Pediatric Resuscitation Russian Field Hospital Nias, Indonesia 4/05 Russian Field Hospital Nias,...

Pediatric ResuscitationPediatric Resuscitation

Russian Field Hospital

Nias, Indonesia

Russian Field Hospital

Nias, Indonesia

Lecture Objectives Lecture Objectives

The goal of this module:

• Perform rapid cardiopulmonary assessment

• Recognize signs of respiratory distress, respiratory failure, and shock

Respiratory failure Shock

Cardiopulmonary failure

Cardiopulmonary arrest

Progression of Respiratory Failure and Shock

Various Conditions

Comparison of SurvivalComparison of Survival

0%Respiratory

arrestCardiopulmonary

arrest

Survivalrate

Rapid Cardiopulmonary Assessment

1. Evaluation of general appearance (mental status, tone, responsiveness)

2. Physical examination of airway, breathing, and circulation (ABCs)

3. Classification of physiologic status

Rapid cardiopulmonary assessment should be accomplished in less than 30 seconds!

Pediatric Assessment TrianglePediatric Assessment Triangle

General AppearanceGeneral Appearance

Evaluation of General Appearance

• General color (“looks good” vs “looks bad”)

• Mental status, responsiveness

• Activity, movement,

muscle tone

• Age-appropriate response

Breathing EvaluationBreathing Evaluation

Physical Examination: Airway Physical Examination: Airway

• Clear

• Maintainable

• Not maintainable

without intubation

Evaluating RespirationsEvaluating Respirations

• Respiratory rate

• Respiratory effort (work of breathing)

• Breath sounds/air entry/tidal volume

— STRIDOR (inspiration)

— WHEEZE (expiration)

• Skin color and pulse oximetry

Rapid Cardiopulmonary Assessment:Classification of Status

•Respiratory distress: Increased work of breathing

•Respiratory failure: Inadequate oxygenation or ventilation

Cardiovascular AssessmentCardiovascular Assessment

Cardiovascular VariablesAffecting Systemic Perfusion

Blood pressure

Cardiac output

Systemic vascular resistance

Stroke volume

Heart rate

Preload

Myocardial contractility

Afterload

Response to ShockResponse to Shock

Vascular resistance

Blood pressure

Cardiac

output

Compensatedshock

Decompensatedshock

Decompensated ShockDecompensated Shock

Compensatory mechanisms fail to maintain adequate cardiac output

and blood pressure

Physical Examination: Circulation

• Cardiovascular function

— Heart rate

— Pulses, capillary refill

— Blood pressure

• End-organ function/perfusion

— Brain

— Skin

— Kidneys

Typical Assessment Order:

— Observe mental status

— Feel for heart rate, pulse quality, skin temperature, capillary refill

— Measure blood pressure

— (Measure urine output later)

Evaluation of responsiveness

• A — Awake

• V — responsive to Voice

• P — responsive to Pain

• U — Unresponsive

Heart Rates in ChildrenHeart Rates in Children

85 220 300

Normal

60 180 200

Infant

Compensating?

Evaluation of skin perfusion

• Temperature of extremities

• Capillary refill

• Color

— Pink

— Pale

— Blue

— Mottled

Palpation of Central and Distal Pulses

Capillary RefillCapillary Refill

Prolonged capillary refill (10 seconds) in a 3-month-old with shock

Physical Examination:Circulation

Age Minimum systolic blood pressure (5th percentile)

0 to 1 month 60 mm Hg

>1 month to 1 year 70 mm Hg

1 to 10 years of age 70 mm Hg + (2 age in years)

>10 years of age 90 mm Hg

Estimate of Minimum Systolic Blood Pressure

Minimum Systolic BP by age(5% of the range of normal)Minimum Systolic BP by age(5% of the range of normal)

0-30 days 1mon - 1 yr 1 yr - 10 yr > 10 yrs

minimum BP

Physical Examination:Circulation

• Cardiovascular function

— Heart rate

— Pulses, capillary refill

— Blood pressure

• End-organ function/perfusion

— Brain (Mental Status)

— Skin (Capillary Refill Time)

— Kidneys

Kidneys

• Urine Output

— Normal: 1 to 2 mL/kg per hour

— Initial measurement of urine in bladder not helpful

Evaluation of End-Organ Perfusion

Classification of Physiologic Status: Shock

Early signs (compensated)

— Increased heart rate

— Poor systemic perfusion

Late signs (decompensated)

— Weak central pulses

— Altered mental status

— Hypotension

Septic Shock Is DifferentSeptic Shock Is Different

• Cardiac output may be variable

• Perfusion may be high, normal, or low

• Early signs of sepsis/septic shock include

— Fever or hypothermia

— Tachycardia and tachypnea

— Leukocytosis, leukopenia, or increased bands

Special Situations: Trauma Special Situations: Trauma

• Airway and Breathing problems are more common than Circulatory shock

• Use the ABC or assessment triangle approach plus

— Airway + cervical spine immobilization

— Breathing + pneumothorax management

— Circulation + control of bleeding

• Identify and treat life-threatening injuries

Special Situations: Trauma Special Situations: Trauma

Spinal Precautions? Pneumothorax?

Bleeding control?

Special Situations: Toxicology Special Situations: Toxicology

• Airway obstruction, Breathing depression, and Circulatory dysfunction may be present

• Use the ABC and assessment triangle approach, plus watch for— Airway: reduced airway protective mechanisms— Breathing: respiratory depression— Circulation: arrhythmias, hypotension,

coronary ischemia• Identify and treat reversible complications• Administer antidotes

Special Situations: Toxicology Special Situations: Toxicology

Respiratory Effort and

Is the Patient Awake enough

to maintain airway?

Arrythmias?Vascular Tone?

Ischemia?

Classification of Physiologic Status: Cardiopulmonary Failure

Cardiopulmonary failure produces signs of respiratory failure and shock:

• Agonal respirations

• Bradycardia

• Cyanosis and poor perfusion

Classification of Cardiopulmonary Physiologic Status

• Stable

• Respiratory distress

• Respiratory failure

• Shock

— Compensated

— Decompensated

• Cardiopulmonary failure

Pathway to Decompensation

FULL ARREST

RESPIRATORY FAILURE

Respiratory DistressDECOMPENSATED

Respiratory DistressCompensated

CIRCULATORY FAILURE

Circulatory DistressDECOMPENSATED

Circulatory DistressCompensated

Many CausesAsthma, ShockFB, Secretions

Toxins, etc.

Rapid Cardiopulmonary Assessment: Summary

• Evaluate general appearance• Assess ABCs• Classify physiologic status

— Respiratory distress— Respiratory failure— Compensated shock— Decompensated shock— Cardiopulmonary failure

• Begin management: support ABCs

CheckpointCheckpoint

•Rapidly perform assessment

•Use the information to prioritize your resuscitation efforts

•Remember the Pediatric Assessment Triangle as we practice cases

Rapid Cardiopulmonary Assessment ApplicationRapid Cardiopulmonary Assessment Application

• CC: Severe vomiting and diarrhea

• Physical exam: Gasping respirations, bradycardia, cyanosis, and poor perfusion

What ar the results of your RAPID ASSESSMENT?

What is the PHYSIOLOGIC STATUS?

What are the emergency interventions?

A 3-week-old infant arrives in the ED:

What is this Child’s Assessment?

Rapid Cardiopulmonary Assessment ApplicationRapid Cardiopulmonary Assessment Application

• Response to intubation and ventilation with 100% oxygen:— Heart rate: 180 bpm — Blood pressure: 50 mm Hg systolic— Pink centrally, cyanotic peripherally— No peripheral pulses— No response to painful stimuli

What is happening? What is next treatment step?

Case Progression

Pathway to Decompensation

FULL ARREST

RESPIRATORY FAILURE

Respiratory DistressDECOMPENSATED

Respiratory DistressCompensated

CIRCULATORY FAILURE

Circulatory DistressDECOMPENSATED

Circulatory DistressCompensated

Many CausesAsthma, ShockFB, Secretions

Toxins, etc.

Rapid Cardiopulmonary Assessment Application: Response to Therapy

• Vital signs improved

Pediatric IntubationPediatric Intubation

Andrew Garrett, MDDivision of Transport and Emergency Medicine

GoalsGoals

•Review of some basic concepts of pediatric airway management

• Introduce/review RSI in a stress-free environment

•Have a chance to practice intubation skills later today

Review and Overview of Airway Management

•Children at higher risk for hypoxia and respiratory failure:

•Anatomic differences

•Higher metabolic rate

•Ambiguous symptoms of hypoxia

•Head trauma is common in pediatrics

•Limited practice of management skills

Airway Anatomic Differences (Extrathoracic)

•Relatively larger tongue

•Tongue placed superiorly (C3-4)

•Angle of epiglottis angled away from larynx

•Vocal folds can trap ET tube

•Narrowest area at cricoid vs. glottis

AnatomyAnatomyepiglottis

False VC

cartilage

esophagustrachea

True VC

Cricoid CartilageCricoid Cartilage

Airway Anatomic Differences(Intrathoracic)

• Compliance of conducting airways at high flow rates

• Fewer, smaller alveoli (< 8 yrs)

• Smaller FRC (functional reserve)

• Decreased diffusion

• Metabolic Rate

• 2 x adult oxygen consumption rate

• Shorter tolerance of apnea

Can your patient be managed without intubation?

•The A of the ABC’s

•Chin lift

• Jaw thrust

•Suction

•Oropharyngeal airway

•Nasopharyngeal airway

Intubation OverviewIntubation Overview

• Positioning• Choose the tube size• Choose the blade size and type• Insertion distance• Sedation• Paralysis• Equipment

Positioning the PatientPositioning the Patient

•Alignment of the 3 axis

•Oropharynx, Pharynx, Trachea

Positioning thoughtsPositioning thoughts

• Don’t rush this part…

• Be careful of cervical spine injury

• Infant

• Large occiput, gentle lift of shoulder

• Use a folded towel

• Adolescents and Adults

• Extension of head on a towel support

Proper alignment for intubation (almost…)Proper alignment for intubation (almost…)

Tube Size Tube Size

•Cuffed vs. Uncuffed (age cutoff ~8 yrs)

•Remember pediatric airway anatomy

• ( Age + 4 ) / 4 for > 1 year old

•3.5 for newborn

•2.5 for preemie (< 28 weeks)

•3 for in between

Choose your bladeChoose your blade

•Macintosh

• Into the vallecula, lift the epiglottis from its foundation to visualize the trachea

•Miller

•Past the epiglottis, directly lift the epiglottis with traction to visualize

Macintosh vs. MillerMacintosh vs. Miller

Preemie

Neonate

<2 yrs

2-6 yrs

6-12 yrs

>12 yrs

Insertion DistanceInsertion Distance

•Guidelines:

•< 4 kg weight (kg) + 6 *•>4 kg 3 x ET tube size

•Distance to mandibular ridge

•* usually a slightly high position

Confirmation of PlacementConfirmation of Placement

•Auscultation

•Capnography

•Radiography

•Visualization

The Technique of R.S.I.The Technique of R.S.I.

•Keep it simple, not stressful

• In a nutshell:

•What drug has been proven to increase the chance of successfully performing endotracheal intubation?

•Keep it simple, not stressful

• In a nutshell:

•What drug has been proven to increase the chance of successfully performing endotracheal intubation?

•A paralytic agent such as succinylcholine

•Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

•The rest of the drugs are because we’re nice (but that’s optional!)

–SEDATIVE

• Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

• The rest of the drugs are because we’re nice (but that’s optional!)

– SEDATIVE• Etomidate, benzos, propofol, etc.• Serves to make it a more pleasant

experience• Don’t need to duplicate efforts

•Or because we think they should help prevent a side effect

–ATROPINE

–ATROPINE• Dryer work environment• Heart rate stabilization

–LIDOCAINE *

• Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

• Or because we think they should help prevent a side effect

– LIDOCAINE *• A bit questionable• May help prevent ICP increase

• Don’t forget the basics though:

• BVM skills

• Positioning

• Preparedness

• Don’t rush, RSI is not a rescue airway technique, use BVM until you are ready

RSI: Rapid Sequence Intubation

•“full stomach rule” in urgent intubations•Preoxygenation 1-5 minutes with 100%•Utilize Sellick maneuver•Choreography of medications•Confidence of providers to adequately ventilate

after medications are given.•Rule out airway compression from mass effect

if paralysis is being considered.

SedationSedation

•Fentanyl 1-2 mcg/kg IV

•Midazolam 0.1 mg/kg IV

•Diazepam 0.1 mg/kg IV

•Ketamine* 0.5-2 mg/kg IV

•* can be tripled for IM dosing

ParalysisParalysis

• Succinylcholine * 1-2 mg/kg IV• 5 to 10 min

• Rocuronium 1 mg/kg IV• ~30-45 minutes

• Pancuronium 0.1 mg/kg IV• ~1-2 hours

• Vecuronium 0.1 mg/kg IV• ~30 minutes

• * can be doubled for IM dosing

Plans B and C?Plans B and C?

• After deciding to undertake RSI• Make sure you have a backup/failed airway plan

–LMA–Combitube–Fiberoptic, Bougie, Digital

• The final option–Surgical airway

• Percutaneous or Open

Equipment and TechniqueEquipment and Technique

Take a moment to double check your equipment and medications before you start

The flow of thingsThe flow of things

•Examination (esp. neuro status, etc.)

•Equipment checklist

•Preoxygenate

•Sedate, Paralyze, Intubate, Secure

•Confirm placement

•Continuous evaluation of placement

Tips from the Field:Tips from the Field:

•Know the size and depth of the tube

•Confirm placement with every move

•Tape tape tape!

•When in doubt, take it out and bag!

•Don’t forget the CXR

•Check your battery and bulb

Ready to Intubate?Ready to Intubate?

Ideal circumstances!Reality!

CirculationCirculation

•After the RAPID ASSESSMENT is done•After BREATHING interventions are started•Priorities

•STOP major bleeding•Get IV access

–IV, IO, umbilical vein–We will review techniques

CirculationCirculation

•Priorities• IV Fluids

–Preload, afterload–Saline 20 mL per kg–Give it fast–Repeat assessments and vital signs–Repeat if necessary–Consider blood?

IV FluidsIV Fluids

Blood pressure

Cardiac output

Systemic vascular resistance

Stroke volume

Heart rate

Preload

Myocardial contractility

Afterload

Cardiovascular CasesCardiovascular Cases

Objectives

•Differentiate shock from hypotension

•Distinguish compensated from decompensated shock

•Outline appropriate shock management

• Identify and manage selected pediatric dysrhythmias

Shock and Hypotension

•Shock is inadequate perfusion and oxygen delivery.

•Hypotension is decreased systolic blood pressure.

•Shock can occur with increased, decreased, or normal blood pressure.

Recognition of Shock

Compensated: Decompensated:

• Normal level of consciousness

• Altered level of consciousness (ALOC)

• Tachycardia • Profound tachycardia, or bradycardia

• Normal or delayed perfusion

• Delayed perfusion

• Normal or increased BP • Hypotension

Management of ShockManagement of Shock

Interventions:• Open airway • Provide

supplemental oxygen

• Support ventilation• Shock position• Vascular access/fluid

resuscitation• Vasopressor support

9-month-old infant

•A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.

9-month-old infant

Circulation to SkinPale skin color

Work of BreathingNo retractions or abnormal airway sounds

AppearanceAgitated, makes eye contact

Initial Assessment

• Airway - Open and maintainable • Breathing - RR 50 breaths/min, clear lungs,

good chest rise• Circulation - HR 180 beats/min; cool, dry, pale

skin; CRT 3 seconds • Disability - AVPU=A• Exposure - No sign of trauma, weight 8 kg

What is this child’s physiologic state?

What are your treatment priorities?

• Assessment: Compensated shock, likely due to hypovolemia with viral illness

• Treatment priorities:• Provide oxygen, as tolerated• Obtain IV access en route

–Provide fluid resuscitation• 20 ml/kg of crystalloid, repeat as needed

•160 ml normal saline infused

•HR decreased to 140 beats/min

•Patient alert and interactive, receiving second bolus on emergency department arrival

15-month-old child

• A previously healthy 15-month-old child presents with 12 hours of fever, 1 hour of lethargy and a “purple” rash.

15-month-old child

Circulation to SkinPale skin color

Work of BreathingNo retractions or abnormal airway sounds

AppearanceNo eye contact, lies still with no spontaneous movement

Initial Assessment

• Airway - Open• Breathing - RR 60 breaths/min, poor chest rise• Circulation - HR 70 beats/min; faint brachial pulse;

warm skin; CRT 4 seconds; BP 50 mm Hg/palp • Disability - AVPU=P• Exposure - Purple rash, no sign of trauma, weight 10 kg

What is your assessment of this patient?

What is her problem?

•This patient is in decompensated shock.

What are your treatment and transport priorities for this patient?

Treatment PrioritiesTreatment Priorities

• Begin BVM ventilation with 100% oxygen.

• Fluid resuscitation:

• IV/IO access on scene

• 20 ml/kg of crystalloid, repeat as needed en route

• Vasopressor therapy

Patient received 20 ml/kg (200 ml) with no change in level of consciousness, HR or BP.

What are your treatment priorities now?

•Consider endotracheal intubation

•Provide second 20 ml/kg fluid bolus

•Vasopressor support

3-year-old toddler

•Toddler is found cyanotic and unresponsive

•Child last seen 1 hour prior to discovery

•Open bottle of blood pressure medicine found next to child

3-year-old toddler

Circulation to SkinCyanotic, mottled

Work of BreathingGurgling breath sounds

AppearanceNo spontaneous activity; unresponsive

Initial Assessment

• Airway - Partial obstruction by tongue• Breathing - RR 15 breaths/min, poor air entry • Circulation - HR 30 beats/min; faint femoral

pulse; CRT 3 seconds; BP 50/30 mm Hg • Disability - AVPU=P• Exposure - No sign of trauma

• The monitor shows the following rhythm.

What are your treatment priorities for this patient?

Treatment Priorities

• Open airway• BVM ventilation/consider intubation• Chest compressions• IV/IO access on scene

–Medications (epinephrine, atropine)–Possible antidote - naloxone–Fluid resuscitation

• Check glucose• Rapid transport

•Patient’s heart rate improved to 70 beats/min with assisted ventilation.

•Color, CRT and pulse quality improves.

•After BVM, patient’s RR increases to 20 breaths/min, good chest rise

•Rapid glucose check 100 mg/dL

12-month-old child

• You arrive at the house of a 12-month-old child.

• Mother states the child has a history of heart disease and has been fussy for the last 3 hours.

• Mother states the child weighs 10 kg.

12-month-old child

Circulation to SkinLips and nailbeds blue

Work of BreathingMild retractions

AppearanceAlert but agitated

• On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count.

What rhythm does the monitor show?

How can you distinguish SVT from sinus tachycardia?

Sinus Tachycardia

SVT versus Sinus Tachycardia

SVT (Supraventricular Tachycardia)

Sinus Tachycardia

• Vague history of irritability, poor feeding

• History of fever, vomiting/diarrhea, hemorrhage

• Cardiac monitor: QRS complex narrow; R to R interval regular; no visible P waves

• Cardiac monitor: QRS complex narrow; R to R interval varies; P waves present and upright

• HR > 200 beats/min • HR < 220 beats/min

Treatment PrioritiesTreatment Priorities

• Supplemental oxygen• Obtain IV access• Convert rhythm based on hemodynamic stability

–Stable: vagal maneuvers or adenosine–Unstable:

• IV /IO access obtained - adenosine• No IV/IO and unconscious - synchronized

cardioversion

•Blow-by oxygen administered

• IV started

•Adenosine 0.1 mg/kg (1mg), given rapid IVP with 5 ml saline flush

•Five seconds of asystole, followed by conversion to NSR

Conclusion

• Cardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis.

• Management priorities for shock include airway management, oxygen and fluid resuscitation.

• Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present.

Advanced TopicsAdvanced Topics

Two Thumb–Encircling Hands Technique Preferred

Effective Bag-Mask Ventilation Is an Essential BLS Skill

• Use only the amount of force and tidal volume needed to make the chest rise

• Avoid excessive volume or pressure

• Increased inspiratory time may reduce gastric inflation

• Cricoid pressure may reduce gastric inflation Cricoid cartilage

Occluded esophagus

Cervical vertebrae

2-Rescuer Bag-Mask Ventilation2-Rescuer Bag-Mask Ventilation

• One rescuer uses both hands to open the airway and maintain a tight mask-to-face seal

• The second rescuer compresses the manual resuscitator bag and may apply cricoid pressure if appropriate

• Both rescuers verify adequate chest expansion

Prehospital Tracheal Intubation vs Bag-Mask Ventilation

• Bag-mask ventilation may be as effective as intubation if transport time is short

• Tracheal intubation requires training and experience

• Confirmation of tracheal tube position strongly recommended

• Monitoring of quality improvement important

Complications of Prehospital Tracheal Intubation

• Successful tracheal intubation rate: 57%• Intubation attempts increased time at the scene by

2 to 3 minutes• Unrecognized tube displacement or misplacement: 8%

— Esophageal intubation: 2%— Unrecognized extubation: 6%— Esophageal intubation or unrecognized extubation fatal

(for 14 of 15 patients)

Gausche. JAMA. 2000;283:783.

Confirmation of Tracheal Tube Placement in Pediatric Advanced Life Support

• Visualize tube through cords

• Assess breath sounds, chest rise bilaterally

• Secondary confirmation:

— Oxygenation (oximetry)

— Exhaled CO2 (capnography)

Tube ConfirmationTube Confirmation

• No single confirmation device or examination technique is 100% reliable

• Detection of exhaled CO2 is reliable in patients weighing >2 kg with a heart rate

• Exhaled CO2 can be helpful in cardiac arrest• Confirmation of tube position is particularly

important after intubation and after any patient movement

Insertion of the Laryngeal Mask Airway in ChildrenInsertion of the Laryngeal Mask Airway in Children

• The LMA consists of a tube with a cuffed mask at the distal end.

• The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.

Use of Laryngeal Mask Airway in Pediatric Advanced Life SupportUse of Laryngeal Mask Airway in Pediatric Advanced Life Support

• Extensive experience with pediatric and adult patients in the operating room

• An acceptable alternative to intubation of the unresponsive patient when the healthcare provider is trained

• Contraindicated if gag reflex intact• Limited data outside the operating room

(Class Indeterminate)

Intraosseous Needles Are Recommended for Patients >6 Years of Age

• Successful use of intraosseous needles has been documented in older children and adolescents

• Devices for adult use are commercially available

• “No one should die because of lack of vascular access”

Drug Therapy for Cardiac ArrestDrug Therapy for Cardiac Arrest

• Epinephrine: the drug of choice— Initial IV/IO dose: 0.01 mg/kg (tracheal: 0.1 mg/kg)— Do not routinely use high-dose (1:1,000)

epinephrine— Good at getting heart rates to return— Poor long term outcome

Resuscitation of the Newly Born Outside the Delivery Room

• Priority: Establish effective ventilation• Provide chest compressions if heart rate is <60 bpm despite

adequate ventilation with 100% oxygen for 30 seconds

• If meconium is observed in amniotic fluid:— Deliver head and suction pharynx (all infants)— If infant is vigorous, no direct tracheal suctioning— If respirations are depressed or absent, poor tone, or HR

<100 bpm, suction trachea directly

Potentially Reversible Causes of Arrest: 4 H’sPotentially Reversible Causes of Arrest: 4 H’s

• Hypoxemia

• Hypovolemia

• Hypothermia

• Hyper-/hypokalemia and metabolic causes (eg, hypoglycemia)

Potentially Reversible Causes of Arrest: 4 T’sPotentially Reversible Causes of Arrest: 4 T’s

• Tamponade

• Tension pneumothorax

• Toxins/poisons/drugs

• Thromboembolism (pulmonary)

Pediatric Resuscitation Russian Field Hospital Nias, Indonesia 4/05 Russian Field Hospital Nias,...

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