PDLS © : The Pediatric Patient Unique Anatomic and Physiologic Features

Body Size and Composition height and weight increase throughout childhood height and weight increase throughout childhood less protective fat and muscle less protective fat and muscle large surface area predisposes to hypothermia large surface area predisposes to hypothermia

Body Proportions body proportions account for unique injury patterns in childhood body proportions account for unique injury patterns in childhood large head increases risk of head injury accompanying any other major traumatic injury large head increases risk of head injury accompanying any other major traumatic injury large, “unprotected” intraabdominal organs increases risk of liver, spleen, bowel injury following less severe trauma large, “unprotected” intraabdominal organs increases risk of liver, spleen, bowel injury following less severe trauma

Etiologies of Cardiopulmonary Failure Many Etiologies Cardiopulmonary Failure Respiratory Failure Circulation Failure (shock)

Respiratory Distress and Failure respiratory distress: increased work of breathing respiratory distress: increased work of breathing respiratory failure: inadequate oxygenation and/or ventilation to meet metabolic needs respiratory failure: inadequate oxygenation and/or ventilation to meet metabolic needs

Signs of Respiratory Distress and Failure signs of respiratory distress: signs of respiratory distress: - tachypnea, tachycardia - retractions (intercostal, superclavicular, nasal flaring) - grunting signs of respiratory failure signs of respiratory failure - altered mental status - poor color - hypotonia

Infant with Increased Respiratory Effort Note use of intercostal and accessory muscles Note use of intercostal and accessory muscles

Features of the Pediatric Upper Airway large occiput large occiput small mouth small mouth large tongue large tongue anterior and cephalad larynx anterior and cephalad larynx angled cords angled cords large, floppy epiglottis overriding airway large, floppy epiglottis overriding airway narrow cricoid ring narrow cricoid ring

Neonatal Airway Large head Large head Small nares Small nares Large tongue Large tongue High glottis High glottis Overhanging epiglottis Overhanging epiglottis Angled cords Angled cords Narrow cricoid region Narrow cricoid region

Airway Equipment for the Young Pediatric Patient straight blade: compresses large tongue and mandibular tissue straight blade: compresses large tongue and mandibular tissue uncuffed tube in children < 8 years uncuffed tube in children < 8 years tube size = age years tube size = age years (for children over 2 years)

Features of the Pediatric Lower Airway short trachea short trachea narrow caliber of all airway structures narrow caliber of all airway structures compliant chest wall compliant chest wall horizontal ribs horizontal ribs diaphragm as a respiratory muscle diaphragm as a respiratory muscle

Features of the Pediatric Cardiovascular System shock: defined as the clinical state of inadequate perfusion to meet metabolic needs shock: defined as the clinical state of inadequate perfusion to meet metabolic needs degree of shock is based on evaluation of the end organs of perfusion: degree of shock is based on evaluation of the end organs of perfusion: - skin (color, temperature, cap refill) - CNS (developmentally appropriate behavior, lethargy, anxiety) - central vs peripheral pulses - renal (urine output)

Simultaneous Palpation of Proximal and Distal Pulses

Features of the Pediatric Cardiovascular System cardiac output is rate dependent: infants cannot increase stroke volume to compensate for shock cardiac output is rate dependent: infants cannot increase stroke volume to compensate for shock smaller total blood volume: cc/kg smaller total blood volume: cc/kg increased parasympathetic output: increased vagal tone increased parasympathetic output: increased vagal tone

Hemodynamic Changes with Blood Loss

Pediatric Vital Signs mean heart rate decreases with age mean heart rate decreases with age tachycardia is an early and nonspecific sign of shock tachycardia is an early and nonspecific sign of shock mean blood pressure increases with age mean blood pressure increases with age blood pressure is usually normal even in a child with moderate-severe hypoperfusion blood pressure is usually normal even in a child with moderate-severe hypoperfusion increased peripheral vascular tone allows for normal blood pressure until end-stage shock increased peripheral vascular tone allows for normal blood pressure until end-stage shock vital signs not helpful in gauging degree of shock in children vital signs not helpful in gauging degree of shock in children

Pediatric Cervical Spine fulcrum is at C2-3 fulcrum is at C2-3 growth plate of dens growth plate of dens weak neck muscles weak neck muscles large head increases momentum large head increases momentum SCIWORA because of ligamentous laxity SCIWORA because of ligamentous laxity most fractures occur at C1-2 most fractures occur at C1-2 difficulty with immobilization: large head/small chest allow for excessive flexion in supine position difficulty with immobilization: large head/small chest allow for excessive flexion in supine position

Head Injury in the Young Pediatric Patient skull is more compliant offers less protection to the brain skull is more compliant offers less protection to the brain open sutures and fontanel open sutures and fontanel mobile middle meningeal artery mobile middle meningeal artery intracranial bleeds occur without accompanying fracture intracranial bleeds occur without accompanying fracture intracranial bleed can cause shock intracranial bleed can cause shock

Features of the Pediatric Abdomen thinner abdominal wall with less fat and muscle thinner abdominal wall with less fat and muscle decreased anterior-posterior diameter decreased anterior-posterior diameter large liver and spleen extend below ribs large liver and spleen extend below ribs kidney contains less perinephric fat kidney contains less perinephric fat gastric distention (with ventilation or crying) can present as a tense abdomen gastric distention (with ventilation or crying) can present as a tense abdomen

Skeletal System Fractures seen exclusively in children: Fractures seen exclusively in children: - growth plate (Salter Harris) fracture - torus fractures - bowing fractures - greenstick fracture

Skeletal System physis is site of growth physis is site of growth physis is the weakest part of bone physis is the weakest part of bone physis is composed of cartilage and separates epiphysis from metaphysis physis is composed of cartilage and separates epiphysis from metaphysis fractures of the physis are described by the Salter Harris Classification fractures of the physis are described by the Salter Harris Classification