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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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Presentation on theme: "Recognition of the seriously ill child 23/03/11 Dr. John Twomey, Consultant Paediatrician, Department of Paediatrics/ Emergency Department Medical Students."— Presentation transcript:

1 Recognition of the seriously ill child 23/03/11 Dr. John Twomey, Consultant Paediatrician, Department of Paediatrics/ Emergency Department Medical Students

2 Describe what you see

3 15 th century, unknown artist

4 1664, Gabriel Metsu

5 1885, Eugene Carriers

6 2006, Life magazine

7 The sick child

8 Some Ground Rules!

9 Diverse range from infancy to adolescence

10 Children Are Not “Little Adults”

11 What are the key differences to consider in children?

12 Weight Anatomical Physiological Psychological

13 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 (>10 yrs): 10 yrs = 30 kg 12 yrs = 40 kg 14 yrs = 50 kg 16 yrs = 60 kg

14 Anatomical Airway -Large head -Short & soft trachea -Small face & mandible -Loose teeth & Large tongue -Easily compressible floor of the mouth -Obligate nasal breathers (<6/12) -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

15 Anatomical Breathing -Lung immaturity -Small air-surface interface (<3m²) -Less small airways (1/10 of adult) -Small upper & lower airways -R 1/r4 -Diaphragmatic Breathing -More horizontal ribs

16 Anatomical Circulation -RV>LV (0-6/12) => LV>RV -Blood circulating volume/body weight = mls/kg -Absolute volume is small (critical importance of relatively small amounts of blood loss) Body Surface Area -BSA:Wt ↓ with ↑ age -Small children have a high ratio => relatively more prone to hypothermia

17 Physiological Respiratory -Infant - ↑ BMR & O2 Consumption => ↑ RR Age (yrs)RR (bpm) < >

18 Physiological Cardiovascular -CO = SV x HR -Infant – small stoke volume => ↑ HR Age (yrs)HR (bpm) < >

19 Physiological Cardiovascular -Infant - ↓ systemic resistance => ↓ BP -SBP = 80 + (age x 2) Age (yrs)SBP(mmHg) < >

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

21 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 => altered physiological parameters => difficult to interpret -Explain as clearly as possible (Knowledge allays fear) -Parental presence at all times

22 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 child’s condition Reassessment - Stabilisation – achieving homeostasis and system control Transfer – to a definitive care environment (PICU)

23 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)

24 WETFAG Weight = (Age + 4)2 Energy = 4 J/kg asynchronous shock Tube = (Age/4) /- 0.5 Fluids = 20 mls/kg 0.9% NaCl Adrenaline = Adrenaline 10 μg/kg IV/IO (0.1ml/kg of 1:10,000); 100 μg/kg (0.1ml/kg of 1:1,000) ETT Glucose = Dextrose 10% 5ml/kg IV

25 1º Assessment & Resuscitation

26 ABCD(E) Airway Breathing Circulation Disability (Exposure)

27 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 => BLS & Advanced Airway Support

28 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

29 BLS Infant (<1)Child (1-14) Head tilt position NeutralSniffing Initial rescue breaths 55 Pulse Landmark Technique Brachial/femoral 1 finger’s breadth above xiphisternum 2 fingers/2 thumbs Carotid 1 finger’s breadth abovexiphisternum 1 or 2 hands CPR ratio15:2

30 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 (<1ml/kg/hr in children; <2ml/kg/hr in infants) Cardiac failure: Cyanosis not correcting with O2/Tachycardia out of proportion to respiratory difficulty/↑JVP/Gallop rhythm/Murmur/Enlarged liver/ Absent femoral pulses => IV/IO access x2; bloods incl. G&X-match; fluid bolus (20ml/kg); inotropes, intubation & CVP monitoring if >3 boluses

31 Disability Conscious level: P ~ GCS Intubation if “P” or “U”; Rx hypoglycaemia; Rx seizure A ALERT V responds to VOICE P responds only to PAIN U UNRESPONSIVE

32 (Exposure) – Not part of 1º Assessment but do early

33 ABC - DEFG Don’t Ever Forget Glucose

34 Reassessment of ABCD(E) at frequent intervals

35 2º Assessment & Emergency Treatment

36 Airway & Breathing Symptoms: Breathlessness/Coryza/Cough/Grunting/Stridor/Wheeze/ 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

37 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 1:1,000 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 Magill’s forceps ONLY IN EXTREME CASES OF A THREAT TO LIFE ?Anaphylaxis

38 Airway & Breathing Cough, wheeze & ↑SOB – ?Acute exacerbation of asthma – Inhaled Salbutamol (2.5mg{ 5yo}) & 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 1:1,000)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2)/Chlorphenaramine/Prednisolone ?IFB

39 Management of a Choking Child

40 Ineffective Cough & Conscious Infants (<1) Back Blows (x5) and Chest Thrusts (x5) (1/second)

41 Ineffective Cough & Conscious Children (1-14) Back Blows (x5) and Abdominal Thrusts (x5) (1/second) (Heimlich Manoeuvre)

42 Circulation Symptoms: Breathlessness/Fever/Palpitations/Feeding difficulties/ Drowsiness/Pallor/Fluid loss/Poor urine output Signs: Tachy -or bradycardia/Hypo- or hypertension/Abnormal pulse volume or rhythm/Abnormal skin perfusion or colour/ Cyanosis/Pallor/Hepatomegaly/Auscultatory crepitations/Murmur/Peripheral oedema/↑JVP/Hypotonia/Purpura Investigations: U&E/FBC/ABG/Coag screen/Blood culture/ECG/CXR

43 Shock Acute failure of circulatory function

44 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

45 Shock Types: Phase 1 - Compensated Phase 2 - Decompensated Phase 3- Irreversible

46 Phase 1- Compensated Compensatory mechanisms to preserve vital organ function Sympathetic + => ↑Systemic Arterial Resistance; ↑HR; ↑secretion of angiotensin & vasopressin Clinical Features: agitation/confusion, pallor, ↑HR, cold peripheries, ↑CRT

47 Phase 2 - Decompensated Compensatory mechanisms start to fail Aerobic => anaerobic metabolism => lactic acidosis Sluggish blood flow => platelet adhesion Release of numerous chemical mediators => ↑capillary permeability & other deleterious consequences Clinical Features: ↓BP, ↓LOC, acidotic breathing, ↓/no UO

48 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

49 Circulation Shocked child with no obvious fluid loss – ?sepsis - IV ceftriaxone Shock with rash & stridor – ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of 1:1,000) 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

50 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 < 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

51 What is this rhythm?

52 Supraventricular Tachycardia (SVT) Commonest non-arrest arrhythmia in childhood HR >220bpm Narrow QRS complex (< 0.08 sec) Palpitations Lightheadedness Dizziness Chest discomfort Shock (if prolonged - younger)

53 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 < 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 min) Procainamide (15mg/kg over min) Flecainide (2mg/kg over 20 min)

54 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

55 Fluids in Resuscitation 0.9% NaCl 20 ml/kg (10ml/kg in DKA or Trauma) >/= 3 boluses (60ml/kg = ¾ of total circulating blood volume!) = consider RSI Larger volumes => 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 => hyponatraemia

56 Disability Symptoms: Headache/Fits or Seizures/Change in behaviour/Change in conscious level/Weakness/Visual 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: U&E/blood glucose/ABG/Coag screen/Blood culture/Blood & urine toxicology – salicylate/Neuroimaging

57 Disability Seizure – 1 st Ix – hypoglycaemia - IV glucose (5ml/kg of Dextrose 10%) Seizure > 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 ( g/kg { ml/kg of mannitol 20 %} over 20 min) + IV frusemide (1mg/kg)/+/- Dexamethasone (0.5mg/kg BD) Neurosurgery input Depressed level of consciousness/irritability/convulsions – ?meningitis/encephalitis - IV ceftriaxone/acyclovir

58 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)

59 Exposure Symptoms: Rash/Swelling of lips/tongue/Fever Signs: Purpura/Urticaria/Angio-oedema

60 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 1:1,000)

61 Reassessment, Stabilisation & Transfer

62 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 child’s condition Reassessment - Stabilisation – achieving homeostasis and system control Transfer – to a definitive care environment (PICU)

63

64

65 The Hypocratic Oath! Epiglottitis Don’t lie patient down! Don’t do a lateral x-ray Management of shock Too much fluid too quickly can => cerebral oedema No dextrose as resuscitation fluid (=> hyponatraemia) Duct-dependent CHD Avoid excessive O %) No LP if altered level of consciousness ↑BP, ↓HR, irregular respirations (Cushing’s 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 (√refractory hypotension) “Don’t Ever Forget Glucose”

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