Transcript
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
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