recognition and management of the seriously ill child dr esyld watson consultant in adult and...
TRANSCRIPT
Recognition and management of the seriously ill child
Dr Esyld WatsonConsultant in Adult and Paediatric Emergency Medicine
Learning outcomes
To understand the aetiology of and clinical pathways to cardiorespiratory arrest in children
To use a rapid ABCDE assessment to determine the clinical state
To distinguish between compensated and decompensated respiratory or circulatory failure
To initiate treatment interventions based on ABCDE assessment and reassessment
Aetiology of cardiorespiratory arrest
Children are different to adults
Adults◦Usually a primary cardiac arrest◦Sudden and unpredictable in onset◦Usually due to arrhythmia◦Not usually preceded by hypoxia and
acidosis◦Successful outcome depends on early
defibrillation
Aetiology of cardiorespiratory arrest
Children◦ Most children have secondary arrest◦ Respiratory and/or circulatory failure leads to
hypoxia and acidosis.◦ Myocardial hypoxia results in bradycardia then
asytole◦ Early recognition and treatment of respiratory
and circulatory failure can prevent progression to arrest
◦ 10 - 20% of children have primary cardiac arrest - usually due to congenital or acquired heart disease
Pathways to cardiorespiratory arrest
Compensated circulatory failureCompensated respiratory failure
Cardiorespiratory failure
Cardiorespiratory arrest
Decompensated
circulatory failure
Decompensated
respiratory failure
Normal Values
Recognition of the seriously ill child is based on assessment of:
Airway (c-spine consideration in trauma)
Breathing Circulation Disability Exposure
Oxygenation
Ventilation
Perfusion
A - Airway
Assessing the airway
B - Breathing
Assessing breathingoxygenation and ventilation
Minute ventilation = Tidal volume x RR
Respiratory rate (RR)
Work of breathing
Tidal volume (chest expansion)
Oxygenation (pulse oximetry)
Assessing respiratory rate
Increased RR is often the first sign of respiratory difficulty
RR varies with age, fever, pain and anxiety as well as in respiratory failure
Monitor the trend in RR
Assessing the work of breathing
Assessing tidal volume
Tidal volume (look, listen, feel) ◦Compare one side of chest with the other◦Subjective assessment: breath sounds
should be audible in both bases◦(Feel for trachea; is it central?)
Assessing respiratory sounds
Stridor
Wheeze
Grunting
Assessing oxygenation◦ Cyanosis is unreliable
(SpO2 < 80%)
Any child with a breathing problem must have pulse oximetry
Clinical signs of hypoxia Irritability, agitation,
drowsiness, level of consciousness
Decompensation?
Increasing respiratory rate Sudden fall in respiratory rate Exhaustion Reduced interaction with caregivers,
agitation Diminishing level of consciousness
C - Circulation
Assessing circulatory status
Assessing pulses
Comparison of central and peripheral pulses◦Reflects stroke volume◦As shock progresses peripheral pulses are
lost before central pulses
Assessing heart rate
Increased HR is often the first sign of circulatory compromise
HR varies with age, fever, pain and anxiety as well as in circulatory failure
It is more important to monitor the trend in HR than to rely on absolute value
Assessing skin perfusion
Feel skin temperature ◦Warm / cold line
Skin colour ◦Mottling◦Pallor◦Peripheral cyanosis ◦Rashes
Assessing capillary refill time
CRT > 2 sec is abnormal
Assess peripherally and centrally
Assessing cerebral perfusion
Early signs◦Loss of interest in surroundings◦Irritability, agitation
Late signs◦Drowsiness, loss of consciousness,
hypotonia (floppy)
Assessing renal perfusion
Urine output is an index of organ perfusion
Nappy weights or number of wet nappies
Urinary catheter (> 1 ml kg-1 h-1) How many times passed urine that
day?
Decompensation? Steadily increasing HR Sudden fall in HR Increasing peripheral vasoconstriction Reduced interaction with care givers,
agitation Diminishing level of consciousness Hypotension
D - Disability
Assessing disability
Evaluate the level of responsiveness◦Alert◦Voice◦Pain◦Unresponsive to painful stimulus
Posturing Pupil reaction Glucose
E- Exposure
Exposure
Respect dignity Rashes Bruising Injuries Environment temperature
Cardiorespiratory failure
There is usually some respiratory compensation for decompensated circulatory failure and vice versa
Cardiorespiratory failure is global failure of oxygenation, ventilation and perfusion
If untreated will lead to cardiorespiratory arrest
Management based on initial assessment
Decide on clinical status of the child:
Stable Compensated respiratory failure Decompensated respiratory failure Compensated circulatory failure Decompensated circulatory failure Cardiorespiratory failure
Stable child
Confirm clinical status Take a more detailed history Examination and investigations to
aid diagnosis Begin treatment Reassess
Compensated respiratory failure
Assess ABCDE O2 therapy
(non-threatening)
Monitoring (pulse oximetry, HR, RR)
Specific therapy Reassess Seek expert help
Decompensated respiratory failure
Open and maintain airway
High-flow O2
Ventilate
Assess adequacy of ventilation
Reassess and monitor Seek expert help
Compensated circulatory failure Assess airway High-flow O2 Monitoring IV / IO access Fluid bolus 20 ml kg-1
0.9% NaCl Reassess after any
intervention Seek expert help
Decompensated circulatory failure
Open and maintain the airway High-flow O2
Support ventilation if required Immediate IV / IO access,
fluid bolus 20 ml kg-1 0.9% NaCl
Reassess Repeat fluid boluses Seek expert help
Cardiorespiratory failure Open and maintain the
airway High-flow O2 Support ventilation Immediate IV / IO access,
fluid boluses Reassess and monitor Seek expert help Consider tracheal
intubation and mechanical ventilation
Any questions?
Summary
Airway (c-spine consideration in trauma)
Breathing Circulation Disability Exposure
Oxygenation
Ventilation
Perfusion
• Compensated V Decompensated• Cardiorespiratory Failure