Pediatrics Flashcards
(75 cards)
1
Q
Introduction
A
- children differ from adults in their anatomy, physiology, and emotions
- know baseline and expectations of different ages
- your approach to pediatric patients:
- must be based on age -> can effect cognitive markers based on age
- must accommodate developmental and social issues
2
Q
neonate and infant
A
- neonatal period- first month of life **
- infancy- first 12 months*
- first birthday -> toddler
- during assessment:
- keep child warm -> do not have intrinsic thermoregulation (cant shiver) -> NEVER let them get cold
- cold child = dead child
- support a young infants head and neck - head and neck are disproportionate
- if child is quiet, listen to heart and lungs first
3
Q
birth - 2 months
A
- controls gate - track movement but stare into space
- turns head
- begins crying to communicate needs -> three needs -> im hungry, im tired, i have to poop
- crying peaks at 6 weeks
- trust develops in parents
4
Q
2-6 months
A
- can recognize caregivers*
- makes eye contact
- use both hands
- rolls over- babys cant fall off the ground
- most sleep through the night
- increase awareness
- explore their own body
- uses expression of joy, anger, fear, surprise
- seeks attention
5
Q
6-12 months
A
- sits without support
- crawls
- puts things in month
- teething begins
- eats soft foods
- babbles (learns first word by 12 months)- girls learn before boys
- remembers objects
- curious about what objects do
- separation anxiety disorders
- start of tantrums
- self determination while eating
6
Q
neonate - infant
A
-birth to 12 months
7
Q
toddler
A
-12 to 36 months
8
Q
12-18 months
A
- crawls
- walks*
- front teeth emerge ahead of molars*- teething
- sensory development
- imitates others*
- makes believe
- understands more than expressed
- knows major body parts
- knows 4-6 words
- basic reasoning
- understands object permanence
- separation anxiety
9
Q
18-24 months
A
- improved gait and balance
- runs
- climbs
- head grows more slowly than body
- begins to understand cause/effect*
- labels object *- “this is my toy”
- speech picks up to about 100 words by 24 months* -> rapid growth in speech
- attachment to certain objects, such as pacifier, doll, or blanket
10
Q
group 10
A
- rare
- can lead to death of baby
- conflicting evidence to manage
11
Q
24-36 months
A
- develops fine motor skills
- toilet training
- goes up and down stairs with help
- jumps with both feet
- can draw a circle
- follows 2 step commands*
- names at least 1 color
- knows 250-500 words
- can came a friend
- separates fairly easily from parents
12
Q
toddler
A
- 1 to 2
- use the pediatric assessment triangle (PAT) to assess the child
- PAT- appearance, circulation to skin, work of breathing
- PAT tells you if the child is sick or not sick
- strategies for examination:
- examine on parents lap (separation anxiety)
- get down to the child’s level
- have a parent assist when possible if they arnt making the situation complicated
- engage the parents!
- be flexible
13
Q
preschool age child
A
- ages 3-5
- becoming verbal and active
- respect modesty- they dont want people around when they go to the bathroom, embarrassed when naked
- let child participate
- set limits on behavior if the child acts out
14
Q
school age child (middle childhood)
A
- ages 6-12
- greater understanding may increase fear
- know the finality of life
- by age 8, anatomy and physiology is similar to adults
- explain steps in simple language
15
Q
adolescence
A
- ages 13-17
- with respect to CPR, once secondary sexual characteristics (breasts, underarm hair) have developed, treat as an adult
- address and reassure patient
- address them as children but equal person in care
- offer as much control as appropriate
16
Q
the head
A
- infants and young children’s heads are large relative to the rest of their bodies
- children grow into their head
- take care when positioning airway
- airway is more anterior to the neck
- cover head to prevent heat loss
- cover head, feet, hands, torso (in that order)
- during infancy, the anterior and posterior fontanelles are open -> fuse when toddler
17
Q
the neck and airways
A
- short neck, smaller airway
- more prone to obstruction
- epiglottis is at the back of posterior oral pharynx
- epiglottis is long and floppy
- difficult to see vocal cords during intubation
- lungs -> height
- medication -> weight
- airway-> age
18
Q
vocabulary
A
- vocabulary expands a bit - 20 to 25 words
- 12 months - know a few words -> goal is 5
- 24- 100 words
- 24-36- 250-500 words
19
Q
toilet trained
A
age 3
20
Q
managing neck and airway
A
- keep nares clear with suctioning
- smaller holes/size are easier to block
- avoid hyperextension of neck
- keep the airway clear of all secretions
- use care when managing the airway
21
Q
the respiratory system
A
- smaller tidal volume (height)
- double metabolic oxygen demand- younger the child -> higher heart rate
- heart rate is 150 when born
- smaller functional residual capacity
- faster breathing
- neonate (0-1 month)- 30-60 respirations
- infant (1 month- 1 year)- 25-50
- toddler- (1-3 years)- 20-30 respirations
- preschool (3-5 years)- 20-25 respirations
- school age- (6-12 years)- 15-20
- adolescent (13-17)- 12-20
- adult (>18)- 12-20
22
Q
diaphratic breathers
A
- infants use diaphragm during inspiration
- belly breathers
- haven’t developed muscles of respiration yet
- diaphragm connects torso to abdomen
- experience muscle fatigue quicker
- highly susceptible to hypoxia
- can spiral into cardiovascular collapse
- bradycardic child is hypoxic until proven otherwise- administer oxygen
23
Q
children rely on pulse rate to:
A
- blood pressure is meaningless number in initial assessment for children
- compensate for decreased oxygenation
- increase heart rate -> increase cardiac output
- maintain cardiac output
- if a child has a decreased heart rate -> failure/death -> past compensatory mechanism
- neonate (0-1 month) - 100-180
- infant (1 month -1 year)- 100-160
- toddler (1-3 years)- 90-150
- preschool age (3-5 years)- 80-140
- school age (6-12 years)- 70-120
- adolescent (13-17)- 60-100
- 18+ - 60-100
24
Q
2 leading causes of cardiac arrest in children
A
- respiration causes -> hypoxia -> cardiac collapse (disease, obstruction)
- trauma from bleeding
25
cardiovascular system
- limited but vigorous cardiac reserve
- can shoot up their heart rate to compensate to their condition -> much faster and more meaningful in a child but much shorter lasting
- injured children can be in shock and maintain BP for long periods
- more blood loss before hypotension
- hypotension is an ominous/late sign- failure
26
cardiovascular system
- limited but vigorous cardiac reserves
- children can increase rate to compensate for conditions faster and more meaningful that adults but shorter
- injured children can be in shock and maintain blood pressure for long periods
- more blood loss before hypotension
- hypotension is an ominous/late sign- failure/death
27
the heart
-ECG: Large right-sided forces are normal in
young infants (in adults its left sided)
-Cardiac output is rate dependent in infants
and young children.
-Mediastinum is more mobile.
-High risk of injury to mediastinal organs
28
the nervous system
- neural tissue and vasculature are fragile
- brain, spinal cord is not as well protected
- pediatric brain- nearly twice the blood flow -> bleed out a lot quicker
- makes even minor injuries significant
- increases risk of hypoxia
- head has a lot more flexibility with swelling bc sutures of not fused yet
29
spinal column
- vertebral fractures and spinal cord injuries in young children are uncommon
- rare because of seat belts, air bags, car seats now
- with a significant mechanism of injury:
- assume cervical spine injury
- transport with spinal immobilization
30
spine
- most likely to be injury in places where the spine has nothing to protect
- cervical and lumbar spine
31
abdomen and pelvis
- organs are situated more anteriorly and are relatively large
- liver and spleen extend below rib cage
- even seemingly insignificant forces can cause serious internal injury
32
musculoskeletal system
- adult height requires bone growth
- most growth plates will be closed by late adolescence
- growth plate fractures can be seen with low energy MOIs
- immobilize all sprains or strains
33
the chest and lungs
- chest wall is quite thine
- less adipose, muscle, soft tissue
- ribs are more pliable
- risk of pneumothorax during bag mask ventilation
- signs are often subtle
34
integumentary system
- thinner and more elastic skin
- larger BSA/weight ratio
- less subcutaneous tissue
- can get cold a lot faster
- KEEP CHILD WARM
35
metabolic differences
- limited stores of glycogen and glucose
- baseline- 40-50 mg/deciliter
- newborns lack the ability to shiver
- keep warm during transport
- newborns requiring aggressive resuscitation should not be overly warmed
36
parents of ill or injured children
- rapport with parents is critical
- approach in a calm, professional manner
- transport with the child
- remember that your first priority is the child
37
primary assessment
use pediatric assessment triangle to form a general impression
- are they sick or not sick
- do i have time to figure out whats going on
- test*
- appearance, work of breathing, circulation to skin
38
pediatric patient assessment
- differs from adult assessment
- adapt your assessment skills
- have age appropriate equipment
- review age appropriate vital signs
39
appearance
- a child with a grossly abnormal appearance requires immediate life-support interventions and transportation
- tone- is the child moving or resisting exam? does the child have good muscle tone? is the child limp, listless, or flaccid
- instructiveness- how alert is the child? how readily does a person, object, or sound distract the child or draw the childs attention?
- consolability- can the child be consoled or comforted by the caregiver or by the hospital professional
- look or gaze- does the child fix his or her gaze on a face, or is there a nobody home glassy eyed stare (dolls eyes)
- speech or cry- is the cry strong, spontaneous, or weak or high pitched? is the content of speech age appropriate or confused or garbled
40
work of breathing
- reflects attempt to compensate for abnormalities in oxygenation (getting oxygen in), ventilation (Getting CO2 out)
- NOT RATE
- abnormal airway sounds- snoring, muddled or hoarse speech, stridor, grunting, or wheezing
- abnormal posturing- sniffing position, tripod position, refusing to lie down
- retraction- supraclavicular, intercostal or substernal retraction of the chest wall; head bobbing in infants
- flaring- flaring of the nares on inspiration
- wheezes- lower airway
- stridor- upper airway -> concerning because there is only one upper airway
41
circulation to skin
- determine adequacy of cardiac output and core perfusion
- first thing you stop profusing when your sick is skin and then the GI track -> this is why you go pale and get nauseous
- pallor- white or pale skin or mucous membranes from inadequate blood flow
- mottling- patchy skin discolorations due to vasoconstriction or vasodilation
- cyanosis- bluish discoloration of skin and mucous membranes
42
respiratory emergencies
- frequently encountered
- respiratory failure and arrest precede majority of cardiopulmonary arrests
- early identification and intervention are critical
43
respiratory distress
-increased work of breathing results in adequate gas exchange******* test
44
respiratory failure
- no longer ability to compensate
- patient can no longer compensate
- hypoxia and/or carbon dioxide retention occur
- adequacy of gas exchange is the difference between distress and failure
45
respiratory arrest
-patient is not breathing spontaneously
46
respiratory arrest, distress, and failure
- use PAT to determine severity before touching the patient
- assess work of breathing by noting:
- patients position of comfort
- presence or absence of retractions
- grunting or flaring
47
assess the airway
- listen for stridor in awake patients
| - check for obstruction in obtunded patients
48
assess breathing
- determine respiratory rate
- listen for air entry and abnormal breath sounds
- check pulse oximetry
- listen for amount of breaths for 30 seconds
- is severe distress listen for a minute
- put stethoscope on the back
- beyond PAT
49
apical pulse
- put stethoscope on the apex (bottom) of the heart
| - listen to beats in 30 seconds
50
foreign body aspiration or obstruction
- infants and toddlers have a high risk of foreign body aspiration
- button battery's - leading cause of choking
- mild obstruction:
- awake
- stridor
- increased work of breathing
- good color
- coughing
- severe obstruction:
- cyanotic
- unconscious
- bradycardia
- death
51
removing a foreign body
- deliver five back slaps and five chest thrusts
| - point babys head towards ground- gravity!
52
anaphylaxis
- potentially life threatening allergic reaction
- triggered by exposure to an antigen
- IgE
- onsent of symptoms occurs immediately
- Hives
- respiratory distress
- circulatory compromise
- respiratory or cardiovascular pathology/involvement*** -> anaphylaxis
- H1- presence in lungs- Benadryl-diphenhydramine*****
- H2- presence in GI tract - famotidine (pepsin)*
- give epinephrine for vasoconstriction and bronchodilation
53
severe anaphylaxis
- child may be unresponsive
- primary assessment may reveal:
- hives
- fluid resuscitation for shock- lack of vascular tone -> distributive shock -> NOT a lack of volume
- diphenhydramine - H1
- bronchodilators
- histamine blockers - 24 hours
- always give oxygen
54
croup
- viral infection of the upper airway*********
- PAT typically reveals an alert infant or toddler with the following:
- audible stridor with activity or agitation
- barky cough
- some increased work of breathing
- normal skin color
55
initial management of croup
- position of comfort
- avoid agitating child -> you can increase RR
- nebulized (racemic**) epinephrine
- assisted ventilation with bag mask ventilation may be necessary
56
epiglottisits
- inflammation of the supraglottic structures
- epiglottis- covers the larynx during ingestion
- symptoms progress rapidly
- intubating a child is a ONE shot thing -> swelling will make it worse
- ask about immunizations, and get the child to an appropriate hospital
- be prepared with a bag mask device and an ET tube
- classic presentation:
- sick
- anxious
- sitting in sniffing position
- caused by H flu (vaccinated against)
- drooling***
- inability to swallow**
- increased work of breathing
- pallor or cyanosis
57
asthma
- disease of the small airways
- reversible
- main components:
- bronchospasms
- mucus production
- airway inflammation
- results of hypoxia
- give:
- anticholinergic- dry out the lungs
- dilators
58
triggers of asthma
- upper respiratory infections
- allergies
- exposure to cold
- changes in the weather
- second hand smoke
59
clinical signs of asthma
- frequent cough
- wheezing
- general signs of respiratory distress
- easy to treat in most cases
60
initial management of asthms
- position of comfort
- supplemental oxygen
- bronchodilators
- epinephrine for severe respiratory distress -> quick to use bc children mostly dont have heart issues
61
bronchiolitis
- leading cause is RSV- respiratory syncytial virus**
- common cause of children ICU admissions
- more common in children born early or low birth weight*
- inflammation or swelling of small airways in lower respiratory tract due to viral infection
- highly contagious
- characteristics findings include:
- mild to moderate retractions
- tachypnea
- diffuse wheezing and crackles
- mild hypoxia
62
danger of respiratory failure : bronchiolitis
- sleepy; obtunded
- severe retractions
- diminished breath sounds (especially lower-> alveoli)
- moderate to severe hypoxia
63
bronchiolitis: greatest risk for respiratory failure
- first month of life
- prematurity
- lung disease
- congenital heart disease
- immunodeficiency
- support care and time***
64
bronchiolitis: management
- support care and time*
- entirely supportive care
- position of comfort
- supplemental oxygen
- inhaled albuterol or nebulized racemic epinephrine may be given for moderate to severe respiratory distress
65
oxygenation
- all patients with respiratory emergencies should receive supplemental oxygen
- common methods for pediatric patients
- blow by technique
- nonrebreathing mask
66
blow by technique
- mask is held up to the face but not attached -> children dont like it
- best used when:
- small amount of oxygen is needed
- patient cannot tolerate the mask
67
bag mask ventilation
- use if airway positioning or adjunct does not improve respiratory effort
- may need to try a variety of mask sizes
- delivery breaths at a rate of 12-20 breaths/min for infants and children
- errors in technique can result in gastric distention or a pneumothorax
- surplus of air go into GI -> children are diaphragmatic
- two person bag mask ventilation is usually more effective
68
endotracheal intubation
- passing an ET tube through the glottic opening and sealing the tube with a cuff inflated against the tracheal wall
- consider only if:
- bag mask technique is not effective
- transport times are long
- long term
- advantages- definitive airway, decreased risk of aspiration
69
complications of endotracheal intubation
- bradycardia due to hypoxia -> taking to long or too many attempts
- increased ICP- blade stimulating vagal stimulants
- incorrect placement
- gagging if the person is awake or not fully sedated -> increases ICP
70
indications of endotracheal intubation
- cardiopulmonary arrest
- traumatic brain injury
- inability to maintain a patent airway
- need for prolonged ventilation
- remember the differences between the adult and pediatric airways
71
length based resuscitation tape
- broselow tape***
- in most cases a childs height is associated with weight
- use the tape to measure the length of the child -> depending on this it tells you which ventilator settings and size tubes, blades, bvms to use
72
pediatric equipment
- mandatory
- laryngoscope blades sizes (smallest) 0-3 (biggest)
- ET tubes sizes 2.5 - 6
- 2.0 for a premature baby
- any size laryngoscope handle can be used
73
The appropriately sized blade extends from
| the patient’s mouth to the tragus of the ear
- Length-based resuscitation tape measure, or
- General guidelines:
- Premature newborn: size 0 straight blade
- Full-term newborn to 1 year: size 1 straight blade
- 2 years to adolescent: size 2 straight blade
- Adolescent +: size 3 straight or curved blad
74
choosing ET tube size
-Younger than 1 year: length-based resuscitation
tape measure
− Older than 1 year: uncuffed formula
• [Age (in years) + 16] ÷ 4 = Size of tube (in mm)
− For cuffed tube, go down half a size
-2 years old -> 4.5 - and 4 for a cuffed
75
orogastric and nasogastric tube insertion
- invasive gastric decompression: placement of a nasogastric (NG) tube or orogastric (OG) tube to decompress the stomach
- removes the contents with suction
- makes assisting ventilation easier
- contraindicated in unresponsive children
