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Recognition and management of the seriously ill child Dr Esyld Watson Consultant in Adult and Paediatric Emergency Medicine.

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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 outcomes  To understand the aetiology of and clinical pathways to cardiorespiratory arrest in children  To use a rapid ABCDE assessment to determine the clinical state  To distinguish between compensated and decompensated respiratory or circulatory failure  To initiate treatment interventions based on ABCDE assessment and reassessment

3 Aetiology of cardiorespiratory arrest  Children are different to adults  Adults ◦ Usually a primary cardiac arrest ◦ Sudden and unpredictable in onset ◦ Usually due to arrhythmia ◦ Not usually preceded by hypoxia and acidosis ◦ Successful outcome depends on early defibrillation

4 Aetiology of cardiorespiratory arrest  Children ◦ Most children have secondary arrest ◦ Respiratory and/or circulatory failure leads to hypoxia and acidosis. ◦ Myocardial hypoxia results in bradycardia then asytole ◦ Early 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 disease

5 Pathways to cardiorespiratory arrest Compensated circulatory failureCompensated respiratory failureCardiorespiratory failure Cardiorespiratory arrest Decompensated circulatory failure Decompensated respiratory failure

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7 Recognition of the seriously ill child is based on assessment of:  A irway (c-spine consideration in trauma)  Breathing  Circulation  Disability  Exposure Oxygenation Ventilation Perfusion

8 A - Airway

9 Assessing the airway

10 B - Breathing

11 Assessing breathing oxygenation and ventilation Minute ventilation = Tidal volume x RR  Respiratory rate (RR)  Work of breathing  Tidal volume (chest expansion)  Oxygenation (pulse oximetry)

12 Assessing respiratory rate  Increased RR is often the first sign of respiratory difficulty  RR varies with age, fever, pain and anxiety as well as in respiratory failure  Monitor the trend in RR

13 Assessing the work of breathing

14 Assessing tidal volume  Tidal volume (look, listen, feel) ◦ Compare one side of chest with the other ◦ Subjective assessment: breath sounds should be audible in both bases ◦ (Feel for trachea; is it central?)

15 Assessing respiratory sounds  Stridor  Wheeze  Grunting

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20 Assessing oxygenation ◦ Cyanosis is unreliable (SpO 2 < 80%)  Any child with a breathing problem must have pulse oximetry  Clinical signs of hypoxia  Irritability, agitation, drowsiness, level of consciousness

21 Decompensation?  Increasing respiratory rate  Sudden fall in respiratory rate  Exhaustion  Reduced interaction with caregivers, agitation  Diminishing level of consciousness

22 C - Circulation

23 Assessing circulatory status

24 Assessing pulses  Comparison of central and peripheral pulses ◦ Reflects stroke volume ◦ As shock progresses peripheral pulses are lost before central pulses

25 Assessing heart rate  Increased HR is often the first sign of circulatory compromise  HR varies with age, fever, pain and anxiety as well as in circulatory failure  It is more important to monitor the trend in HR than to rely on absolute value

26 Assessing skin perfusion  Feel skin temperature ◦ Warm / cold line  Skin colour ◦ Mottling ◦ Pallor ◦ Peripheral cyanosis ◦ Rashes

27 Assessing capillary refill time  CRT > 2 sec is abnormal  Assess peripherally and centrally

28 Assessing cerebral perfusion  Early signs ◦ Loss of interest in surroundings ◦ Irritability, agitation  Late signs ◦ Drowsiness, loss of consciousness, hypotonia (floppy)

29 Assessing renal perfusion Urine output is an index of organ perfusion  Nappy weights or number of wet nappies  Urinary catheter (> 1 ml kg -1 h -1 )  How many times passed urine that day?

30 Decompensation?  Steadily increasing HR  Sudden fall in HR  Increasing peripheral vasoconstriction  Reduced interaction with care givers, agitation  Diminishing level of consciousness  Hypotension

31 D - Disability

32 Assessing disability  Evaluate the level of responsiveness ◦ Alert ◦ Voice ◦ Pain ◦ Unresponsive to painful stimulus  Posturing  Pupil reaction  Glucose

33 E- Exposure

34 Exposure  Respect dignity  Rashes  Bruising  Injuries  Environment temperature

35 Cardiorespiratory failure  There is usually some respiratory compensation for decompensated circulatory failure and vice versa  Cardiorespiratory failure is global failure of oxygenation, ventilation and perfusion If untreated will lead to cardiorespiratory arrest

36 Management based on initial assessment Decide on clinical status of the child:  Stable  Compensated respiratory failure  Decompensated respiratory failure  Compensated circulatory failure  Decompensated circulatory failure  Cardiorespiratory failure

37 Stable child  Confirm clinical status  Take a more detailed history  Examination and investigations to aid diagnosis  Begin treatment  Reassess

38 Compensated respiratory failure  Assess ABCDE  O 2 therapy (non-threatening)  Monitoring (pulse oximetry, HR, RR)  Specific therapy  Reassess  Seek expert help

39 Decompensated respiratory failure  Open and maintain airway  High-flow O 2  Ventilate  Assess adequacy of ventilation  Reassess and monitor  Seek expert help

40 Compensated circulatory failure  Assess airway  High-flow O 2  Monitoring  IV / IO access  Fluid bolus 20 ml kg % NaCl  Reassess after any intervention  Seek expert help

41 Decompensated circulatory failure  Open and maintain the airway  High-flow O 2  Support ventilation if required  Immediate IV / IO access, fluid bolus 20 ml kg % NaCl  Reassess  Repeat fluid boluses  Seek expert help

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43 Cardiorespiratory failure  Open and maintain the airway  High-flow O 2  Support ventilation  Immediate IV / IO access, fluid boluses  Reassess and monitor  Seek expert help  Consider tracheal intubation and mechanical ventilation

44 Any questions?

45 Summary  A irway (c-spine consideration in trauma)  Breathing  Circulation  Disability  Exposure Oxygenation Ventilation Perfusion Compensated V Decompensated Cardiorespiratory Failure


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