Emergency ScenariosProf. Hamida EsahliPICU Elkhadra Hospital

Secondary Cardiac Arrest

Most Cases of cardiac arrest in children are preceded by respiratory failure

Most common form in children Heart stops due to ischemia or hypoxia

secondary to another condition Arrest rhythm is usually bardycardia

progressing to asystole Hypoxia initially present Out com depends on prevention or prompt

resuscitation

PATHWAY LEADING TO CARDIAC ARREST IN CHILDREN

RESPIRATORY

OBSTRUCTION

FLUID

LOSS

RESPIRATORY

DEPPREESION

FLUID

MALDITRUBITON

FABO

ASTHMA

CONVULSION

POISINING

RASIED ICP

BLOOD LOSS

BURNS

VOMITING

SEPSIS

ANAPHYLAXIS

CARDIAC FAILURE

RESPIRATORY FAILURE CIRCULATORY FAILURE

CARDIAC ARREST

THE STRUCTURED APPOROACH

Primary survey

Resuscitation

Secondary survey

Emergency treatment

Continuing stabilization and

definitive care

Scenario case1

An 18 month old girl is brought into the A&E department by paramedics having been found lying face down in the neighbours outdoor swimming pool. Her mother states that she had been missing for 5 minutes. Basic life support has been carried out on the pool side and during transportation to hospital

Initial Impression The child is pulseless and apnoeic.

She is very cold to touch

Cardiac Arrest

ABC

Check the pulse

Attach monitor/defibrillator

Shockable

Ventricular Fibrillation (VF) Ventricular Tachycardia (VT)

NON Shockable

Asystole / Pulseless Electrical Activity (PEA)

Ventricular Fibrillation (VF)

No Pulse: Shockable

Advanced paediatrics life support

During CPR

Attempt /Verify Tracheal intubation Intraosseous /Vascular access

Check Electrodes/Paddles position and contactGive Adrenaline every 3 minutes

Consider antiarrhythmics

Consider giving BicarbonateCorrect reversible causes ( 4H/4T)

Hypoxia Tension Pneumothorax Hypovolaemia TamponadeHyper/hypokalaemia Toxic/therapeuticHypothermia Thromboemboli

Adrenaline

IV / IO 10 mcg /kg 0.1 ml/kg of 1:10 000 solution

ET 100 mcg/kg 0.1ml/kg of 1:1 000 solution

May be repeated every 3 minutes

DrowningManagement

Intubate to prevent aspiration Gastric drainage to remove

swallowed water Measure core temperature

and treat hypothermia Full trauma assessment for other

injuries

DrowningInvestigations

Blood glucose Arterial blood gases and lactate Urea, electrolytes and coagulation status Blood and sputum cultures Chest x–ray Lateral cervical spine x-ray or CT scan

HypothermiaManagement of cardiac arrest

Hypothermia may be protective, continue to resuscitate until expert advice obtained

Active core rewarming vital Do not give initial medications until core

> 30o C Give initial defibrillating shocks but do not

repeat until core >30o C Volume expansion may be needed

HypothermiaManagement

External rewarming Remove wet

clothing Wrap warmly Radiant heat Warm air system Direct heat

Core rewarming IV fluids to 39oC Ventilator gases to

42oC Gastric/bladder/

peritoneal/pleurallavage at 42o C

Endovascular warming Extra-corporeal

rewarming with by-pass

Key Treatment Points

Airway Oral tracheal intubation   Breathing Bag and mask with added O2

  Bag and ETT with added O2

  Circulation VF protocol   General Therapy Uninterrupted BLS   Specific Therapy Resus until T>32, active rewarming  

Diagnosis Cardio-respiratory arrest, ventricular

fibrillation, hypothermia secondary to drowning

Worldwide Clinical NeedWorldwide Clinical Need

Intensive Care

Pre-Hospital

Surgery

Rapid ResponseEmergency Medicine

Medical Center

Scenario case 2

History   A 3 year old girl was eating a sandwich when she

suddenly started coughing, and then stopped breathing. Her mother picked her up and slapped her back but couldn't dislodge the food. She called an ambulance. On arrival a paramedic performed abdominal thrusts and dislodged piece of bread. Basic life support was started.

Initial Impression Apnoeic and pulseless

Clinical Course} The child remains in asystole until

satisfactory ventilation is achieved, initial drugs have been given and one cycle of the asystole protocol has been completed. She then develops sinus tachycardia on the monitor but there is no pulse

She has PEA secondary to a tension pneumothorax. This responds to chest decompression. Guide weight 14kg

PEA no palpable pulses

PROTOCOL FOR ASYSTOLE AND PEA

2min CPR High flow O2, IV/IO access

ROSC

Oxygen should be titrated (spO2 94%-98%)

Therapeutic hypothermia

Blood glucose control

Parental presence

Drugs used in CPR

Adrenaline; induce vasoconstriction, increase coronary perfusion

Amiodarone; is a membrane –stabilising anti-arrhythmic drug, used in treatment of shockable rhythms

Atropine; is effective in increasing HR when bradycardia is caused by excessive vagal tone

Sodium bicarbonate; the routine use of it is not recommended.

Calcium; administration of calcium during cardiac arrest has been associated with increased mortality

Magnesium; is indicated with documented hypomagnesaemia or with polymorphic VT

Assess rhythm

Continues CPR

Post cardiac arrest treatment

If signs of life check rhythm if perfusable rhythm, check pulse.

Adrenaline immediately and then every 4minutes 1omcg/kg IV or IO

Consider 4Hs and 4Ts

Proximal Humerus Proximal Humerus

Proximal Tibia Proximal Tibia

Distal Tibia Distal Tibia

Distal FemurDistal Femur

Intraosseous access sites for the pediatric patient

Site is most suitable for patients5 years of age and older

Site is suitable most for patients5 years of age and older

Key Treatment Points Airway Establish airway patency   Oral tracheal intubation 

Breathing Bag and mask with added O2

  Bag with TT with added O2

 

Circulation IV/IO access  Asystole protocol   PEA protocol  General Therapy Uninterrupted BLS  Specific Therapy Needle Thoracocentesis 

Scenario case3

History A 10 month old girl is brought into the

Emergency Department with a 12 hour history of vomiting and diarrhoea

  Initial Impression Respiratory rate

36, pulse 130, capillary refill 4 seconds. Appears pale and hypotonic.

 

Clinical  The child continues to have vomiting and profuse

watery diarrhoea. Blood pressure is 90 systolic. Following 20 ml/kg of normal saline the pulse rate comes down to 115 per minute and the child appears more alert. The child is started on maintenance fluids but an hour later when she is about to go to the ward and following further vomiting and profuse diarrhoea she again has a pulse rate of 140 and is pale and lethargic. A further fluid bolus corrects this. The serum sodium taken on insertion of the IV cannula is reported as 132 mmol/l

Key Treatment Points

Airway Establish airway patency 

Breathing Oxygen via face mask 

Circulation IV access  Fluid bolus x 2 

General Therapy Calculation of maintenance fluids and electrolytes  

Diagnosis Gastroenteritis

Scenario case4

History  A five day old infant is brought to A&E

by his parents. He was born at full term and was born by a normal delivery. Initially he was well, but over the last 24 hours he has become increasingly lethargic and has not fed for 8 hours

High flow oxygen should be administered and airway breathing and circulation assessed. IV access is only possible via the intraosseous route. Blood sugar should be checked. The infant worsens after the first bolus of fluid and femoral pulses are still absent.

 

Initial Impression  He is pale and drowsy but responding to

pain. Respiratory rate is 75bpm, heart rate 195bpm and pulses are difficult to feel. Capillary refill time is seven seconds centrally.

 Additional History and Observations Mum was well through the delivery. There

are no risk factors for infection. 

Features suggesting a cardiac cause of circulatory Inadequacy

Cyanosis, not correcting with oxygen therapy Tachycardia out of proportion to respiratory

difficulty Raised jugular venous pressure Gallop rhythm, murmur Enlarged heart on CXR Enlarged liver Absent femoral

APPROACH TO THE INFANT WITH A DUCT-DEPENDENT CONGENITAL HEART DISEASE

Neonates with ,duct-dependent pulmonary circulation (e.g., critical pulmonary

stenosis, pulmonary atresia, tricuspid atresia)

Neonates with duct-dependent systemic circulation (eg transposition of great

arteries, .aortic stenosis, /Artesia,left hypoplastic heart, coractation of aorta) .

Emergency Treatment of Duct-Dependent Congenital Heart Disease

Give an intravenous infusion of Prostin (e.g. for PGE2):

Initial dose of 5 nanograms/kg/min (may be increased. to 20 nanograms/kg/min in 5-nanograms/kg /min increments until side, effects develop

Suggested preparation of PGE2 : Add 1ampule(500mcg) to 50 ml = 0.6ML/ h x weight kg needed to infuse 0.1 mcg/kg/min

This is a duct dependant lesion and requires treatment with an IV infusion of alprostadil. This condition can be difficult to differentiate from sepsis in the neonate so if the candidate gives IV antibiotics this should be accepted as good practice. Guide weight 4kg

Key Treatment Points

Airway Airway opening manoeuvres  

Breathing High flow oxygen   Plan for intubation  

Circulation IV access   1 x fluid bolus  

Specific Therapy IV alprostadil   Contact Cardiac centre     Diagnosis Shock secondary to coarctation of the aorta

Scenario case5

History  A four year old boy is brought to A&E by his

parents He has been unwell for twenty-four hours with right-sided abdominal pain, and over the last few hours he has had some bile stained vomiting. His father tried to wake him and give him a drink, but was unable to rouse him.

  Initial Impression Unrousable. Pale child. Shallow breathing.

Cold, mottled peripheries

Additional History and Observations   Respiratory rate 45 bpm, barely fogging the mask.

Capillary refill time is 7 seconds and heart rate 170 bpm. The abdomen is rigid on palpation.

  Clinical Course The child becomes bradycardic and apnoeic while IV

access is sought. Bag and Mask ventilation is started, and if compressions are not started the child develops PEA. The child improves after two boluses of fluid. A surgical opinion should be sought. Guide weight 16kg.

 

while IV access is sought. Bag and Mask ventilation is started, and if compressions are not started the child develops PEA. The child improves after two boluses of fluid. A surgical opinion should be sought. Guide weight 16kg.

Key Treatment Points

Airway Establish airway patency 

Breathing High flow oxygen   Attempt bag-mask ventilation with O2

 

Circulation

Chest compression   IV access   Bradycardia protocol   Fluid bolus x 2  

Specific Therapy IV Antibiotics   Surgical opinion    

Diagnosis Septic shock secondary to perforated appendix  

Diagnosis Septic shock secondary to

perforated appendix 

Scenario case6

History   A 3 year old boy is carried into Accident & Emergency in

his fathers arms. He is pale, limp and having difficulty breathing. The father says he has been unwell and coughing for 3 days.

  Initial Impression Respiratory rate is 60 with marked intercostal recession

and a tracheal tug. Pulse 150. He is thin, pale and only responsive to painful stimulation.

 Additional History and Observations  His temperature is 36oC. SaO2 is 76% in 100% O2 by face

mask. Capillary perfusion is 6 sec. BP 60/? and thready

Clinical Course  The child is peripherally shut down and

needs a bolus of fluids and IV antibiotics. Despite high flow O2 saturation remains poor as he is exhausted and needs elective intubation. If this is not carried out bradycardia develops prior to asystole.. There is then gradual improvement. Guide weight 14 kg.

 

SIRS

systemic inflammatory response syndrome(SIRS) the presence of at least two of the following four criteria,

one of which must be abnormal temperature or leukocyte count:

core [oral or rectal]temperature of>38.5C or <36C Tachycardia, in the absence of external stimulus , chronic

drugs, or painful stimuli, or otherwise unexplained persistent elevated period or for children< 1 year old : bradycardia , in absence of vagal stimulus , B-blocker drugs, or congenital heart depression over a 0.5-h time period

Tachypnea for an acute process not related to underlying neuromuscular disease.

Leukocyte count elevated or depressed for age [ not secondary to chemotherapy-induced leucopenia] or >10% immature

Primary Survey

EFFORT

EFFICACY

EFFECT

EFFECT OF INADUQUATE RESPIRATION

Heart Rate; Tachycardia – bradycardia Skin colour: Pallor, mottling secondary to

endogenous epinephrine Mental Status :Agitation, restlessness, reduced

conscious level, coma

Key Treatment Points

Airway Establish airway patency   Breathing High flow O2 via face mask   Electively intubate & ventilate with 100% O2

  Circulation IV access   Fluid bolus   Specific Therapy IV antibiotics     Diagnosis Severe bilateral pneumonia (probably streptococcus pneumoniae)

Diagnosis Severe bilateral pneumonia

(probably streptococcus pneumoniae)

Scenario case7

History   A five-year-old boy is brought into the A&E

department with vomiting and fever. The parents describe these symptoms as having developed during the morning and he now doesn’t want to walk at all.

  Initial Impression   Respiratory rate 25/min, SaO2 98%, heart rate

95/min, capillary refill 2s, temperature 40.7ºC. Initially responds to voice

Additional History and Observations

  He had been complaining of headache.

His blood pressure is 120/95 and he has good pulses. He has small, poorly reactive pupils. Exposure reveals some petechia on his abdomen and lower limbs.

Clinical Course His conscious level deteriorates. He

requires airway control, assessment of conscious level and posture, management of raised intra-cranial pressure and i.v. antibiotics. An anaesthetic colleague may help with intubation. Guide weight 18kg.

 

Central Neurological Failure

Conscious Level

Posture

Pupillary Signs

Central Neurological FailureConscious Level

Alert A Responds to Voice V Responds only to Pain P Unresponsive U

. He requires airway control, assessment of conscious level and posture, management of raised intra-cranial pressure and i.v. antibiotics. An anaesthetic colleague may help with intubation. Guide weight 18kg.

Treatment of disability in shock

The priority in patients with a mixed picture of shock and meningitis is brain perfusion is dependent on adequate cardiac output.

If signs of raised ICP persist tracheal intubation and mechanical ventilation should be initiated urgently.

Monitor CO2 levels by capnography and blood gases, and keep in a normal range

Insert a urinary catheter early, and monitor urine output.

Nurse the child with 20° head elevation and midline position.   Lumbar puncture must be avoided as its performance may cause

death through coning of the brainstem through the foramen magnum.

Key Treatment Points Airway Establish airway patency   Insert oropharyngeal airway  

Breathing High flow O2

  Orotracheal intubation & ventilate with O2

 

Circulation IV access  

Disability Head in-line and raised 20º   Mannitol  

Specific Therapy IV cefotaxime / ceftriaxone   IV dexamethasone    

Diagnosis Acute meningitis – raised intra-

cranial pressure