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Care of the very sick childCare of the very sick child
Morris Earle, Jr. MD, MPHMorris Earle, Jr. MD, MPHUMASS Memorial Medical SchoolUMASS Memorial Medical School
Worcester, MAWorcester, MA
and Sarah A. Murphy, MDand Sarah A. Murphy, MDMassGeneral Hospital for ChildrenMassGeneral Hospital for Children
Boston, MABoston, MA
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Care of the very sick child: Care of the very sick child: Presentation OverviewPresentation Overview
• This presentation will focus on the principles that are common to:
• Emergency Triage Assessment and Treatment (ETAT)
• Pediatric Advanced Life Support (PALS)• and the treatment of very sick children
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Presentation OverviewPresentation Overview
• We will focus on:– Recognition of very sick children– Rapid assessment of ABCs– Treatment of A,B, and C according to ETAT
guidelines– Next steps in treatment of a very sick child– Rapid differentials for various signs and
symptoms
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Care of the very sick child: ETATCare of the very sick child: ETAT
• “Emergency Triage Assessment and Treatment”
– Deaths in hospital often occur within 24 hours of admission
– Many of these deaths could be prevented if very sick children are identified quickly and appropriate treatment started immediately
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ETATETAT
– ETAT is a set of guidelines developed by the WHO for health care providers
– It is meant to aid in the rapid recognition and treatment of very sick children
– Based on the principle of recognizing “emergency signs” and beginning appropriate therapy for them when present
– Like PALS and other treatment protocols, follows the format of ABC
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Why does having a system for rapid recognition and Why does having a system for rapid recognition and treatment matter?treatment matter?
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““The management of sick young infants at The management of sick young infants at primary health centres in a rural developing primary health centres in a rural developing
country”country” Archives of Disease in Childhood 2005:90:200-205Archives of Disease in Childhood 2005:90:200-205 Duke, Oa, Mikela et al (Papua New Guinea) Duke, Oa, Mikela et al (Papua New Guinea)
• Signs predicting death were: – not able to feed– fast respiratory rate– retractions– apnea– cyanosis– “too small”– “skin cold”– severe abdominal distension– bulging fontanelle– hypothermia (<36 axillary)
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““The management of sick young infants at The management of sick young infants at primary health centres in a rural developing primary health centres in a rural developing
country”country”
Conclusions:
• signs predictive for death may warrant:– emergency treatment – longer observation – or urgent referral
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• Respiratory compromise was present in 25% of young infants
• Failure to give oxygen therapy was a modifiable factor in 27% of deaths within health facilities
• A high proportion of seriously ill young infants were discharged from health facilities
early without adequate follow up
““The management of sick young infants at The management of sick young infants at primary health centres in a rural developing primary health centres in a rural developing
country”country”
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Care of the very sick childCare of the very sick child
1) Diagnosis: Who is “very sick” ?
2) Management:Airway
Breathing Circulation
Etc…
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Recognizing a “very sick Recognizing a “very sick child”child”
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WHO-identified “Emergency Signs” (ETAT) WHO-identified “Emergency Signs” (ETAT) that require immediate intervention:that require immediate intervention:
• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Signs of severe dehydration
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Respiratory Rate >60 (infant)>40 (toddler)
>30 (child) >20 (teen)
Heart Rate >160 (infant) >120 (child) > 90 (teen)
EarlyEarly Signs of Severe Illness: Signs of Severe Illness: Abnormal Vital SignsAbnormal Vital Signs
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Abnormal Vital SignsAbnormal Vital Signs
Hypo or hyperthermia
Later Signs:
Hypotension:
< 60 systolic (newborn)
< 70 (infant)
< 70 +(age x 2) (child)
< 90 (teen)
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Assessment of the Very Sick Assessment of the Very Sick ChildChild
Rapid assessment of a sick child begins with ABC’s…
Assess and treat Airway, Breathing, and then Circulation, in that order
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A = AirwayA = Airway
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The ten commandments of The ten commandments of Pediatric Intensive Care; Pediatric Intensive Care;
• Airway
• Airway
• Airway
• Airway
• …Et cetera
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Complete Airway Obstruction;Complete Airway Obstruction;
• Either dead
or
• Has a foreign body – needs heimlich maneuver (child)– or five back blows and chest compressions
(infant)
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5 Back blows:5 Back blows: for infant with for infant with
suspected suspected foreignforeign
body and body and complete complete
airway airway obstructionobstruction
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Alternate with 5 chest compressionsAlternate with 5 chest compressions
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Heimlich Maneuver for a childHeimlich Maneuver for a child
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Partial Airway Obstruction:Partial Airway Obstruction:
• Look for signs of Partial obstruction!– Stridor– Snoring– Accessory muscle use– Abdominal breathing
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Partial Airway Obstruction:Partial Airway Obstruction:
Child is Conscious:
1. Inspect mouth and remove foreign body if present
2. Clear secretions from mouth and throat
3. Allow child to assume most comfortable position
Child is Unconscious:
1. Tilt head (unless concern for trauma to head/neck- then do jaw thrust with 2nd person stabilizing neck)
2. Inspect mouth, remove foreign bodies
3. Clear secretions from mouth and throat
4. Check airway by feeling for breath, watching for chest rise, listening for breath sounds
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Positioning airway: Positioning airway: 1.Sniffing position1.Sniffing position
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The sniffing positionThe sniffing position
•
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Adjust Airway:Adjust Airway:2. jaw thrust2. jaw thrust
• Should be used if there is any concern about neck trauma or cervical spine injury
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Adjust Airway:Adjust Airway:3. Artificial airway3. Artificial airway
• Oral airway if unconscious
• Nasal airway if conscious
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Nasopharyngeal Airway:
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Insertion of oral airwayInsertion of oral airway
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Sizing of oral airwaySizing of oral airway
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B: BreathingB: Breathing
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Assessment of Breathing:Assessment of Breathing:signs of respiratory distresssigns of respiratory distress
• Tachypnea
• Retracting
• Grunting
• Flaring
• Use of accessory muscles
• Stridor
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RetractionsRetractions
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Respiratory DistressRespiratory Distress
• If patient exhibits signs of respiratory distress, administer oxygen:
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Assisted Breathing:Assisted Breathing:bag and mask techniquebag and mask technique
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The sniffing positionThe sniffing position
•
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Bag and Mask Ventilation:Bag and Mask Ventilation:watch for chest risewatch for chest rise
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Assisted Breathing: IntubationAssisted Breathing: Intubation
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Use of curved bladeUse of curved blade
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Use of straight bladeUse of straight blade
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View of vocal cordsView of vocal cords
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Assisted Breathing: Assisted Breathing:
• Chest must rise well
• Check for proper placement of ETT with CO2 detector if available
• Check for equal breath sounds in axillae
• Confirm placement with xray
• Place nasogastric or orogastric tube
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For the following “emergency signs”:For the following “emergency signs”:
Severe Respiratory Distress,Severe Respiratory Distress,Central Cyanosis,Central Cyanosis,
oror Obstructed Airway: Obstructed Airway:
• Emergency Management:– Manage choking if foreign body aspiration– Position airway properly– Administer oxygen– Assist in ventilation if needed– Make sure child is warm
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C = CirculationC = Circulation
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Assessment of Circulation: Assessment of Circulation: ShockShock
• Cold hands AND:– Capillary refill >2 seconds– Weak and fast pulse
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Signs of ShockSigns of Shock
• Tachycardia
• Poor perfusion (>2 second capillary refill)
• Weak pulses
• Cool extremities
• Poor mentation, lethargy
• Poor urine output
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ShockShock
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For the following “emergency signs”:For the following “emergency signs”:
Cold hands,Cold hands,Capillary refill >2 seconds,Capillary refill >2 seconds,andand Weak and fast pulse: Weak and fast pulse:
• Emergency Management:– Stop any bleeding– Give oxygen– Make sure child is warm– Give fluids (see chart)– Give glucose– Full assessment and treatment
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For the child in shock it is For the child in shock it is imperative to give fluids…imperative to give fluids…
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Obtain IV access!Obtain IV access!If unable to place IV, place IOIf unable to place IV, place IO
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ShockShock
• Early detection and aggressive management improves survival
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Vascular AccessVascular Access
• Consider intraosseous line placement as initial attempt for victims of cardiac arrest
• No upper age limit for attempt at intraosseous access (Class IIa, LOE 5)
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Intraosseus needle insertionIntraosseus needle insertion
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Intraosseus needle insertionIntraosseus needle insertion• Alcohol swabs• 18G needle with trochar (at least 1.5 cm in length)• 5 ml syringe• Infusion fluid• Local anaesthesia may be required if the patient is
conscious.
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Intraosseus needle: alternative siteIntraosseus needle: alternative site
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Treatment of Shock:Treatment of Shock:
• First! assess if child is severely malnourished• If not:
– Insert IV or IO– Prepare a bag of Ringers Lactate or Normal Saline– Infuse 20ml/kg as rapidly as possible– Reassess after 1st infusion and repeat if no
improvement– Reassess after 2nd infusion and repeat if no
improvement– Reassess after 3rd infusion. If no improvement give
20cc/kg of blood transfusion, or a 4th bolus of fluids if patient has diarrheal illness
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Treatment of Shock:Treatment of Shock:
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• If a child is severely malnourished it may be difficult to distinguish shock from malnourishment
• In addition, shock from sepsis and dehydration may coexist
• Fluids must be given very slowly • Monitor pulse and breathing every 5-10 mins• Over-hydration can lead to heart failure
Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients
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• If the child is lethargic or unconscious:– Keep warm– Give 10% glucose 5ml/kg– Then give IVF: 15ml/kg over 1 hour– Re-assess every 5-10mins for improvement or
worsening– STOP infusion if respiratory rate increases or pulse
increases as this means fluids are worsening the child’s condition
– If improvement after fluid, may repeat x1 over an hour– Then switch to oral or NG re-hydration and initiate re-
feeding
Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients
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• If the child does not improve with first fluid bolus:– Assume child is in septic shock as opposed to
dehydration related shock– Give maintenance fluids– Transfuse 10ml/kg of blood, when available,
slowly, over 3 hours– Start antibiotic treatment– Initiate re-feeding
Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients
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• If severely malnourished child is NOT lethargic or unconscious, but is alert:– Give 10% glucose: 10ml/kg by mouth or
nasogastric tube– Move to assessment and treatment for severe
malnourishment
Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients
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Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients
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Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients
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After A, B, C, move on to assess After A, B, C, move on to assess the “other C”, D, and then other the “other C”, D, and then other
organ functions…organ functions…
Assessment of the very sick Assessment of the very sick child:child:
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The “other C’s”= coma or The “other C’s”= coma or convulsionsconvulsions
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Assess for Coma or Assess for Coma or Convulsions: AVPUConvulsions: AVPU
• Is the child:– Alert?– Responding to Voice?– Responding to Pain?– Unconscious?
• A child who is not alert but responding to voice is lethargic
• A child who does not respond to pain is unconscious
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Assess for Coma or Assess for Coma or Convulsions:Convulsions:
• Is the child having rhythmic movements and unresponsive?
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For the following “emergency signs”:For the following “emergency signs”:
ComaComaoror
Convulsing:Convulsing:
• Emergency Management:– A, B, C– Give oxygen– Diazepam or Paraldehyde rectally for
convulsions (seizures)– Position unconscious child in protective
manner– Give IV glucose– Full assessment and treatment
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D = DehydrationD = Dehydration
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Severe Dehydration in Child Severe Dehydration in Child with Diarrheawith Diarrhea
• Diarrhea plus– Lethargy– Sunken eyes– Very slow skin pinch
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For the following “emergency sign”:For the following “emergency sign”:
Diarrhea with Diarrhea with lethargy, sunken eyes, or very slow lethargy, sunken eyes, or very slow
skin pinch:skin pinch:
• Emergency Management:– Make sure child is warm– If child is NOT severely malnourished
• Insert IV and give rapid fluid boluses• Treat diarrhea
– If child is severely malnourished:• Do not insert IV• Treat per malnourishment guidelines
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Review: Assessment and treatment Review: Assessment and treatment of the very sick childof the very sick child
• After assessing for, and immediately treating “emergency signs”, the caregiver should then move on to looking for “priority” signs which warrant urgent treatment
• Emergency Signs:– Obstructed Breathing– Severe Respiratory Distress– Central Cyanosis– Signs of Shock– Coma– Convulsions– Signs of severe dehydration
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Review: Assessment and Review: Assessment and Treatment of the very sick child:Treatment of the very sick child:
• Priority signs:– Sick child less than 2 mos– Very high temperature– Trauma or other surgical condition– Pallor– Poisoning– Severe Pain– Respiratory Distress– Restless/Irritable– Malnutrition– Oedema– Burns
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• Remember: start with assessing and securing A,B, C!
Review: Assessment and Review: Assessment and Treatment of the very sick child:Treatment of the very sick child:
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Special Note about: Emergency Findings in Special Note about: Emergency Findings in a Severely Malnourished Child:a Severely Malnourished Child:
• All children with severe malnourishment require prompt attention and treatment of malnourishment
• A severely malnourished child who presents with airway obstruction or severe respiratory distress, coma or convulsions should be treated as you would a non-malnourished child
• Severely malnourished children who are dehydrated should NOT be re-hydrated by IV unless they are in shock
• Severely malnourished children in shock should be re-hydrated cautiously with frequent re-assessment of their response to fluids