T he y re no t little a dults, b ut Pe a rls fo r yo ur ne xt pe - PDF document

3/7/2018 T he y’ re no t little a dults, b ut Pe a rls fo r yo ur ne xt pe dia tric the y a re little huma ns tra uma pa tie nt Alisa Mc Que e n MD, F AAP, F ACE P Alisa Mc Que e n MD, F AAP, F ACE P Asso c ia te Pro fe sso r o f Pe dia tric s Asso c ia te Pro fe sso r o f Pe dia tric s T he Unive rsity o f Chic a g o T he Unive rsity o f Chic a g o I have no re le vant financ ial re latio nships to disc lo se . Childre n a re little huma ns Childre n a re no t little a dults 1

3/7/2018 Ob je c tive s Ob je c tive s I de ntify a na to mic diffe re nc e s b e twe e n De sc rib e the physio lo g ic diffe re nc e s the a dult a nd pe dia tric a irwa y a nd b e twe e n a dult a nd pe dia tric c irc ula tio n a pply yo ur kno wle dg e to the a nd a pply this kno wle dg e to the ma na g e me nt o f the pe dia tric a irwa y in ma na g e me nt o f hypo vo le mic sho c k in tra uma . pe dia tric tra uma . 6 mo nth o ld fo und unre spo nsive a t ho me . Apne ic , pulse le ss Asysto le o n mo nito r Ca se HR 0 R 0 BP 0 CPR initia te d Pre dic to rs o f Diffic ult Airwa y • F a c ia l ha ir “At a c a rdia c a rre st, the first • Re stric te d ne c k mo b ility pro c e dure is to ta ke yo ur • Re stric te d mo uth o pe ning o wn pulse .” • Ob e sity • Pre g na nc y L a w # 3 T he Ho use o f Go d 2

3/7/2018 Yo u a re e xpe rts in the T he se a re a dult pro b le ms e me rg e nt ma na g e me nt o f the diffic ult a irwa y Ne o na ta l Airwa y Ana to my Ho w do yo u mo dify yo ur a ppro a c h in the pe dia tric Tongue pa tie nt? Epiglottis Vocal cords Cricoid ring Ne o na ta l Airwa y Mo dific a tio ns Ne o na ta l Airwa y Diffe re nc e s More prominent occiput #1 blade Large tongue Large tongue Epiglottis is floppy Straight blade Epiglottis is floppy Airway is anterior Airway is Look up anterior Narrowest portion Make sure your cuff Narrowest portion is below the cords is below the cords is down 3

3/7/2018 Ne o na ta l Airwa y Mo dific a tio ns Ne o na ta l Airwa y Mo dific a tio ns More prominent occiput Towel roll beneath the shoulders Size matters Infants are small 4

3/7/2018 But they are not that small! Atro pine ? Atro pine fo r pro te c tio n a g a inst b ra dyc a rdia I nfa nts ha ve e xa g g e ra te d pa ra sympa the tic to ne L a ryng o sc o py c a n ma ke the m b ra dyc a rdic Suc c inylc ho line c a n ma ke the m b ra dyc a rdic 5

3/7/2018 Hypo xia ma ke s the m T he tre a tme nt fo r b ra dyc a rdic hypo xia is no t a tro pine Suc c e ssfully intub a te d Vita ls re ma in 0-0-0 I O e sta b lishe d Ba c k to o ur c a se E pi g ive n A wo rd o n se c uring tha t I O Source: http://mdnxs.com/topics ‐ 2/procedures/intraosseous ‐ vascular ‐ access/ 6

3/7/2018 So urc e : https:/ / www.a lie m.c o m/ 2016/ tric k-se c uring -intra o sse o us-ne e dle / Suc c e ssfully intub a te d Childre n a re Vita ls re ma in 0-0-0 hig hly re spo nsive to e pine phrine I O e sta b lishe d E pi g ive n Childre n a re hig hly re spo nsive ROSC to vo lume e xpa nsio n HR 160 BP 50/ 20 “Push – Pull” me tho d to b o lus I V fluids 7

3/7/2018 Ba c k to o ur c a se T wo mo nths a g o … E D visit fo r “c rying ” No rma l vita ls No rma l e xa m e xc e pt fo r a fe w b ruise s o n the le g s AAP Committee on Child Abuse and Neglect. Evaluating children with fractures for child physical abuse. Pediatrics 2014;133:e477 ‐ e489. 8

3/7/2018 T E N – 4 Rule • Pilo t study o f c hildre n a g e 3 a nd unde r a dmitte d to PI CU fo r injury • Me c ha nism (a b use vs a c c ide nta l) de te rmine d b y e xpe rt c hild a b use re vie w • Cha ra c te ristic s o f a b use d vs a c c ide nta lly injure d c hildre n c o mpa re d • I de ntifie d hig h risk fe a ture s: b ruising o n to rso , e a rs, ne c k, o r a ny b ruise in infa nt < 4 mo nths Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67 ‐ 74. Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67 ‐ 74. T E N – 4 Rule • T o rso , e a rs, ne c k in a c hild le ss tha n fo ur ye a rs o ld F ra c ture s in Child Ab use • Any b ruise in a c hild le ss tha n fo ur mo nths o ld Avo id the tra p o f thinking c e rta in fra c ture s a re pa tho g no mo nic fo r no n a c c ide nta l tra uma . Co nside r c hild a b use Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67 ‐ 74. 9

3/7/2018 Pa rie ta l skull fra c ture Spira l fra c ture Murphy R e t a l. T ra nsve rse fra c ture s o f the fe mo ra l sha ft a re a b e tte r pre dic to r o f no na c c ide nta l tra uma in yo ung c hildre n tha n spira l fra c ture s a re . J Bo ne a nd Jo int Surg e ry 2015;97:106-11. Pa rie ta l skull fra c ture Co rne r fra c ture “b uc ke t ha ndle ” fra c ture Cla ssic me ta physe a l le sio n Co rne r fra c ture “b uc ke t ha ndle ” fra c ture Cla ssic me ta physe a l le sio n Ba c k to o ur c a se 10

3/7/2018 Sib ling study • Ho use ho ld c o nta c ts o f a b use d c hildre n e va lua te d – I f a g e < 5: physic a l e xa m I nfa nt ha s a 2 ye a r o ld – I f a g e < 2: physic a l e xa m + ske le ta l surve y sib ling a t ho me – I f a g e < 6 mo nths: physic a l e xa m + ske le ta l surve y + ne uro ima g ing • 479 ho use ho ld c o nta c ts Lindberg D et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193 ‐ 201. No ne o f the se 12% with fra c ture s fra c ture s ha d T a ke ho me po ints a sso c ia te d 25% with fra c ture s physic a l e xa m finding s A twin is 20 time s mo re like ly to ha ve a fra c ture Lindberg D et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193 ‐ 201. Optimize oxygenation to Avoid the tiny blades prevent bradycardia 11

3/7/2018 Se c ure yo ur I O with the ma sk fro m a n a mb u b a g Don’t rely on atropine Use the “Push–Pull” me tho d to b o lus I V fluids Bruising o n the to rso , e a r, o r ne c k o r a nywhe re <4 mo nths Co nside r a b use Ge t a ske le ta l surve y o n Childre n a re little huma ns ho use ho ld c o nta c ts o f a b use d c hildre n 12