RECOGNITION OF PEDIATRIC

EMERGENCIES
Dr. Lilia Dewiyanti, SpA, MSiMed.
 Many etiologies

Respiratory failure Shock

Cardiopulmonary failure

Cardiopulmonary arrest

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 Outcome of respiratory vs Cardiopulmonary Arrest in
Children

100% 75 – 90 %
Survival rate

75%

7 – 11 %

Respiratory arrest Cardiopulmonary arrest

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Core Knowledge and Skills

1. Recognize respiratory distress and

potensial respiratory failure
2. Recognize shock
3. Describes priorities for
management of
respiratory distress, failure, and
shock

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 Is this child in respiratory failure
or shock ?

Is this child in respiratory

failure or shock?

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 The Three Phases of
Rapid Cardiopulmonary Assessment

1. Physical examination

2. Classification of physiologic status

3. Initial management priorities

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The ABCs

Normal Vital Functions Are Maintained

By To Provide
Airway Ventilation
Breathing Oxygenation
Circulation Perfusion

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 Primary Abnormalities in Respiratory Failure

Ventilation
Airway
And
Breathing
Oxygenation

Circulation

Perfusion

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 Classification of Respiratory Failure

Potential respiratory failure

Theraphy
(eg, positioning, oxygen administration)

Improvement Deterioration
Potential Probable
Resp. failure Resp. failure

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Initial Assessment

Pediatric Assessment Triangle :

Wo
ce

rk
r an

of
ea
p

Br
Ap

eat
hin
g
Circulation to Skin

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Appearance (“Tickles” =TICLS)

 Tonus
 Interactiveness

e
anc
 Consolability

ar
pe
 Look/Gaze

Ap
 Speech/Cry

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Potential respiratory failure

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Work of Breathings

Wo  Abnormal airway sounds

rk
of
Br
e at  Abnormal positioning
 Retractions
hin
gs

 Nasal flaring

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The sniffing position
The abnormal tripod position

Retractions
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 Circulation to Skin
Characteristic of Circulation to Skin

 Pallor
 Mottling
 Cyanosis
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PAT: Potential Respiratory Failure

Wo
e
Increased

rk
nc
Normal

of
a ra

B
pe

rea
Ap

t hin
g
Circulation to Skin

Normal

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PAT: Respiratory Failure

Wo
Increased
Abnormal

rk
or
nc

of
a ra decreased

B
pe

rea
Ap

thin
g
Circulation to Skin

Normal or abnormal

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Rapid Cardiopulmonary Assessment
Physical Examination - Airway

1. Clear

2. Maintainable

3. Unmaintanable without intubation

4. Obstructed

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Rapid Cardiopulmonary Assessment
Physical Examination - Breathing

1. Rate

2. Effort / mechanics

3. Air entry

4. Skin color and temperature

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Rapid Cardiopulmonary Assessment
Physical Examination - Breathing

Evaluation of rate, effort, and mechanics

• Tidal Volume ( V T)

• Minute ventilation (MV)

• MV = VT X RR

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Rapid Cardiopulmonary Assessment
Physical Examination : Breathing

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 Primary Abnormalities in Shock

Ventilation
Airway
And
Breathing
Oxygenation

Circulation

Perfusion

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PAT: Shock

Wo
e

rk
nc
Abnormal Normal

of
a ra

B
pe

rea
Ap

thin
g
Circulation to Skin

Abnormal

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 Basic Relationships of Cardiovascular Parameters

Preload

Stroke Myocardial
Volume contractility

Cardiac Afterload
Output
Heart
Rate
Blood
Pressure
Systemic
Vascular
Resistance

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 Cardiac Output = Heart Rate X Stroke Volume

Inadequate Compensation
• Increased heart rate
• Increased SVR
• Posible increased SV

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 resistensi vaskular
140

100

% kontrol
60
Curah
jantung Tekanan darah
20

25 50 75
%tase kehilangan darah

Respons hemodinamik terhadap kehilangan darah

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Child in shock

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Rapid Cardiopulmonary Assessment
Physical Examination - Circulation

1. Heart rate

2. Systematic perfusion
• Peripheral pulses
• Skin perfusion
• Level of consciousness
• Urine output

3. Blood pressure

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 Heart rates in Normal Children

Age Range

Newborn – 3 Mos 85 – 200 bpm

3 mos – 2 yrs 100 – 190 bpm

2 – 10 yrs 60 – 140 bpm

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Palpation of Central dan Distal Pulses

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Rapid Cardiopulmonary Assessment
Physical Examination - Circulation

Skin perfusion
• Extremity temperature
• Capillary refill
• Color
• Pink
• Mottled
• Pale
• Blue

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 Normal capillary refill is < 2
seconds in a warm
environment

Capillary refill

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Rapid Cardiopulmonary Assessment
Physical Examination - Circulation
Level of consciousness
•A = Awake
•V = Responsive to voice
•P = Responsive to pain
•U = Unresponsive

Child in shock with depressed mental status

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Renal perfusion

• Urine output (Normal: 1 to 2 mL/kg/hour) reflects

• Glomerular filtration rate reflects

• Renal blood flow reflects

• Vital organ perfusion

What information does blood pressure provide ?

What is inadequate blood pressure ?

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 Rapid Cardiopulmonary Assessment
Physical Examination - Circulation

Age Fifth percentile mmHg

Systolic BP

0 – 1 Mo 60

> 1 mo – 1 yr 70

> 1 yr 70 + (2 x age in years)

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 Review of the Physical Findings in Shock

Early signs (compensated)

• Increased heart rate

• Poor systemic perfusion

Late signs (decompensated)

• Weak central pulses

• Altered mental status
• Decreased urine output
• Hypotension

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Child dying with anasarca , MOSF
despite resuscitation efforts

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Definition of Cardiopulmonary Failure

Deficits in
• Ventilation
• Oxygenation
• Perfusion

Resulting in
• Agonal respiration
• Bradycardia
• Cardiopulmonary arrest

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 Rapid Cardiopulmonary Assessment

Ventilation
Airway
And
Breathing
Oxygenation

Circulation

Perfusion

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 The Three Phases of
Rapid Cardiopulmonary Assessment

1. Physical examination

2. Classification of physiologic status

3. Initial management priorities

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Rapid Cardiopulmonary Assessment
Classification of Physiologic status
• Stable

• Respiratory failure
• Potential
• Probable

• Shock
• Compensated
• Decompensated

• Cardiopulmonary failure

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 The Three Phases of
Rapid Cardiopulmonary Assessment

1. Physical examination

2. Classification of physiologic status

3. Initial management priorities

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Rapid Cardiopulmonary Assessment -
Priorities of Initial Management
Stable
• Begin further workup
• Provide specific theraphy as indicated
• Reassess frequently

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 Rapid Cardiopulmonary Assessment -
Priorities of Initial Management
Potential RF Probable RF
Keep with caregiver Separate from caregiver
Position of comfort Control airway
Oxygen as tolerated 100 % FiO2
Assist ventilation
Nothing by mouth Nothing by mouth
Monitor pulse oximetry Monitor pulse oximetry
Consider cardiac monitor Cardiac monitor
Establish vascular- access

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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

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Rapid Cardiopulmonary Assessment -
Priorities of Initial Management

Cardiopulmonary failure

• Oxygenate, ventilate, monitor

• Reassess for
• Respiratory failure
• Shock
• Obtain vascular access

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 Case No 1

A 3-week-old infant arrives at the emergency department.

• CC : Vomiting and diarrhea

• PE : Gasping respirations, bradycardia, cyanosis

What is the physiologic status ?

What are the initial interventions ?

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Case No 1 - Cardiopulmonary failure

Response to intubation and ventilation with FiO2 1.00

• HR : 180; BP 50 mm Hg systolic
• Pink centrally; cyanotic peripherally
• No peripheral pulses
• No response to venipuncture

What is the physiologic status ?

What is the cause ?

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Case No 1 - Response to Therapy

• Vital sign improved

• Perfusion still poor

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What is the heart size ?

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Case No 2

A 3-day-old infant has a history of irritability and

one episode of vomiting
PE : Gasping respirations, bradycardia, cyanosis

What is the physiologic status ?

What are the initial interventions ?

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Case No 2 - Cardiopulmonary failure

Response to oxygenation and ventilation with FiO2 1.00

• HR : 180; BP 40 mm Hg systolic
• Pink centrally; cyanotic peripherally
• No peripheral pulses
• No response to venipuncture

What is the physiologic status ?

What is the next intervention ?

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Chest X-ray after fluid bolus

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