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
Emphasise the ABCDE approach

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
Emphasise 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 rarely
Must intervene to prevent this occurring.
Outcome is very poor if CPA occurs.

5. Pathways to cardiorespiratory arrest
Compensated circulatory failure
Compensated respiratory failure
Decompensated
circulatory failure
respiratory failure
Cardiorespiratory failure
Cardiorespiratory arrest
Summary slide
Successful resuscitation in children depends upon early recognition of respiratory and circulatory failure and measures to prevent progression to cardiorespiratory arrest

6. Normal Values

7. Recognition of the seriously ill child is based on assessment of:
Airway (c-spine consideration in trauma)
Breathing
Circulation
Disability
Exposure
Oxygenation
Ventilation
Perfusion
The 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 both
Treatment will be based on this assessment.
Can be done in 30 seconds.

8. A - Airway

9. Assessing the airway
An 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 adults
Stridor is an inspiratory noise indicating extrathoracic obstruction of the upper 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
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 other
Subjective 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
Stridor
Wheeze
Grunting
Volume 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 oximetry
Clinical signs of hypoxia
Irritability, agitation, drowsiness, level of consciousness
Cyanosis is not a reliable indicator of the degree of hypoxia; it may never be observed in a profoundly hypoxic child if there is significant anaemia
SpO2 of < 90% in air or < 95% in supplemental oxygen indicates respiratory failure
When SpO2 is < 70% pulse oximetry is inaccurate, although trends will still be reliable

21. Decompensation? Increasing respiratory rate
Sudden fall in respiratory rate
Exhaustion
Reduced interaction with caregivers, agitation
Diminishing level of consciousness
Ask candidates for the signs of decompensation

22. C - Circulation

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 volume
As shock progresses peripheral pulses are lost before central pulses
Consider which pulses are central and peripheral in infants and children and easily accessible

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
Skin temperature much more useful than skin colour.

27. Assessing capillary refill time
CRT > 2 sec is abnormal
Assess peripherally and centrally
Play video clip.
Caution if the child has been in cold weather, consider central CRT

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?
Regular measurement of urine output very helpful in assessing perfusion
Can be a relatively early sign of circulatory failure
Normal infant usually has six wet nappies a day

30. Decompensation? Steadily increasing HR Sudden fall in HR
Increasing peripheral vasoconstriction
Reduced interaction with care givers, agitation
Diminishing level of consciousness
Hypotension
Ask candidates for the signs of decompensation
Emphasise that hypotension is a late sign and it should be possible to determine decompensation before hypotension occurs.

31. D - Disability

32. Assessing disability Evaluate the level of responsiveness Posturing
Alert
Voice
Pain
Unresponsive to painful stimulus
Posturing
Pupil reaction
Glucose
Painful 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 floppy
If there is serious brain dysfunction, stiff posturing may be demonstrated.

33. E- Exposure

34. Exposure Respect dignity Rashes Bruising Injuries
Environment temperature
Complete 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 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
Ask 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 instituted
In 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 diagnosis
Begin treatment
Reassess
For a stable patient more time can be taken in getting a more detailed history and enlisting further expert help to make a diagnosis
Remember to reassess however as the child may deteriorate at any time

38. Compensated respiratory failure
Assess ABCDE
O2 therapy (non-threatening)
Monitoring (pulse oximetry, HR, RR)
Specific therapy
Reassess
Seek expert help
Non-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 resistance
Pulse oximetry is important to assess effect of oxygen therapy.

39. Decompensated respiratory failure
Open and maintain airway
High-flow O2
Ventilate
Assess adequacy of ventilation
Reassess and monitor
Seek expert help
BMV if inadequate ventilation.
Always reassess.

40. Compensated circulatory failure
Assess airway
High-flow O2
Monitoring
IV / IO access
Fluid bolus 20 ml kg % NaCl
Reassess after any intervention
Seek expert help
Reassess after each fluid bolus – CRT, pulse volume, skin temperature, HR, BP

41. Decompensated circulatory failure
Open and maintain the airway
High-flow O2
Support ventilation if required
Immediate IV / IO access, fluid bolus 20 ml kg-1 0.9% NaCl
Reassess
Repeat fluid boluses
Seek expert help

43. Cardiorespiratory failure
Open and maintain the airway
High-flow O2
Support ventilation
Immediate IV / IO access, fluid boluses
Reassess and monitor
Seek expert help
Consider tracheal intubation and mechanical ventilation
Urgent management is required to avoid cardiorespiratory arrest

44. Any questions?

45. Oxygenation Ventilation Perfusion
Summary
Airway (c-spine consideration in trauma)
Breathing
Circulation
Disability
Exposure
Oxygenation
Ventilation
Perfusion
The 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 both
Treatment will be based on this assessment.
Can be done in 30 seconds.
Compensated V Decompensated
Cardiorespiratory Failure