Recognition of the seriously ill child

1. Recognition of the seriously ill child 23/03/11 Dr. John Twomey, Consultant Paediatrician, Department of Paediatrics/ Emergency Department Medical Students

2. Describe what you see

3. 15th century, unknown artist

4. 1664, Gabriel Metsu

5. 1885, Eugene Carriers

6. 2006, Life magazine

7. The sick child

8. Some Ground Rules!

9. Diverse range from infancy to adolescence

10. Children Are Not “Little Adults”

11. What are the key differences to consider in children?

12. Weight • Anatomical • Physiological • Psychological

13. Weight • Centile Charts • Broselow Tape • Formula (1-10yrs): Wt (kg) = (age + 4)2 • Estimate (0-1 yrs): Newborn = 3.5 kg 6/12 = 7 kg 12/12 = 10 kg • Estimate (>10 yrs): 10 yrs = 30 kg 12 yrs = 40 kg 14 yrs = 50 kg 16 yrs = 60 kg

14. Anatomical Airway • Large head • Short & soft trachea • Small face & mandible • Loose teeth & Large tongue • Easily compressible floor of the mouth • Obligate nasal breathers (<6/12) • Adenotonsillar hypertrophy • Horse-shoe shaped epiglottis projecting posteriorly • High & anterior larynx (straight bladed laryngoscope) • Cricoid ring = narrowest part of the airway (Larynx in adults) & is susceptible to oedema (uncuffed ett) • Symmetry of carinal angles

15. Anatomical Breathing • Lung immaturity • Small air-surface interface (<3m²) • Less small airways (1/10 of adult) • Small upper & lower airways • R 1/r4 • Diaphragmatic Breathing • More horizontal ribs

16. Anatomical Circulation • RV>LV (0-6/12) => LV>RV • Blood circulating volume/body weight = 70-80 mls/kg • Absolute volume is small (critical importance of relatively small amounts of blood loss) Body Surface Area • BSA:Wt ↓ with ↑ age • Small children have a high ratio => relatively more prone to hypothermia

17. Physiological Respiratory • Infant - ↑ BMR & O2 Consumption => ↑ RR

18. Physiological Cardiovascular • CO = SV x HR • Infant – small stoke volume => ↑ HR

19. Physiological Cardiovascular • Infant - ↓ systemic resistance => ↓ BP • SBP = 80 + (age x 2)

20. Physiological Immune system • Immature immune system • Maternal antibodies (x 1st 6/12) • Protective effect of breast feeding

21. Psychological Communication • No or limited verbal communication • Many non-verbal cues • Age-appropriate communication Fear • Additional distress to the child and adds to parental anxiety => altered physiological parameters => difficult to interpret • Explain as clearly as possible (Knowledge allays fear) • Parental presence at all times

22. A Structured Approach • 1º Assessment - Resuscitation – identifying & treating the immediate threats to life – closed or obstructed airway, absent or distressed respiration, pulselessness, shock • 2º Assessment - Emergency Treatment – to start to treat the underlying cause of the child’s condition • Reassessment - Stabilisation – achieving homeostasis and system control • Transfer – to a definitive care environment (PICU)

23. A Structured Approach • Preparation (before the child arrives) • Teamwork (with a designated team leader) • Communication (with contemporaneous recording of history, clinical findings, treatments) • Consent (assumed if acting in the best interests of the child)

24. WETFAG • Weight = (Age + 4)2 • Energy = 4 J/kg asynchronous shock • Tube = (Age/4) + 4 ---- +/- 0.5 • Fluids = 20 mls/kg 0.9% NaCl • Adrenaline = Adrenaline 10 μg/kg IV/IO (0.1ml/kg of 1:10,000); 100 μg/kg (0.1ml/kg of 1:1,000) ETT • Glucose = Dextrose 10% 5ml/kg IV

25. 1º Assessment & Resuscitation

26. ABCD(E) • Airway • Breathing • Circulation • Disability • (Exposure)

27. Airway & Breathing Effort of breathing: • RR/Recession/Inspiratory & expiratory noises/Grunting/Use of accessory muscles/Nasal flaring/Gasping Efficacy of breathing: • Chest expansion/Abdominal excursion/ Chest auscultation/Pulse oximetry Exceptions: • Exhaustion/↑ICP/NM d/o Effect of respiratory inadequacy on other organs: • ↑/↓ HR/Pallor/Cyanosis {NB anaemia}/Agitation/ Drowsiness/LOC/Hypotonia => BLS & Advanced Airway Support

28. Basic Life Support (BLS)

29. BLS

30. Circulation Cardiovascular status: • HR/Pulse volume/CRT/BP Effect of circulatory inadequacy on other organs: • ↑RR (2º to metabolic acidosis)/Pallor/ Cyanosis/Agitation/Drowsiness/LOC/↓ UO (<1ml/kg/hr in children; <2ml/kg/hr in infants) Cardiac failure: • Cyanosis not correcting with O2/Tachycardia out of proportion to respiratory difficulty/↑JVP/Gallop rhythm/Murmur/Enlarged liver/ Absent femoral pulses => IV/IO access x2; bloods incl. G&X-match; fluid bolus (20ml/kg); inotropes, intubation & CVP monitoring if >3 boluses

31. Disability Conscious level: • P~ GCS </= 8/15 Posture: • Decorticate/Decerebrate Pupils: • Dilatation/Unreactivity/ Inequality Effect of central neurological failure on other organs: • Hyperventilation/Cheyne-Stokes/Apnoea • ↑BP, ↓HR, abnormal breathing (Cushing’s Triad) => Intubation if “P” or “U”; Rx hypoglycaemia; Rx seizure

32. (Exposure) – Not part of 1º Assessment but do early

33. ABC - DEFG Don’t Ever Forget Glucose

34. Reassessment of ABCD(E) at frequent intervals

35. 2º Assessment & Emergency Treatment

36. Airway & Breathing Symptoms: • Breathlessness/Coryza/Cough/Grunting/Stridor/Wheeze/ Hoarseness/Drooling & inability to drink/Abdominal pain/ Chest pain/Apnoea/Feeding difficulties Signs: • Cyanosis/Tachypnoea/Recession/Grunting/Stridor/ Wheeze/Chest wall crepitus/Tracheal shift/Abnormal percussion note/Crepitations on auscultation/Acidotic breathing Investigations: • O2 sats/Peak flow/End-tidal or trans-cutaneous CO2/ Blood culture/CXR/ABG

37. Airway & Breathing ↑ Respiratory secretions – • Suction - ? Fatigued/depressed conscious level Barking Cough in a well child – • ?Croup – PO/IM Dexamethasone (0.6mg/kg stat or 0.15mg/kg BD x 2-3/7)/Nebulised budesonide (2mg)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2) – NB TRANSIENT ↑HR; REBOUND Quiet stridor, drooling, sick-looking child – • ?Epiglottitis/Bacterial Tracheitis (Pseudomembranous Croup) - Intubation & IV ceftriaxone NB AVOID VENEPUNCTURE (BEFORE INTUBATION) AND X-RAYS Sudden onset of respiratory distress leading to apnoea in a conscious toddler – • ?Inhaled foreign body -“choking child” manoeuvre/direct laryngoscopy & use of Magill’s forceps ONLY IN EXTREME CASES OF A THREAT TO LIFE • ?Anaphylaxis

38. Airway & Breathing Cough, wheeze & ↑SOB – • ?Acute exacerbation of asthma – Inhaled Salbutamol (2.5mg{<5yo}; 5mg {>5yo}) & O2/PO prednisolone (2mg/kg) or IV hydrocortisone (4mg/kg then 2mg/kg QDS) • ?IFB • ?Anaphylaxis Infant with wheeze and respiratory distress – • ?Bronchiolitis – Supportive Mx – PO/NG/IV fluids/O2 • ?IFB • ?Anaphylaxis Pyrexia, breathing difficulties but no stridor/wheeze – • ?Pneumonia – Antibiotics/Adequate hydration/ +/- chest drain Stridor following ingestion of a new food – • ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of 1:1,000)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2)/Chlorphenaramine/Prednisolone • ?IFB

39. Management of a Choking Child

40. Ineffective Cough & Conscious Infants (<1) • Back Blows (x5) and Chest Thrusts (x5) (1/second)

41. Ineffective Cough & Conscious Children (1-14) • Back Blows (x5) and Abdominal Thrusts (x5) (1/second) (Heimlich Manoeuvre)

42. Circulation Symptoms: • Breathlessness/Fever/Palpitations/Feeding difficulties/ Drowsiness/Pallor/Fluid loss/Poor urine output Signs: • Tachy -or bradycardia/Hypo- or hypertension/Abnormal pulse volume or rhythm/Abnormal skin perfusion or colour/ Cyanosis/Pallor/Hepatomegaly/Auscultatory crepitations/Murmur/Peripheral oedema/↑JVP/Hypotonia/Purpura Investigations: • U&E/FBC/ABG/Coag screen/Blood culture/ECG/CXR

43. Shock Acute failure of circulatory function

44. Shock Types: • Cardiogenic – heart defects - arrhythmias • Hypovolaemic – fluid loss – haemorrhage, GE • Distributive – vessel abnormalities – septicaemia, anaphylaxis • Obstructive – fluid restriction – tension pnuemo, cardiac tamponade • Dissociative – inadequate O2-releasing capacity of blood – CO poisoning, methaemoglobinaemia

45. Shock Types: • Phase 1 - Compensated • Phase 2 - Decompensated • Phase 3- Irreversible

46. Phase 1- Compensated • Compensatory mechanisms to preserve vital organ function • Sympathetic + => ↑Systemic Arterial Resistance; ↑HR; ↑secretion of angiotensin & vasopressin Clinical Features: • agitation/confusion, pallor, ↑HR, cold peripheries, ↑CRT

47. Phase 2 - Decompensated • Compensatory mechanisms start to fail • Aerobic => anaerobic metabolism => lactic acidosis • Sluggish blood flow => platelet adhesion • Release of numerous chemical mediators => ↑capillary permeability & other deleterious consequences Clinical Features: • ↓BP, ↓LOC, acidotic breathing, ↓/no UO

48. Phases 3 - Irreversible • Retrospective Dx • Death is inevitable despite therapeutic intervention resulting in adequate restoration of circulation • EARLY RECOGNITION & EFFECTIVE TREATMENT OF SHOCK IS VITAL

49. Circulation Shocked child with no obvious fluid loss – • ?sepsis - IV ceftriaxone Shock with rash & stridor – • ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of 1:1,000) Neonate with unresponsive shock – • ?duct-dependent CHD – Prostaglandin (Alprostadil 0.05μg/kg/min) Pallor with dark brown urine – • ? Haemolysis ?SCD – O2, rehydration +/- Transfusion, antibiotics, analgesia

50. Circulation No pulse – • ?Cardiac Arrhythmia - Assess cardiac rhythm – asystolé, PEA, VF, PLVT Poor feeding with HR 230bpm – • ?SVT Algorithm – vagal stimulation, If IV access - IV adenosine (100μg/kg; ↑x100μg/kg every 2 min to a max of 500μg/kg {300μg/kg in < 1/12}), If No IV access & shocked – DC cardioversion (1J/kg then 2J/kg) Infant/young child with Hx vomiting, drawing up legs & pallor ++ +/- abdominal mass – • ?intussusception/malrotation/volvulus etc. - Surgical advice – Paediatric Surgeon - Dublin/Abdominal USS, stabilisation & transfer