ACUTELY ILL CHILD Dr. Siasu
Pathways to Pediatric Cardiac Arrest Precipitating Conditions Respiratory Circulatory
Sudden Cardiac
Respiratory Distress Shock Respiratory Failure
Decide what to do based on your assessment and initial categorization of the clinical condition
ACT For PALS Activate Emergency Response System Start CPR Obtain code cart, monitor/defibrillator Place patient on monitor and pulse oximeter Give oxygen Start treatment (nebulizer, IVF) Reassess the patient as you are providing interventions
Cardiopulmonary Failure CARDIAC ARREST
Timely intervention in seriously ill or injured child is the key to preventing progression toward cardiac arrest Assess Act
Categorize
Determine if condition is Life threatening Not life threatening
Decide 4 Parts to Pediatric Assessment 1. General Assessment – quick visual & auditory observation of appearance, work of breathing, circulation = General assessment done only in few seconds
2. Primary Assessment – rapid hands – on ABCDE approach to evaluate cardiopulmonary and neurologic function, vital signs and pulse oximetry 3. Secondary Assessment – medical history using SAMPLE head – to – toe physical examination 4. Tertiary Assessment – laboratory, radiographic, advanced tests that help to establish the child’s physiologic condition and diagnosis Categorize TYPE SEVERITY Respiratory
Circulatory
- Upper airway obstruction - Lower airway obstruction - Lung tissue disease - Disordered control of breathing - Hypovolemic shock - Distributive shock - Cardiogenic shock - Obstructive shock
General Assessment Appearance - Muscle tone, interaction, speech, cry Work Breathing - Increased work of breathing - Decreased or (-) respiratory effort (apneic) - Abnormal sounds (wheeze, grunting, stridor) Circulation - Abnormal skin color (pale or mottling), bleeding
- Respiratory distress - Respiratory failure
- Compensated shock - Hypotensive shock (before it was called decompensated shock)
Primary Assessment AIRWAY Look Listen Feel Status Clear – airway open chest will rise = with secretions do suctioning while the head is tilt = obstruction do tracheostomy
Maintainable – maintained by simple measures Not maintainable – needs advanced interventions
BREATHING Check for Respiratory rate Respiratory effort = manifested by retractions Tidal volume Airway and lung sounds Pulse oximetry = normal O2 sat >90% Normal RR by Age <1 y.o 30-60/min 1-3 y.o. 24-40 4-5 y.o. 22-34
6-12 y.o. 18-30 13-18 y.o. 12-16 CIRCULATION Assessment cardiovascular function Skin color, temperature Heart rate Rhythm Blood pressure Pulses (both peripheral and central) CRT = Normal: <2 seconds in a warm environment End-organ function Brain perfusion (mental status) GCS: = 13-15 – mild head injury = 9-12 – moderate injury = 3-8 – severe head injury
Skin perfusion Renal perfusion (urine output) = normal: 1cc/kg/hr Normal Heart Rate by Age (per minute)
Age NB to 3 mos 3 mos to 2 yo 2 yo to 10 yo >10 yo
Awake Rate 85-205 100-190 60-140 60-100
Mean 140 130 80 75
Sleeping Rate 80-160 75-160 60-90 50-90
Normal Blood Pressure by Age Age 1 d.o. 4 d.o. 1 mo 3 mos 6 mos 1 y.o. 2 y.o. 7 y.o. 15 y.o.
Systolic BP (mm Hg) Female Male 60-76 60-74 67-83 68-84 73-91 74-94 78-100 81-103 82-102 87-105 68-104 67-103 71-105 70-106 79-113 79-115 93-127 95-131
Diastolic BP (mm Hg) Female Male 31-45 30-44 37-53 35-53 36-56 37-55 44-64 45-65 46-66 48-68 22-60 20-58 27-65 25-63 39-77 38-78 47-85 45-85
Hypotension Age Systolic BP (mm Hg) Term (0-28 d.o.) <60 1 mo to 12 mos <70 1 y.o. to 10 y.o. 5th BP% <70 + (age in years x 2) >10 y.o. <90 DISABILITY APVU Pediatric Response Scale (evaluate cerebral cortex function) Alert Voice Painful Unresponsive
Glascow Coma Scale Responsive
Adult
Child
Infant
EYE OPENING
Spontaneous To speech To pain None Oriented
Spontaneous To speech To pain None Oriented, Appropriate Confused Inappropriate words Incomprehensibl e words None Obeys command
Spontaneous To speech To pain None Coos and babbles Irritable cries Cries to pain
BEST VERBAL RESPONS E
BEST MOTOR RESPONS E
Confused Inappropriate words Incomprehensibl e sounds None Obeys Localizes Withdraws Abnormal flexion Extensor response None
Localizes painful stimulus Withdraws to pain Flexion to pain Extension to pain None
Code d Value 4 3 2 1 5 4 3
Moans to pain None Moves spontaneousl y Withdraw to touch Withdraws to pain Decorticate to pain Decerebrate
2
None
1 3-15
TOTAL SCORE
1 6 5 4 3 2
Signs of Life Threatening Condition Airway Breathing Circulation Disability Exposure
Complete or severe airway obstruction Apnea, significant work of breathing (-) pulses, poor perfusion, hypotension, bradycardia Unresponsiveness, depressed consciousness Significant hypothermia, bleeding, petechiae with septic shock, abdominal distension with an acute abdomen
Secondary Assessment Signs and Symptoms Allergies Medications Past Medical History Last Meal Events RESPIRATORY DISTRESS Clinical state characterized by ↑ RR & ↑ respiratory effort Signs: Tachypnea Tachycardia Increased respiratory effort (nasal flaring, retractions) Abnormal airway sounds Pale, cool skin Changes in mental status (Picture)
Respiratory failure = air hunger Shock = bleeding
RESPIRATORY FAILURE Clinical state of inadequate oxygenation, ventilation or both End stage of respiratory distress Probable respiratory failure indications 1. Marked tachypnea (early) 2. Bradypnea (late) 3. Tachycardia (early) 4. Bradycardia (late) 5. Increased, decreased or no respiratory effort 6. Cyanosis 7. Poor to absent distal air movement 8. Stupor, coma TYPES OF RESPIRATORY PROBLEMS I. Upper Airway Obstruction Can occur in nose, pharynx or larynx Mild to severe Causes o Foreign Body aspiration o Swelling of tissues lining upper airway (anaphylaxis, hypertrophy, tonsillar, croup, epiglotittis) o Mass in airway lumen (pharyngeal or peritonsillar abscess or tumor) o Thick secretions in nasal passages (tracheal rings) o Congenital airway abnormality o Iatrogenic (ex subglottic stenosis for ET) Signs o Tachypnea o Increased inspiratory respiratory effort o Change in voice o Stridor o Poor chest rise o Poor air entry II. Lower Airway Obstruction Occur in the lower trachea, bronchi, bronchioles Causes o Asthma o Bronchiolitis Signs o Tachypnea o Wheezing o Increased in respiratory effort (inspiratory retractions, nasal flaring and prolonged expiration) o Prolonged expiratory phase with increased expiratory effort o Cough
III. Lung Tissue Disease Affect the substance of the lung Causes o Pneumonia o Pulmonary edema o ARDS o Pulmonary contusion o Allergic reaction o Toxins, vasculitis, infiltrative disease Signs: o Tachypnea o Tachycardia o Increased in respiratory effort o Grunting sounds o Hypoxemia o Crackles o Diminished breath IV. Disordered Control of Breathing Abnormal breathing pattern that produces symptoms of inadequate respiratory rate, effort, or both Causes o Neurologic disorders (seizures, CNS infections, brain tumor, neuromuscular disease, head injury, hydrocephalus) Signs o Variable respiratory rate o Variable respiratory effort o Shallow breathing o Central apnea Rapid Cardiopulmonary Assessment – Priorities of Initial Management Potential Respiratory Probable Respiratory Failure Failure Keep with caregiver Separate from caregiver Position of comfort Control airway Oxygen as tolerated 100% FIO2 Nothing by mouth Assist ventilation Monitor pulse oximetry Nothing by mouth Consider cardiac monitor Monitor pulse oximetry Cardiac monitor Establish vascular access The earlier you detect respiratory distress or respiratory failure and start appropriate treatment, the better chance the child has for a good outcome SHOCK Condition that results from inadequate delivery of oxygen and nutrients to meet the metabolic demand of the tissue Can result from:
o o o o
Inadequate blood volume or inadequate oxygen – carrying capacity = hypovolemic Inappropriately distributed blood volume = distributive
Impairment of heart contractility = cardiogenic Obstructed blood flow = obstructive
Physiology Shock Inadequate tissue perfusion can lead to o Tissue hypoxia o Anaerobic metabolism o Accumulation of lactic acid and CO2 o Irreversible cell & organ damage death Factors Influencing Oxygen Delivery Preload Contractility Afterload
Causes: o Diarrhea o Hemorrhage o Vomiting o Inadequate fluid intake o Osmotic diuresis o Third – space losses o Burns 2. Distributive Shock Inappropriate distribution of blood volume with inadequate organ and tissue perfusion Causes: o Septic shock o Anaphylactic shock o Neurogenic shock
Cardiac Output Stroke Volume X Heart Rate
x O2 Content O2 Delivery
= Contractility inotropic = Preload, Contractility and afterload problems are managed medically
Compensatory Mechanisms to Maintain Oxygen Tachycardia Increased Systemic Vascular Resistance Increased contractility Increased venous tone Categorization of Shock by Severity (Effect on Blood Pressure) 1. COMPENSATED Normal BP with inadequate tissue perfusion Signs Increased heat rate
Heart Skin
Increased Systemic Vascular Resistance
Circulation Pulses
Increased Splanchnic Vascular Resistance
Kidney Intestine
Tachycardia Cold, pale, diaphoretic Delayed CRT Weak peripheral pulses Narrow pulse pressure Oliguria, ileus, vomiting
2. HYPOTENSIVE SHOCK Decreased BP – inadequate tissue perfusion Change in mental status Late signs of shock Types of SHOCK 1. Hypovolemic Shock Most common cause of shock in children worldwide
Septic Shock Pathophysiology o Infectious organisms or byproducts activate immune system and cells (neutrophils, monocytes, macrophages) o Interaction stimulate release of inflammatory mediators (cytokines) which produce vasodilatation and immune capillary permeability Consensus Definition & Clinical Characteristics of Pediatric Sepsis Systemic Inflammatory Response Syndrome Sepsis Severe Sepsis Septic Shock Systemic Inflammatory Response Syndrome (SIRS) Presence of 2 of the 4 criteria, one is abnormal temperature or leukocytes count: o Core temperature >38oC or <36oC o Tachycardia in absence of external stimulus, chronic drugs or pain or unexplained persistent elevation ½ - 4 hr period o Children < 1 year old bradycardia unexplained over ½ - hour time period o Mean RR >2 SD above normal for age or mechanical ventilation for an acute process not related to underlying neuromuscular disease or general anesthesia o Leukocytes count ↑ or ↓ for age (not caused by chemotherapy) pr >10% immature neutrophils Sepsis SIRS and suspected or proven infection
Severe Sepsis Sepsis + CV dysfunction or ARDS or Sepsis + 2 or more other organ failures Septic Shock Sepsis + CV dysfunction despite administration of isotonic IVF boluses ≥ 40 mL/kg in 1 hour CV dysfunction characterized by the following: - hypotension (SBP <5% for age) or - need vasoactive drug to maintain BP in normal range or 2 of the following characteristics of inadequate organ perfusion: o Unexplained metabolic acidosis, BP >5 mEq/L o Increased arterial lactate greater than twice the upper limit of normal o Oliguria: u.o. <0.5 mL/kg/hr o CRT > 5 sec o Core to peripheral temperature gap > 3oC 3. Cardiogenic Shock Characterized by: o Decreased cardiac output o Marked tachycardia o High systemic vascular resistance Primary Assessment o Tachypnea o Increased respiratory effort o Tachycardia o Signs of CHF (pulmo edema, hepatomegaly, jugular venous distention) o Cyanosis (for cyanotic CHD or pulmo edema) o Normal or low blood pressure o Weak or absent peripheral pulses o Normal then weak central pulses o CRT delayed Inadequate tissue perfusion from myocardial dysfunction Causes: o CHD o Myocarditis o Cardiomyopathy o Arrhythmias o Sepsis o Poisoning or drug toxicity o Myocardial injury 4. Obstructive Shock Impaired cardiac output caused by physical obstruction of blood flow
Types: o Cardiac tamponade o Tension pneumothorax o Ductal - dependent congenital heart disease o Massive pulmonary embolism
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 = isotonic solution @ 20cc/kg bolus
Monitor oxygenation, heart rate, and urine output Consider vasoactive infusion
Case No 1: 3 weeks old presents to the emergency department CC: Vomiting and diarrhea PE: Bradycardia, gasping, cyanosis - What is the physiologic status? - What are the initial intervention? Cardiopulmonary Failure = Response to intubation and ventilation with FIO2=1.00 HR: 180; BP: 50 mmHg systolic Pink centrally; cyanotic peripherally No peripheral pulses No response to venipuncture What is the physiologic status? Hypotensive What is the cause? Hypovolemic shock Response to Therapy Vital signs improved Perfusion still poor Chest X-ray: What is the heart size? Case No. 2 A 3-day old infant has a history of irritability and one episode of vomiting PE: Gasping, bradycardia, cyanosis What is the physiologic status? What are the initial interventions? Cardiopulmonary Failure = Response to oxygenation and ventilation: HR: 180; BP: 40 mm Hg systolic Pink centrally Cyanotic peripherally No peripheral pulses
No response to venipuncture
Cause: Cardiogenic shock What is the physiologic status? What is the next intervention? Chest X-ray After Fluid Bolus (Picture) -END-
