Recognition of the seriously ill child

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Recognition of the seriously ill child

• 23/03/11
• Dr. John Twomey,
• Consultant Paediatrician,
• Department of Paediatrics/ Emergency Department
• Medical Students

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• Describe what you see

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15th century, unknown artist
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1664, Gabriel Metsu
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1885, Eugene Carriers
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2006, Life magazine
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• The sick child

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• Some Ground Rules!

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Diverse range from infancy to adolescence
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Children Are Not Little Adults
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• What are the key differences to consider in
  children?

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• Weight
• Anatomical
• Physiological
• Psychological

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Weight

• Centile Charts
• Broselow Tape
• Formula (1-10yrs)
• Wt (kg) (age 4)2
• Estimate (0-1 yrs)
• Newborn 3.5 kg
• 6/12 7 kg
• 12/12 10 kg
• Estimate (gt10 yrs)
• 10 yrs 30 kg
• 12 yrs 40 kg
• 14 yrs 50 kg
• 16 yrs 60 kg

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Anatomical

• Airway
• Large head
• Short soft trachea
• Small face mandible
• Loose teeth Large tongue
• Easily compressible floor of the mouth
• Obligate nasal breathers (lt6/12)
• Adenotonsillar hypertrophy
• Horse-shoe shaped epiglottis projecting
  posteriorly
• High anterior larynx (straight bladed
  laryngoscope)
• Cricoid ring narrowest part of the airway
  (Larynx in adults) is susceptible to oedema
  (uncuffed ett)
• Symmetry of carinal angles

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Anatomical

• Breathing
• Lung immaturity
• Small air-surface interface (lt3m²)
• Less small airways (1/10 of adult)
• Small upper lower airways
• R 1/r4
• Diaphragmatic Breathing
• More horizontal ribs
  

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Anatomical

• Circulation
• RVgtLV (0-6/12) gt LVgtRV
• Blood circulating volume/body weight 70-80
  mls/kg
• Absolute volume is small (critical importance of
  relatively small amounts of blood loss)
• Body Surface Area
• BSAWt ? with ? age
• Small children have a high ratio gt relatively
  more prone to hypothermia

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Physiological

• Respiratory
• Infant - ? BMR O2 Consumption gt ? RR

Age (yrs) RR (bpm)
lt1 30-40
1-2 25-35
2-5 25-30
5-12 20-25
gt12 15-20
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Physiological

• Cardiovascular
• CO SV x HR
• Infant small stoke volume gt ? HR

Age (yrs) HR (bpm)
lt1 110-160
1-2 100-150
2-5 95-140
5-12 80-120
gt12 60-100
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Physiological

• Cardiovascular
• Infant - ? systemic resistance gt ? BP
• SBP 80 (age x 2)

Age (yrs) SBP(mmHg)
lt1 70-90
1-2 80-95
2-5 80-100
5-12 90-110
gt12 100-120
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Physiological

• Immune system
• Immature immune system
• Maternal antibodies (x 1st 6/12)
• Protective effect of breast feeding

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Psychological

• Communication
• No or limited verbal communication
• Many non-verbal cues
• Age-appropriate communication
• Fear
• Additional distress to the child and adds to
  parental anxiety gt altered physiological
  parameters gt difficult to interpret
• Explain as clearly as possible (Knowledge allays
  fear)
• Parental presence at all times

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A Structured Approach

• 1º Assessment - Resuscitation identifying
  treating the immediate threats to life closed
  or obstructed airway, absent or distressed
  respiration, pulselessness, shock
• 2º Assessment - Emergency Treatment to start to
  treat the underlying cause of the childs
  condition
• Reassessment - Stabilisation achieving
  homeostasis and system control
• Transfer to a definitive care environment (PICU)

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A Structured Approach

• Preparation (before the child arrives)
• Teamwork (with a designated team leader)
• Communication (with contemporaneous recording of
  history, clinical findings, treatments)
• Consent (assumed if acting in the best interests
  of the child)

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WETFAG

• Weight (Age 4)2
• Energy 4 J/kg asynchronous shock
• Tube (Age/4) 4 ---- /- 0.5
• Fluids 20 mls/kg 0.9 NaCl
• Adrenaline Adrenaline 10 µg/kg IV/IO (0.1ml/kg
  of 110,000) 100 µg/kg (0.1ml/kg of 11,000) ETT
• Glucose Dextrose 10 5ml/kg IV

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• 1º Assessment
• Resuscitation

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ABCD(E)

• Airway
• Breathing
• Circulation
• Disability
• (Exposure)

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Airway Breathing

• Effort of breathing
• RR/Recession/Inspiratory expiratory
  noises/Grunting/Use of accessory muscles/Nasal
  flaring/Gasping
• Efficacy of breathing
• Chest expansion/Abdominal excursion/ Chest
  auscultation/Pulse oximetry
• Exceptions
• Exhaustion/?ICP/NM d/o
• Effect of respiratory inadequacy on other organs
• ?/? HR/Pallor/Cyanosis NB anaemia/Agitation/
  Drowsiness/LOC/Hypotonia
• gt BLS Advanced Airway Support

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Basic Life Support (BLS)
EMS activation before BLS witnessed sudden collapse with no apparent preceding morbidity witnessed sudden collapse in a child with a known cardiac condition and in the absence of a known or suspected respiratory or circulatory cause of arrest
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BLS
Infant (lt1) Child (1-14)
Head tilt position Neutral Sniffing
Initial rescue breaths 5 5
Pulse Landmark Technique Brachial/femoral 1 fingers breadth above xiphisternum 2 fingers/2 thumbs Carotid 1 fingers breadth abovexiphisternum 1 or 2 hands
CPR ratio 152 152
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Circulation

• Cardiovascular status
• HR/Pulse volume/CRT/BP
• Effect of circulatory inadequacy on other organs
  
• ?RR (2º to metabolic acidosis)/Pallor/
  Cyanosis/Agitation/Drowsiness/LOC/? UO
  (lt1ml/kg/hr in children lt2ml/kg/hr in infants)
• Cardiac failure
• Cyanosis not correcting with O2/Tachycardia out
  of proportion to respiratory difficulty/?JVP/Gallo
  p rhythm/Murmur/Enlarged liver/ Absent femoral
  pulses
• gt IV/IO access x2 bloods incl. GX-match fluid
  bolus (20ml/kg) inotropes, intubation CVP
  monitoring if gt3 boluses

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Disability

• Conscious level
• P GCS lt/ 8/15
• Posture
• Decorticate/Decerebrate
• Pupils
• Dilatation/Unreactivity/ Inequality
• Effect of central neurological failure on other
  organs
• Hyperventilation/Cheyne-Stokes/Apnoea
• ?BP, ?HR, abnormal breathing (Cushings Triad)
• gt Intubation if P or U Rx hypoglycaemia Rx
  seizure

A ALERT V responds to VOICE P responds only to PAIN U UNRESPONSIVE
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(Exposure) Not part of 1º Assessment but do
early
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• ABC - DEFG
• Dont Ever Forget Glucose

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• Reassessment of ABCD(E) at
• frequent intervals

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• 2º Assessment
• Emergency Treatment

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Airway Breathing

• Symptoms
• Breathlessness/Coryza/Cough/Grunting/Stridor/Wheez
  e/ Hoarseness/Drooling inability to
  drink/Abdominal pain/ Chest pain/Apnoea/Feeding
  difficulties
• Signs
• Cyanosis/Tachypnoea/Recession/Grunting/Stridor/
  Wheeze/Chest wall crepitus/Tracheal
  shift/Abnormal percussion note/Crepitations on
  auscultation/Acidotic breathing
• Investigations
• O2 sats/Peak flow/End-tidal or trans-cutaneous
  CO2/ Blood culture/CXR/ABG

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Airway Breathing

• ? Respiratory secretions
• Suction - ? Fatigued/depressed conscious level
• Barking Cough in a well child
• ?Croup PO/IM Dexamethasone (0.6mg/kg stat or
  0.15mg/kg BD x 2-3/7)/Nebulised budesonide
  (2mg)/Nebulised adrenaline (5ml of 11,000
  nebulised in O2) NB TRANSIENT ?HR REBOUND
• Quiet stridor, drooling, sick-looking child
• ?Epiglottitis/Bacterial Tracheitis
  (Pseudomembranous Croup) - Intubation IV
  ceftriaxone NB AVOID VENEPUNCTURE (BEFORE
  INTUBATION) AND X-RAYS
• Sudden onset of respiratory distress leading to
  apnoea in a conscious toddler
• ?Inhaled foreign body -choking child
  manoeuvre/direct laryngoscopy use of Magills
  forceps ONLY IN EXTREME CASES OF A THREAT TO LIFE
  
• ?Anaphylaxis

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Airway Breathing

• Cough, wheeze ?SOB
• ?Acute exacerbation of asthma Inhaled
  Salbutamol (2.5mglt5yo 5mg gt5yo) O2/PO
  prednisolone (2mg/kg) or IV hydrocortisone
  (4mg/kg then 2mg/kg QDS)
• ?IFB
• ?Anaphylaxis
• Infant with wheeze and respiratory distress
• ?Bronchiolitis Supportive Mx PO/NG/IV
  fluids/O2
• ?IFB
• ?Anaphylaxis
• Pyrexia, breathing difficulties but no
  stridor/wheeze
• ?Pneumonia Antibiotics/Adequate hydration/ /-
  chest drain
• Stridor following ingestion of a new food
• ?Anaphylaxis - IM adrenaline (10µg/kg 0.01ml/kg
  of 11,000)/Nebulised adrenaline (5ml of 11,000
  nebulised in O2)/Chlorphenaramine/Prednisolone
• ?IFB

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Management of a Choking Child
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Ineffective Cough Conscious

• Infants (lt1)
• Back Blows (x5) and Chest Thrusts (x5) (1/second)

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Ineffective Cough Conscious

• Children (1-14)
• Back Blows (x5) and Abdominal Thrusts (x5)
  (1/second) (Heimlich Manoeuvre)

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Circulation

• Symptoms
• Breathlessness/Fever/Palpitations/Feeding
  difficulties/ Drowsiness/Pallor/Fluid loss/Poor
  urine output
• Signs
• Tachy -or bradycardia/Hypo- or hypertension/Abnorm
  al pulse volume or rhythm/Abnormal skin perfusion
  or colour/ Cyanosis/Pallor/Hepatomegaly/Auscultato
  ry crepitations/Murmur/Peripheral
  oedema/?JVP/Hypotonia/Purpura
• Investigations
• UE/FBC/ABG/Coag screen/Blood culture/ECG/CXR

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Shock

• Acute failure of circulatory function

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Shock

• Types
• Cardiogenic heart defects - arrhythmias
• Hypovolaemic fluid loss haemorrhage, GE
• Distributive vessel abnormalities
  septicaemia, anaphylaxis
• Obstructive fluid restriction tension pnuemo,
  cardiac tamponade
• Dissociative inadequate O2-releasing capacity
  of blood CO poisoning, methaemoglobinaemia

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Shock

• Types
• Phase 1 - Compensated
• Phase 2 - Decompensated
• Phase 3- Irreversible

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Phase 1- Compensated

• Compensatory mechanisms to preserve vital organ
  function
• Sympathetic gt ?Systemic Arterial Resistance
  ?HR ?secretion of angiotensin vasopressin
• Clinical Features
• agitation/confusion, pallor, ?HR, cold
  peripheries, ?CRT

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Phase 2 - Decompensated

• Compensatory mechanisms start to fail
• Aerobic gt anaerobic metabolism gt lactic
  acidosis
• Sluggish blood flow gt platelet adhesion
• Release of numerous chemical mediators gt
  ?capillary permeability other deleterious
  consequences
• Clinical Features
• ?BP, ?LOC, acidotic breathing, ?/no UO

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Phases 3 - Irreversible

• Retrospective Dx
• Death is inevitable despite therapeutic
  intervention resulting in adequate restoration of
  circulation
• EARLY RECOGNITION EFFECTIVE TREATMENT OF SHOCK
  IS VITAL

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Circulation

• Shocked child with no obvious fluid loss
• ?sepsis - IV ceftriaxone
• Shock with rash stridor
• ?Anaphylaxis - IM adrenaline (10µg/kg 0.01ml/kg
  of 11,000)
• Neonate with unresponsive shock
• ?duct-dependent CHD Prostaglandin (Alprostadil
  0.05µg/kg/min)
• Pallor with dark brown urine
• ? Haemolysis ?SCD O2, rehydration /-
  Transfusion, antibiotics, analgesia

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Circulation

• No pulse
• ?Cardiac Arrhythmia - Assess cardiac rhythm
  asystolé, PEA, VF, PLVT
• Poor feeding with HR 230bpm
• ?SVT Algorithm vagal stimulation, If IV access
  - IV adenosine (100µg/kg ?x100µg/kg every 2 min
  to a max of 500µg/kg 300µg/kg in lt 1/12), If No
  IV access shocked DC cardioversion (1J/kg
  then 2J/kg)
• Infant/young child with Hx vomiting, drawing up
  legs pallor /- abdominal mass
• ?intussusception/malrotation/volvulus etc. -
  Surgical advice Paediatric Surgeon -
  Dublin/Abdominal USS, stabilisation transfer

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What is this rhythm?
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Supraventricular Tachycardia (SVT)

• Commonest non-arrest arrhythmia in childhood
• HR gt220bpm
• Narrow QRS complex (lt 0.08 sec)
• Palpitations
• Lightheadedness
• Dizziness
• Chest discomfort
• Shock (if prolonged - younger)

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SVT

• Vagal stimulation glove containing ice over
  face immersion in iced water unilateral carotid
  sinus massage valsalva (blow through a straw!)
• If IV access - IV adenosine (100µg/kg ?x100µg/kg
  every 2 min to a max of 500µg/kg 300µg/kg in lt
  1/12)
• If No IV access shocked DC cardioversion
  (1J/kg then 2J/kg)
• No response SEEK SPECIALIST PAEDIATRIC
  CARDIOLOGY ADVICE
• Amiodarone (5mg/kg over 20-60 min)
• Procainamide (15mg/kg over 30-60 min)
• Flecainide (2mg/kg over 20 min)

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Intussusception A Medical Emergency!

• Infant/young child with Hx vomiting, drawing up
  legs pallor /- abdominal mass
• ABC
• High-flow O2
• IV fluid resuscitation
• PFA
• Abdominal USS
• Inform Paediatric Consultant
• Stabilisation Transfer for definitive Mx

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Fluids in Resuscitation

• 0.9 NaCl 20 ml/kg (10ml/kg in DKA or Trauma)
• gt/ 3 boluses (60ml/kg ¾ of total circulating
  blood volume!) consider RSI
• Larger volumes gt haemodilution - Albumin??
• Use CVP (cardiac preload) as a guide
• Blood
• fully cross-matched 1º
• type-specific non-cross matched 15 min
• O-negative 0 min
• NOT dextrose because gt hyponatraemia

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Disability

• Symptoms
• Headache/Fits or Seizures/Change in
  behaviour/Change in conscious level/Weakness/Visua
  l disturbance/Fever
• Signs
• Altered level of consciousness/Convulsions/Altered
  pupil size reactivity/Abnormal
  posture/abnormal oculo-cephalic reflexes/
  Meningism/Papilloedema or retinal
  haemorrhage/Altered deep tendon reflexes/?BP/?HR/
  Irregular breathing pattern
• Investigations
• UE/blood glucose/ABG/Coag screen/Blood
  culture/Blood urine toxicology
  salicylate/Neuroimaging

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Disability

• Seizure 1st Ix
• hypoglycaemia - IV glucose (5ml/kg of Dextrose
  10)
• Seizure gt 5 min duration
• IV lorazepam (0.1mg/kg)/PR diazepam (0.5mg/kg
  max 4mg)/Buccal midazolam (0.5mg/kg)
• Decreasing level of consciousness/abnormal
  posturing/abnormal ocular motor reflexes
• ? ?ICP - Intubation ventilation/head in-line
  20-30º head-up position/IV mannitol (0.25-0.5g/kg
  1.25-2.5ml/kg of mannitol 20 over 20 min)
  IV frusemide (1mg/kg)//- Dexamethasone (0.5mg/kg
  BD) Neurosurgery input
• Depressed level of consciousness/irritability/conv
  ulsions
• ?meningitis/encephalitis - IV ceftriaxone/acyclovi
  r

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Disability

• Drowsiness with sighing respirations
• ?DKA - IV Normal saline (0.9) insulin
• Vomiting, hypoglycaemia coma
• ?metabolic encephalopathy IV glucose, ABCD
  send metabolic screen esp ammonia Metabolic
  Team input
• Unconscious with inconsistent history
• ? NAI Mx as per any unconscious child,
  ophthalmology, bloods, skeletal survey,
  neuroimaging (if not already done)
• Unconscious with pin-point pupils
• ? Opiate poisoning - IV naloxone (10µg/kg) IM
  naloxone (100µg/kg)

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Exposure

• Symptoms
• Rash/Swelling of lips/tongue/Fever
• Signs
• Purpura/Urticaria/Angio-oedema

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Exposure

• Shock/?LOC/Purpuric rash
• ?Meningococcal septicaemia Blood culture, PCR
  IV ceftriaxone
• Shock/Stridor/Urticarial rash
• ?Anaphylaxis - IM adrenaline (10µg/kg 0.01ml/kg
  of 11,000)

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• Reassessment,
• Stabilisation
• Transfer

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A Structured Approach

• 1º Assessment - Resuscitation identifying
  treating the immediate threats to life closed
  or obstructed airway, absent or distressed
  respiration, pulselessness, shock
• 2º Assessment - Emergency Treatment to start to
  treat the underlying cause of the childs
  condition
• Reassessment - Stabilisation achieving
  homeostasis and system control
• Transfer to a definitive care environment (PICU)

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The Hypocratic Oath!

• Epiglottitis
• Dont lie patient down!
• Dont do a lateral x-ray
• Management of shock
• Too much fluid too quickly can
• gt cerebral oedema
• No dextrose as resuscitation fluid
• (gt hyponatraemia)
• Duct-dependent CHD
• Avoid excessive O2
• (sats _at_ 88-92)
• No LP if altered level of consciousness
• ?BP, ?HR, irregular respirations (Cushings
  Triad)
• Normal fundoscopy does not exclude acute ?ICP
• NaHCO3 has NO role in initial management of DKA
• Steriods have NO role in the initial management
  of
• Meningococcal Septicaemia (vrefractory
  hypotension)
• Dont Ever Forget Glucose

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