CIRCULATION

Rapid assessment The circulatory status reflects the effectiveness of cardiac output as well as end-organ perfusion The rapid assessment includes: Cardiovascular function End-organ perfusion (systemic circulation) To asses the effective circulation – assess both cardiac parameters and end organ perfusion parameters

Cardiovascular function For age based vitals Refer SOS - HOPE APP Cardiovascular function Heart rate: age-dependent Ranges Central and peripheral pulses: compare the femoral, brachial, and radial pulses AGE ( year ) Normal Heart Rate ( beats/min) <1 year 100 – 160 1-2 year 90 – 150 2-5 year 80 – 140 6-12 year 70 – 120 >12 year 60 – 100

Blood Pressure Blood pressure: age-dependent For age based vitals Refer SOS-HOPE APP Blood Pressure Blood pressure: age-dependent Use the following guidelines to estimate the lowest acceptable (5th percentile) systolic BP (SBP) Newborn – 1 month < 60 mmHg SBP 1 month – 1 year < 70 mmHg SBP 1–10 years < 70 mmHg + (2 X age in years) SBP > 10 years < 90 mmHg SBP Suggest delegates to look for normogram of vitals in HOPE APP

End-organ perfusion Skin perfusion: capillary refill (<2 sec normal), color, extremity temperature (relative to ambient temperature) Demonstrate Capillary refill

Behavior and appearance indicate CNS perfusion CNS perfusion: mental status, level of consciousness, irritability, consolablity Level of consciousness A - Alert V - Verbal responsiveness P - Painful responsiveness U - Unresponsive Assessing sensorium is to understand weather brain perfusion affected or not

Compensated Shock Tachycardia Cool and pale distal extremities Prolonged capillary refill (>2 seconds) despite warm ambient temperature Weak peripheral pulses compared with central pulses Normal systolic blood pressure

Decompenated Shock Depressed mental status Decreased urine output Tachypnea Weak central pulses Deterioration in color/Mottling Falling systolic blood pressure

Case -1 A 10 month old AYUSH Brought to the Clinic On mother’s lap The nurse observed that The baby is not active & eyes are sunken Immediately the nurse asks for the history, Mother says the child has continuous diarrhea & vomiting since 48hours

On Examination Interact! The attending Pediatrician quickly examines the child What to look for ? Look for signs of dehydration Whether the child has signs of shock?

Signs of Severe Dehydration GC : Lethargic, floppy EYES : very much sunken MOUTH & TONGUE : very dry SKIN PINCH : goes back very slowly

Signs of shock Pulse – fast, low volume (feeble) Extremities – cold & mottled CFT – Prolonged >2secs BP – Normal or low or not recordable The sensorium – Irritable or drowsy, respiration rapid or shallow Suggestions - Oliguria , These additional signs may be present

Case 1 contd Interact! AYUSH is lethargic, wt 10 kg. Eyes : very much sunken Skin pinch : goes back very slowly Pulse : fast ,feeble Extremities : cold ,mottled CFT : Prolonged >2secs BP : Normal What is your assessment?

Assess, Decide & Act Ayush Has signs of severe dehydration & In shock BP normal- compensated shock Hypovolaemic shock

Interact! How do you manage?

Golden hour Management of shock GOAL Restoration Of Tissue Perfusion And Oxygenation. PRINCIPLES A - establishment of Airway. B - maintenance of Breathing. C - restoration of Circulatory blood volume - fluid resuscitation Suggestions - Oxygenation can be improved by- a) Admn of high conc. O2 b) Transfusion to keep Hb > 10 c) Ventilatory support Tissue Perfusion – Fluid resuscitation & vasoactive agents are used to improve perfusion

Management of Shock Airway-clear & patent Breathing-Provide O2 to Maintain SaO2>92% Establish peripheral IV line/ IO Start Ringer’s Lactate or Normal saline 20 ml/kg bolus (Ayush is 10kg needs 200ml over 5-10 min) Reassess for signs of improvement

Response after 20 ml/kg (NS)bolus Interact! Pulse well felt HR 140/min BP - 90/66 CFT<2sec WHAT NEXT?

Next step? Ayush needs Dehydration correction Continue IV fluid-100ml/kg over 6hrs - RL/ NS. Ayush needs 1000ml of fluid over 6 hours for correction of dehydration (300ml over 1 hour & remaining 700ml over 5 hrs) Reassess & If able to take orally give ORS.

Case 2 Master A 5 year old weight of 20 kg Short 3 day history of fever and ARI Brought with difficulty breathing and increased sweating from last night Stress on sweating and breathlessness on day 3 of viral illness

On Evaluation Appears apprehensive Well hydrated Tachypnea rate about 40/min Tachycardia 180/min Peripheral pulses feeble BP 60/40 mmhg Liver 3 cm Pulse Oximeter saturation 90% Stress on tachycardia , feeble pulses , low BP increased liver size , and low saturation

Assessment Careful evaluation of the CVS/RS JVP/Hepatomegaly Gallop rhythm Tender hepatomegaly Probably myo-pericarditis Triage category –

Management Stabilize ABC Oxygen Vascular access IV fluids Transport consider inotropes if hypotensive or time to shift > 4 hrs Monitoring Discuss about IV fluids – which fluid , how much ? And how fast ? What parameters to look for after bolus fluid is given ?

Case 3 A 5 yr old Ashwini, 20kg Brought with h/o tiredness, headache since 6 hrs Had h/o fever, headache since 5 days Suggestions Fever , headache since 5 days . Afebrile for last 2 days. Pain abdomen, tiredness ,headache since 6 hrs

On Examination Interact! Restless, irritable. Flushing present Pulse- 180/min weak & thready extremities cold & mottled CFT> 6sec BP 70/50mm Hg What is your assessment?

Assessment Ashwini is in shock Hypotensive shock ?Dengue shock syndrome. Suggestion – Can put ? Mark before DSS

Dengue shock syndrome Management A - clear B - good C - IV/IO access Send for Hematocrit, platelet count & Dengue serology

Fluid Therapy in DSS ( WHO guidelines ) IV fluid RL bolus 100ml stat (10ml/kg over 15 minutes) Reassess If improves, Continue IV Fluid RL/NS 10 ml/kg/hr for one hour, Then continue at the rate of 5-7ml/kg/ hr for next 1-2 hour, then reduce to 3-5ml/kg/hr for next 2-4 hour, & then to 2-3 ml/kg for 24 – 48 hours. In DSS(if in compensated shock, that is BP is normal but in shock ,the Initial Fluid bolus should be given slowly at 5- 10ml/kg/hr over one hour )

Case - 4 4 year old, fever 3 days Rapid breathing, “not his usual self” Not taking feeds since previous night Has not passed urine that day

Assessment Looks sick, dusky Grunting, RR 50/min Pulse 180/min, low volume Capillary refill 5 sec BP 80/50 mm Hg Saturation 80% Decreased breath sounds left side CBG 100 mg/dl

Response Free flow oxygen with nonrebreathing mask IV access, 20 ml/kg normal saline bolus, reassess CRT,HR,BP Up to 3 boluses if needed Monitor cirulation constantly – HR,CRT,BP,Sats Ceftriaxone 100 mg/kg after collecting blood for culture Transport with medical supervision When ever possible give first dose of antibiotics as soon as possible, if facilities are present take blood culture before starting antibiotics

Conclusion Assess circulation in orderly fashion Follow protocol for resuscitation Monitor continuously until stable , including during transport Communicate with receiving hospital, document what you have done