2. CIRCULATION

3. 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

4. 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

5. 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

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

7. 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

8. 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

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

10. 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

11. 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?

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

13. 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

14. 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?

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

16. Interact!
How do you manage?

17. 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

18. 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

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

20. 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.

21. 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

22. 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

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

24. 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 ?

25. 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

26. 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?

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

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

29. 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 ml/kg/hr over one hour )

30. 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

31. 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

32. 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

33. 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