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PRE-HOSPITAL EMERGENCY CARE COURSE
www.basics.org.uk
Introduction to Paediatrics
“Still kids are ill kids”
© BASICS Education March 2016
Objectives
Reinforce the basic principles of emergency
assessment and management of children and
babies
Underline the importance of further paediatric
emergency medical / trauma training:
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NLS
•
APLS / PHPLS
•
PEPP
Not small adults…
•
Physical size –0.8kg to 80kg
•
Anatomical & Physiological
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Airway differences / Compensatory mechanisms
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Physiological / metabolic –normal values
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Communication
•
Psychological
•
The child
•
The scene
•
Those treating them
•
Parents & Carers
Childhood mortality
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< 1 year: Congenital abnormalities
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> 1 year: Trauma – mobile & inquisitive
Hypoxia & hypovolaemia - common causes of death
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Often “subtle” clinical warnings:
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Time to correct – but only if detected early
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Healthy hearts which compensate well
Cardio-respiratory arrest: Bleak outcome
•
Need to recognise and treat impending
respiratory / circulatory failure EARLY
“From the door” assessment
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Appearance :
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Responsive, orientated or “not quite right” ?
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Work of breathing
•
Effectiveness of circulation
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Not sick ? - little sick ? - BIG SICK ?
Appearance
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Fully conscious and orientated
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Interacts appropriately with caregiver and
others
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If concerned by abnormal appearance /
interactions, ask caregiver what is ‘normal’
“From the door” assessment
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Appearance :
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Work of Breathing
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Increased: rapid & noisy
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Effectiveness of circulation
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Not sick ? - little sick ? - BIG SICK ?
Differences: Airway & Breathing
Smaller airway
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Obstructs more easily
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Large tongue
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Delicate soft tissues
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Trachea is pliable & occludes if the head is
flexed/extended beyond neutral
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First six months: obligate nasal breathers
Big occiputs
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Head flextion if uncontrolled - obstructs airway
Pliable ribs
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Intercostal recession
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Increased use of accessory muscles
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Faster respiratory rates
Recognition of Respiratory
Distress
Increased work of breathing
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Nasal flaring
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Posture
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Wheeze / stridor
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Use of accessory muscles
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Recession
Decreased effectiveness
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Respiratory rate & depth
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Heart rate
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Level of consciousness
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Cyanosis
Management
GIVE
HIGH FLOW
OXYGEN
Management
Open airway
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Manual (care with chin lift)
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Simple airway adjuncts
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Supraglottic airway
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Needle cricothyroidotomy
Support breathing
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Pocket mask (Adult -upside down)
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Bag-valve-mask
Intubated children pre-hospital are often dead
children in hospital
Differences in circulation
•
Healthy hearts – effective compensation
•
Small children have small circulating blood
volume
- 80ml/kg at birth
•
Heart rate varies with age
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Blood pressure – poor indicator of shock
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BP drops after a loss of 25% of total
circulating volume
•
Presence of peripheral pulses does NOT
correlate with systolic blood pressures
•
“Hypotensive resuscitation” dangerous in
children
Recognition of circulatory
failure
•
“From the door” assessment
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Cardiovascular parameters
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Effects on organs
Cardiovascular parameters
OBSERVATION
LIFE THREATENING SIGNS
Pulse rate
Bradycardia
Capillary refill
Greater than 2secs
Skin colour
Increasing pallor
Skin temperature
Increasingly cold centrally
Blood pressure
Hypotension (late sign)
Level of consciousness Reducing
Management of shock
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Manage A & B
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High flow oxygen
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Control external haemorrhage
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10ml/kg IV / IO fluid (to a maximum of 20 ml/kg)
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5ml/kg IV /IO fluids for uncontrolled,
uncompensated haemorrhage
•
•
Titrate to effect
Tranexamic Acid (TXA)
Be aware of the potentially compensating child
Disability
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Check AVPU
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Posture –floppy, stiff
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Pupils
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Children are prone to hypoglycaemia
so check glucose – “DEFG”
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10% Dextrose @ 2ml/kg
Trauma - scene safety &
control
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Emotions cloud judgements
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Focus on normal principles of scene assessment
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Look for signs of ejection
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Look under seats etc
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Look for evidence of children:
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Toys
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Child seats etc.
Management of trauma
Airway
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Open and maintain
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C spine control
Breathing
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High flow oxygen
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Assist if necessary
Circulation
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Control external haemorrhage
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IV / IO access
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20ml / kg fluids (max)
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5ml / kg if indicated (uncontrolled, uncompensated)
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Tranexamic acid 15mg/kg
Trauma
CHILDREN DIE OF HYPOXIA
Give high flow oxygen
Analgesia
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Children feel pain and MUST have adequate
analgesia
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Paediatric pain scoring
pain ladder / pandas – questionable benefit
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IV morphine is gold standard
Naloxone works well in children
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Intra nasal Diamorphine or Ketamine effective
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Entonox – needs explanation
Foreign body airway
obstruction
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If ventilation is adequate do not interfere with it
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Take to hospital without intervention
– unless NOT breathing
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Visually remove foreign body
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Treat for choking - RC(UK) guidelines
•
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mild
•
acute
Abdominal thrust – FAST scan required – covert
bleeds
Medical conditions
Croup
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Keep child calm and do NOT attempt IV
access
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Do not examine throat
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Can be life threatening due to respiratory
obstruction
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NOT always a benign illness
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Stat dexamethasone orally – single dose
(0.15mg/kg)
Medical conditions
Anaphylaxis
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Know how to use an ‘Epipen’, ’Anapen’ or ‘JEXT’
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Colour coded dosage systems
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1:1,000 Adrenaline intramuscular injection
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RC(UK) guidelines
Medical conditions
Asthma
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Assess severity: Mild, Acute, Life-threatening
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Salbutamol via large volumiser spacer Nebulised
Salbutamol / Ipatropium through oxygen driven
nebuliser
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BTS Guidelines
Medical conditions
Meningococcal sepsis
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Rash is not always classical
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Treat for shock
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Benzylpenicillin
or Cefotaxime / ceftriazone
Urgent transfer to hospital
Medical conditions
Convulsions
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Protect patient from environment
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60% incontinent of urine
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Assess and manage A B C
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Status Epilecticus:
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Treat with rectal diazepam or buccal/intra-nasal midazolam
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IV / IO access if necessary
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Always check blood sugar –’DEFG’
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“Febrile fits” commonest
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always admit first fit
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establish cause of fever and treat - ? sepsis
Basic Life Support
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Use adult BLS if necessary (size rather than age)
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15:2 preferred
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Use paed pads (where available) if under 25kgs
When not available, use adult pads front and back
Urgent transfer to hospital
Suspected abuse / neglect
Make no assumptions for good or bad
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It is not our place to accuse
If suspected – report it
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Document your suspicions
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Handover to senior clinician
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Contact local social services
If parents refuse to let the child travel
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Document
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Discuss with senior person in organisation
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Risk to life: Call Police
Statutory obligation to report
Keep it simple
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Practice scenario drills regularly
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Be familiar with your equipment
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Keep an aide memoire of basic doses,
weights and equipment sizes
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Always go back to first principles of A, B, C, if
things are going wrong
Keep things awfully simple
so things don’t become simply awful
Introduction to paediatrics
Questions ?
Summary
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Adopt a “From the door approach”
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“Not Sick, little sick, BIG SICK”
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Be aware of the differences in anatomy,
physiology and psychology
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Keep things awfully simple so that things
don’t become simply awful
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Access additional paediatric resuscitation
training / courses