dangerous and bad practices in kids: being a smooth ... · 4/21/2015 6 infants born at 36 weeks...
TRANSCRIPT
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Mimi Lu, MD Assistant Residency Program Director
Director, Pediatric EM Education
Department of Emergency Medicine University of Maryland School of Medicine
Describe differences in the evaluation
and management of neonatal and
pediatric patients compared to adult
patients.
List examples of harm when utilizing the
same approach to treatment of these
patients.
Infant Adult
Tongue Relatively large,
intraoral
Normal
Epiglottis Floppy, anterior,
cephalad
Firm
Vocal cord
angle
Inclined Flat
Glottis C3 level C5-C6 level
Cricothyroid
Membrane
Small, narrowest
point
Normal
Trachea Small, short,
collapsible
Large, stationary
Children > 2 years: ETT size: (Age/4) + 4
ETT depth (lip): ETT size x 3
Cuffed tube okay
Except newborns (<30 days)
ETT size: (Age/4) + 3.5
Uncuffed tube ETT = uncuffed endotracheal tube size.
20-25 week gestation:
25-30 week gestation:
30-35 week gestation:
35-40 week gestation:
2.0-2.5 ETT
2.5-3.0 ETT
3.0-3.5 ETT
3.5-4.0 ETT
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Nasal breathers
Diaphragmatic dependence
Weak accessory muscles
Limited respiratory reserve
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
> 60
>30
>15
Normal RR may reflect fatigue
Smaller blood volumes
Compensatory mechanisms
Age-dependent variations
Increased body surface area
Decr oxygen
delivery
Clinical exam
More myocardial
dysfunction
› Low CO, high SVR (60%)
› Low CO, low SVR
› High CO, low SVR
(20%)
Decr oxygen
extraction
Lab parameters
High CO, low SVR
Hypotension
Children Adults
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
Delayed cap refill, thready pulses, cool extremities
Hypotension is a LATE sign
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[2 x age] + 90
NS or LR 20 ml/kg x 3
› 10 ml/kg in newborns or congenital
heart disease
Anticipate fluid needs
› 3:1 crystalloid to blood loss
› PRBCs/FFP 10 ml/kg
5 ml/kg in newborns
Monitor response
› UOP: 1 ml/kg/hr
› UOP infants < 1y: 2 ml/kg/hr
Ill patients with depressed mental status are hypoglycemic until proven otherwise
Treat for BS < 50
Rule of 50
› D10 5 ml/kg (age < 1 year)
› D25 2 ml/kg (age 1 – 8 year)
› D50 1 ml/kg (age > 8 year)
[2 x age] + 10 kg
Estimate weight in kilograms
Broselow tape
PAWPER tape
PalmPEDi
BlueCard CNMC
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Infant (1 rescuer).
Berg M D et al. Circulation 2010;122:S862-S875 Copyright © American Heart Association
Infant (2 rescuers).
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Cricoid pressure
LMA
Minute ventilation
End Tidal CO2
Avoid hyperoxia
Wide complex tachycardia
Defibrillation
Calcium
Etomidate
Post-resuscitative care
Kattwinkel J et al. Circulation
2010;122:S909-S919
Copyright © American Heart Association
Maintain A-B-C sequence
Most arrests due to asphyxia
De-emphasize peri-partum suctioning
ETT suctioning for nonvigorous newly born
with meconium-stained amniotic fluid
(Class IIb, LOE C)
Use oximetry if: (Class I, LOE B)
› Resuscitation anticipated
› PPV adminstered
› Persistent cyanosis
› Supplementary oxygen is administered
Attach probe to pre-ductal
› Right wrist or palm
Begin PPV if the infant remains apneic or gasping, or if the HR < 100
Begin chest compressions for HR <60 despite adequate ventilation with supplementary oxygen for 30 seconds.
Compression: ventilation ratio = 3:1 › 90 compressions and 30 breaths to achieve
approximately 120 events per minute
› Pause for ventilation
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Infants born at 36 weeks gestation with
evolving moderate to severe hypoxic-
ischemic encephalopathy should be
offered therapeutic hypothermia.
› Begin within 6 hours after birth
› Maintain for 72 hours
(Class IIa, LOE A)
Adults/
Adolescents
Infants/
Children
Neonates
Sequence C-A-B C-A-B A-B-C
Compression rate
(bpm)
100 100 90:30
events/min
Depth >2 inches 1.5-2
inches
1/3 AP
diameter Compression:ventilation
- 1 rescuer
- 2 rescuers
30:2
30:2
30:2
15:2
3:1
3:1
Pause for ventilation
after intubation?
No No Yes
Critically ill infant = sepsis
Sweating with feeds = CHF
Persistent tachycardia = myocarditis
Critically ill infant = hypoglycemic
Non-accidental trauma is always in the
differential