Presentation on theme: "Recognition and management of the seriously ill child Dr Esyld Watson Consultant in Adult and Paediatric Emergency Medicine."— Presentation transcript:
1 Recognition and management of the seriously ill child Dr Esyld Watson Consultant in Adult and Paediatric Emergency Medicine
2 Learning outcomesTo understand the aetiology of and clinical pathways to cardiorespiratory arrest in childrenTo use a rapid ABCDE assessment to determine the clinical stateTo distinguish between compensated and decompensated respiratory or circulatory failureTo initiate treatment interventions based on ABCDE assessment and reassessmentEmphasise the ABCDE approach
3 Aetiology of cardiorespiratory arrest Children are different to adultsAdultsUsually a primary cardiac arrestSudden and unpredictable in onsetUsually due to arrhythmiaNot usually preceded by hypoxia and acidosisSuccessful outcome depends on early defibrillation
4 Aetiology of cardiorespiratory arrest ChildrenMost children have secondary arrestRespiratory and/or circulatory failure leads to hypoxia and acidosis.Myocardial hypoxia results in bradycardia then asytoleEarly recognition and treatment of respiratory and circulatory failure can prevent progression to arrest% of children have primary cardiac arrest - usually due to congenital or acquired heart diseaseEmphasise that in children there is not usually an underlying cardiac disorder.Acidosis and hypoxia due breathing or circulation problems are common.If left untreated lead to myocardial ischaemia and CRA. Primary cardiac arrest does occur, although rarelyMust intervene to prevent this occurring.Outcome is very poor if CPA occurs.
5 Pathways to cardiorespiratory arrest Compensated circulatory failureCompensated respiratory failureDecompensatedcirculatory failurerespiratory failureCardiorespiratory failureCardiorespiratory arrestSummary slideSuccessful resuscitation in children depends upon early recognition of respiratory and circulatory failure and measures to prevent progression to cardiorespiratory arrest
7 Recognition of the seriously ill child is based on assessment of: Airway (c-spine consideration in trauma)BreathingCirculationDisabilityExposureOxygenationVentilationPerfusionThe aim of the rapid clinical assessment is to provide information on the child’s oxygenation, ventilation and perfusion.This will determine whether there is a breathing or circulatory problem or bothTreatment will be based on this assessment.Can be done in 30 seconds.
9 Assessing the airwayAn assessment of the airway can only be made if the child is attempting to breath or the child is receiving assisted ventilation.The airway of children and infants is more susceptible to obstruction secondary to oedema as it is proportionately narrower than in adultsStridor is an inspiratory noise indicating extrathoracic obstruction of the upper airway
11 Assessing breathing oxygenation and ventilation Minute ventilation = Tidal volume x RRRespiratory rate (RR)Work of breathingTidal volume (chest expansion)Oxygenation (pulse oximetry)
12 Assessing respiratory rate Increased RR is often the first sign of respiratory difficultyRR varies with age, fever, pain and anxiety as well as in respiratory failureMonitor the trend in RR
13 Assessing the work of breathing Play video clip and ask candidates to identify features of respiratory distress.They will appear with the next click of the mouse.Head bobbing – in infants when sternocleidomastoid muscles brought into use as accessory respiratory muscles
14 Assessing tidal volume Tidal volume (look, listen, feel)Compare one side of chest with the otherSubjective assessment: breath sounds should be audible in both bases(Feel for trachea; is it central?)Tidal volume can be assessed by observation of chest movement, palpation, auscultation and percussion.
15 Assessing respiratory sounds StridorWheezeGruntingVolume of noises does not correspond to severity of respiratory compromise
20 Assessing oxygenation Cyanosis is unreliable (SpO2 < 80%)Any child with a breathing problem must have pulse oximetryClinical signs of hypoxiaIrritability, agitation, drowsiness, level of consciousnessCyanosis is not a reliable indicator of the degree of hypoxia; it may never be observed in a profoundly hypoxic child if there is significant anaemiaSpO2 of < 90% in air or < 95% in supplemental oxygen indicates respiratory failureWhen SpO2 is < 70% pulse oximetry is inaccurate, although trends will still be reliable
21 Decompensation? Increasing respiratory rate Sudden fall in respiratory rateExhaustionReduced interaction with caregivers, agitationDiminishing level of consciousnessAsk candidates for the signs of decompensation
23 Assessing circulatory status Target organs most easily assessed are brain and kidneys.Assessing liver edge can be very important in children with suspected cardiac failure.This baby survived and left hospital with all limbs intact.
24 Assessing pulses Comparison of central and peripheral pulses Reflects stroke volumeAs shock progresses peripheral pulses are lost before central pulsesConsider which pulses are central and peripheral in infants and children and easily accessible
25 Assessing heart rateIncreased HR is often the first sign of circulatory compromiseHR varies with age, fever, pain and anxiety as well as in circulatory failureIt is more important to monitor the trend in HR than to rely on absolute value
26 Assessing skin perfusion Feel skin temperatureWarm / cold lineSkin colourMottlingPallorPeripheral cyanosisRashesSkin temperature much more useful than skin colour.
27 Assessing capillary refill time CRT > 2 sec is abnormalAssess peripherally and centrallyPlay video clip.Caution if the child has been in cold weather, consider central CRT
28 Assessing cerebral perfusion Early signsLoss of interest in surroundingsIrritability, agitationLate signsDrowsiness, loss of consciousness, hypotonia (floppy)
29 Assessing renal perfusion Urine output is an index of organ perfusionNappy weights or number of wet nappiesUrinary catheter (> 1 ml kg-1 h-1)How many times passed urine that day?Regular measurement of urine output very helpful in assessing perfusionCan be a relatively early sign of circulatory failureNormal infant usually has six wet nappies a day
30 Decompensation? Steadily increasing HR Sudden fall in HR Increasing peripheral vasoconstrictionReduced interaction with care givers, agitationDiminishing level of consciousnessHypotensionAsk candidates for the signs of decompensationEmphasise that hypotension is a late sign and it should be possible to determine decompensation before hypotension occurs.
32 Assessing disability Evaluate the level of responsiveness Posturing AlertVoicePainUnresponsive to painful stimulusPosturingPupil reactionGlucosePainful stimulus can be delivered by applying sternal pressure.A child who is unresponsive to painful stimuli has a significant degree of neurological derangement equivalent to a Glasgow coma scale score of 8 or less.Seriously ill children become floppyIf there is serious brain dysfunction, stiff posturing may be demonstrated.
34 Exposure Respect dignity Rashes Bruising Injuries Environment temperatureComplete exposure whilst maintaining dignity is important to collect all clinical information
35 Cardiorespiratory failure There is usually some respiratory compensation for decompensated circulatory failure and vice versaCardiorespiratory failure is global failure of oxygenation, ventilation and perfusionIf untreated will lead to cardiorespiratory arrest
36 Management based on initial assessment Decide on clinical status of the child:StableCompensated respiratory failureDecompensated respiratory failureCompensated circulatory failureDecompensated circulatory failureCardiorespiratory failureAsk the candidates what are the types of clinical status one an deterime?Once assessment has been performed and the clinical status decided then the management plan can be institutedIn reality assessment and treatment will occur at the same time.
37 Stable child Confirm clinical status Take a more detailed history Examination and investigations to aid diagnosisBegin treatmentReassessFor a stable patient more time can be taken in getting a more detailed history and enlisting further expert help to make a diagnosisRemember to reassess however as the child may deteriorate at any time
38 Compensated respiratory failure Assess ABCDEO2 therapy (non-threatening)Monitoring (pulse oximetry, HR, RR)Specific therapyReassessSeek expert helpNon-threatening O2 therapy is important as upsetting the child will increase oxygen demand and worsen respiratory distress.If a child has narrowed upper airways this will also cause turbulent air flow and increasing airway resistancePulse oximetry is important to assess effect of oxygen therapy.
39 Decompensated respiratory failure Open and maintain airwayHigh-flow O2VentilateAssess adequacy of ventilationReassess and monitorSeek expert helpBMV if inadequate ventilation.Always reassess.
40 Compensated circulatory failure Assess airwayHigh-flow O2MonitoringIV / IO accessFluid bolus 20 ml kg % NaClReassess after any interventionSeek expert helpReassess after each fluid bolus – CRT, pulse volume, skin temperature, HR, BP
41 Decompensated circulatory failure Open and maintain the airwayHigh-flow O2Support ventilation if requiredImmediate IV / IO access, fluid bolus 20 ml kg-1 0.9% NaClReassessRepeat fluid bolusesSeek expert help
43 Cardiorespiratory failure Open and maintain the airwayHigh-flow O2Support ventilationImmediate IV / IO access, fluid bolusesReassess and monitorSeek expert helpConsider tracheal intubation and mechanical ventilationUrgent management is required to avoid cardiorespiratory arrest
45 Oxygenation Ventilation Perfusion SummaryAirway (c-spine consideration in trauma)BreathingCirculationDisabilityExposureOxygenationVentilationPerfusionThe aim of the rapid clinical assessment is to provide information on the child’s oxygenation, ventilation and perfusion.This will determine whether there is a breathing or circulatory problem or bothTreatment will be based on this assessment.Can be done in 30 seconds.Compensated V DecompensatedCardiorespiratory Failure