Resuscitation & Stabilisation of the Critically Ill Child Sandra Stark Nurse Consultant ScotSTA R.
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Transcript of Resuscitation & Stabilisation of the Critically Ill Child Sandra Stark Nurse Consultant ScotSTA R.
![Page 1: Resuscitation & Stabilisation of the Critically Ill Child Sandra Stark Nurse Consultant ScotSTA R.](https://reader035.fdocuments.in/reader035/viewer/2022070410/56649ebd5503460f94bc6349/html5/thumbnails/1.jpg)
Resuscitation & Stabilisation of the Critically Ill Child
Sandra StarkNurse Consultant ScotSTAR
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Resuscitation
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Differences Between Adults & Children
LESS THAN YOU THINK!!!!
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Paediatric vs Adult Resuscitation
Focus on the similarities
Airway
Breathing
Circulation
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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
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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
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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
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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,
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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)
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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
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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
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Neurology DifferencesModified GCS??
Hypoglycaemia can be a big problem
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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
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Paediatric Burns
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Paediatric BurnsAdults – rule of 9s
More complex in paeds
Easiest way – palmar surface (including fingers) of patient’s hand represents approximately 1%
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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
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StabilisationDiscussion regarding retrieval to
appropriate centre
Ongoing care & optimisation
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Interventions
Airway/intubationVentilationHaemodynamic supportVascular access (arterial/venous)Other – blood, medications
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Who Will Perform Interventions?Local team
Retrieval team
Joint
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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
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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
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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
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How to Make up Inotropes
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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!!
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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
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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
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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
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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
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www.snprs.scot.nhs.uk
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Questions??