Emergency in Pediatrics

FKIK UNTAN Oct 7th, 2011 Dr. Rini Andriani, Sp A

RAPID CARDIOPULMONARY ASSESSMENT (9)

Sensorium Skin Color Respiratory Rate / Effort Skin Temperature Cardiac Rate and Rhythm Quality of Pulses Capillary Refill Time Blood Pressure Urine Output

RAPID CARDIOPULMONARY ASSESSMENT

CLASSIFICATION OF PHYSIOLOGIC STATUS

Stable

Respiratory Failure
Potential airway and breathing problems Probable fails to improve or deteriorates despite therapy

Shock

Compensated Decompensated hypotension

Cardiopulmonary Failure

Many Etiologies

Respiratory Failure

Shock

Cardiopulmonary Failure

Cardiopulmonary Arrest

PRIMARY ABNORMALITIES IN RESPIRATORY FAILURE

Airway & Breathing

Ventilation

Oxygenation Circulation Perfusion

PRIMARY ABNORMALITIES IN SHOCK

Ventilation

Airway & Breathing

Oxygenation Circulation Perfusion

Respiratory Distress and Failure

Respiratory distress and potential respiratory failure: increased work of breathing Respiratory failure: inadequate oxygenation or ventilation that may occur with or without respiratory distress

Recognition of Potential Respiratory Failure

Airway patency (upper versus lower airway obstruction) Air entry: Chest rise, breath sounds, stridor, wheezing Respiratory Rate: too fast or too slow Respiratory Effort: Accessory muscles, retractions, grunting, head bobbing, nasal flaring Heart rate, pulses, skin perfusion Level of consciousness

Approach to Patient with Potential Respiratory Failure

Open airway and assist ventilation as needed Administer oxygen Monitor heart rate, respirations, pulse oximetry Obtain arterial blood for gas analysis and electrolytes, and perform chest x-ray

Case Scenario - Breathing

Provide Oxygen Awake

Nonrebreathing mask

Altered mental status or breathing difficulty Bag-valve mask Unresponsive or Endotracheal respiratory failure intubation

RAPID CARDIOPULMONARY ASSESSMENT

PRIORITIES OF INITIAL MANAGEMENT

POTENTIAL
RESPIRATORY FAILURE

PROBABLE
RESPIRATORY FAILURE

Keep with caregiver Position of comfort Oxygen as tolerated Nothing by mouth Monitor pulse oximetry Consider cardiac monitor

Separate from caregiver Control airway 100% FiO2 Assist ventilation Nothing by mouth Monitor pulse oximetry Cardiac monitor Establish vascular access

BASIC RELATIONSHIPS OF CARDIOVASCULAR PARAMETERS

Preload

Stroke Volume Cardiac Output Blood Pressure Systemic Vascular Resistance

Myocardial Contractility

Heart Rate

Afterload

HEMODYNAMIC RESPONSE TO HEMORRHAGE

140
Percent of control 100 60
Vascular resistance

20

Cardiac output

Blood pressure

Compensated shock

Decompensated shock

CARDIAC OUTPUT = heart rate X stroke volume

Inadequate

Compensation

heart rate systemic vascular resistance possible stroke volume

DEVELOPMENT OF SHOCK FROM PULSE RATE DISTURBANCES

PULSE RATE Fast CO = = HR X X SV

Slow Absent

= =

X X

N 0

REVIEW OF THE PHYSICAL FINDING IN SHOCK Early signs (Compensated) heart rate poor systemic perfusion
Late signs (Decompensated) weak central pulses Altered mental status urine output hypotension

DEFINITION OF CARDIOPULMONARY FAILURE

Deficits in
Ventilation

Oxygenation Perfusion

Resulting in

Agonal respiration Bradycardia Cardiopulmonary Arrest

Many Etiologies

Respiratory Failure

Shock

Cardiopulmonary Failure Cardiopulmonary Arrest

Death

Cardiopulmonary Recovery

Impaired Neurologic Recovery

Unimpaired Neurologic Recovery

Secondary Brain Injury

Trauma Shock Hypoxia

Hypotension

Intracranial
Pressure

Decreased Cerebral Perfusion

Pediatric Trauma
Isolated Head (CNS) injury Airway compromise Multiple Trauma

Respiratory failure
Shock

Cardiopulmonary Arrest (final common pathway)

Lower Limits of Normal Systolic Blood Pressure by Age

Age 0 to 1 month >1 month to 1 year Minimum systolic blood pressure (5th percentile) 60 mm Hg 70 mm Hg

1 to 10 years of age
>10 years of age

70 mm Hg + (2 age in years)
90 mm Hg

RAPID CARDIOPULMONARY ASSESSMENT

PRIORITIES OF INITIAL MANAGEMENT

SHOCK

Administer oxygen (FiO2 = 1.00) and ensure adequate airway and ventilation Establish vascular access

Provide volume expansion Monitor oxygenation, heart rate, and urine output Consider vasoactive infusions

RAPID CARDIOPULMONARY ASSESSMENT

PRIORITIES OF INITIAL MANAGEMENT

CARDIOPULMONARY FAILURE

Oxygenate, ventilate, monitor

Reassess for :

respiratory failure shock

Obtain vascular access

Treatment of Shock

Initial rapid fluid administration of 20 mL/kg of

Crystalliod Colloid Blood

Resuscitation of Hemorrhagic Shock

Estimated blood volume (EBV) of a child 25% of EBV = 80 mL/kg = 20 mL/kg

Algorithm for Fluid Resuscitation in Shock

20 mL/kg crystalloid REASSESS 20 mL/kg crystalloid

REASSESS
20 mL/kg crystalloid or 10 mL/kg colloid REASSESS 20 mL/kg crystalloid or consider 10 to 20 mL/kg colloid or packed red blood cells

Hazard of Glucose-Containing Infusions

5% dextrose contains 5 g/100 mL 1 g/20 mL 20 mL/kg = 1 g glucose/kg Avoid use of glucose-containing solutions to replace volume

Treatment of Acute Metabolic Acidosis Caused by Dehydration

Restore circulating blood volume Maximize respiratory compensation Treat underlying cause The use of bicarbonate is controversial

What are the indications for and advantages of endotracheal intubation in the treatment of shock?

Advantages of Intubation in Shock

Facilitates delivery of maximal FiO2 Decreases work of breathing Enables controlled hyperventilation Ensures control of airway

Approach to Acute Deterioration

Bag ventilate/auscultate Displaced tube: Withdraw or remove tube; bag; reintubate Obstructed tube Patient stable suction tube Patient unstable extubate Pneumothorax suspected: perform needle thoracentesis Equipment check ventilate with bag attached to endotracheal tube

INTRAOSSEOUS NEEDLE PLACEMENT

1-2 cm distal and medial to tibial tubercle Perpendicular to flat surface of bone Secure purchase, aspirates, easy flow Marrow space
noncollapsible veins for easy absorption to circulation

INTRAOSSEOUS NEEDLE IN PLACE

Over 6 years: distal tibia

Under 6 years:proximal tibia

DRUGS THAT CAN BE GIVEN ENDOTRACHEALLY

Lidocaine Epinephrine Atropine Naloxone

ENDOTRACHEAL DRUG DELIVERY

Epinephrine dose is 10 x IV
dose: 0.1 mg/kg (use 1:1000)

Other drug doses are increased

2x to 3x IV dose

INOTROPES IN POSTARREST SHOCK

Postarrest shock

Fluid Bolus
Reassess Hypotensive Epinephrine or Dopamine Infusion Normotensive

Dobutamine, Epinephrine or Dopamine

TREATMENT OF SEPTIC SHOCK

the initial priority is fluid

resuscitation depression

use inotropes to treat myocardial use vasopressors to correct

hypotension

COMPARISON OF INOTROPIC DRUGS

DRUG Epinephrine Dobutamine Dopamine USES Symptomatic bradycardia Shock (including anaphylactic) Hypotension Cardiopulmonary Arrest Normotensive cardiogenic shock

Low
High

Improve renal, splanchnic blood flow

Hypotension

PREPARATION OF DRUG INFUSIONS : The Rule of 6

DRUG CALCULATION RULE

0.6 x body wt (kg) = # mg to Epinephrine add to diluent to make 100 ml volume

1 ml / hr delivers 0.1 ug/kg/min

The Rule of 6
DRUG CALCULATION RULE

6 x body wt (kg) = # mg to Dopamine add to diluent to make 100 ml Dobutamine volume

1 ml / hr delivers 1.0 ug/kg/min

REVIEW OF INOTROPE USE

DRUG DOSAGE REMARKS

Epinephrine infusion
Dobutamine Dopamine HCl

Begin at 0.1ug/kg/min Higher dose used during CPR 2 20 ug/kg/min

Titrate to desired effect

Titrate to desired effect

2 20 ug/kg/min

Adrenergic action dominates at 15 20 ug/kg/min

Airway : Breathing : Circulation :

Disability : Evaluate :

Stabilize and maintain Maintain adequate ventilation and oxygenation Maintain adequate organ perfusion
Assess the central nervous system Evaluate other systems and the etiology of arrest

STABILIZATION - AIRWAY

Frequently assess airway clinically Consider endotracheal intubation Tape the tube securely NGT CXR Sedation ? Muscle relaxants ?

STABILIZATION AIRWAY
SEDATIVES / MUSCLE RELAXANTS FOR VENTILATED PATIENTS

Commonly used sedatives

Diazapam Morphine

0.1 to 0.2 mg/kg/ IV 0.1 to 0.3 mg/kg/ IV

Commonly used postintubation muscle relaxant Pancuronium 0.1 mg/kg/ IV

STABILIZTION - BREATHING
Establish ventilator parameters

Assess adequacy of breathing with

Physical examination Oxygen saturation monitor End-tidal CO2 ABG

STABILIZATION - CIRCULATION

Establish two vascular lines Provide maintenance fluids : D5 0.25% NS infusion

INFUSION RATE

WEIGHT

< 10 kg

4 ml/kg /hr 40 ml/h + 2ml/kg/hr for each kg > 10 kg 60 ml/h + 1ml/kg/hr for each kg > 20kg

10 to 20 kg
> 20 kg

STABILIZATION - CIRCULATION
Fluid boluses / vasopressors Evaluate

heart rate monitor End-organ perfusion Urine Output Heart size on Chest x-ray

STABILIZATION - DISABILITY

Perform brief neurologic examination with assessment of vital signs

hyperventilate if increased intracranial pressure is suspected

STABILIZATION
EVALUATION OF OTHER SYSTEMS

control patients temperature measure blood glucose and correct hypoglycemia

STABILIZATION EVALUATION
LABORATORY / RADIOGRAPHY

Chest X ray ABG Serum electrolytes Glucose BUN / creatinine CBC

Thank You

CASE SENARIO
A 2-year old boy, approximately 12 kg, has been resuscitated after a submersion injury. He required CPR, intubation, & pharmacologic and fluid resuscitation. His cervical spine is immobilized; he is responsive only to painful stimuli.

Vital Signs

HR : 110 bpm RR : 10 breath per min BP : 90/55 mmHg Temp : 36.2 C

What would you do first? How should the patient be stabilized?

CASE - STABILIZATION
AIRWAY

BREATHING
listen / watch ABG Monitor : HR, O2 saturation, end tidal CO2

Assess / listen Tape Endotracheal Tube Nasogastric Tube CXR Sedation as Needed

CASE - STABILIZATION Circulation

two vascular lines maintenance fluids blood samples for laboratory analysis
brief examination of the central nervous system

Disability Assessment

CASE VENTILATORY PARAMETERS

What are the patients initial ventilator settings?

FiO2 Ventilation rate? Tidal Volume? PEEP? Inspiratory time?

GUIDELINES FOR VENTILATORY SETTINGS

FiO2 : 1.00 (100%) Rate : 16 to 20 per min Tidal Volume : 10-15 ml/kg Inspiratory time : 0.05 1.0 sec Peak inspiratory Pressure : 20 30 cmH2O PEEP : 2 4 cm H2O

CASE - DEVELOPMENT
The patients trachea remains intubated. He becomes more alert but very agitated and is pulling at his IV lines.

What should be done now?

CASE - PROGRESSION

After adequate sedation, the patient is relaxed and is mechanically ventilated. What would be his maintenance and bolus fluids.

Bolus
Composition ? Amount ?

Maintenance
Composition ? Infusion rate ?

REVIEW OF FLUIDS
Maintenance

D5 0.25% normal saline Rate : 40 ml/hr + (2 kg x 2 ml/hr) = 44 ml/hr Boluses: 20 ml/kg = 240 ml normal saline or LRS

CASE PROGRESSION

The patients glucose is 20 mg/dl by bedside analysis

What fluid would you give now?

CASE PROGRESSION
The patient now has two IV lines in place, is on a mechanical ventilator, and is sedated.

How can each of the following be clinically assessed?

Respiratory Status Cardiovascular Status Neurologic Status

ONGOING ASSESSMENT
Respiratory Chest rise Breath Sounds Cyanosis Agitation Pulse-oximetry End-tidal CO2 Cardiovascular Neurologic Level of Heart rate/Rhythm Consciousness Pulse Quality Capillary Refill Level of Consciousness Urine Output Blood Pressure Pupillary Response

CASE : LABORATORY & RADIOLOGY

Which blood test are indicated? Which radiologist studies are important? What other test might be considered?

CLINICAL PARAMETER

What additional clinical parameters should be evaluated?

ANSWER

Temperature monitoring and stabilization. Medications as indicated.

STABILIZATION/ TRANSPORT
Pediatric Intensive Care Area

Improved survival of critically ill children Provide a spectrum of some services for postresuscitation of patients

TRANSPORT

This patient requires intensive care. The nearest facility is 100 miles away.

What do you do now?

TRANSPORT DECISIONS

mode of transport transport team transport triage preparation for transport communication post-transport follow-up

CASE PROGRESSION
While awaiting the transport team, the intubated child becomes cyanotic. He is beginning to move and seems agitated.

What additional assessment should be done immediately?

ASSESSMENT OF VENTILATION, OXYGENATION, AND PERFUSION

heart rate: 170 bpm pulses weak peripherally skin cyanotic chest hyperexpanded with decrease breath sounds on the right side ABG: pH 7.11 PaCO2 60, Pa O2 40

What is your assessment? What is your plan?

ASSESSMENT
POSSIBLE TENSION PNEUMOTHORAX

PLAN Check oxygen source Check ventilator settings Remove from ventilator; manually ventilate Confirm endotracheal tube position and patency Suction the endotracheal tube Consider needle thoracostomy

Should a chest radiograph be performed to confirm the diagnosis?

NEEDLE THORACOSTOMY
A needle is inserted in the second intercostal space in the midclavicular line, and a rush of air is noted. The patients color and vital signs improve, but he remains agitated.

What do you consider now?

CASE PROGRESSION
You contact the tertiary hospital and inform them of the patients status

What and with whom should you communicate?

TRANSPORT
COMMUNICATION

Physician to physicial nurse to nurse provide information

brief history treatment current clinical status change in clinical staturs

TRANSPORT
IMMEDIATE PREPARATION

Secure the airway, I Vs, spine, and any fractures copy patient charts copy patient radiograph gather blood products provide laboratory phone numbers prepare consent

ASSESSMENT OF CARDIOVASCULAR FUNCTION

Assess ventilation, heart rate, endorgan perfusion, peripheral pulses, blood pressure Is CPR needed? Is cardiovascular instability present

FAST PULSE : NARROW VENTRICULAR COMPLEX

SUPRAVENTRICULAR TACHYCARDIA (SVT) vs SINUS TACHYCARDIA (ST) : HISTORY

SINUS TACHYCARDIA

SUPRAVENTRICULAR TACHYCARDIA

fever pain volume loss

diarrhea, vomiting, bleeding

irritability, lethargy poor feeding tachypnea sweating pallor hypothermia

FAST PULSE : NARROW VENTRICULAR COMPLEX

SUPRAVENTRICULAR TACHYCARDIA (SVT) vs SINUS TACHYCARDIA (ST) : HEART RATE SINUS TACHYCARDIA SUPRAVENTRICULAR TACHYCARDIA

P waves RR / PR Infants Children

Present & Normal Variable RR w/ constant PR < 220 bpm < 180 bpm

Absent or abnormal Abrupt rate change to or from normal > 220 bpm > 180 bpm

FAST PULSE: WIDE-COMPLEX VENTRICULAR vs SUPRAVENTRICULAR TACHYCARDIA WITH ABERRANCY

Wide-complex tachycardia should be considered ventricular in origin

SHOCK 2O TO TACHYARRYTHMIA WITH PULSE : TREATMENT

ETIOLOGY

TREATMENT

adenosine (if vascular access

available) synchronized cardioversion synchronized cardioversion lidocaine bretylium

Narrow QRS
Probable SVT

Wide QRS
Probable VT

DRUG TREATMENT OF SVT

ADENOSINE

0.1 to 0.2 mg/kg Maximum single dose: 12 mg

ECG OF JUNCTIONAL BRADYCARDIA

What is the rhythm? What intervention should be considered?

ETIOLOGY OF BRADYCARDIA

hypoxemia drugs

cardiac disease (rare)

CASE STUDY: SLOW PULSE

A 3 month old infant presents with

respiratory rate of 10/min central pulse rate of 45 bpm absent peripheral pulses mottled skin capillary refill > 5 seconds

SLOW PULSE TREATMENT

oxygenation (FiO2 = 1.00) & ventilation chest compressions epinephrine atropine consider pacing

SLOW PULSE TREATMENT

Epinephrine vs Atropine

EPINEPHRINE TREATMENT OF SYMPTOMATIC BRADYCARDIA

IV / IO Dose
0.01 mg/kg 0.1ml/kg of 1:10,000

ET Dose
0.1 mg/kg 0.1 ml/kg of 1:1000

ATROPINE TREATMENT OF SYMPTOMATIC BRADYCARDIA

IV / IO dose

0.02 mg/kg 0.1 mg

Minimum dose

Maximum single dose (may repeat once)

Child : 0.5 mg Adolescent : 1 mg

CASE STUDY: ABSENT PULSE

A 8 y/o submersion victim with

apnea

no palpable pulses

What arrhythmias could be present?

ABSENT PULSE (COLLAPSE RHYTHMS)

Asystole Ventricular Fibrillation

Pulseless ventricular tachycardia

Pulseless electrical activity / electromechanical dissociation

ABSENT PULSE : (COLLAPSE RHYTHMS) ASYSTOLE

ABSENT PULSE : (COLLAPSE RHYTHMS) ASYSTOLE

TREATMENT

CPR Secure Airway Hyperventilate with 100% oxygen Obtain IV or IO access Epinephrine q 3 5 min

VENTRICULAR FIBRILLATION

What pulse rate would result from this rhythm? What are the priorities for intervention?

ABSENT PULSE: VENTRICULAR TACHYCARDIA / FIBRILLATION

CPR Defibrillate up to 3 times if needed Epinephrine / Defibrillate Lidocaine / Defibrillate Bretylium / Defibrillate

ABSENT PULSE: VENTRICULAR TACHYCARDIA / FIBRILLATION

DRUG DOSAGE REMARKS

Lidocaine Bolus 1 mg/kg

Lidocaine Infusion
(120 mg lidocaine/100 ml diluent)

Bolus of 1 mg/kg needed if 20-50 ug/kg/min lidocaine bolus (1-2.5 ml/kg/hr) has not been administered in previous 15 min.

CASE STUDY : ABSENT PULSE

PULSELESS ELECTRICAL ACTIVITY ELECTROMECHANICAL DISSOCIATION

A 2 y/o child was struck by an automobile

Respiratory rate = 0 (apnea) Central pulse = absent

CASE STUDY : RHYTHM

What are the priorities of treatment?

ABSENT PULSE : PEA / EMD

TREATMENT

CPR (ventilation, oxygenation, chest compressions) Epinephrine every 3-5mins Treat cause

ABSENT PULSE : PEA / EMD

Potentially correctable causes severe hypoxia hypovolemia tension pneumothorax cardiac tamponade severe acidosis electrolyte disturbances hypothermia

SUMMARY OF THERAPY BY PULSE RATE IN CHILD WITH SHOCK

PULSE RATE
Fast

TREATMENT
Synchronized cardioversion Adenosine (in SVT if IV access available)

Slow

Ventilation, oxygenation, compressions, epinephrine

Absent (collapse)

CPR VF or VT: immediate fibrillation PEA/EMD : identify and treat cause Epinephrine

VENTRICULAR FIBRILLATION

VENTRICULAR TACHYCARDIA

SINUS TACHYCARDIA

SUPRAVENTRICULAR TACHYCARDIA

ASYSTOLE

WARNING

Treat the patient

Not the Rhythm