02 Paed History Exam & Procedures-2010

8/12/2019 02 Paed History Exam & Procedures-2010

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PAEDIATRICHISTORY,

EXAMINATIONANDPROCEDURES

E.O.D. ADDO-YOBO MD FGCP MWACP MSc DTCH MB ChBSeptember 2010


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HISTORYAND

EXAMINATION


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Objective

Towards the establishment of a diagnosis

which leads to appropriate management:Why is THIS child (name, age, sex, Wt, Ht, etc.)......from this area (environment)

...having this problem (presenting complaints andpeculiar examination findings)

....at this time? (time/seasonal variations inpresentation)


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FOCUS IN CHILD HEALTH Prenatal/Conception issues

Congenital problems/abnormalities; Genetic problems

Peri-natal problemsMishaps around delivery leading to immediate/long term health

problems Post-natal problems

Infections e.g. meningitis leading to Cerebral palsy, hearing loss

Growth and DevelopmentPhysiological and anatomical changes e.g. Jaundice and liver immaturity,

Milestones (myelination )Nutrition and environmental influences

Failure to thrive, abnormal milestones

Behavioural changes

Disease prevention and Control Measures(Immunisations)

Need to know whatconstitutes normality ina child to appreciate the

abnormal child


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Key Points in History taking -1

Presenting complaints Peculiar Issues in Child health:

Poor feeding Convulsion, Startling

Reduced activity Irritability Vomiting and regurgitation Beware maternal perception of symptoms, local terminologies

History of presenting complaints

Direct Questioning To clarify presenting symptoms To assess all other systems Beware: subjective symptoms

Drug History(regular drugs used vrs drugs used in current illness)


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Child Examination From Head to Toes By systems Genitals remove clothing Systematic reporting Child on couch Babies on lap/ couch Basic measurements

Wt, Ht, Length, Head circumference(Use of centile charts)


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Guide to examination INSPECTION

General appearance importante.g. size, colour, facies, symmetry, movement, etc

The more you see, the better you perceive

PALPATION gentle but objective PERCUSSION AUSCULTATIONappropriate tools essential NB: Variation of characteristics with age: e.g. anthropometrics, Head

circ, Pulse, BP,Respiratory rates.


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On Inspection


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On Inspection - 2


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Notes May be difficult to stick to a systematic approach

Need to develop a comprehensive style and stick to itMake it work for you should allow you to be thorough

You may have to Examine first what child allows you to doBUTpresent in orderly and logical manner. Critical inspection veryuseful

Count Respiratory Rate when child is calm/before getting too close, ortouching

Conjunctival pallor not always reliable: check palms, soles

Always ask for and examine Child Health Record Book, Road-To-Health-Chart especially in


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Child Health Record Book


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Synthesis of information

USING KNOWLEDGE TO DECIPHER INFORMATION INTODIAGNOSIS

Its an art. Expertise comes with practice.

E.g.: Well- nourished, severely pale, jaundiced child: ??Skinny, severely pale, jaundiced ??Well- nourished, severely pale, not jaundiced child: ??Wasted, severely pale, not jaundiced child: ??

Impressions: Should summarise the problem and put it in context: e.g.

Severe Anaemia secondary to Malaria Severe Anaemia secondary to Sickle Cell Disease Severe Anaemia secondary to Haemorrhagic diathesis Severe Anaemia secondary to Malnutrition


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Discuss Diagnosis, Investigations, treatmentwith Doctor on duty SMO/Resident Specialist/Consultant.

Investigations:

Each investigation should help confirm or reject one or more of the suspecteddiagnoses e.g. CXR, Lateral Cervical Xray; WBC total and Diff; ESR

Develop Initial Treatment plan:Immediate life-saving measuresLater remedial measures

e.g. IV fluids (specify), Antibiotics, etc.

There should be a reason for every action.Spell out clearly signs that need to be monitored ......

..... and subsequent actions to be taken

State Final Diagnosis/Diagnoses: the faster the better!

Specific treatment & Counselling

Other Notables:


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Objective & OutlineOutline Relevance General principles Specific Procedures Blood letting Procedures Restraints and Torniquets Peripheral & Central lines Lumbar puncture Catherisation Pleural and Pericardial taps CPR Approach to FB aspiration

Objective

To give a quick

overview of what toexpect andapproach tolearning


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Relevance of procedures

Life saving

Life supportingDiagnostic


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General principles

Benefits vs Risks

Invasiveness

Anatomical considerations

Subsequent processes

Costs Is it worth all that?


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Paediatric Patient Needs

Pediatric-sized equipment

Pediatric medications and formulary

Tables of age-based normal values

Paediatric scales, and appropriate sizedassessment tools for children of all ages.

Child-friendly staff Child-friendly environment


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Disinfection

Absolute alcohol

Swabbing technique Sterile vs clean technique?


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Blood Letting / Vascular Access

Capillary sampling Finger / Heel prick

Venous sampling

Arterial blood sampling

Precautions:SiteSize of vessel vrs needleBleeding tendency


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Blood letting: - Heel Prick Suitable for infants


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Blood letting: - Finger Prick Best use for children

> 6 mths / > 9 kg

Middle and Ring fingers

Index and Thumb have thicker skin (avoid)

Little finger, thin tissue (avoid)


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Max. Amounts of blood to be drawn from children


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Vascular Access - Peripheral lines

PurposeHydration, Transfusion, Drugs venous access

IV Peripheral, Ext. jugular Central

Femoral, Umbilical, int. jugular veins

Intraosseous

Cut-down distal saphenous / saphenofemoral

Precautions

Complications


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Vascular Access - basics

Immediate Access is best with Peripheral IV or

IntraOsseous (IO)

Central venous and cut-down requires

more time but more secure


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Factors influencing choice of vein

Age of child

Previous uses and condition of veins

Weight: obese / wasted Clinical status of the infant / child

Other clinical procedures required

Type and length of treatment

Child / parental preference Anticipated degree of co-operation

Medication, infusates to be administered


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IV lines


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Undesirables!!


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Site Selection


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Site Selection


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Restraints

Protective measure

Limits movement

Necessary

Appropriate

Safe

Effective Comfort

Move other parts


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Tourniquets Essence: Venous and not arterial occlusion

Ideal: Human hand grip by assistant

Broad band better than narrow strip Release immediately after access

Complications:IschaemiaBiochemical interruptions


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Intraosseous Lines:Commercially available Needles


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Intraosseous Needles -

Alternatives


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Umbilical Vein Catheterization

Potential IV site for neonates < 2wks old

Single, thin walled, large-diameter lumen

Insert till free flow or 4 - 5cm depth Resistanceportal vein/ductus venosus

Complications

Haemorrhage Infection

Thrombosis

Air Embolus


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Exchange Blood transfusion Definition

Principle

to exchange up to 2x total blood volume Indications:

Hyperbilirubinaemia Kernicterus

Severe infection

Severe malaria

Sickling crisis involving vital organ

* Polycythaemia


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Circulating blood volume

Age Blood volume (ml/kg)

Neonate 75 - 80

Infants 75 80

Children 70 75

Adult 65 75


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Exchange Blood transfusion

Equipment Blood, Lines (giving set), 3-way taps,

Drugs: - Calcium gluconate

Complications: Hypothermia Hypoglacaemia Hypocalcaemia Infections Cardiac arrest Stress/Shock


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Lumbar Punctures

Position Max. flexion

Note Breathing

Superior edge of iliaccrest L4/5, L3/4

Needle bevel up &perpendicular to skinor towards umbilicus


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CONTRAINDICATION TO LP

Recent / Prolong convulsive seizures

Deep Coma

Signs of increased Intra-Cranial Pressure Altered pupillary size / responses

Absent Dolls eye reflex, decerebrate / decorticate

Abnormal respiratory pattern

Papilloedema, Hypertension & Bradycardia

Cardiopulmonary instability

Local infection / Coagulation disorder

Other focal neurological signs


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Suprapubic tap

Disinfection Absolute alcohol

Swabbing technique Mode of entry

Scapel Needle

Post proceduredressing


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Bladder Catheterization

Female patients Labia/Vulva adhesions are contraindication

Uncircumcised male patients Do not forcibly retract the foreskin

All patients Determine correct catheter size and do not use

excessive force in catheter placement


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Airway & Breathing Support


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Effective Bag-Mask Ventilation Is an Essential BLS Skill

Use only the amount offorce and tidal volumeneeded to make the

chest rise Avoid excessive volume

or pressure Increased inspiratory

time may reduce gastricinflation Cricoid pressure may

reduce gastric inflation

Cricoid cartilageOccluded esophagus

Cervical vertebrae


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Cardio-pulmonary Resuscitation - 1 Rescuer


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Two ThumbEncircling Hands Technique

2-Rescuer CPR


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Cardio-pulmonary Resuscitation

Compression landmarks, method & ratio

Lower half of sternum 1-2 fingers above xyphisis & Heel of one hand other hand on

top (>1yr) @ 1 2 inches depth

1 fingers width below intermammary line & 2 thumb-encirclinghands or 2-finger technique (100 events/min

30:2 (>8yrs old) @~100 events/min


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Pleural / Pericardial Taps Pericardiocentesis

Indication life-threatening cardiac tamponade Site Lt xyphoid

@ 45

tip of Lt scapulaLt 5thICS adjacent to sternum ECG , Ultrasound

Needle Thoracostomy Site: 7th 9thICS,inferior angle scapula 3-way taps / stopcock optional Precautions


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Pericardial taps


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Passage of Tubes

Nasogastric / Orogastric tubes NG smaller, easier to tolerate

epistaxis, avoid in maxillofacial injury OG larger lumen for lavage and/or charcoal

more noxious, patient might bite it

Indications

Feeding / Medication Decompression / drainage (Ryles & Flatus tubes) Lavage

Precautions avoid endotracheal intubation


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Foreign Body Aspiration

Food items are

the mostcommonlyaspirated FB.

Balloons are themost common FBto result in death.


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Foreign Body Airway ObstructionFBAO

Age-specific obstructed airway support:(FBAO) Universal choking sign

FBAO? If victim > 1yr ( 1-8yr, or > 8yr) Abdominal thrust

FBAO? If victim < 1yr (Infant or Newborn) Noabdominal thrust

Back blows or Chest thrusts


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Summary

Diff. b/n adult and child

Anatomy, Physiology ,total blood volume

Cost benefit analysis Use appropriate equipment for children

Consider other methods and sites

Observe Standard precautions

Reasonably restrain child but do not suffocate orinjure

Take just enough blood, not too much

Do NO harm!3/2/2014 55


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02 Paed History Exam & Procedures-2010

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