1. Relax Children are just little adults

2. themes the critically ill and injured child taking action not APLS not PEM in general 3. Disclosures 4. PICU Kids ED Trauma centre Trauma centre Trauma centre 5. ...but where are the kids? 6. Transfers were: Sicker Needed more ICU care Had a longer stay More ventilation More inotropes 7. Half of unplanned transfers from St.Elsewhere They were sicker/younger but Died more often (8% vs 6%) Risk adjusted mortality 0.65 (0.53-0.80) 8. Selection bias? 9. Maybe...., but 10. Anecdotally..... Errors of Omission and delay Wait for help Failure to intervene Cliff drop of kids pathology Benjamin Ellis CCL http://www.flickr.com/photos/jamin2/3191895921/ 11. 6 year old 1/7 hx T 37.9 C RR 35 Pulse 170 BP 100/52 12. Oxygen Fluids Antibiotics 13. Multiple cannulation attempts ED docs Paediatricians 14. 5 hours later Circulatory collapse Dies in ED 15. why? 16. Why are we scared of kids? Where are we scared? 1. Unfamiliarity 2. High stakes 3. Because people tell us we should be! 17. Children are not little adults!!!! 18. World Health Organisation http://www.who.int/ceh/capacity/Children_are_not_little_adults.pdf 19. Children are not little adults 20. Is this still ABC? 21. transferrable skills 22. Neonates 23. aliens & prehumans 24. Scary Aliens Weird stuff often precipitated by infection Treat what you can whilst working out the hard stuff! 25. Is it really that different? 26. but really? 27. EmergencyEmergency MedicineMedicine PICUPICUPaediatricsPaediatrics AnaestheticsAnaesthetics 28. The resuscitiationist 29. Transferrable skills Adult practice to Paeds practice 30. Kids are more difficult than adults. Co-morbidity? Anatomical variation? Range of conditions? 31. ToP TiPs Airway issues Lots of normal RSI Rescue 32. be prepared 33. Pressure control more popularPressure control more popular Tidal volume reasonable (5-8 ml/kg)Tidal volume reasonable (5-8 ml/kg) or maybe better to look at chest wall excursion with pressure controlor maybe better to look at chest wall excursion with pressure control Aim for lower FiOAim for lower FiO22 albeit with higher PEEPalbeit with higher PEEP 4-6 to start4-6 to start 6-8 if bad lung disease6-8 if bad lung disease 8-10 if wet lungs8-10 if wet lungs SpO2 = 88-96%SpO2 = 88-96% Chest tubesChest tubes 34. Circulation Fluids Trauma resus Access 35. 1 2 IO 36. 1 2 IO Consider external jugular 37. Fluids APLS 20ml/Kg in sepsis APLS 10ml/Kg in trauma 38. Fluid requirements Sepsis - Adequate volume important within 1-2 hours Reduced mortality less persistent hypovolaemia no increase in ARDS each additional hour of shock doubles odds of death. reduced PICU stay Role of early fluid resuscitation in pediatric shock. Carcillo JA, Davis AL, Zaritsky A. JAMA 1991;266: 1242-1245. Early reversal of Pediatric - Neonatal septic shock by Community Physicians is associated with improved outcome. Han YY, Carcillo JA, Dragotta M et al. Peds 2003;112: 793-799. 39. In severe sepsis likely requirement for volume is 200-360ml/Kg in first 24 hours 40. FEAST trial Higher mortality in kids with large fluid boluses 41. Question? Is 20ml/Kg too much Dose/response may be better in 5ml/Kg aliquots 42. Fluid choice? Little evidence Saline causes hyperchloraemic acidosis Colloids (albumin) after 40-60ml/Kg Plasmalyte coming into practice 43. octaplas - prior reduced plasma Trauma 44. Tranexamic acid 15mg/Kg over 1 hour 2mg/Kg/Hr for 8 hours 45. 53 patients in 15 months No improvement in mortality Feasibility proven 46. Therapeutic end points Titrate to effect Normal pulses with no difference central/peripheral Warm extremities Return of Urine output (>0.5-1ml/Kg/Hr), HR, Cap refill, LOC SVC or mixed venous gas Normalising base deficit and lactate 47. Today... Fire up the simulator Kids & Adults in the past Kids & Adults in the future 48. you are the resuscitationist 49. resuscitation aims to restore physiology resuscitation skills are learned in adult medicine most if not all skills are transferrable 50. kids are little adults 51. Thanks NWTS Ralph MacKinnon Kate Parkins Rachel Jenner Katherine Potier 52. End points Its you There is specialism here but not that much in the beginning Beware the neonate - they are not human If you did adult resus on kids how often would it go badly wrong? Crack on with it 53. Where is the expertise? PICU? Paeds anaesthesia EM physicians? Paediatricians? 54. AdultsAdults KidsKids Emergency WorkEmergency Work PEM GP EM 55. antidote