
  • Check Pulse
    • Tachycardia, bradycardia
    • Cap Refill
    • Extremity injuries - fractures and lacerations
      • Neuro status
what is normal vitals signs
What is Normal: Vitals Signs
  • Vitals vary by age
    • Simple rules to demystify pediatric vitals
what is normal vitals signs11
What is Normal: Vitals Signs
  • Respiratory
    • Assess Airway
    • Respiratory Rate

Newborn 1 year 18 years

Rate <40 24 18

what is normal vitals signs12
What is Normal: Vitals Signs
  • Air Entry
    • Chest rise, breath sounds, stridor or wheezing
      • Quiet versus noisy tachypnea
  • Mechanics
    • Grunting or retractions
  • Color
what is normal vitals signs13
What is Normal: Vitals Signs
  • Take home, bottom line
    • Respiratory rate > 60 is abnormal
what is normal vitals signs14
What is Normal: Vitals Signs
  • Circulation
    • Normal heart rates:

1-3mo 3mo-2yr 2-10yr >10yr

85-200 100-190 60-120 75

what is normal vitals signs15
What is Normal: Vitals Signs
  • Abnormal
    • Less than 5 years >180, <80
    • Greater than 5 years > 160
  • Anything greater than 220 = SVT
what is normal vitals signs16
What is Normal: Vitals Signs
  • Blood Pressure

Newborn 1 year >1 year

Systolic >60 >70 70+(2 x age)

what is normal vitals signs17
What is Normal: Vitals Signs
  • Blood pressure
    • Cap Refill – < 2 Seconds normal
  • CNS Perfusion
    • Recognize parents, responsive
what is normal vitals signs18
What is Normal: Vitals Signs
  • Take home, bottom line
    • Pulse > 220 consider SVT
    • Cap refill > 2 seconds not normal
    • BP in kids > 1 year = 70 + (2 x age)
what is normal development
What is Normal: Development
  • Easy social and motor milestones:
    • 2 month olds smile
    • 4 month olds roll over
    • 6 month olds sit
    • 9 month olds cruise
    • 12 month olds walk
review of rashes
Review of Rashes
  • Rashes are visual things
    • Usually can’t tell what to do for rashes over the phone - have to see them
slide21

Rash 1

Habif: Clinical Dermatology

slide22

Rash 2

Habif: Clinical Dermatology

slide23

Rash 3a

Habif: Clinical Dermatology

slide24

Rash 3b

Habif: Clinical Dermatology

slide25

Rash 4

Nelson: Pediatrics

slide26

Rash 5a

Habif: Clinical Dermatology

slide27

Rash 5b

Habif: Clinical Dermatology

slide28

Rash 6a

Habif: Clinical Dermatology

slide29

Rash 6b

Habif: Clinical Dermatology

slide30

Rash 7

Habif: Clinical Dermatology

slide31

Rash 8

Habif: Clinical Dermatology

slide32

Rash 9

Habif: Clinical Dermatology

slide33

Rash 10

Habif: Clinical Dermatology

slide34

Rash 11

Habif: Clinical Dermatology

rashes
Rashes
  • Take home, bottom line
    • Check for blanching – petechiae and purpura do not blanch
    • Toxic vs. nontoxic
    • Check for oral lesions
    • Check the palms and soles
    • Most rashes are benign
red flags
Red Flags
  • Diagnostic categories or history that should heighten your concern and raise your triage class
  • Mnemonic: CATNITS
red flags38
Red Flags
  • CATNITS
    • Congenital problems
      • Inborn errors of metabolism
        • Neurologic Disease, seizures
        • Vomiting, acidosis, hypoglycemia
        • Liver or cardiac disease
      • Congenital Heart Disease
      • Chromosomal Abnormalities
red flags39
Red Flags
  • CATNITS
    • Allergic
      • History of anaphylaxis or significant medication reaction
      • History of respiratory distress with previous reactions
red flags40
Red Flags
  • CATNITS
    • Trauma
      • Loss of consciousness > 2 minutes
      • Altered LOC now
      • Limb threatening injury
      • Bleeding not controlled
red flags41
Red Flags
  • CATNITS
    • Neoplasm
      • Recent chemotherapy - Fever and neutropenia
      • Anemia or thrombocytopenia
red flags42
Red Flags
  • CATNITS
    • Infectious
      • Signs and symptoms of septic shock/meningitis, including rash
      • Any reason to be immune compromised
        • Examples: Immune deficiency, protein loosing enteropathy, on steroids
red flags43
Red Flags
  • CATNITS
    • Toxins
      • Ingestion of dangerous vs. non toxic substance
        • Many interventions are time dependent
        • Patients may deteriorate rapidly
red flags44
Red Flags
  • CATNITS
    • Social/Psychiatric
      • Patient threat to himself/herself or others
      • Possibility of abuse or neglect
pediatric fluids
Pediatric Fluids
  • Bolus
    • 10 to 20 cc/kg
    • 0.9 NS only, ever, always
  • Maintenance Fluids
    • 4 – 2 – 1 rule
    • Neonates and infants: D5 0.2 NS
    • Children: D5 0.45 NS
pediatric fluid problem
Pediatric Fluid Problem

6 mos old child comes in with 24 hours of n/v/d. Not made urine for 12 hours.

Wt = 8kg

Would you bolus, how much, what fluid?

What is maintenance?

slide47
Defibrillation 2J/kg then 4J/kg, 4J/kg

Epinephrine 0.01mg/kg (1:10,000)

Atropine 0.01mg/kg

Glucose D10 2-4ml/kg (not D50)

Drugs you can give through an ET tube (NAVEL)

Narcan

Atropine

Valium

Epi

Lidocaine

Pediatric Resuscitation Doses

pediatric fever 38 c rectally
Pediatric Fever = 38 C rectally
  • Tylenol 15 mg/kg for kids < 6 mos
  • Tylenol or Motrin 10 mg/kg > 6 mos
  • 0 to 4 weeks of age
    • Admit for IV abx and apnea monitoring
    • CBC, BMP, U/A, UCX, BCX, CXR, LP
    • Ampicillin and cefotaxime
pediatric fever
Pediatric Fever
  • 4 – 12 weeks of age
    • Look sick = admit
    • Most of these will be admitted
    • CBC, BMP, U/A, UCX, BCX
    • ? Lumbar puncture
    • Abx  ampicillin + cefotaxime or ceftriaxone
      • If meningitis then add vancomyocin
the end

The End

Any Questions?