Resuscitation & Stabilisation of the Critically Ill Child Sandra Stark Nurse Consultant ScotSTAR
Jan 13, 2016
Resuscitation & Stabilisation of the Critically Ill Child
Sandra StarkNurse Consultant ScotSTAR
Resuscitation
Differences Between Adults & Children
LESS THAN YOU THINK!!!!
Paediatric vs Adult Resuscitation
Focus on the similarities
Airway
Breathing
Circulation
Common Presentations Respiratory distress
Usually infective in origin Bronchiolitis, LRTI, croup
Infection/sepsis Large range of support required
Seizures
Trauma
Decreased GCS Intracranial pathology Infection Trauma NAI
DifferencesPathways leading to cardiac arrest in children
are different
Rarely due to primary cardiac disease
Usually due to circulatory +/- respiratory failure
If child arrests, likely to be more decompensated
Airway Differences Head large, neck small- tends to cause neck flexion
Tongue relatively large◦ May obstruct airway in unconscious child◦ Obstructs view at laryngoscopy
Easy to compress airway when holding face mask
Beware the child with airway obstruction who has an oxygen requirement
Head tilt◦ Neutral in the infant◦ Sniffing in the child
Intubation Differences As in adults, often can maintain airway with good bag/mask If need intubation or to assist, have variety of sizes close to
hand ETT size – 4 + age/4 (drop half a size if cuffed) Epiglottis in children horseshoe shaped & projects
posteriorly Larynx high & anterior (C2-3 in infant compared to C5-6 in
adult) Trachea short – tube displacement more likely Pre-oxygenation vital – more likely to desaturate More likely to be bradycardic during intubation
◦ Infants more pronounced vagal response◦ Bradycardia with direct laryngeal stimulation◦ Can be due to hypoxia◦ More likely to stimulate vagal response (vagus nerve) in infant
intubation with direct laryngeal stimulation,
Breathing DifferencesHigher metabolic rate & oxygen consumption so
higher RRWork of breathing – nasal flaring, intercostal &
subcostal recessions due to compliant chest wallInfants rely on diaphragmatic breathing – more
likely to fatigue & cause respiratory failureMore compliant chest wall – may have lung injury
without fractured ribsIf rib # present, implies significant forceImportant to remember when BVM not to use
excessive force (tidal volume 5-10ml/kg)
Circulation DifferencesChild’s circulating blood volume 70ml-
80ml/kg
Higher than an adult but relatively small so easier to dilute
Small SV in infants so CO increased by HR
HR response to fluids can be blunted in infants
Cardiac DecompensationCardiac arrest – likely to be asystole or PEA
Uncommon to require shock
Children will maintain cardiovascular parameters (ie BP) until almost pre-terminal then deteriorate very quickly
Bradycardia/hypotension LATE sign of decompensation
Primary cardiac disease uncommon in children – consider in neonates or children with known cardiac disease
Neurology DifferencesModified GCS??
Hypoglycaemia can be a big problem
Paediatric SpineSpinal injuries relatively rare
More flexible joint capsules & interspinous ligaments
Relatively large head compared with neck – thus movement greater and more injuries at level of occiput to C3
Spinal cord injury without radiological abnormalities more common in children
Paediatric Burns
Paediatric BurnsAdults – rule of 9s
More complex in paeds
Easiest way – palmar surface (including fingers) of patient’s hand represents approximately 1%
Essential Equations
Weight (Age+4) multiplied by 2Formula for weight
◦ Average birth weight 3.5kg◦ Increased to 10kg by 1 year
Broselow tapes◦ Colour coded system for paediatrics
Energy = 4J/kgFluid = 20ml/kg (10ml/kg in trauma or DKA)Sugar = 3ml/kg of 10% dextroseAdrenaline = 0.1ml/kg of 1:10,000
StabilisationDiscussion regarding retrieval to
appropriate centre
Ongoing care & optimisation
Interventions
Airway/intubationVentilationHaemodynamic supportVascular access (arterial/venous)Other – blood, medications
Who Will Perform Interventions?Local team
Retrieval team
Joint
Intubation - Tips If referring team can intubate saves time if they do so
Don’t cut tubes too short
Short ETT◦ Easy to dislodge◦ CXR to confirm position
Many children will maintain A & B with PEEP/oxygen – correct haemodynamics before administering anaesthetic
Common regime◦ Fentanyl (1-2mcg/kg) if required◦ Ketamine 2mg/kg◦ Rocuronium 1mg/kg◦ Resus drugs drawn up-adrenaline/atropine◦ Beware thio/propofol
Ventilation - TipsLow threshold for intubation children for
transfer◦Especially any airway obstruction◦Safer to intubate in good environment before you
leave
Watch tidal volumes – easy to over inflate small lungs
Difficulties with ventilation◦Suction, physio can make a big difference
Circulation - Tips
IO access if unable to get access◦Also remember external jugular vein for access◦Scalp veins in neonates
Inotropes if required (consider when >40ml/kg fluid resuscitation)
Adrenaline or dopamine can be used peripherally
2 points of access before you leave
How to Make up Inotropes
Neurology - TipsBeware of hypoglycaemia
◦3-5ml/kg 10% dextrose
Midazolam/morphine for sedation◦Morphine 20-40mcg/kg/hr◦Midazolam 0.1mg/kg/hr◦Bolus rocuronium for transfer
Small adults◦Use what you are comfortable with!!
Head InjuryMay require time-critical response for
neurosurgical interventionPrevent secondary brain injury with
appropriate ventilation/circulatory support◦Desaturation & low BP very bad for heads◦In child with head injury & raised ICP, even one
episode of hypotension can cause significant morbidity
Other . . . Heat loss more of a problem-packaging
important
Higher body surface area for heat loss
In trauma, energy transmitted to body that has less connective tissue & fat and closer proximity to multiple organs – significant injury may exist in absence of fractures
Cardiac . . .Very rare to have primary cardiac diseaseCardiac compromise often secondary to
other pathologyNeonates
◦Cyanosed◦Cardiac findings ie absent femorals
Older children◦History of cardiac disease/pathology
Cardiac PresentationA, B, C . . .Often breathing can be supported with PEEP
◦May need intubation but optimise other systems first
◦The ‘oxygen’ dilemma . . .Cautious with fluid
◦Use 10ml/kg aliquots & assess response◦In neonates with duct dependent disease, discuss
with tertiary centre & consider prostin◦Sepsis/metabolic other differentials in ‘shut
down’ neonate – sepsis FAR MORE COMMON
www.snprs.scot.nhs.uk
Questions??