CRACKCast E166 – General approach to the paediatric patient

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We’re beginning the paediatric series. Here’s a general approach to use as we focus on specific pathologies in the upcoming weeks!

ShownotesPDF here

Rosen’s In Perspective

There are a few physiologic/anatomic considerations unique to kids that we should keep in mind:

  • Temperature regulation: KEEP THEM COVERED AND WARM!
    • Rapid heat loss (larger surface area–to–mass ratio, resulting in more heat loss to the environment than in adolescents and adults.)
    • Takes more energy to stay warm (Maintenance of a stable body temperature can be a significant metabolic demand for young infants, especially those stressed by injury or illness.)
  • Airway
    • Here’s the list we keep reviewing!

 A helpful approach: think about the patient as you walk into the resus room preparing to intubate:

  • 2 big: head, tongue
  • 2 small: narrow easily blocked nasal airways, narrow cricoid,
  • 2 short: airway (depth = 3 x ett), time to desaturation (less reserve)
  • 2 tall: epiglottis/floppy, think tall (prepare, pep talk, pee)

 First, after a pit-stop and pre-resus breathing/ “pep talk”, do that airway “pause”/checklist or whatever you do to bring the stress level and noise in the room down!!!

  1. Big head:

The relatively larger occiput in infants and young children can cause neck flexion in the supine position, leading to potential airway obstruction. To open the airway, particularly during intubation attempts, a towel roll placed under the shoulders may be needed to align the laryngeal, pharyngeal, and oral airway axes

  1. Important, but easily clogged noses

In addition, airways in children are much smaller in diameter and much more easily obstructed with secretions. Because young infants preferentially breathe through their noses, respiratory distress can develop from copious nasal secretions. Thus, suctioning the nose and upper airway can dramatically diminish an infant’s work of breathing.

  1. Big tongues

Infants and young children also have relatively large tongues, which may lead to airway obstruction during periods of changes in muscle tone, such as during a seizure. Use of a nasopharyngeal airway can alleviate the obstruction by allowing a clear passage of inhaled gases.

  1. Anterior larynx; floppy epiglottis

the pediatric larynx is more anterior and cephalad, and the epiglottis is composed of more flexible cartilage, making it floppy.  

  • CV system
    • Bradycardia and/or hypotension are OMINOUS, LATE SIGNS.
    • Children have the ability to increase their heart rate and vasoconstrict peripherally to shunt blood centrally. Hypotension is a late finding of shock in previously healthy children, and interventions should ideally occur before the onset of hypotension.
    • Watch out for unexplained tachycardia in the resting child
  • MSK system
    • More likely to # bones than sprain ligaments
    • The physis is the weakest part of a bone
    • Their bones remodel better than adult’s bones
  • Immune system
    • Febrile infants younger than 1 month are a particularly high-risk group and have a 10% or higher rate of serious bacterial infection. For this reason, the evaluation of infants with fever differs from the evaluation of older children and adults; the evaluation varies by age and vaccination status.
  • Considerations:
    • Use the weight-based dosing system!
    • ceftriaxone is not recommended for infants younger than 28 days because it can displace bilirubin from albumin, leading to kernicterus or bilirubin-induced neurologic dysfunction (BIND)

Core questions

[1] List age specific vital signs (RR, HR)

Look it up! These are the “max” – approximate

1-3-5-7-9-

6-5-4-3-2-

Age RR HR
<1 yr 60 160
3 y 50 150
5 y 40 140
7 y 30 130
9 y 20 120

 

Age (y) RR HR
<1 30-60 100-160
1-2 24-40 90-150
2-5 22-34 80-140
6-12 18-30 70-120
>12 12-16 60-100

By age 11 their vitals are essentially = to an adult’s vital range. Check out this great web-page too (it lists HR by awake or sleeping, which is GOLD): https://www.pedscases.com/pediatric-vital-signs-reference-chart 

[2] What is the lower fifth percentile of systolic BP for the neonate, infant, and 1-10 yr old child?

60-70-(70+2*age)

Age Lower 5th percentile of SBP
0-28 days 60 mmHg
1-12 months 70 mmHg
1-10 years 70 mmHg + (2*age in years)

[3] Describe the 3 components of the Pediatric Assessment Triangle.

This is the “gestalt” or quick look from across the room. It’s the sick vs well determination! It is easy! We should know our “ABC’s”.

See Rosen’s Fig. 160.2 and Table 160.4 for more details, the ABCs are

  • Appearance/gestalt look: TICLS (tone, irritable/interactive, consolable, look/gaze, speech/cry)
  • work of Breathing: Sounds, HOUNDS
    • Head position,
    • bObbing
      • Head bobbing (the use of neck muscles to assist respiration) and seesaw breathing (ineffective breathing pattern, in which the abdomen moves outward while the chest moves inward during inspiration) are signs of impending respiratory failure.
    • Uncooperative
    • Nasal flaring
    • Drawing/retractions
      • suprasternal, supraclavicular, intercostal, and subcostal areas
    • Snoring / Seesaw
    • abnormal respiratory patterns may provide clues about a nonrespiratory illness. Effortless tachypnea may be a sign of shock from any cause, whereas deep rapid breathing without other auscultative findings may be compensation for a metabolic acidosis.”  – Rosen’s 9th edition, Ch 160
  • Circulation to skin
    • PCPC (pallor, delayed cap refill, petechiae, cyanosis, mottling)
      • See Rosen’s Fig 160.5 for mottling vs. cutis marmorata
      • Cutis marmorata is a normal finding in young infants in a cool environment. In contrast to infants with mottling, infants with cutis marmorata will be otherwise well-appearing, and the skin findings will diminish or disappear if the infant is placed in a warm environment.

[4] Describe the Canadian Pediatric Triage and Acuity Scale

Check out this link for the PDF from the 2008 CJEM updated article: http://caep.ca/sites/caep.ca/files/caep/2008_revisions-to-the-canadian-triage-and-acuity-scale-paediatric-guidel.pdf

  • This is a specific consensus guideline that tailors the adult CTAS (Canadian Emergency Department Triage and Acuity Scale) to pediatric presentations to the ER
  • It still uses the standard colour palettes:
    • It adopts the adult poster colour palette for the CTAS level colour assignment: Level I – blue, Level II – red, Level III – yellow, Level IV – green, and Level V – white
  • It uses the “critical look”, first order modifiers (level of consciousness, respiratory rate and effort, and heart rate and circulatory status) and second order modifiers (temperature, pain, mechanism of injury and glucose) to calculate the CTAS score 

This is used to help the triage nurse estimate:

  • “What is this patient’s priority (urgency) to be seen?” and
  • “How long can the patient safely wait?”

The reference ranges for paeds CTAS can be found here: http://caep.ca/sites/caep.ca/files/caep/files/paedctas.pdf

[5] List 5 historical indicators of child abuse

  • They are:
    • History lacking in detail
    • Inconsistency – details change with repeated questioning
    • History inconsistent with child’s developmental status
    • Reported mechanism inconsistent with injury
  • See Rosen’s Box 160.3 for the original
  • Use those “spiny-senses” or trust your “gut” if something doesn’t seem right on history!
  • Be sure to take that thorough history!

[6] List 5 features of suggestive of child abuse on physical examination and/or radiology?

  • Any bruises in young precruising infants
  • Patterned ecchymosis, burns, or skin marks (abrasions, lacerations)
  • Bruises on the ears, trunk, inner things, neck, or groin
  • Posterior oropharynx bruising or lacerations
  • Posterior rib fractures
  • Classic metaphyeal fractures
  • Any fracture in a nonambulatory child
  • Fractures in different stages of healing

Look for those patterns! (cigarette burns, hand prints, rope burns)

Wisecracks

[1] What are developmental milestones (gross motor and otherwise) for 1-24 months?

Age (mo) Gross motor Fine, social, language
1 mo Lifts head Alert to sound and face
3 mo Rolls over Smiles, and recognises voices
6 Sits independently babbles
9 Cruises Single words
12 Walks Two words
15 Goes up stairs Four words
18 Runs 8 words
24 Goes down stairs Sentences (2 word) 

[2] What are other considerations in the management of pediatric patients: consent, pediatric-readiness, pediatric-friendly ERs?

Consent

Much of the legality around pediatric consent is region-specific; but Rosen’s includes a helpful discussion on the controversy around pediatric competence and consent:

“If a condition that is threatening to life or health exists, treatment should be

provided under the doctrine of implied consent. If an emergency

medical condition is not suspected after a screening examination,

non-emergent care should be delayed until guardian consent is

obtained, unless the minor is legally able to consent for care.” – Rosen’s 9th ed

 The CMPA has a helpful article on the subject: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/can-a-child-provide-consent. Here are a few excerpts:

The CMPA reviewed its medico-legal case files that closed between 2007 and 2012 involving patients between the ages of one and 18. There were 451 complaints to regulatory authorities (Colleges) involving child patients, and of these 55% resulted in an unfavourable medico-legal outcome for physicians. Consent and communication issues featured prominently in these cases.

Age of consent — The legal age of majority has become largely irrelevant in determining when a young person may consent to his or her medical treatment. The concept of maturity has replaced chronological age, except in Québec, where the age of consent is 14 years and older.

How does a physician determine whether or not a child has the capacity to consent? By discussing with the child, the physician should be reasonably confident that the child understands the nature of the proposed treatment and its anticipated effect. The child should also understand the consequences of refusing treatment. One way to gauge this capacity is to use the teach-back technique: ask the child to re-phrase what they have just been told and invite the child to ask questions. More complex medical situations may require more rigour in determining whether the child understands. It is prudent for physicians to also encourage the child to invite a family member to attend the discussion.”

“The Canadian Paediatric Society requires that the minor demonstrate comprehension of the magnitude of the intervention, the probabilities of harm and benefit, and the consequences of consent or refusal. The American Academy of Pediatrics policy statement emphasizes that a minor’s choice must be voluntary and rational.” – Royal College of Canada

“but minors can generally consent if they are emancipated or if they are seeking treatment for mental health issues, drug or alcohol abuse, contraception, pregnancy, or testing for or treatment of sexually transmitted infections.” – Rosen’s 9th edition

Paediatric readiness

If you work in a shop that rarely sees children, or in a rural centre – you should have a preparedness plan to get ready for the sick child who may walk through your doors!

Here’s a great website and toolkit that lists the recommended supplies and medications you should have available!

https://emscimprovement.center/projects/pediatricreadiness/readiness-toolkit/equipment-supplies-oand-medications/

https://emscimprovement.center/projects/pediatricreadiness/

Here’s how the above project got started: https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Emergency-Departments-Improve-Readiness-to-Care-for-Children.aspx

Pediatric friendly ERs

Appropriate use of sedation, anesthesia, analgesia, and nonpharmacologic methods of pain management can increase the patient’s cooperation and increase visit satisfaction for the child and parent. Children have significant anxiety and fear surrounding medical procedures, leading to additional challenges in performing procedures successfully.

 In addition to reducing pain and anxiety during the acute visit, adequate pain control is likely to have long-term benefits. Multiple studies have demonstrated that inadequate procedural pain control can lead to increased pain perception with future painful procedures.

 Evidence shows that it is usually therapeutic for families and parents to be present in the resuscitation room or during critical procedures.

These shownotes were copy edited and uploaded by Kevin Lam (@KevinHLam)

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Adam Thomas

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Adam Thomas
- 36 mins ago
Chris Lipp
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..