RECOGNITION OF PEDIATRIC EMERGENCIES

Dr. Lilia Dewiyanti, SpA, MSiMed.

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Many etiologies

Respiratory failure Shock

Cardiopulmonary failure

Cardiopulmonary arrest

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Outcome of respiratory vs Cardiopulmonary Arrest in Children

100%

75%

Survival rate

Respiratory arrestCardiopulmonary arrest

75 – 90 %

7 – 11 %

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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

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Is this child in respiratory failure or shock ?

Is this child in respiratory failure or shock?

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The Three Phases ofRapid Cardiopulmonary Assessment

1. Physical examination

2. Classification of physiologic status

3. Initial management priorities

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The ABCs

Normal Vital Functions Are Maintained

By

AirwayTo ProvideVentilation

Breathing Oxygenation

Circulation Perfusion

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Primary Abnormalities in Respiratory Failure

AirwayAnd

Breathing

Ventilation

Oxygenation

Circulation

Perfusion

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Classification of Respiratory Failure

Potential respiratory failure

Theraphy(eg, positioning, oxygen administration)

ImprovementPotential

Resp. failure

DeteriorationProbable

Resp. failure

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Initial Assessment

Pediatric Assessment Triangle :

App

eara

nce

Work of B

reathing

Circulation to Skin

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Appearance (“Tickles” =TICLS)

Tonus Interactiveness Consolability Look/Gaze Speech/Cry

App

eara

nce

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Potential respiratory failure

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Work of Breathings

Abnormal airway sounds

Abnormal positioning Retractions Nasal flaring

Work of B

reathings

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The sniffing position

The abnormal tripod position

Retractions

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Characteristic of Circulation to Skin

Pallor (putih pucat)

Mottling (bercak2)

Cyanosis (kebiruan)

Circulation to Skin

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App

eara

nce

Work of B

reathing

Circulation to Skin

PAT: Potential Respiratory Failure

Normal Increased

Normal

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App

eara

nce

Work of B

reathing

Circulation to Skin

PAT: Respiratory Failure

AbnormalIncreased

or decreased

Normal or abnormal

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Rapid Cardiopulmonary AssessmentPhysical Examination - Airway

1. Clear

2. Maintainable

3. Unmaintanable without intubation

4. Obstructed

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Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing

1. Rate

2. Effort / mechanics

3. Air entry

4. Skin color and temperature

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Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing

Evaluation of rate, effort, and mechanics

• Tidal Volume ( V T)

• Minute ventilation (MV)

• MV = VT X RR

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Rapid Cardiopulmonary AssessmentPhysical Examination : Breathing

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Primary Abnormalities in Shock

AirwayAnd

Breathing

Ventilation

Oxygenation

Circulation

Perfusion

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App

eara

nce

Work of B

reathing

Circulation to Skin

PAT: Shock

Abnormal Normal

Abnormal

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Basic Relationships of Cardiovascular Parameters

BloodPressure

CardiacOutput

SystemicVascularResistance

StrokeVolume

HeartRate

Preload

Myocardialcontractility

Afterload

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Cardiac Output = Heart Rate X Stroke Volume

Inadequate Compensation• Increased heart rate• Increased SVR• Posible increased SV

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29Respons hemodinamik terhadap kehilangan darah

25 50 75

%tase kehilangan darah

% k

ontr

ol

20

60

100

140

resistensi vaskular

Tekanan darah

Curahjantung

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Child in shock

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Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation

1. Heart rate

2. Systematic perfusion• Peripheral pulses• Skin perfusion• Level of consciousness• Urine output

3. Blood pressure

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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

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Palpation of Central dan Distal Pulses

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Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation

Skin perfusion

• Extremity temperature• Capillary refill • Color

• Pink• Mottled• Pale• Blue

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Normal capillary refill is < 2 seconds in a warm environment

Capillary refill

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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

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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 ?

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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)

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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

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Child dying with anasarca , MOSFdespite resuscitation efforts

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Definition of Cardiopulmonary Failure

Deficits in

Resulting in

• Ventilation• Oxygenation• Perfusion

• Agonal respiration • Bradycardia• Cardiopulmonary arrest

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Rapid Cardiopulmonary Assessment

AirwayAnd

Breathing

Ventilation

Oxygenation

Circulation

Perfusion

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The Three Phases ofRapid Cardiopulmonary Assessment

1. Physical examination

2. Classification of physiologic status

3. Initial management priorities

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Rapid Cardiopulmonary AssessmentClassification of Physiologic status

• Stable

• Respiratory failure

• Potential• Probable

• Shock

• Compensated• Decompensated

• Cardiopulmonary failure

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The Three Phases ofRapid Cardiopulmonary Assessment

1. Physical examination

2. Classification of physiologic status

3. Initial management priorities

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Rapid Cardiopulmonary Assessment -Priorities of Initial Management

Stable• Begin further workup• Provide specific theraphy as indicated• Reassess frequently

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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

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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

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Rapid Cardiopulmonary Assessment -Priorities of Initial Management

Cardiopulmonary failure

• Oxygenate, ventilate, monitor• Reassess for

• Respiratory failure• Shock

• Obtain vascular access

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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 ?

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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

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Case No 1 - Response to Therapy

• Vital sign improved• Perfusion still poor

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What is the heart size ?

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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 ?

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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

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Chest X-ray after fluid bolus