szima sándor m - belgyógyászati...
TRANSCRIPT
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Szima Sándor M.D
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Difference between the pediatric
and the adult
Anatomy
Physiologic
Different pathways
Age specific disease
Special management
Communication
Aspect of the law
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Scale of the childhood period kor megjegyzés
Newborn 0 – 28 day Newl(ly) born: first few hours
Infant 1 month – 1 year
Child 1 – 18 yrs
•Toddler and preschooler
1 – 8 yrs
•Schooler 8 – 12 yrs
•Adolescent 12 – 18 yrs
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Body weight 0-8 years
Body weight[kg] = 2 x (age in years + 4)
After 8 years
Body weight [kg] = 3 x age in years
After the puberty
Adult parameters
Body surface area / body weight is bigger in
childhood
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Anatomy differences – head-neck
Big head, short neck, protuberant occiput – flexion of the neck
The face and the mouth are small
The tongue is big.
Result: Tendency for the obstruction of the airway
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Anatomy differences – nose/throat
Young infants able to breathing only via nose until 3 months old.
Narrow nose
Short mandibula
Result: Tendency for the obstruction of the airway
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Anatomy differences – Larynx Difficult intubation
Big tongue
Position of the larynx different from the adults. The glottis and the oropharynx positison is NOT straight.
Tube without cuff until 8 years old.
The bifurcation and the larynx are closed – Easy endobronchial intubation.
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Physiologic differences Immature pulmo
Obligatory nasal respiration until 4 month old.
Power of the heart depend on the frequency. Bradycardia can cause serious systemic perfusion problem
The low blood pressure is very late sign of the shock.
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Physiologic differences
Higher body watercontent (infancy ~75%)
Extracellular fluid (blood, lympha) is bigger than the adults (~40%)
Faster water turnover.
Immature kidney.
Result: Exsiccosis, dehydration is very ferquent.
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Physiologic differences
Respiratory muscles easy exhausted
Immature immune system – infections
Increased oxigen consumption
Apnoe of the infancy
Need for early support of the ventillation
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Physiologic differences
Lower contractility of the heart
Higher heart frequency
Bradycardia tendency (hypoxia)
Cardiac output depend on the frequency
Blood pressure compensation with the
frequency, but it can easy exhausted
The bradycardia is more dangeorus than the
tachycardia.
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Physiologic differences
Immature central nervous system
Increased seizure affection
Respiratory control problems
(apnoe, SIDS)
Increased affection for the brain oedema
Later sign of the brainoedema – because the opening suturas
Different type of the seizures
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Physiologic differences Hypoglicaemia, seizures, apnoe can cause
serious CNS damage
Immature temperature control
Relative big body surface area – temperature, evaporation
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Physiologic differences Bigger fluid demand
Bigger energy demand
Bigger oxigendemand
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Speciality in the communication Limited verbal contact
The non-verbal communication has bigger
part
Function of the parents (history, non
pharmacology anxiolysis)
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Patophysiologic differences Affect for the airway oedema
Lower functional residual capacity
Higher oxigen using
Answer for the hypoxia – bradycardia.
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Patophysiologic differences In case of hypovolaemia
The heart has insufficient contractily capacity. First compensatoric mechanism is the increased frequency.
In case of hypovolaemia the organism can compensated for long time, but than the decompensation is rapid.
Primary arrhytmia is rare.
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Patophysiologic differences The vomiting is not only sign of the
gastrointestinal problem.
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Respiratory rate Pulsus Blood pressure (MAP)
Under 1 month 30-40 / 43/ min< 80 – 180 / min 75 Hgmm(50)
Under 1 year 30-40 / 34/ min< 80 - 180 / min 100 Hgmm(60)
átl./min.:
90/70 years
x 2
2-5 yrs 24-30 60 – 130 / min 100 Hgmm(70)
6-12 yrs 20-24 60 – 110 / min 100 Hgmm (70)
13-18 yrs 12-20 60 – 100 / min 110 Hgmm (70)
Adult 12/ min< 60-100 /min
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The sick patient first examination AVPU
A(3)Open – possibility of obstruction - obstructed
B(4) RR – TV – WOB –SpO2
C(5) Frequency – RR – CRT – Quality of pulsus –
Preload
Disability
Events
Aimed examination
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Criticaly ill? Loss of consiciouness
Confusion
Seizures
Respiratoric failure
Increased WOB
Cyanosis
Trauma
Burn
Fever and purpura
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Respiratory tract SpO2 immediate!!! RR WOB Paradox breathing Sounds
Inspiratoric: upper airway (extrathorax) Exspiratoric: lower tract (intrathorax) „no breath sound” – the worst sign
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Respiratory tract Grunting especially in newborn Cyanosis and pallor – later sign! Tachycardia then bradycardia Confusion – nervous, anxious than LOC
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Circulation - pulsus Heart rate
Most important sign of any stress Fever, anxious, pain, hypoxia, hypovolaemia
In the newborn answer for the hypoxia is bradycardia
Quality of the pulsus Full vs.easy overpress
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Circulation – blood pressure Compensating mechanism
Vasoconstriction
Tachycardia – first sign
Myocardioum increased contractility
In case of shock the low blood pressure is very late sign! (loss about 40% blood volume)
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Circulation – systemic perfusion Periferial vascular resistency
Capillary refill time.
Press the skin for 5 sec then release. Normal time is < 2 sec. First sign of the shock.
Temperature of the skin
Difference between the central and the periferial pulsus
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Circulation – systemic perfusion Brain – “D” Worsening brain perfusion – confusion, LOC,
seizures, dilatation of pupils Agitation, lethargy, irritability Alert Voice response Pain response Unconscious
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Circulation – systemic perfusion Renal
Urine output <1 ml/kg/hour
More output is very good sign of the effectivness of the therapy
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Circulation – preload Fullness of jugular vein
Crakcles above the pulmo
Size of the hepar
Periferial oedema is not general
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Neurology AVPU
Size and the reactions of the pupils
Spontaneus movement
Sensoral examination
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Circumstance Symptoms
Allergia
Medicine
Past history
Last meal
Events 32
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Management of the critically ill children
A – Airway patency (manually, equipement)
B – oxigen, ventillation(bag and mask)
C – monitor
- IV/IO
20 ml/kg crystalloid
D – Endotracheal intubation –
Respiratory failure
GCS< 9 / AVPU
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Airway protection Manual
Neutral position of the head
Jaw thrust
Equipment
Nasopharyngeal tube
Oropharyngeal tube
Supraglottic tube
Endotracheal tube
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Secure of the airway Optimal size
Premedication
Preoxigenization
The endotracheal intubation is not condition for the airway patency nor the oxigenization.!!
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Drugs for the premedication Analgetics
1. Fentanyl 2-4 ug/kg iv.
2. Morphin 0,1 mg/kg iv.
Sedatives
1. Midazolam 0,1-0,3 mg/kg iv.
2. Propofol 1,5-2,5 mg/kg iv.
3. Ketamin 1-2 mg/kg iv.
4. Etomidate 0,2-0,3 mg/kg iv.
In the case of shock give half-dose!
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Tube size in pediatric patient Tube size (ID): years4 + 4 (+/- 0,5)
End of the tube:
-orotracheal intubation: years/2 + 12 cm
-nasotracheal intubation: years/2 + 15 cm
Think about one size smaller and bigger plus alternative management.
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Size of the spatula: •preterm: 0 •term: 1 •1 month-1(-2) years: 1-2 •1(-2) year-8 years:2 •Over the 8 years: 3
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Parenteral fluid intake Venal route
Intraosseal route –
Unsuccesful venipuncture or CPR/shock
Tuberositas tibiae – caudal 1cm, 2cm medial
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Parenteral ways for the drugs IV/IO.
Inhalative
Per rectum
Intranasal
Buccal
Muscular
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Cause of the respiratory failure Pulmonary: tachypnoe + dyspnoe
Extrapulmonary: „Only” tachypnoe
Upper airway obstruction
Bronchiolitis
Bronchitis
Asthma
Pneumonia
Foreign body
Trauma
PTX/HTX/Hyrdothorax
Heart failure
Kidney failure
DKA
Other metabolic problem
CNS problem
Anaemia
Toxin
Environment hypoxia
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Upper airway obstruction Naspoharyngitis – little infancy
Laryngitis
Foreign body
Tonsillitis
Epiglottitis
Trauma
Allergy 41
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Laryngitis Viral infections
Influenza, parainfluenza virus, RSV, adeno-, rhinovirus etc.
Subglottic oedema
Recidiva is often
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Laryngitis General night time shortness of breath
Fall, early winter
Between 6 months and 3 years
Bark, hoarsness, dry cough
Inspiratoric or if serious in- and exspiratoric stridor
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Laryngitis
Croup score
3-5 moderate
Overs 6 PICU
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Score 0 1 2
Stridor - Inspir. In+exspir.
Cough - muddy Bark
Levegő beáramlás normal reduced Minimal
Nasal flare+dyspnoe - Jugular Jug.+substernális
+intercost.
Cyanosiss - 21% FiO2 35%
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Laryngitis COLD humidification
Rest
Micronephrin – inhalation with 3 ml NaCl 0,9%
under 20 kg - 0,25 ml
20-40 kg - 0,5 ml
over 40 kg - 0,75 ml
Epinephrine 10x dose.
Steroid – 2-4 mg/kg
Anticipate need to intubate, assist ventilations
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Epiglottitis
Bacterial infection
High fever
Rare frequency than the laryngitis
(Vaccination against the H. influenzae B type)
BUT life threatening disease!!
The child is sitting, leak of the saliva, septicotoxic status.
High concentration oxygen
Rapid transport
MUST NOT attempt to visualize airway.
Immediate PICU! 46
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Asthma bronchiale
Genetic predisposition Trigger factor - viral infection Pathway Bronchospasm Increased mucus Airway oedema Signs Tachypnoe, dyspnoe, Obstruction of the airway Expiratory whezzing Silent pulmo
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Asthma bronchiale ABC Oxigen Bronchodilatation
Salbutamol – Ventolin puff 1-2 Ipratrominum bromatum Berodual (20 drops/ ml)0,1 ml / kg Epinephrine/Bricanyl 0,01 mg/k im. or iv., slowly, monitor of the
heart rate
Steroid i.v. or p.r. Methylprednisolon – 2mg/kg
Magnesium-sulfate 25-50 mg/kg over 2-4 min. Diaphyllin i.v.
4-5 mg/kg Infusion 0,5-1mg/kg/óra
Ventillation Low TV and frequency, Low PEEP
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Anaphylaxys Allergen mediated immunology pathways
when minimum two organs involved
Breathings – circulation – GI - Skin
Respiratory failure
Primer and secunder circulation failure
Anaphylactic shock – one type of distributive shock
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Anaphylaxys
Epinephrine
under 6 months – 50 ug im.
6 months – 6 yrs. – 150 ug im.
6 yrs. -12 yrs. – 250 ug im.
Over 12 yrs. – 500 ug im.
Steroid 4 mg/kg
Chlorpheniramine
under 6 months - 0,25 ug/kg
6 months - 6 yrs - 2,5 mg
6 yrs – 12 yrs - 5 mg
over 12 yrs - 10-20 mg
Fluid – cristalloid minimum 20 ml/kg
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Circulation failure Arrhytmias
Congenital or acquired vitium
Congenital or acquired myopathia
Extracardiac causes
Respiratory failure
Sepsis
Anaphylaxys
Metabolic causes
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Arrhytmia in pediatric patients Primary problems is rare
In the most cases results of compensation of any serious problem (tachycardia) or sign of the exhausting (bradycardia).
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Arrhytmia – Bradycardia
Bradycardia is always a serious status
In most cases the serious hypoxia is the reason not the heart problem
Treat the hypoxia, not the bradycardia
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Arrhytmia – Bradycardia ABC
Oxigen
Treat the cause of the problem (Hypoxia, hypovolaemia, hypoglycaemia, hypothermia)
Medication
Atropin 0,01-0,02 mg/kg i.v. Epinephrine 0,01 mg/kg – 0,01-0,5 ug/kg/min i.v. Dopamin 5-10 μg/kg/min
Pacemaker ONLY when the oxigenization, ventillation chest compression and the
pharmacology therapy not improving the patient. Bad tissue perfusion plus heart frequency under 60/min – start the chest compression.
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Arrhytmia – Tachycardia
Most important is the sinustachycardia
Causes: fever , infection, pain, anxious,
hypoxia, hypovolaemia.
Primary in childhood
PSVT - often
Atrial fluttern - rare
Ventricular tachycardia – very rare
Other – extreme rare
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Arrhytmia – Tachycardia Sinustachycardia – treat the cause.
Supraventricular tachycardia Oxigen, Valsalva, cool the face i.v/i.o. Adenosin (0.1, 0.15, 0.2 mg/kg i.v/i.o.)
If not stable : Sedatoanalgesia Cardioversion (1–4J/kg )
Stable or ineffective cardioversion
fast amiodarone (5 mg/kg) or Any medicine which earlier was effective
VT Stable – amiodarone, Non - stable – cardioversio, then amiodarone.
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Vitium cordis Big left – right shunt: the O2 is bad
In the case of cyanotic vitium the O2 ineffective
Give oxigen only:
If the earlier non cyanotic patient become cyanotic
Earlier cyanotic patient SpO2 worsening
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Manage of the cyanotic patient
Slightly sedation Parenteral fluid 20 ml/kg x3 Drugs
blocker iv. (pl.: Betaloc 0,1 mg/kg) Systemic vasopressors
noradrenalin, efedrin, fenilefrin vazopressin?
Avoid from the mimetics ( pl. Dobutrex, epinephrine).
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Loss of consiciouness Respiratory and heart failure
Meningoencephalitis
Postconvulsiv tenebrositas
Hypo/hyperglycaemia
Trauma
Intoxication
Stroke – SAV – ICP
Metabolic (kidney-hepar-electrolites)
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Seizures in childhood Febriles seizures
Meningoencephalitis
Change in the treatment of the epileptic patient
Metabolic-electrolit problem
Hypoxia, brain ischaemia
ICP elevated (VP shunt, tumor)
Trauma
Hypoglycaemia
Intoxication (TCA, organophosphate, theophyllin, cyclosporin, Pb etc.)
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Seizures in childhood Simple seizure:
Between 6 months – 5 years
Shorter than 15 minutes, generalized, occurs once in a 24h period
Complicated seizure:
Longer than 15 minutes
Focal
New neurolgic symptoms
Earlier neurologic problem
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Seizures in childhood
ABC
Diazepam per rectum
Under 15 kg 5 mg
Over 15 kg 10 mg
Midazolam 0,1 mg/kg iv. 2x repeated every 5 minutes.
Epanutin 15 mg/kg iv. over 15-20 minutes – monitor!!
Propofol / Barbiturát - sedatoanalgesia.
Bloodsugar!!!!
Trauma – intox ….
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Trauma Over 1 year the trauma is the common cause.
Different injuries – because of different anatomy.
Less muscle and subcutan fat tissue.
Soft bones – life threatenig injury without bone fracture.
„Top-heavy”.
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Trauma ITLS
Golden hour - Platina ten minutes
Fast examination
ABC -MILS + high flow oxigen
Only treat the life threatening injuries
Load-go-and-treat:
Stop the bleeding,
Airway patency, BMV, treat the tension PTX
Fast atraumatic transport – IV/IO – painkiller – ETI?
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Burn BSA Lund-Browder formula
Fluid management: Parkland formula
4ml/kg x % burned area (½-t az in the 1. 8h, second ½-t during 16h)
If there is shock – give bolus fluid
Painkiller – Nubain – Fentanyl – Morphin
Airway burning – early intubation
Send to special care unit
- 15 -20% feletti égés
- head-neck-airway-hand-genitale-encircling
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Thank you!
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