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Emergency in Pediatrics

FKIK UNTAN

Oct 7th, 2011

Dr. Rini Andriani, Sp A


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RAPID CARDIOPULMONARY

ASSESSMENT (9) Sensorium Skin Color

Respiratory Rate / Effort Skin Temperature Cardiac Rate and Rhythm Quality of Pulses

Capillary Refill Time Blood Pressure Urine Output


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RAPID CARDIOPULMONARY ASSESSMENTCLASSIFICATION OF PHYSIOLOGIC STATUS

Stable

Respiratory Failure

Potential airway and breathing problems

Probable fails to improve or deterioratesdespite therapy

Shock Compensated

Decompensated hypotension

Cardiopulmonary Failure


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Many Etiologies

Respiratory Failure Shock


Cardiopulmonary Arrest


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PRIMARY ABNORMALITIES IN

RESPIRATORY FA ILURE

Airway

&Breathing

Circulation

Ventilation

Oxygenation

Perfusion


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PRIMARY ABNORMALITIES INSHOCK

Airway

&Breathing

Circulation

Ventilation

Oxygenation

Perfusion


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Recognition of Potential

Respiratory Failure Airway patency (upper versus lower airway

obstruction)

Air entry: Chest rise, breath sounds, stridor,wheezing

Respiratory Rate: too fast or too slow

Respiratory Effort: Accessory muscles,retractions, grunting, head bobbing, nasal flaring

Heart rate, pulses, skin perfusion

Level of consciousness


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Approach to Patient withPotential Respiratory Failure

Open airway and assist ventilation as

neededAdminister oxygen

Monitor heart rate, respirations, pulse

oximetry Obtain arterial blood for gas analysis and

electrolytes, and perform chest x-ray


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Case Scenario - BreathingProvide Oxygen

Awake Nonrebreathing

mask

Altered mental status

or breathing difficulty Bag-valve mask Unresponsive or Endotracheal

respiratory failure intubation


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RAPID CARDIOPULMONARY ASSESSMENTPRIORITIES OF INITIAL MANAGEMENT

POTENTIALRESPIRATORY FAILURE

PROBABLERESPIRATORY FAILURE

Keep with caregiver Separate from caregiver

Position of comfort Control airway

Oxygen as tolerated100% FiO2

Assist ventilation

Nothing by mouth Nothing by mouth

Monitor pulse oximetry Monitor pulse oximetry

Consider cardiac monitorCardiac monitor

Establish vascular access


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BASIC RELATIONSHIPS OF

CARDIOVASCULAR PARAMETERS

BloodPressure

CardiacOutput

SystemicVascularResistance

StrokeVolume

HeartRate

Preload

MyocardialContractility

Afterload


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HEMODYNAMIC RESPONSE TO

HEMORRHAGE

Vascular

resistance

Bloodpressure

Cardiac

output

Compensated

shock

Decompensated

shock

140

100

60

20Percentofco

ntrol


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CARDIAC OUTPUT

= heart rate X stroke vo lume

Compensation

heart rate systemic vascular

resistance

possible strokevolume

Inadequate


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DEVELOPMENT OF SHOCK FROMPULSE RATE DISTURBANCES

PULSE

RATE

CO = HR X SV

Fast = X

Slow = X N Absent 0 = 0 X 0


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REVIEW OF THE

PHYSICAL FINDING IN SHOCK

Early signs (Compensated)

heart rate poor systemic perfusion

Late signs (Decompensated)

weak central pulses

Altered mental status

urine output hypotension


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DEFINITION OF

CARDIOPULMONARY FAILURE

Deficits in

Ventilation

Oxygenation

Perfusion

Resulting in

Agonal respiration

Bradycardia



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Many Etiologies

Respiratory Failure Shock



Death Cardiopulmonary Recovery

ImpairedNeurologic

Recovery

UnimpairedNeurologic

Recovery


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Secondary Brain InjuryTrauma

Shock Hypoxia

Hypotension IntracranialPressure

Decreased

Cerebral Perfusion


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Pediatric Trauma

Isolated Head Multiple(CNS) injury Trauma

Airway compromise

Respiratory failure

Shock

Cardiopulmonary Arrest(final common pathway)


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Age Minimum systolic bloodpressure (5th percentile)

0 to 1 month 60 mm Hg

>1 month to 1 year 70 mm Hg

1 to 10 years of age 70 mm Hg + (2 age in years)

>10 years of age 90 mm Hg

Lower Limits of Normal Systolic

Blood Pressure by Age


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SHOCK

Administer oxygen (FiO2 = 1.00) andensure adequate airway and ventilation

Establish vascular access

Provide volume expansion

Monitor oxygenation, heart rate, andurine output

Consider vasoactive infusions


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CARDIOPULMONARY FAILURE

Oxygenate, ventilate, monitor Reassess for :

respiratory failure

shock

Obtain vascular access


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Treatment of Shock

Initial rapid fluid administration of

20 mL/kg of

Crystalliod

Colloid Blood


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Resuscitation of Hemorrhagic Shock

Estimated blood volume = 80 mL/kg

(EBV) of a child 25% of EBV = 20 mL/kg


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Algorithm for Fluid Resuscitation inShock

20 mL/kg crystalloid

REASSESS

20 mL/kg crystalloidREASSESS

20 mL/kg crystalloid or 10 mL/kg colloid

REASSESS

20 mL/kg crystalloid or consider 10 to 20 mL/kg colloid or

packed red blood cells


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Hazard of Glucose-ContainingInfusions

5% dextrose contains

5 g/100 mL

1 g/20 mL

20 mL/kg = 1 g glucose/kg

Avoid use of glucose-containing solutionsto replace volume


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Treatment of Acute Metabolic AcidosisCaused by Dehydration

Restore circulating blood volume

Maximize respiratory compensation

Treat underlying cause

The use of bicarbonate is controversial


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Advantages of Intubation in Shock

Facilitates delivery of maximal FiO2 Decreases work of breathing Enables controlled hyperventilation

Ensures control of airway


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INTRAOSSEOUS NEEDLE PLACEMENT

1-2 cm distal and medial to

tibial tubercle

Perpendicular to flat

surface of bone

Secure purchase,

aspirates, easy flow

Marrow space

noncollapsible veins for

easy absorption to circulation


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INTRAOSSEOUS NEEDLE IN PLACE

Over 6 years: distal tibia Under 6 years:proximal tibia


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DRUGS THAT CAN BE GIVENENDOTRACHEALLY

Lidocaine

EpinephrineAtropine

Naloxone


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ENDOTRACHEAL DRUG DELIVERY

Epinephrine dose is 10 x IVdose:

0.1 mg/kg (use 1:1000)

Other drug doses are increased2x to 3x IV dose


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INOTROPES IN POSTARREST SHOCK

Postarrest shock

Fluid Bolus

Reassess

Hypotensive Normotensive

Epinephrine or

Dopamine Infusion

Dobutamine,Epinephrine or

Dopamine


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TREATMENT OF SEPTIC SHOCK

the initial priority is fluidresuscitation

use inotropes to treat myocardialdepression

use vasopressors to correcthypotension


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COMPARISON OF INOTROPIC DRUGS

DRUG USES

Epinephrine

Symptomatic bradycardiaShock (including anaphylactic)

Hypotension


Dobutamine Normotensive cardiogenic shock

Dopamine

Low Improve renal, splanchnic blood flow

High Hypotension


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PREPARATION OF DRUG INFUSIONS :The Rule of 6

DRUG CALCULATION RULE

Epinephrine 0.6 x body wt (kg) = # mg toadd to diluent to make 100 mlvolume

1 ml / hr del ivers 0.1 ug/kg/min


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The Rule of 6

DRUG CALCULATION RULE

Dopamine

Dobutamine

6 x body wt (kg) = # mg toadd to diluent to make 100 ml

volume

1 ml / hr del ivers 1.0 ug/kg/min


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REVIEW OF INOTROPE USE

DRUG DOSAGE REMARKS

Epinephrineinfusion

Begin at 0.1ug/kg/minHigher dose used during

CPR

Titrate todesired effect

Dobutamine 2 20 ug/kg/min Titrate todesired effect

DopamineHCl

2 20 ug/kg/minAdrenergic

actiondominates at 15 20 ug/kg/min


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Airway: Stabilize and maintainBreathing : Maintain adequate ventilation

and oxygenation

Circulation : Maintain adequate organperfusion

Disability : Assess the central nervoussystem

Evaluate : Evaluate other systems and theetiology of arrest


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STABILIZATION -AIRWAY

Frequently assess airway clinically

Consider endotracheal intubation

Tape the tube securely NGT

CXR

Sedation ?

Muscle relaxants ?


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STABILIZATIONAIRWAYSEDATIVES / MUSCLE RELAXANTS

FORVENTILATED PATIENTS

Commonly used sedatives

Diazapam 0.1 to 0.2 mg/kg/ IV Morphine 0.1 to 0.3 mg/kg/ IV

Commonly used postintubation muscle relaxant Pancuronium 0.1 mg/kg/ IV


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STABILIZTION - BREATHING

Establish ventilator parameters

Assess adequacy of breathing with Physical examination

Oxygen saturation monitor

End-tidal CO2 ABG


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STABILIZATION - CIRCULATION

Establish two vascular lines Provide maintenance fluids :

D5 0.25% NS infusion

WEIGHT INFUSION RATE< 10 kg 4 ml/kg /hr

10 to 20 kg40 ml/h + 2ml/kg/hr for

each kg > 10 kg

> 20 kg60 ml/h + 1ml/kg/hr for

each kg > 20kg


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STABILIZATION - CIRCULATION

Fluid boluses / vasopressors

Evaluate

heart rate monitor

End-organ perfusion

Urine Output Heart size on Chest x-ray


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STABILIZATION - DISABILITY

Perform brief neurologicexamination with assessment

of vital signs

hyperventilate if increased

intracranial pressure issuspected


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STABILIZATIONEVALUATION OF OTHER SYSTEMS

control patients temperature

measure blood glucose andcorrect hypoglycemia


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STABILIZATION EVALUATIONLABORATORY / RADIOGRAPHY

Chest Xray

ABG

Serum electrolytes

Glucose

BUN / creatinine

CBC


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Thank You


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CASE SENARIO

A 2-year old boy, approximately 12 kg, hasbeen resuscitated after a submersion injury. Herequired CPR, intubation, & pharmacologic andfluid resuscitation. His cervical spine is

immobilized; he is responsive only to painfulstimuli.

Vital Signs HR : 110 bpm RR : 10 breath per min

BP : 90/55 mmHg Temp : 36.2 C

What would you do first?

How should the patient be stabilized?


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CASE - STABILIZATION

AIRWAY

Assess / listen

Tape Endotracheal

Tube

Nasogastric Tube

CXR

Sedation asNeeded

BREATHING

listen / watch

ABG

Monitor : HR,

O2 saturation,end tidal CO2


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CASE - STABILIZATION

Circulation two vascular lines maintenance fluids

blood samples for laboratory analysisDisability Assessment

brief examination of the centralnervous system

CASE VENTILATORY


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CASEVENTILATORY

PARAMETERS

What are the patients initial

ventilator settings? FiO2

Ventilation rate?

Tidal Volume? PEEP?

Inspiratory time?

GUIDELINES FOR VENTILATORY


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GUIDELINES FOR VENTILATORY

SETTINGS

FiO2 : 1.00 (100%)

Rate : 16 to 20 per min

Tidal Volume : 10-15 ml/kg

Inspiratory time : 0.051.0 sec

Peak inspiratory Pressure : 2030 cmH2O

PEEP : 24 cm H2O


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CASE - PROGRESSION

After adequate sedation, the patient isrelaxed and is mechanically ventilated.

What would be his maintenance and

bolus fluids.

Bolus Composition ?

Amount ?

Maintenance Composition ?

Infusion rate ?


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REVIEW OF FLUIDS

Maintenance

D5 0.25% normal saline

Rate : 40 ml/hr + (2 kg x 2 ml/hr)

= 44 ml/hr

Boluses: 20 ml/kg = 240 mlnormal saline or LRS


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CASE

PROGRESSIONThe patients glucose is 20

mg/dl by bedside analysis

What fluid would you give now?


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CASEPROGRESSION

The patient now has two IV lines inplace, is on a mechanical ventilator,and is sedated.

How can each of the following beclinically assessed?

Respiratory Status

Cardiovascular Status

Neurologic Status


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ONGOING ASSESSMENT

Respiratory Cardiovascular Neurologic

Chest rise Heart rate/RhythmLevel of

Consciousness

Breath Sounds Pulse Quality Pupillary Response

Cyanosis Capillary Refill

AgitationLevel of

ConsciousnessPulse-oximetry Urine Output

End-tidal CO2 Blood Pressure


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CASE :

LABORATORY & RADIOLOGY

Which blood test are indicated?

Which radiologist studies are

important?

What other test might be considered?


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CLINICAL PARAMETER

What additional clinical

parameters should be evaluated?


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ANSWER

Temperature monitoring and

stabilization. Medications as indicated.


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STABILIZATION/ TRANSPORT

Pediatric Intensive Care Area

Improved survival of critically illchildren

Provide a spectrum of some servicesfor postresuscitation of patients


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TRANSPORT

This patient requires intensive

care. The nearest facility is

100 miles away.

What do you do now?


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TRANSPORT DECISIONS

mode of transport

transport team

transport triage

preparation for transport

communication post-transport follow-up


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CASE PROGRESSION

While awaiting the transport team,the intubated child becomes

cyanotic. He is beginning to moveand seems agitated.

What additional assessment shouldbe done immediately?


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ASSESSMENT OF VENTILATION,

OXYGENATION, AND PERFUSION

heart rate: 170 bpm

pulses weak peripherally

skin cyanotic chest hyperexpanded with decrease breath

sounds on the right side

ABG: pH 7.11 PaCO260, Pa O240

What is your assessment? What is your plan?

ASSESSMENT


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ASSESSMENTPOSSIBLE TENSION PNEUMOTHORAX

PLAN

Check oxygen source

Check ventilator settings

Remove from ventilator; manually ventilate

Confirm endotracheal tube position andpatency

Suction the endotracheal tube Consider needle thoracostomy

Should a chest radiograph be performed to

confirm the diagnosis?


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NEEDLE THORACOSTOMY

A needle is inserted in the secondintercostal space in the

midclavicular line, and a rush of airis noted. The patients color and vitalsigns improve, but he remains

agitated.

What do you consider now?


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CASE PROGRESSION

You contact the tertiary hospital and

inform them of the patients status

What and with whom should you

communicate?


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TRANSPORTCOMMUNICATION

Physician to physicial

nurse to nurse

provide information

brief history

treatment

current clinical status

change in clinical staturs

T A S O T


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TRANSPORTIMMEDIATE PREPARATION

Secure the airway, I Vs, spine, and any

fractures

copy patient charts copy patient radiograph

gather blood products

provide laboratory phone numbers

prepare consent


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ASSESSMENT OF

CARDIOVASCULAR FUNCTION

Assess ventilation, heart rate, end-

organ perfusion, peripheral pulses,

blood pressure Is CPR needed?

Is cardiovascular instability present


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FAST PULSE :

NARROW VENTRICULAR COMPLEX

SUPRAVENTRICULAR TACHYCARDIA (SVT) vs

SINUS TACHYCARDIA (ST) : HISTORY

SINUS TACHYCARDIA SUPRAVENTRICULAR

TACHYCARDIA

fever

pain

volume loss

diarrhea, vomiting, bleeding

irritability, lethargy

poor feeding

tachypnea sweating

pallor

hypothermia


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FAST PULSE :

NARROW VENTRICULAR COMPLEX

SUPRAVENTRICULAR TACHYCARDIA (SVT) vs

SINUS TACHYCARDIA (ST) : HEART RATE

SINUS

TACHYCARDIA

SUPRAVENTRICULAR

TACHYCARDIA

P waves Present & Normal Absent or abnormal

RR / PR

Variable RR w/

constant PR

Abrupt rate change to

or from normal

Infants < 220 bpm > 220 bpm

Children < 180 bpm > 180 bpm

FAST PULSE WIDE COMPLEX VENTRICULAR


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FAST PULSE: WIDE-COMPLEX VENTRICULARvsSUPRAVENTRICULAR TACHYCARDIAWITH ABERRANCY

Wide-complex tachycardia should be considered

ventricular in origin


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SHOCK 2O TO TACHYARRYTHMIA WITH

PULSE : TREATMENT

ETIOLOGY TREATMENT

Narrow QRS

Probable SVT

adenosine (if vascular accessavailable)

synchronized cardioversion

Wide QRS

Probable VT

synchronized cardioversion

lidocaine

bretylium


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DRUG TREATMENT OF SVT

ADENOSINE

0.1 to 0.2 mg/kg

Maximum single dose: 12 mg


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ETIOLOGY OF BRADYCARDIA

hypoxemia

drugs

cardiac disease (rare)


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CASE STUDY: SLOW PULSE

A 3 month old infant presents with

respiratory rate of 10/min central pulse rate of 45 bpm

absent peripheral pulses

mottled skin

capillary refill > 5 seconds


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SLOW PULSE TREATMENT

Epinephrinevs

Atropine


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EPINEPHRINE TREATMENT OFSYMPTOMATIC BRADYCARDIA

IV / IO Dose ET Dose

0.01 mg/kg 0.1 mg/kg

0.1ml/kg of

1:10,000

0.1 ml/kg of

1:1000

ATROPINE TREATMENT OF


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ATROPINE TREATMENT OF

SYMPTOMATIC BRADYCARDIA

IV / IO dose

0.02 mg/kg

Minimum dose

0.1 mg

Maximum single dose (may repeat once)

Child : 0.5 mg

Adolescent : 1 mg


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CASE STUDY: ABSENT PULSE

A 8 y/o submersion victim with

apnea no palpable pulses

What arrhythmias could be present?


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ABSENT PULSE


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ABSENT PULSE :

(COLLAPSE RHYTHMS) ASYSTOLE

TREATMENT

CPR

Secure Airway

Hyperventilate with 100% oxygen

Obtain IV or IO access Epinephrine q 3 5 min


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ABSENT PU SE VENTRICU AR


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ABSENT PULSE: VENTRICULARTACHYCARDIA / FIBRILLATION

CPR

Defibrillate up to 3 times if needed

Epinephrine / Defibrillate

Lidocaine / Defibrillate

Bretylium / Defibrillate

ABSENT PULSE: VENTRICULAR


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ABSENT PULSE: VENTRICULAR

TACHYCARDIA / FIBRILLATION

DRUG DOSAGE REMARKS

Lidocaine Bolus 1 mg/kg

Lidocaine

Infusion

(120 mg lidocaine/100

ml diluent)

20-50 ug/kg/min

(1-2.5 ml/kg/hr)

Bolus of 1 mg/kg

needed if

lidocaine bolus

has not beenadministered in

previous 15 min.


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CASE STUDY : ABSENT PULSE

PULSELESS ELECTRICAL ACTIVITY

ELECTROMECHANICAL DISSOCIATION

A 2 y/o child was struck by an automobile

Respiratory rate = 0 (apnea)

Central pulse = absent


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ABSENT PULSE : PEA / EMDTREATMENT

CPR (ventilation, oxygenation, chest

compressions)

Epinephrine every 3-5mins

Treat cause


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ABSENT PULSE : PEA / EMD

Potentially correctable causes

severe hypoxia

hypovolemia tension pneumothorax

cardiac tamponade

severe acidosis

electrolyte disturbances

hypothermia

SUMMARY OF THERAPY BY PULSE


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SUMMARY OFTHERAPY BY PULSERATE IN CHILD WITH SHOCK

PULSE RATE TREATMENT

Fast

Synchronized cardioversion

Adenosine (in SVT if IV access available)

Slow Ventilation, oxygenation, compressions,

epinephrine

Absent

(collapse)

CPR

VF or VT: immediate fibrillation

PEA/EMD : identify and treat cause

Epinephrine


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VENTRICULAR FIBRILLATION


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VENTRICULAR TACHYCARDIA


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SINUS TACHYCARDIA

SUPRAVENTRICULAR


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SUPRAVENTRICULAR

TACHYCARDIA


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ASYSTOLE


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WARNING

Treat the patient

Not the Rhythm

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