appraoch to acutely ill paediatric...

APPRAOCH TO ACUTELY

ILL PAEDIATRIC PATIENT

SRI LANKA COLLEGE OF PAEDIATRICIANS

11

/12

/20

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Edu

cation

& Train

ing Sri Lan

ka Co

llege of P

aediatrician

s 1

Structured Approach

Cardiac Arrest

11/12/2019Education & Training Sri Lanka College of Paediatricians

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In adults Due to Cardiac disease

In children Due to Circulatory failure

or Respiratory failure

Airway Obstruction

Respiratory Depression

Alveolar/Chest Wall Failure

Fluid Loss

Fluid Mal-distribution

Heart Failure

Foreign body, asthma, croup, bronchiolitis

Respiratory Failure

Cardiac Arrest

Circulatory Failure

Convulsions, sepsis, poisoning, ↑ICP

Pneumonia, chest trauma & myopathy

Bleeding, burns, diarrhoea, vomiting

Sepsis, anaphylaxis, DSS

Myocardial depression, congenital abnormality


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Acutely ill patient presents with


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• Sudden obstruction to airway

• Impending respiratory arrest

• Intractable seizure

• Slow pulse with poor signs of life

Differences Between Adults and Children

Compensatory mechanisms may mask signs of severe

illness

Smaller physiological reserves

Potential for rapid deterioration

Difficult to assess

Technical procedures can be more difficult


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How do you reduce preventable

cardiac arrest ?


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• Don’t make diagnosis

• Primary survey & Resuscitation

• Fix the problem as you identify

• Airway problem

• Breathing problem

• Circulatory problem

• Neurological problem

• Tentative diagnosis

• Secondary survey and stabilization

Approach to acutely ill patient

Objectives

Follow the blue print of structured approach


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Blue Print structured approach is used to a patient

who is deteriorating or collapsed in front of you

Structured Approach

“The Blueprint” DRS approach

Triage

Position

Initial Stabilisation

Directed History and Examination

Commence Specific Treatment

Ongoing Care 11/12/2019Education & Training Sri Lanka College of Paediatricians

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D R S Approach


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DANGER Scene safety

RESPONSE Checking the response of the patient

SEND FOR HELP Seeking advice

Remember personal

protection!!

Check for danger (violence, self harm)

Put on some gloves / masks

Put on some eye protection if required

Lifting a heavy patient


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Structured Approach

TRIAGE

Sorts patients according to the level of urgency of their

illness so they are seen:

In an appropriate area

At an appropriate time

Allows safe and efficient management


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12Structured Approach

Triage

Less Urgent

Immediate / imminent life threatening

Potentially life threatening Potentially life serious Situational urgency

Triage Red Flags

A/D- Lethargy, decreased activity and difficulty

rousing.

B- Increased respiratory effort, grunting respiration

C- Pale colour and mottling

C- Decreased oral intake (<50% normal intake in a day)

and <4 wet nappies a day

D- Fever > 39C, Flushed face

Significant limb pain in febrile children


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INITIAL STABILISATION

POSITION THE PATIENT

as appropriate to the presentation

Propped up position Breathing difficulty

Status asthmatics

Severe pneumonia

Severe stridor

Lying down position

Neurological

Legs elevated position

Shock

Head elevated position

Raised ICP 11/12/2019Education & Training Sri Lanka College of Paediatricians

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Structured Approach

“The Blueprint”


Airway

Breathing

Circulation

Disability

Exposure

Reassess

• Measurement (Temp & RBS)

• Monitoring (RR, ECG, SpO2)

• Reassess

• Directed History and Examination and Ix –

• Reassess

• Commence Specific Treatment

• Ongoing Care


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Structured Approach

AIRWAY (simultaneous assessment + treatment)

Patency is the absolute first priority

Cervical spine protection is part of airway

assessment and treatment


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Normal SpO2 does not exclude obstruction

Airway

Assess airway patency

Passage of air

Abnormal sounds originating from airway

Secretions

Drooling

Normal oxygen saturation does not exclude compromised airway

RR and/or HR in patient with airway obstruction impending cardiorespiratory arrest


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Airway

Neonates obligatory nose breathers

Big occiputs

Big tongue

Larynx higher and more anterior

Epiglottis at 450 angle, large and floppy

Cervical spine more cartilaginous and flexible


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Breathing

Thorax more pliable & “Belly breathers”

Higher “normal” respiratory rate

Higher relative oxygen consumption lower

functional residual capacity result in rapid

oxygen desaturation


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Minute volume – Tidal volume x RR

INITIAL STABILISATIONBREATHING

(simultaneous assessment + treatment)

Work of Breathing

Respiratory rate & Rhythm

Accessory muscle use

Recessions

Noises

Flaring of the nostrils

Child's position

Signs of Resp Failure

Chest expansion Air entry Pulse oximetry in air /

oxygen Tracheal Tug Paradoxical Breathing


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Recognition of the seriously ill child

Effects of respiratory inadequacy

CYANOSIS IS

A PRE–TERMINAL SIGN

OXYGEN SATURATION OF

<85% IN AIR

IS A PRE-TERMINAL SIGN


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Breathing

Assess work + efficacy of breathing

Marked tachypnoea indicates critical illness

Absence of signs of ↑ respiratory work does not

exclude respiratory failure

Weak / exhausted

Neuromuscular / central disease

Low respiratory rate may indicate impending

respiratory arrest

Silent chest is a pre-terminal sign11/12/2019Education & Training Sri Lanka College of Paediatricians

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Breathing - Be concerned if

RR out of normal range for age (esp low RR)

Somnolent, agitated, confused or comatose

SpO2 < 92%

Cyanosed

Can hear little or nothing on auscultation

Deteriorating despite therapy


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Normal Paediatric Parameters

Age Weight (kg) Heart rate

(per min)

Respiratory rate BP Systolic

(mmHg)

Premature 1 145 <40 42 ± 10

Newborn 2-3 125 60 ± 10

1 month 4 120 24-35 80 ± 16

6 month 7 130 89 ± 29

1 year 10 130 20-30 96 ± 30

2-3 years 12-14 120 99 ± 25

4-5 years 16-18 100 99 ± 20

6-8 years 20-26 100 12-25 105 ± 13

10-12 years 32-42 75 112 ± 19

>14 years 50 75 12-18 120 ± 2011/12/2019Education & Training Sri Lanka College of Paediatricians

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Airway & Breathing

intervention

Neutral / Sniffing position

High oxygen through Face mask & reservoir bag

Bag & Mask ventilation

Intubation 11/12/2019Education & Training Sri Lanka College of Paediatricians

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Circulation

Higher resting pulse rate

Lower “normal” blood pressure

Limited capacity to increase stroke volume

Rely on increasing HR to increase cardiac output

Hypertension in children is premorbid

Volume resuscitation is with isotonic crystalloid

solutions.11/12/2019Education & Training Sri Lanka College of Paediatricians

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CO = SV x HR

Circulation - Rapid Assessment

Assess perfusion

Pulse rate & volume

Capillary refill time

Heart rate

Blood pressure (both supine & seated)

Skin colour

Skin temperature (cold line)


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Capillary Refilling Time


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(1) press for 5s

(2) release

(3) colour should return <2s in well-perfused, warm child

(4) A delay of >2s with other signs of shock and in a warm

child suggests poor peripheral perfusion


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Circulation - Assessment

Heart rate outside normal range

Tachycardia consistent sign in shock

Good indicator of severity of shock

A falling heart rate may indicate pre-terminal

decompensation rather than improvement.

Check Mean Arterial Pressure (MAP)


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Recognition of the seriously ill child

Cardiovascular signs

HYPOTENSION ISA PRE–TERMINAL SIGN


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Shock ≠ Hypotension

Hypotension is a late feature of shock

May indicate pre-terminal decompensation

Signs of shock can be subtle

Rule of thumb:

Over 1 year : 70 + 2 x (age in years)

is the 5th percentile for systolic blood pressure11/12/2019Education & Training Sri Lanka College of Paediatricians

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CIRCULATION

IV access or IO access / Compensated or

Uncompensated shock

Take blood for RBS, FBC, VBG, BC, SE,

Grouping Rh

IV fluids – N Saline 0.9% N Saline 20ml/kg

Check “Hepto-jugular response”


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CIRCULATION

CPR – If HR <60 / poor signs of sings of

circulation

Attach to Cardiac monitor / Identify

the rhythm (Shockable / Non-

shockable)


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Pump failure (Heart) / Response to

fluid therapy (Tank)

Gallop rhythm / murmur

Enlarged liver

Marked tachycardia

Cyanosis despite O2

Absent femoral pulses – new-borns 11/12/2019Education & Training Sri Lanka College of Paediatricians

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Brain Perfusion/Disability

or altered consciousness in absence of

neurological disease severe systemic disease

may manifest as irritability or agitation without cause

consciousness due to neurological disease


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DISABILITY (simultaneous assessment +

treatment)

• A-V-P-U approach

• Glasgow Coma Score (charts

<4 years / > 4 years)

• Glasgow Coma Score – if < 8

and not rapidly improving,

consider intubation to protect

the airway from aspiration


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Conscious level

Posture

Pupillary signs

A-V-P-U scale


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Alert – patient opens eyes spontaneously and knows time, place, person

Voice- Patient only opens eyes or makes sounds or moves to your voice

Pain – Patient only opens eyes or makes sounds or moves to pain

Unresponsive – patient does not open eyes, make sounds or move to pain or voice even

Disability

“P” or “U” means that the

child has an unprotected

airway.


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LRH >4year < 4 year Score

Best Eye

Opening

Spontaneously Spontaneously 4

To Speech To Speech 3

To Pain To Pain 2

None None 1

Best

Verbal Response Orientated Coos, babbles 5

Confused Spontaneously Irritable Cry 4

Inappropriate words Cries only to pain 3

Incomprehensible sounds Moans to pain 2

None None 1

Best

Motor Response Obeys commands Spontaneous movements 6

Localizes (pain) Withdraws from touch 5

Withdraws from (pain) Withdraws from pain 4

Abnormal flexion (pain) Abnormal flexion 3

Abnormal Extension(pain) Abnormal Extension 2

None None 1


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DISABILITY (simultaneous assessment +

treatment)

Posture

Decorticated /

Decerbrated

Pupils

Equal / Unequal /

reacting / non-reacting /

size


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Conscious level

Posture

Pupillary signs

• Decorticate • Decerebrate

Potential central neurological

failure: Posture


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Exposure/Environment

Large surface area in relation to size

results in rapid heat loss.

Look for rashes in skin folds and pressure

areas.


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“what can kill the quickest”

Simultaneous assessment and treatment

Assessment of basic life functions in a sequence which is determined by

• Potential respiratory failure

• Potential circulatory failure

• Potential central neurological failure


• MEASURE

– Temperature

– Fingerprick BSL; if hypoglycaemic, give IV dextrose

• MONITOR

– ECG, SaO2, BP

• REASSESS11/12/2019Education & Training Sri Lanka College of Paediatricians

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If the patient suddenly deteriorates

midway through the sequence,

If an abnormality is identified –

stop sequence,

treat the abnormality,

then continue

simultaneous assessment and treatment

The treatment may be simple, such as a chin lift

• go back to the beginning of the sequence


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DIRECTED HISTORY & EXAMINATION

Maintains focus on patient’s immediate illness

Saves time

Focussed history

Communicate with the child and not just the parents

BE HONEST

Respect the child’s modesty

Flexible approach (least invasive most invasive)11/12/2019Education & Training Sri Lanka College of Paediatricians

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Directed History


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Directed History - SAMPLE History


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S: Signs and symptoms.

A: Allergies

M: Medications

P: Past medical history

L: Last oral intake

E: Events surrounding the injury or illness

PAIN!!!!!

Children Feel Pain

Inadequate Analgesia Is Common

Strategies To Help


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Pain Assessment


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Pain Score


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COMMENCE SPECIFIC TREATMENT

Identify pivotal, time critical interventions

Sepsis – antibiotics

Acute Stridor – steroids / intubation

Severe asthma – nebulisation

Snake envenametion – antivenoum

\ 11/12/2019Education & Training Sri Lanka College of Paediatricians

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ONGOING CARE

Reassess, reassess, reassess

Admit: ICU / general ward

Transfer / retrieval

Handover


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ISBAR

Identification

Situation

Background

Assessment

Recommendation


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Situation

Identify yourself the site/unit you are calling from

Identify the patient by name and the reason for your

report

Describe your concern


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Background

Give the patient's reason for admission

Explain significant medical history


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Assessment

Vital signs

Clinical impressions, concerns


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Recommendation

Explain what you need - be specific about request

and time frame

Make suggestions

Clarify expectations


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Principles of handing over on

I.A.T.M.I.S.T principle


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• Identification

• Age and sex of the patient [5 seconds]

• Time of the incidence and estimated time of arrival

[10 seconds]

• Medical complaint [20 seconds]

• Information related to the complaint / Injuries in

trauma patient (seen or suspected) [25 seconds]

• Signs – Vital signs [35 seconds]

• Treatment that was offered [45 seconds]

Challenging to Assess

Young children

Severely-injured

Cognitive impairment

Immunocompromised

Severe pain


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Structured Approach

DRS approach

Triage

Position

Initial Stabilisation (Airway, Breathing, Circulation,

Disability, Exposure)

Directed History and Examination

Commence Specific Treatment

Ongoing Care


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Structured Approach

“The Blueprint”


Airway

Breathing

Circulation

Disability

Exposure

Reassess

• Measurement (Temp & RBS)

• Monitoring (RR, ECG, SpO2)

• Reassess

• Directed History and Examination and Ix –

• Reassess

• Commence Specific Treatment

• Ongoing Care


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