Physical Exam Key Points

1. Airway, breathing, circulation (ABCs). Focus on the ABCs. Is airway patent? Check for potential obstruction (eg, copious secretions, loose teeth, large tongue, small jaw, tonsillar hypertrophy). Children with certain genetic syndromes, such as trisomy 21 and Pierre-Robin sequence, pose intrinsic increased risk based on their anatomy.

2. Cardiopulmonary findings. Check for wheezing, rales, tachypnea, and work of breathing. Check cardiac rate and rhythm, perfusion, and BP.

3. Mental status. Document prior to sedation to ensure a return to baseline prior to discharge or discontinuation of postseda-tion monitoring.

B. Monitoring. Adequate monitoring is essential, including a minimum of continuous pulse oximetry and noninvasive BP measurement. Capnography and cardiorespiratory monitoring are indicated for moderate to deep levels of sedation. Resuscitation equipment such as airway adjuncts, supplemental oxygen, bag-mask ventilator, and suction should be immediately available, and reversal agents, resuscitative medications, and defibrillator should be nearby. Be aware that once a painful procedure is finished, a patient who is suddenly lacking potent noxious stimuli may relax into hypoxia and hypoventilation. Monitor patient appropriately until he or she reaches baseline level of alertness, vital signs, and ability to retain fluids.

V. Plan. Figure I-7 depicts a useful algorithmic approach to choosing a drug regimen, and Table I—24 summarizes dosing, administration route, and timing. Common pitfalls include failure to predict and prepare for complications, failure to recognize a problem as it occurs, pharmacologic errors, and failure to monitor patient adequately postse-dation. Underdosing may lead to poorly sedated, agitated patients, which in turn may lead to polypharmacy (repeated use of an agent or use of more than two agents). Avoid polypharmacy whenever possible, because complication rate increases dramatically with use of multiple agents.

A. Sedative-Hypnotics. Sedative hypnotic-agents include chloral hydrate, benzodiazepines, and barbiturates. All provide anxiolysis and sedation but have no effect on pain.

1. Chloral hydrate. Somewhat unpredictable in onset (10-30 minutes) and duration (30 to > 120 minutes); generally reserved for painless imaging procedures in infants and young toddlers; often will not produce sleep in older children. Has very bitter taste, can be administered orally or rectally, and is not reversible.

0 0

Post a comment