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Stabilisation of the critically ill child. Dr Reinout J Mildner Consultant Paediatric Intensivist Birmingham Children’s Hospital. Paediatric retrieval services. Stand alone or linked to regional PICU Funded by Specialist Commissioners Roles: - Source of advice
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Stabilisation of the critically ill child Dr Reinout J Mildner Consultant Paediatric Intensivist Birmingham Children’s Hospital
Paediatric retrieval services • Stand alone or linked to regional PICU • Funded by Specialist Commissioners • Roles: - Source of advice - Transportation of critically ill children who qualify for ICU therapy - Education & training - Audit & feedback
Duties of the referring hospital – Golden Hour will be with you, be prepared • Nominated consultant + lead nurse • Appropriately designed + equipped area • Protocols - admission / discharge - resuscitation + stabilisation - treatment of all major conditions - advice, referral + transport to lead PICU • Initiation and maintenance of intensive care, • including location (ED/ Theatres/Ward/ITU) • Involvement of paediatric nurse / consultant • Arrangements for when: - lead centre full - retrieval team not available - transport to ECMO / burns centre - time critical transfers
Paediatric retrieval services • Stand alone (CATS London, WMPRS) or linked to regional PICU (STRS etc) • Managed Lead Consultant Lead Nurse Responsibilities: Oversee programme + clinical review Budgetary responsibility Protocols / guidelines Equipment procurement and maintenance incl ambulance provision Staff recruitment and rota’s Education and training Audit, Quality Improvement, Safety Feedback / Outreach Service development
West Midlands Paediatric Retrieval Service • Advice about or retrieval of any sick child call 0300 200 1100 • Operational team 1. 24 hour co-ordination centre (stand alone service) – Operator + Consultant receive all PICU referrals advice regarding stabilisation bed finding mobilise team 2. Retrieval team Transport nurse Transport doctor Ambulance crew
Ambulance specifications: - Access ramp / tail lift +/- winch - Floor fixing system - Electrical supply - Oxygen / air supply - Rear / forward facing seats - Equipment storage / restraint (CEN compliant) - Heating Trolley specifications: - Hard wearing, overall weight < 140 kg - Able to take and restrain children of all sizes - Floor fixing system – Ferno / Paraid - Electrical management system 12V / 240 V - Accommodate: ventilator Baby PAC/ VentiPAC monitor – Philips, incl ETCO2 infusion pumps - Braun suction unit - Laerdal NO set up - Comply with ICS guidance
Retrieval equipment – age appropriate Airway Oral airways size 000 – 4 Face masks size 00 – 5 ETT uncuffed: 2.0 mm – 6.0 mm ID ETT cuffed 3.0 mm – 7.5 mm ID LMA’s size 1 – 4 Laryngoscopes: Miller 00 and 0, Magill 1 and 2, Mcintosh 1 – 3 McGill forceps large and small Yankauer suckers large and small Needle cricothyrodotomy set Bougies 5Fr – 15Fr, Stylets 2mm – 5 mm Tape to secure ETT Range of NG tubes 4 – 12 Fr + oral syringes Breathing Laerdal self-inflating bags adult and paediatric Ayre’s T-piece 0.5 L, Mapleson C circuits 1 and 2L Chestdrains sizes 8, 10 and 16 Fr NO ready made ventilator circuit Suction cathters 6 – 12 Fr Circulation IV cannula’s 24G – 14 G Lederflex lines 22G 6 and 8 cm Central Lines 4Fr, 4.5Fr, 5Fr (5,8 and 12 cm), 7.5Fr Guidewires (Baby wire, 0.18 and 0.25) Intraosseus needles Urinary catheters Consumables
Upper Airway Anatomy in Infants • Large head • Large tongue • High anterior larynx • Infant epiglottis long, floppy & U shaped • Funnel shaped larynx • Narrow trachea
Positioning Adapted from Walls et al. Manual of Emergency Airway Management. 2nd Ed. 2004.
Standard airway equipment • Oral airways size 000 – 4, nasopharyngeal airways • Face masks size 00 – 5, round + shaped • ETT uncuffed: 2.0 mm – 6.0 mm ID • ETT cuffed 3.0 mm – 7.5 mm ID • Laryngoscopes: Miller 00 - 3, Magill 1 and 2, Mcintosh 1 – 3 • Magill forceps large and small • Yankauer suckers large and small • Bougies 5Fr – 15Fr, Stylets 2mm – 5 mm • LMA’s size 1 – 4 • Needle cricothyrodotomy set • Tape to secure ETT
Laryngoscope Blades • Straight blades are placed under the epiglottis and used to lift anteriorly to expose the cords. • Curved blades are placed in the valecula and lifted anteriorly to expose the cords. Miller Macintosh Wisconsin
Endotracheal tube size • Newborn wt (kg) ETT ID (mm) Length at lip (cm) < 0.7 2.0 6 < 1.0 2.5 7 1.0 3.0 7.5 2.0 3.0 9 3.0 3.0 10.5 3.5 3.5 11 • 6 months 3.5 12 • Over 1 year: (Age in years/4) + 4 12+age/2 • Have one size smaller and larger
Common Problems • Esophageal Intubation • Blade placed too deep, cords not visualized • Tongue obscures visualization • Sweep tongue to one side with blade • More anterior lift • Pull forward with Magill forceps • Cannot see cords • Head is hyper-extended – reposition • Leak on ETT compromising ventilation: upsize • Facial burn: use uncut ETT to allow for facial swelling
Difficult Airways in Infants • Must always be prepared for something abnormal • Increasing awareness of problems beforehand because of neonatal ultrasound • “Things you can see” versus “Things you may find”
Difficult Airways in Infants • Congenital malformations • “Things you can see” • Predictable from looking at the patient • Down’s syndrome • Cleft lip and palate • Pierre Robin syndrome • Treacher Collins syndrome • Goldenhar syndrome • Apert and Crouzon Syndrome
Congenital Malformations • Cleft Lip and Palate • Most common congenital face malformation • Pierre Robin Sequence • Obstruction is usually at the nasopharyngeal level
Congenital Malformations • Apert and Crouzon • Maxillary hypoplasia • Nasopharyngeal airway compromise • Goldenhar syndrome • Unilateral anomalies • Higher incidence of airway anomalies
Congenital Malformations • Treacher Collins • Choanal atresia/stenosis more common • Down’s Syndrome • Large tongue • Subglottic stenosis more common • Remember atlantoaxial instability
Difficult Neonatal Airways • Congenital or acquired malformations • “Things you may find” • Croup • Epiglottitis • Laryngomalacia • Hemangioma or Lymphangioma • Tracheal web • Laryngeal atresia • Subglotic stenosis
Congenital Malformations • Laryngomalacia • A sequence between fully formed to atresia
Congenital Malformations • Laryngeal Web • Tracheal Atresia • Survive only if tracheoesophageal fistula or emergent tracheostomy
Congenital Malformations • Hemangioma or Lymphangioma • Only about 30% present at birth • Get bigger in 1st year of life
Congenital Malformations • Subglottic Stenosis • Can be acquired after prolonged / multiple intubations
Unexpected difficult airway • Return to bag and mask ventilation • Call for help • Consider what problem is • What can be done differently at further attempts? Positioning Tongue Different blade Cricoid pressure Tilt blade tip forward Bougie / NGT guide Smaller size ETT • Can patient be supported awake with NIV? • NB: With every attempt at intubation airway will swell and become more difficult
More recent adjuncts to difficult intubation Airtraq Glidescope
Laryngeal mask airway Patient weight < 6.5 kg 6.5 – 20 kg 20 – 30 kg 30 – 70 kg 70 – 90 kg
Indications for intubation1. Worsening respiratory distress 2. Progressive hypercapnia and/or hypoxia 3. Respiratory arrest / prolonged apnoea • Effort: rate, recession, noise, grunting, nasal flaring, accessory muscle use • Efficacy of breathing: • breath sounds, chest expansion • Effects of inadequate breathing: heart rate, skin colour, mental status
Initial ventilation • Control significant ETT leak: upsize / throat pack • Set Pressure control level + PEEP or • Initial tidal volume 10 - 12 ml/kg • Set rate and inspiratory time • Neonate 30 - 60 bpm • Infant 25 - 40 bpm • Child 14 - 25 bpm • I : E ratio 1 : 3 to 1 : 1 • Avoid very short or > 50 % inspiratory time
Aims clear secretions avoid / improve atelectasis improve V- Q matching Techniques saline lavage + suction chest percussion postural drainage consider re-recruitment Chest physiotherapy and suction
sedation + muscle relaxation • Midazolam infusion 2 - 4 cg/ kg/ min 1mg / ml solution in glucose 5% not if < 6 months • Morphine 20 - 60 cg/ kg/ hr 1 mg / kg morphine in 50 ml Glucose 5 %, run at 1 - 3 ml/hr • Rocuronium 0.6 - 1 mg/ kg/ hr (neat solution) Alternatives: Atracurium, intermittent pancuronium
monitoring Alveolar ventilation • chest movement • PaCO2 / ETCO2 • adjust TV or rate (VC) OR PIP or rate (PC) Oxygenation • SpO2 / PaO2 • adjust FiO2 or PEEP CXR
Think intra-osseus anterior tibial plateau, 2-3 cm below the tibial tuberosity
Ultrasound guided central venous access SLA ‘hockey stick’ transducer
bronchiolitis 1. Apnoeas • need for intubation, usually compliant lungs 2. Mixed picture • airway obstruction • copious secretions + atelectasis • diffuse pneumonitis • volume control/ guarantee ventilation, PEEP 5 – 10 cm H2O
asthma Absolute indications for intubation • cardiac / respiratory arrest • severe hypoxia • deteriorating mental state Relative indication • progressive exhaustion Rare, high risk: CVS instability + barotrauma
asthma • main problems airway resistance + dynamic hyperinflation • use iv salbutamol aminophylline and iv hydrocortisone, trial of Mg – sulphate • iv ketamine, inhalational anaesthesia • PCV / VCV low rate + long expiratory time, permissive hypercapnia • high PIP tolerable • PEEP below PEEPi • monitor blood electrolytes (K+)
ARDS • Open lung approach with limited TV • Titrate PEEP ( 7 - 16 cm H2O) to FiO2 0.6 and SaO2 > 90%. I : E = 1 : 1 • PCV / PRVC, aim tidal volume 6 ml / kg. Maintain MV by rate and allow permissive hypercapnia. • Cardiac support with volume inotropes
focal / unilateral lung disease • Place patient with affected side up postural drainage V - Q mismatch recruitment affected lung • Avoid overdistention unaffected side limit PEEP accept relative hypoxia
Common causes • RTA: pedestrian cyclist passenger in car • Falls: toddlers teenagers • Non-accidental injury: < 1yr • Mechanism important
Epidemiology • Mortality ± 25 - 30% • 40% of trauma deaths age 1-15 yrs • Trimodal distribution • At scene: airway obstruction bleeding head / spinal injury 2. First hours: all of above aspiration 3. Days - weeks: ARDS Sepsis MODS
PRIMARY INJURY • SKULL # • LINEAR / STELLATE • (NON) – DEPRESSED • BASAL • PERIORBITAL ECCHYMOSES • HEMOTYMPANUM • BATTLE’S SIGN • CSF LEAK DIFFUSE AXONAL INJURY • DURAL SAC TEARS • EXTRADURAL HAEMATOMA • SUBDURAL HAEMATOMA • SUBARRACHNOID HAEMATOMA CEREBRAL LACERATION / CONTUSION