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Recognition of the seriously ill child
23/03/11Dr. John Twomey,
Consultant Paediatrician,Department of Paediatrics/ Emergency Department
Medical Students
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Describe what you see
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15th century, unknown artist
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1664, Gabriel Metsu
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1885, Eugene Carriers
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2006, Life magazine
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The sick child
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Some Ground Rules!
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Diverse range from infancy to adolescence
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Children Are Not “Little Adults”
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What are the key differences to consider in children?
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• Weight
• Anatomical
• Physiological
• Psychological
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Weight
• Centile Charts• Broselow Tape• Formula (1-10yrs): Wt (kg) = (age + 4)2• Estimate (0-1 yrs): Newborn = 3.5 kg 6/12 = 7 kg 12/12 = 10 kg• Estimate (>10 yrs): 10 yrs = 30 kg 12 yrs = 40 kg 14 yrs = 50 kg 16 yrs = 60 kg
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Anatomical
Airway - Large head- Short & soft trachea- Small face & mandible- Loose teeth & Large tongue- Easily compressible floor of the mouth- Obligate nasal breathers (<6/12)- Adenotonsillar hypertrophy- Horse-shoe shaped epiglottis projecting posteriorly- High & anterior larynx (straight bladed laryngoscope)- Cricoid ring = narrowest part of the airway (Larynx in
adults) & is susceptible to oedema (uncuffed ett)- Symmetry of carinal angles
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Anatomical
Breathing - Lung immaturity- Small air-surface interface (<3m²)- Less small airways (1/10 of adult)- Small upper & lower airways- R 1/r4- Diaphragmatic Breathing- More horizontal ribs
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Anatomical
Circulation- RV>LV (0-6/12) => LV>RV- Blood circulating volume/body weight = 70-80 mls/kg- Absolute volume is small (critical importance of relatively
small amounts of blood loss)
Body Surface Area- BSA:Wt ↓ with ↑ age- Small children have a high ratio => relatively more prone
to hypothermia
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Physiological
Respiratory- Infant - ↑ BMR & O2
Consumption => ↑ RR
Age (yrs) RR (bpm)
<1 30-40
1-2 25-35
2-5 25-30
5-12 20-25
>12 15-20
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Physiological
Cardiovascular- CO = SV x HR- Infant – small stoke
volume => ↑ HR
Age (yrs) HR (bpm)
<1 110-160
1-2 100-150
2-5 95-140
5-12 80-120
>12 60-100
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Physiological
Cardiovascular- Infant - ↓ systemic
resistance => ↓ BP- SBP = 80 + (age x 2)
Age (yrs) SBP(mmHg)
<1 70-90
1-2 80-95
2-5 80-100
5-12 90-110
>12 100-120
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Physiological
Immune system
- Immature immune system
- Maternal antibodies (x 1st 6/12)
- Protective effect of breast feeding
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Psychological
Communication- No or limited verbal communication- Many non-verbal cues- Age-appropriate communication
Fear- Additional distress to the child and adds to parental
anxiety => altered physiological parameters => difficult to interpret
- Explain as clearly as possible (Knowledge allays fear)- Parental presence at all times
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A Structured Approach
• 1º Assessment - Resuscitation – identifying & treating the immediate threats to life – closed or obstructed airway, absent or distressed respiration, pulselessness, shock
• 2º Assessment - Emergency Treatment – to start to treat the underlying cause of the child’s condition
• Reassessment - Stabilisation – achieving homeostasis and system control
• Transfer – to a definitive care environment (PICU)
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A Structured Approach
• Preparation (before the child arrives)
• Teamwork (with a designated team leader)
• Communication (with contemporaneous recording of history, clinical findings, treatments)
• Consent (assumed if acting in the best interests of the child)
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WETFAG• Weight = (Age + 4)2
• Energy = 4 J/kg asynchronous shock
• Tube = (Age/4) + 4 ---- +/- 0.5
• Fluids = 20 mls/kg 0.9% NaCl
• Adrenaline = Adrenaline 10 μg/kg IV/IO (0.1ml/kg of 1:10,000); 100 μg/kg (0.1ml/kg of 1:1,000) ETT
• Glucose = Dextrose 10% 5ml/kg IV
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1º Assessment
&
Resuscitation
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ABCD(E)
• Airway
• Breathing
• Circulation
• Disability
• (Exposure)
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Airway & Breathing
Effort of breathing:• RR/Recession/Inspiratory & expiratory
noises/Grunting/Use of accessory muscles/Nasal flaring/Gasping
Efficacy of breathing:• Chest expansion/Abdominal excursion/ Chest
auscultation/Pulse oximetryExceptions:• Exhaustion/↑ICP/NM d/oEffect of respiratory inadequacy on other organs:• ↑/↓ HR/Pallor/Cyanosis {NB anaemia}/Agitation/
Drowsiness/LOC/Hypotonia
=> BLS & Advanced Airway Support
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Basic Life Support (BLS)
EMS activation before BLS:
• witnessed sudden collapse with no apparent preceding morbidity
• witnessed sudden collapse in a child with a known cardiac condition and in the absence of a known or suspected respiratory or circulatory cause of arrest
Call emergencyservices
SAFEapproach
CPR15:2
x 1min
Check pulseCheck for signsof circulation
5 rescuebreaths
Look, listen,feel
Airwayopening
manoeuvres
Are youall right?
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BLSInfant (<1) Child (1-14)
Head tilt position Neutral Sniffing
Initial rescue breaths 5 5
Pulse
Landmark
Technique
Brachial/femoral
1 finger’s breadth above xiphisternum
2 fingers/2 thumbs
Carotid
1 finger’s breadth abovexiphisternum
1 or 2 hands
CPR ratio 15:2 15:2
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Circulation
Cardiovascular status:• HR/Pulse volume/CRT/BPEffect of circulatory inadequacy on other organs: • ↑RR (2º to metabolic acidosis)/Pallor/
Cyanosis/Agitation/Drowsiness/LOC/↓ UO (<1ml/kg/hr in children; <2ml/kg/hr in infants)
Cardiac failure:• Cyanosis not correcting with O2/Tachycardia out of
proportion to respiratory difficulty/↑JVP/Gallop rhythm/Murmur/Enlarged liver/ Absent femoral pulses
=> IV/IO access x2; bloods incl. G&X-match; fluid bolus (20ml/kg); inotropes, intubation & CVP monitoring if >3 boluses
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DisabilityConscious level:• P ~ GCS </= 8/15Posture:• Decorticate/DecerebratePupils:• Dilatation/Unreactivity/
InequalityEffect of central neurological
failure on other organs:• Hyperventilation/Cheyne-
Stokes/Apnoea• ↑BP, ↓HR, abnormal
breathing (Cushing’s Triad)
=> Intubation if “P” or “U”; Rx hypoglycaemia; Rx seizure
A ALERT
V responds to VOICE
P responds only to PAIN
U UNRESPONSIVE
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(Exposure) – Not part of 1º Assessment but do early
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ABC - DEFG
Don’t Ever Forget Glucose
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Reassessment of ABCD(E) at
frequent intervals
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2º Assessment &
Emergency Treatment
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Airway & Breathing
Symptoms:• Breathlessness/Coryza/Cough/Grunting/Stridor/Wheeze/
Hoarseness/Drooling & inability to drink/Abdominal pain/ Chest pain/Apnoea/Feeding difficulties
Signs:• Cyanosis/Tachypnoea/Recession/Grunting/Stridor/
Wheeze/Chest wall crepitus/Tracheal shift/Abnormal percussion note/Crepitations on auscultation/Acidotic breathing
Investigations:• O2 sats/Peak flow/End-tidal or trans-cutaneous CO2/
Blood culture/CXR/ABG
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Airway & Breathing↑ Respiratory secretions – • Suction - ? Fatigued/depressed conscious level Barking Cough in a well child – • ?Croup – PO/IM Dexamethasone (0.6mg/kg stat or 0.15mg/kg BD
x 2-3/7)/Nebulised budesonide (2mg)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2) – NB TRANSIENT ↑HR; REBOUND
Quiet stridor, drooling, sick-looking child – • ?Epiglottitis/Bacterial Tracheitis (Pseudomembranous Croup) -
Intubation & IV ceftriaxone NB AVOID VENEPUNCTURE (BEFORE INTUBATION) AND X-RAYS
Sudden onset of respiratory distress leading to apnoea in a conscious toddler –
• ?Inhaled foreign body -“choking child” manoeuvre/direct laryngoscopy & use of Magill’s forceps ONLY IN EXTREME CASES OF A THREAT TO LIFE
• ?Anaphylaxis
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Airway & BreathingCough, wheeze & ↑SOB – • ?Acute exacerbation of asthma – Inhaled Salbutamol
(2.5mg{<5yo}; 5mg {>5yo}) & O2/PO prednisolone (2mg/kg) or IV hydrocortisone (4mg/kg then 2mg/kg QDS)
• ?IFB• ?AnaphylaxisInfant with wheeze and respiratory distress – • ?Bronchiolitis – Supportive Mx – PO/NG/IV fluids/O2• ?IFB • ?AnaphylaxisPyrexia, breathing difficulties but no stridor/wheeze – • ?Pneumonia – Antibiotics/Adequate hydration/ +/- chest drainStridor following ingestion of a new food – • ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of
1:1,000)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2)/Chlorphenaramine/Prednisolone
• ?IFB
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Management of a Choking Child
Assess
IneffectiveCough
EffectiveCough
Unconscious
5 BackBlows
Assess &repeat
Conscious
OpenAirway
5 RescueBreaths
CPR 15:2Check for
FB
5Chest/abdo
Thrusts
EncourageCoughing
Support &Assess
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Ineffective Cough & Conscious
Infants (<1)• Back Blows (x5) and
Chest Thrusts (x5) (1/second)
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Ineffective Cough & Conscious
Children (1-14)• Back Blows (x5)
and Abdominal Thrusts (x5) (1/second) (Heimlich Manoeuvre)
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Circulation
Symptoms:• Breathlessness/Fever/Palpitations/Feeding difficulties/
Drowsiness/Pallor/Fluid loss/Poor urine outputSigns:• Tachy -or bradycardia/Hypo- or hypertension/Abnormal
pulse volume or rhythm/Abnormal skin perfusion or colour/ Cyanosis/Pallor/Hepatomegaly/Auscultatory crepitations/Murmur/Peripheral oedema/↑JVP/Hypotonia/Purpura
Investigations:• U&E/FBC/ABG/Coag screen/Blood culture/ECG/CXR
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Shock
Acute failure of circulatory function
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Shock
Types:• Cardiogenic – heart defects - arrhythmias• Hypovolaemic – fluid loss – haemorrhage, GE• Distributive – vessel abnormalities –
septicaemia, anaphylaxis• Obstructive – fluid restriction – tension pnuemo,
cardiac tamponade• Dissociative – inadequate O2-releasing
capacity of blood – CO poisoning, methaemoglobinaemia
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Shock
Types:
• Phase 1 - Compensated
• Phase 2 - Decompensated
• Phase 3- Irreversible
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Phase 1- Compensated
• Compensatory mechanisms to preserve vital organ function
• Sympathetic + => ↑Systemic Arterial Resistance; ↑HR; ↑secretion of angiotensin & vasopressin
Clinical Features:
• agitation/confusion, pallor, ↑HR, cold peripheries, ↑CRT
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Phase 2 - Decompensated
• Compensatory mechanisms start to fail• Aerobic => anaerobic metabolism => lactic
acidosis• Sluggish blood flow => platelet adhesion• Release of numerous chemical mediators
=> ↑capillary permeability & other deleterious consequences
Clinical Features:• ↓BP, ↓LOC, acidotic breathing, ↓/no UO
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Phases 3 - Irreversible
• Retrospective Dx
• Death is inevitable despite therapeutic intervention resulting in adequate restoration of circulation
• EARLY RECOGNITION & EFFECTIVE TREATMENT OF SHOCK IS VITAL
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Circulation
Shocked child with no obvious fluid loss – • ?sepsis - IV ceftriaxone Shock with rash & stridor – • ?Anaphylaxis - IM adrenaline (10μg/kg =
0.01ml/kg of 1:1,000)Neonate with unresponsive shock – • ?duct-dependent CHD – Prostaglandin
(Alprostadil 0.05μg/kg/min)Pallor with dark brown urine – • ? Haemolysis ?SCD – O2, rehydration +/-
Transfusion, antibiotics, analgesia
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Circulation
No pulse – • ?Cardiac Arrhythmia - Assess cardiac rhythm –
asystolé, PEA, VF, PLVTPoor feeding with HR 230bpm – • ?SVT Algorithm – vagal stimulation, If IV access - IV
adenosine (100μg/kg; ↑x100μg/kg every 2 min to a max of 500μg/kg {300μg/kg in < 1/12}), If No IV access & shocked – DC cardioversion (1J/kg then 2J/kg)
Infant/young child with Hx vomiting, drawing up legs & pallor ++ +/- abdominal mass –
• ?intussusception/malrotation/volvulus etc. - Surgical advice – Paediatric Surgeon - Dublin/Abdominal USS, stabilisation & transfer
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What is this rhythm?
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Supraventricular Tachycardia (SVT)
• Commonest non-arrest arrhythmia in childhood• HR >220bpm• Narrow QRS complex (< 0.08 sec)
• Palpitations• Lightheadedness• Dizziness• Chest discomfort • Shock (if prolonged - younger)
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SVT• Vagal stimulation – glove containing ice over face;
immersion in iced water; unilateral carotid sinus massage; valsalva (blow through a straw!)
• If IV access - IV adenosine (100μg/kg; ↑x100μg/kg every 2 min to a max of 500μg/kg {300μg/kg in < 1/12})
• If No IV access & shocked – DC cardioversion (1J/kg then 2J/kg)
• No response – SEEK SPECIALIST PAEDIATRIC CARDIOLOGY ADVICE
• Amiodarone (5mg/kg over 20-60 min)• Procainamide (15mg/kg over 30-60 min)• Flecainide (2mg/kg over 20 min)
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Intussusception – A Medical Emergency!
• Infant/young child with Hx vomiting, drawing up legs & pallor ++ +/- abdominal mass
• ABC• High-flow O2• IV fluid resuscitation• PFA• Abdominal USS• Inform Paediatric Consultant• Stabilisation & Transfer for definitive Mx
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Fluids in Resuscitation
• 0.9% NaCl 20 ml/kg (10ml/kg in DKA or Trauma)• >/= 3 boluses (60ml/kg = ¾ of total circulating blood
volume!) = consider RSI• Larger volumes => haemodilution - Albumin??• Use CVP (~cardiac preload) as a guide• Blood – fully cross-matched = 1º type-specific non-cross –matched = 15 min O-negative = 0 min
• NOT dextrose because => hyponatraemia
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Disability
Symptoms:• Headache/Fits or Seizures/Change in behaviour/Change
in conscious level/Weakness/Visual disturbance/FeverSigns:• Altered level of consciousness/Convulsions/Altered pupil
size & reactivity/Abnormal posture/abnormal oculo-cephalic reflexes/ Meningism/Papilloedema or retinal haemorrhage/Altered deep tendon reflexes/↑BP/↓HR/ Irregular breathing pattern
Investigations:• U&E/blood glucose/ABG/Coag screen/Blood culture/Blood
& urine toxicology – salicylate/Neuroimaging
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Disability
Seizure – 1st Ix – • hypoglycaemia - IV glucose (5ml/kg of Dextrose 10%)Seizure > 5 min duration –• IV lorazepam (0.1mg/kg)/PR diazepam (0.5mg/kg {max
4mg})/Buccal midazolam (0.5mg/kg)Decreasing level of consciousness/abnormal
posturing/abnormal ocular motor reflexes – • ? ↑ICP - Intubation & ventilation/head in-line & 20-30º
head-up position/IV mannitol (0.25-0.5g/kg {1.25-2.5ml/kg of mannitol 20 %} over 20 min) + IV frusemide (1mg/kg)/+/- Dexamethasone (0.5mg/kg BD) Neurosurgery input
Depressed level of consciousness/irritability/convulsions – • ?meningitis/encephalitis - IV ceftriaxone/acyclovir
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Disability
Drowsiness with sighing respirations – • ?DKA - IV Normal saline (0.9%) & insulinVomiting, hypoglycaemia & coma – • ?metabolic encephalopathy – IV glucose,
ABCD & send metabolic screen esp ammonia – Metabolic Team input
Unconscious with inconsistent history – • ? NAI – Mx as per any unconscious child,
ophthalmology, bloods, skeletal survey, neuroimaging (if not already done)
Unconscious with pin-point pupils – • ? Opiate poisoning - IV naloxone (10μg/kg); IM
naloxone (100μg/kg)
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Exposure
Symptoms:• Rash/Swelling of lips/tongue/Fever
Signs:• Purpura/Urticaria/Angio-oedema
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Exposure
Shock/↓LOC/Purpuric rash
• ?Meningococcal septicaemia – Blood culture, PCR & IV ceftriaxone
Shock/Stridor/Urticarial rash
• ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of 1:1,000)
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Reassessment,
Stabilisation
&
Transfer
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A Structured Approach
• 1º Assessment - Resuscitation – identifying & treating the immediate threats to life – closed or obstructed airway, absent or distressed respiration, pulselessness, shock
• 2º Assessment - Emergency Treatment – to start to treat the underlying cause of the child’s condition
• Reassessment - Stabilisation – achieving homeostasis and system control
• Transfer – to a definitive care environment (PICU)
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The Hypocratic Oath! Epiglottitis • Don’t lie patient down!• Don’t do a lateral x-rayManagement of shock• Too much fluid too quickly can => cerebral oedema• No dextrose as resuscitation fluid (=> hyponatraemia)Duct-dependent CHD• Avoid excessive O2 (sats @ 88-92%)No LP if altered level of consciousness• ↑BP, ↓HR, irregular respirations (Cushing’s Triad)Normal fundoscopy does not exclude acute ↑ICPNaHCO3 has NO role in initial management of DKASteriods have NO role in the initial management of Meningococcal Septicaemia (√refractory hypotension)
“Don’t Ever Forget Glucose”
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