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Paediatric Emergencies in the Recovery Room Michelle McNamara.

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Presentation on theme: "Paediatric Emergencies in the Recovery Room Michelle McNamara."— Presentation transcript:

1 Paediatric Emergencies in the Recovery Room Michelle McNamara

2 Proposed Learning Paediatric Emergencies A.B.C.D.E Airway Breathing Circulation Disability (depressed consciousness, unresponsiveness). Exposure ( significant hypothermia, bleeding, shock).

3 Recovery Room Evolution Speciality Staffing Preparation Child Friendly

4 Paediatric Challenges Not ‘Small’ Adults Are Someone's Child Age groups – size, development Opiate use intra-op/Post-op Emergence delirium Families Fear of mistakes

5 Paediatric Considerations Higher Anaesthetic Morbidity & Mortality Higher Intra-operative Bradycardia (Infants) Higher Respiratory Complications (Recovery) Associated outcomes worse Complications occur in healthy children of normal weight

6 Paediatric Anaesthesia Report Patient specific additions Defer verbal report if condition is unstable or emergency intervention is warranted. Birth history (premature birth, or congenital conditions). Developmental considerations (ensure personal comfort items are present, toy, blanket, religious items). Special needs (e.g. glasses, hearing implants) Pre-operative behaviour, (calm or anxious). Loose teeth (returned for tooth fairy).

7 Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

8 Assessment General Primary Secondary Tertiary SAMPLE Signs & Symptoms Allergies Medication Past Medical History Last Meal Events

9 Paediatric Definitions Premature Newborn – Birth before 37/40 Newborn – Birth to 72 hours Neonate - Infant during first 28 days of life Infant - 1 st year of life (including neonate) Toddler 1-3yrs Preschooler 4-5yrs School Age 6 – 12yrs Adolescent > 13yrs

10 Airway

11 Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

12 Anatomy and Physiology Airway Large Tongue Narrow Nostrils Smaller Airway Opening Short Neck Neonates are obligatory nose breathers More Susceptible to Laryngeal / Bronchospasm Easily Obstructed Airway Post Intubation Oedema

13 Airway problems Tracheal intubation (under 5 years) History of pre-term birth Reactive airway disease Airway surgery Excessive Secretions/Nasal Congestion Parents who smoke.

14 Breathing

15 Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

16 Normal Respiratory Rate by Age Age Infant (< 1yr) Toddler (1 – 3yrs) Preschooler (4 – 5yrs) School Age (6 – 12yrs) Adolesent (13 – 18 years) Breaths Per Minute 30 – – – A respiratory Rate consistently > than 60 bpm in a child of any age is abnormal

17 Normal Spontaneous Ventilation Minimal work Quiet breathing Easy inspiration Passive expiration Rapid in the neonate Decreases in older infants & children

18 Paediatric Considerations (Respiratory) High metabolic rate Oxygen demand is higher Infant Oxygen Consumption is 6-8mls/kg per minute (compared to 4mls/kg for adults) Hypoxaemia more rapid in infants & children A room air Sao2 < 94% in a normal child indicates hypoxaemia.

19 Residual effects of anesthetic agents Opiate Agents Sedative agents Excessive fluid volume Pain/ Anxiety Hypothermia/Hyperthermia Pre-existing Pulmonary Disease. Causes of Respiratory Dysfunction Post Op

20 Early Respiratory Distress Increased Respiratory & Heart Rate; Decreased Oxygen Saturation, Nasal Flaring (Infants); Chest Retractions, use of Accessory Muscles; Poor chest rise Poor air entry Grunting Croup Stridor Wheezing Mottled Colour

21 LATE Respiratory Distress Bradypnoea No respiratory effort Apnoea Cyanosis Poor or absent distal air movement Coma

22 A Decreasing Respiratory Rate Normal A decrease in respiratory rate from a rapid to a more ‘normal’ rate can indicate overall improvement if associated with increased level of consciousness and reduction of work of breathing Abnormal However a decrease in respiratory rate and regularity in a child with a deteriorating level of consciousness can be a sign of a deteriorating or worsening of the Childs clinical condition

23 Types of Respiratory Distress Upper airway obstruction Lower airway obstruction Lung Tissue Disease Disordered control of breathing

24 Croup Inflammation of the upper airway Post-intubation croup Presentation -'bark-like' cough Mild, Moderate, or Severe

25 Causes of Croup Intubation (Traumatic Prolonged or Repeated) Tight fitting E.T.T. Subglottic Injury Coughing (with E.T.T in place) Change of position (whilst Intubated) Surgery >1 hour Surgical trauma May be accompanied by Stridor Respiratory Distress

26 Stridor Shrill Harsh loud Crowing sounds Heard during inspiration, expiration or both.

27 Management of Croup / Stridor Notify Anaesthetist Nebulised cool mist Steroid IV Humidified oxygen Keep N.P.O. Nebulised Epinepherine Keep Pt > 2hrs Re-intubate (size smaller ETT than calculated for the age of the child)

28 Laryngospasm Involuntary muscle contraction of the laryngeal muscles causing the vocal cords to close. Dyspnoea Crowing sound on Inspiration Aphonia (no sound) Rocking Motion of Chest Use of Accessory Muscles.

29 Laryngospasm Nursing Interventions Notify Anaesthetist Administer 100% Humidified Oxygen Positive Pressure Ventilation by BVM Maintaining PEEP to Open Vocal Chords. Prepare for Intubation Oropharyngral Suction as required

30 Bag Mask ventilation

31 Signs & Symptoms Lower airway obstruction Tachypnoea Wheezing, (expiratory most common) Increased respiratory effort Retractions Nasal flaring Prolonged expiration (with expiration being an active rather than a passive process).

32 Bronchospasm Causes Preexisting Airway Disease Asthma, Bronchiolitis Allergy/Anaphalaxis Aspiration Mucous plug Foreign Body Pulmonary Edema.

33 Bronchospasm / Asthma Treatment Notify Anaesthetist Humidified Oxygen 100% Suction Bronchodilators / Ventolin Support ventilation Intubate if necessary Admission overnight

34 Aspiration Causes Residual gastric volume (intra-op) Post op Nausea & Vomiting Inhalation of foreign body e.g. tooth Inability to protect airway

35 Aspiration Nursing Interventions Position head down & turned to the side to promote drainage Humidified Oxygen/Suction Anti-emetic prophylaxis / rescue Notify anaesthetist Chest x-ray I.V. Antibiotic Prepare to re-intubate if necessary

36 Respiratory Management Distress/Failure/Obstruction Notify Anesthetist Reposition/Support the airway Open airway Clear the airway Insert an O.P.A. Or N.P.A. Assist ventilation High concentration O2 Monitor SAO2 / HR Nebulised Medication (Albuterol / Epinepherine) Prepare for Endotreacheal Intubation

37 Circulation

38 Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

39 Normal Heart Rate Age Awake Rate Newborn to 3months 85 –205 3 months to 2 yrs 100 –190 2yrs to 10yrs 60 – 140 > 10yrs Mean Sleeping Rate

40 Normal Blood Pressure by Age (mm Hg) Age Neonate (1 st day) Neonate (4 th day) Infant ( 1 month) Infant ( 3 months) Infant ( 6 Months) Infant ( 1year) Child ( 2 years) Child ( 7years) Adolescent ( 15years) Systolic Diastolic 60 – – – – – – – – – – – – – – –

41 Cardiac Physiology Higher cardiac output Higher baseline heart rate Infants – cardiac output dependent on heart rate DO NOT COMPENSATE for lower B/P Bradycardia in an infant ominous sign (CPR <60) May indicate hypoxaemia B/P lower than adults and increase with age H/R higher than adults and decrease with age

42 Cardiac Arrest Assessment Broselow PaediatricTape H’s Hypoxia Hypovolaemia Hydrogen Ion Hyper/Hypokalaemia Hypoglycaemia Hypothermia T’s Toxins Tamponade Tension Pneumothorax Thrombosis Trauma

43 Circulation Assessment Cardiovascular Vital signs Central and Peripheral Pulses Brain Perfusion (Mental Status) Skin Perfusion (Capillary refill <3 seconds) Renal Perfusion (Urine Output) Infants & Young Children 1.5 – 2ml/kg/hr Older Children & Adolescents 1ml/kg/hr

44 Bradycardia Assess & Support ABC Hypoxemia What is the BP? How is perfusion? Arrhythmias? Adolescent athlete Perform CPR if HR<60/min with poor perfusion

45 Tachycardia Assess & Support ABC Check Perfusion Crying ?Pain Temperature ?Malignant hyperthermia Anxiety Full bladder Fluid overload Medications (glycopyrrolate, atropine) Sinus Tachycardia (Infants <220, Children< 180)

46 Cardiac Arrest Asystole PEA VF Pulseless VT Asystole & PEA most common initial arrest rhythms in under 12yrs Activate Emergency Response, commence CPR per BCLS/PALS guidelines

47 Disability

48 Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

49 Depressed Consciousness Post op Anesthetic, Opiates, Sedatives Hypoglycemia / Hyperglycemia Hypothermia / Hyperthermia Sepsis Seizure Neurological Disease / Head Injury Respiratory Depression Emergence Delirium

50 Paediatric Response Scales Alert Voice Painful Unresponsiveness Modified Glasgow Coma Scale for Infants & children GCS (3 -15) Pupil Response to light PERRL (Pupils Equal Round Reactive to Light)

51 Emergence Delirium Post-Anesthesia Agitation, Emergence Agitation, Post-Anesthetic excitement Non-purposeful movement Incidence 25-80% Preschool children (< 6) Lasts up to 45 minutes Associated with Sevoflurane

52 Emergence Delirium treatment R/o physiologic causes ( ABC / Pain/ Anxiety) Identify Emergence Delirium Include family at bedside promptly Protect from harm Calm environment

53 Exposure

54 Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

55 Normal Temperature Age of child Core Temp ( 0 c) < 6 months months – 1yr yrs 37.2 – 37.0 > 6 yrs 36.6 – 36.8

56 Paediatric Temperature Concerns Larger body surface area/kg Cold Theatre, IV fluids, Anaesthetic Gases Surgery > 1 hour (Wound Exposure) Hypothermia (Core Temperature < 36, infant ) Delayed awakening Cardiac Irritability (Poor Perfusion) Respiratory depression High Temperature is a LATE sign of MH

57 Thermoregulation Shivering Increases metabolic rate & discomfort Infants cannot shiver – to increase heat they; Metabolize brown fat Move Cry Pethidine calms shivering (Lowers seizure threshold) Treat (Bair Hugger)

58 Hypothermic Interventions Warm Recovery Room Warm blankets Hat, Socks, Swaddle, Hold Close Infant Incubator Forced Air Warmer (Bair Hugger) Radiant Heat Lamp/s

59 Shock In Shock, Tissue perfusion is Inadequate Relative to Metabolic Needs Hypovolaemic Shock Distributive Shock Cardiogenic Shock Obstructive Shock PALS Protocol Compensated/Uncompensated Shock

60 Hypovolaemia Fluid/Blood Volume Deficit Assess Imbalance Treat underlying Cause & Correct Imbalance Blood Loss Mild< 30% Moderate 30%-45% Severe >45%

61 A.S.A. Minimum Fasting Guidelines 2 Hours For clear Liquids 4 Hours For Breast Milk 6 Hours For Infant Formula, Non-Human Milk, Light Meal (Tea & Toast) 8 Hours For a Meal (Fried or Fatty Foods)

62 Fluid Requirement Formula Body Weight kg Hourly Fluid Requirement 0 – 10 kg 4ml/kg/hr kg 40ml + 2 ml/kg/hr >20 kg 60ml + 1 ml/kg/hr e.g. 6 kg = 24 ml/hr e.g. 17 kg = 54 ml/hr e.g. 24 kg = 64 ml/hr Maintenance

63 Hypovolaemia Interventions Fluid Resuscitation IV / IO access Bolus 20ml/kg of Isotonic Crystalloid N/S CSL Reassess & Repeat Transfusion RBC 10ml/kg Reassess & Repeat

64 I.V Access sites

65 Paediatric Postoperative care ABCDE System Support Pain Management Anxiety Management Psychosocial Considerations

66 Thank you!

67 References American Heart Association & American Academy of Paediatrics (2005) Paediatric Advanced Life Support Provider Manual. Illinois:Worldpoint ECC,INC. Aitkenhead, A., Smith, G. & Rowbotham, D.(2007) Textbook of Anaesthesia. 5 th edn. London:Churchill Livingstone. De Fazio-Quinn, D.M. (2003) ‘Perianaesthesia nursing as a speciality’ in Drain, C.B. (ed) Peri Anaesthesia Nursing, A Critical Care Approach. Missouri: Elsevier,11:29.

68 References Contd. Johnson, D. (2004) ‘Care of the pediatric Patient’ in Drain, C.B. (ed) Peri Anaesthesia Nursing, A Critical Care Approach. Missouri: Elsevier, 661:681. Motoyama, E., Davis,P. & Smith, P. (1996) Anesthesia for Infants and Children. 6 th edn. St Louis:Mosby. Schick, L. & Windle, P. (2010) PeriAnesthesia Nursing Core Curriculum:Preoperative, Phase 1 And Phase 11 PACU Nursing. Missouri:Saunders

69 References contd Smith, B. & O’Brien, D. (2004) ‘Space Planning and Basic Equipment Systems’, in Drain, C.B. (ed) Peri Anaesthesia Nursing, A Critical Care Approach. Missouri: Elsevier, 1:10. Stoddart, P. & Lauder, G. (2004) Problems in Anaesthesia Paediatric Anaesthesia. London:Taylor & Francis. Trigg, E. & Mohammed,T. (2007) Practices in Childrens Nursing; Guidelines for Hospital and Community. 2 nd edn. London:Churchill livingstone.


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