The child with circulatory probelms

Jamie Ranse: Critical Care Education Coordinator, Staff Development Unit, ACT Health.

THE CHILD WITH CIRCULATORY PROBLEMS

• Differences in children• Circulatory assessment

– General– Dehydration

• Management of circulatory alterations• DVD of circulatory assessment• Case study

overview

• Myocardium• Compensation• Body water• Surface area• Venous access

differences in children

• Less compliant • Has less contractile tissue• Significance:

– CO = HR x SV– Tachycardia– Other signs of shock rapid venous access

differences in children:myocardium

• Normotensive until 25% of their blood volume is lost– Circulating volume– Hypotension late / sudden sign of decompensation

differences in children:compensation

• 60% of body weight of an adolescent• 65% of the preschooler• 80% of the infant• Is distributed between two body compartments

– Intraceullular – Extracellular

differences in children:body water

• Intracellular fluid compartment• Extracellular fluid compartments

– Intravascular– Interstitial– Transcellular

• CSF• Synovial• Pleural

differences in children:body water

differences in children:body water

• Larger surface area / volume ratio• Significance:

– Greater risk of dehydration– Maintenance fluid requirements higher

differences in children:surface area

• Intraosseous cannulation threshold

differences in children:venous access

• Myocardium• Body water• Metabolic rate• Distribution of body fluids• Surface area• Venous access• Immature renal function• Rely on others to give them fluid

summary

• Observation• Palpation• (Percussion)• Auscultation

circulatory assessment:general

• Observe– Skin colour– Work of breathing– Mental status– Hydration status

• Palpation– Pulse characteristics– Capillary refill – Blood pressure

• Auscultation– Chest / heart

circulatory assessment:general

Broad categories• Hypovolaemic• Cardiogenic• Distributive• Obstructive

circulatory assessment:general

Hypovolaemia• Hypovolaemia most common cause of shock in

children• Gastroenteritis most common cause of

hypovolaemia in children

circulatory assessment:general

• Dehydration results from– Reduced intake– Increased fluid loss– Excessive renal loss– From skin and respiratory systems

circulatory assessment:hydration status

• Steiner et al 2003– Prolonged CR – Abnormal skin turgor– Abnormal breathing

• Useful clinical signs include– Cool pale peripheries

& prolonged CR– Decreased skin turgor– Deep breathing– Increased thirst

circulatory assessment:hydration status

circulatory assessment:hydration status – estimating deficit

Mild 3% Reduced urine output

Thirst

Dry mucous membranes

Mild tachycardia

Moderate 5% Dry mucous membranes

Tachycardia

Abnormal respiratory pattern

Lethargy

Reduced skin turgor

Sunken eyes

Severe 10% As above plus

Poor perfusion (mottled, slow CR, altered LOC)

Shock (poor perfusion, weak pulses, tachycardia)

Broad categories

management of circulatory alterations

management of circulatory alterations

• Calculation of fluid replacement– 10mls/kg isotonic solution

• Calculation of fluid maintenance– TKVO – 10mls/hr

• IV / IO

management of circulatory alterations

DVD of circulatory assessment

1010: Called to an infant with 3/7 history of diarrhoea

1015: On arrival 6/12 ♀ named Mary:A: clear and open

B: dyspnoeic

C: skin pale

D: awake and interactive

case study

1020: During your initial examination, you notice Mary’s condition deteriorate…

A: clear

B: ↑ effort, ↑ efficacy

C: sunken fontanel and eyes, poor peripheral circulation, dry mucous membranes, doughy skin, cyanosed

D: flaccid, no response to stimuli, fixed stare

case study

• What are Mary’s problems?• What else do we need to know to assist her?

case study

• Foetal problem – nil• Illnesses / injuries since birth – nil • Immunisation status – fully immunised for her age• Developmental status – normal for her age• Allergies – nil • Events leading up to your arrival

– 3/7 history of diarrhoea – No oral intake for previous 12/24– Unknown urine output

case study

• Observe– Skin colour– Work of breathing– Mental status

• Palpation– Pulse rate v heart rate– Capillary refill – Blood pressure

• Auscultation– Chest / heart

case study: your circulatory assessment

Jamie Ranse: Critical Care Education Coordinator, Staff Development Unit, ACT Health.

THE CHILD WITH CIRCULATORY PROBLEMS