RECOGNITION OF PEDIATRIC EMERGENCIES Dr. Lilia Dewiyanti, SpA, MSiMed.
May 22, 2015
RECOGNITION OF PEDIATRIC EMERGENCIES
Dr. Lilia Dewiyanti, SpA, MSiMed.
2
Many etiologies
Respiratory failure Shock
Cardiopulmonary failure
Cardiopulmonary arrest
3
Outcome of respiratory vs Cardiopulmonary Arrest in Children
100%
75%
Survival rate
Respiratory arrestCardiopulmonary arrest
75 – 90 %
7 – 11 %
4
Core Knowledge and Skills
1. Recognize respiratory distress and
potensial respiratory failure
2. Recognize shock3. Describes priorities for
management of respiratory distress,
failure, and shock
5
Is this child in respiratory failure or shock ?
Is this child in respiratory failure or shock?
6
The Three Phases ofRapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
7
The ABCs
Normal Vital Functions Are Maintained
By
AirwayTo ProvideVentilation
Breathing Oxygenation
Circulation Perfusion
8
Primary Abnormalities in Respiratory Failure
AirwayAnd
Breathing
Ventilation
Oxygenation
Circulation
Perfusion
9
Classification of Respiratory Failure
Potential respiratory failure
Theraphy(eg, positioning, oxygen administration)
ImprovementPotential
Resp. failure
DeteriorationProbable
Resp. failure
10
Initial Assessment
Pediatric Assessment Triangle :
App
eara
nce
Work of B
reathing
Circulation to Skin
11
Appearance (“Tickles” =TICLS)
Tonus Interactiveness Consolability Look/Gaze Speech/Cry
App
eara
nce
12
Potential respiratory failure
13
Work of Breathings
Abnormal airway sounds
Abnormal positioning Retractions Nasal flaring
Work of B
reathings
14
The sniffing position
The abnormal tripod position
Retractions
15
Characteristic of Circulation to Skin
Pallor (putih pucat)
Mottling (bercak2)
Cyanosis (kebiruan)
Circulation to Skin
16
App
eara
nce
Work of B
reathing
Circulation to Skin
PAT: Potential Respiratory Failure
Normal Increased
Normal
17
App
eara
nce
Work of B
reathing
Circulation to Skin
PAT: Respiratory Failure
AbnormalIncreased
or decreased
Normal or abnormal
18
Rapid Cardiopulmonary AssessmentPhysical Examination - Airway
1. Clear
2. Maintainable
3. Unmaintanable without intubation
4. Obstructed
19
Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing
1. Rate
2. Effort / mechanics
3. Air entry
4. Skin color and temperature
20
Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing
Evaluation of rate, effort, and mechanics
• Tidal Volume ( V T)
• Minute ventilation (MV)
• MV = VT X RR
21
Rapid Cardiopulmonary AssessmentPhysical Examination : Breathing
22
Primary Abnormalities in Shock
AirwayAnd
Breathing
Ventilation
Oxygenation
Circulation
Perfusion
23
App
eara
nce
Work of B
reathing
Circulation to Skin
PAT: Shock
Abnormal Normal
Abnormal
24
Basic Relationships of Cardiovascular Parameters
BloodPressure
CardiacOutput
SystemicVascularResistance
StrokeVolume
HeartRate
Preload
Myocardialcontractility
Afterload
25
Cardiac Output = Heart Rate X Stroke Volume
Inadequate Compensation• Increased heart rate• Increased SVR• Posible increased SV
26
29Respons hemodinamik terhadap kehilangan darah
25 50 75
%tase kehilangan darah
% k
ontr
ol
20
60
100
140
resistensi vaskular
Tekanan darah
Curahjantung
27
Child in shock
28
Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation
1. Heart rate
2. Systematic perfusion• Peripheral pulses• Skin perfusion• Level of consciousness• Urine output
3. Blood pressure
29
Heart rates in Normal Children
Age Range
Newborn – 3 Mos 85 – 200 bpm
3 mos – 2 yrs 100 – 190 bpm
2 – 10 yrs 60 – 140 bpm
30
Palpation of Central dan Distal Pulses
31
Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation
Skin perfusion
• Extremity temperature• Capillary refill • Color
• Pink• Mottled• Pale• Blue
32
Normal capillary refill is < 2 seconds in a warm environment
Capillary refill
33
Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation
Level of consciousness
• A = Awake• V = Responsive to voice• P = Responsive to pain• U = Unresponsive
Child in shock with depressed mental status
34
Renal perfusion
• Urine output (Normal: 1 to 2 mL/kg/hour) reflects
• Glomerular filtration rate reflects
• Renal blood flow reflects
• Vital organ perfusion
What information does blood pressure provide ?
What is inadequate blood pressure ?
35
Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation
Age Fifth percentile mmHgSystolic BP
0 – 1 Mo 60
> 1 mo – 1 yr 70
> 1 yr 70 + (2 x age in years)
36
Review of the Physical Findings in Shock
Early signs (compensated)
• Increased heart rate• Poor systemic perfusion
Late signs (decompensated)
• Weak central pulses• Altered mental status• Decreased urine output• Hypotension
37
Child dying with anasarca , MOSFdespite resuscitation efforts
38
Definition of Cardiopulmonary Failure
Deficits in
Resulting in
• Ventilation• Oxygenation• Perfusion
• Agonal respiration • Bradycardia• Cardiopulmonary arrest
39
Rapid Cardiopulmonary Assessment
AirwayAnd
Breathing
Ventilation
Oxygenation
Circulation
Perfusion
40
The Three Phases ofRapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
41
Rapid Cardiopulmonary AssessmentClassification of Physiologic status
• Stable
• Respiratory failure
• Potential• Probable
• Shock
• Compensated• Decompensated
• Cardiopulmonary failure
42
The Three Phases ofRapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
43
Rapid Cardiopulmonary Assessment -Priorities of Initial Management
Stable• Begin further workup• Provide specific theraphy as indicated• Reassess frequently
44
Rapid Cardiopulmonary Assessment -Priorities of Initial Management
Potential RF Probable RF
Keep with caregiverPosition of comfortOxygen as tolerated
Nothing by mouthMonitor pulse oximetryConsider cardiac monitor
Separate from caregiverControl airway100 % FiO2Assist ventilationNothing by mouthMonitor pulse oximetryCardiac monitorEstablish vascular- access
45
46
Rapid Cardiopulmonary Assessment -Priorities of Initial Management
Shock
• Administer oxygen (FiO2 = 1.00) and ensure adequate airway and ventilation• Establish vascular access• Provide volume expansion• Monitor oxygenation, heart rate, and urine output• Consider vasoactive infusions
47
Rapid Cardiopulmonary Assessment -Priorities of Initial Management
Cardiopulmonary failure
• Oxygenate, ventilate, monitor• Reassess for
• Respiratory failure• Shock
• Obtain vascular access
48
Case No 1
A 3-week-old infant arrives at the emergency department.
• CC : Vomiting and diarrhea• PE : Gasping respirations, bradycardia, cyanosis
What is the physiologic status ?
What are the initial interventions ?
49
Case No 1 - Cardiopulmonary failure
What is the physiologic status ?
What is the cause ?
Response to intubation and ventilation with FiO2 1.00
• HR : 180; BP 50 mm Hg systolic• Pink centrally; cyanotic peripherally• No peripheral pulses• No response to venipuncture
50
Case No 1 - Response to Therapy
• Vital sign improved• Perfusion still poor
51
What is the heart size ?
52
Case No 2
A 3-day-old infant has a history of irritability and one episode of vomiting PE : Gasping respirations, bradycardia, cyanosis
What is the physiologic status ?
What are the initial interventions ?
53
Case No 2 - Cardiopulmonary failure
What is the physiologic status ?
What is the next intervention ?
Response to oxygenation and ventilation with FiO2 1.00
• HR : 180; BP 40 mm Hg systolic• Pink centrally; cyanotic peripherally• No peripheral pulses• No response to venipuncture
54
Chest X-ray after fluid bolus