Pediatric Resuscitation

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

2. Lecture Objectives The goal of this module: • Perform rapid cardiopulmonary assessment • Recognize signs of respiratory distress, respiratory failure, and shock

3. Progression of Respiratory Failure and Shock Various Conditions Respiratory failure Shock Cardiopulmonary failure Cardiopulmonary arrest

4. Comparison of Survival 100% Survivalrate 50% 0% Respiratoryarrest Cardiopulmonaryarrest

5. 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!

6. Pediatric Assessment Triangle

7. General Appearance

8. Evaluation of General Appearance • General color (“looks good” vs “looks bad”) • Mental status, responsiveness • Activity, movement, muscle tone • Age-appropriate response

9. Breathing Evaluation

10. Physical Examination: Airway • Clear • Maintainable • Not maintainable without intubation

11. Evaluating Respirations • Respiratory rate • Respiratory effort (work of breathing) • Breath sounds/air entry/tidal volume • STRIDOR (inspiration) • WHEEZE (expiration) • Skin color and pulse oximetry

12. Rapid Cardiopulmonary Assessment:Classification of Status • Respiratory distress:Increased work of breathing • Respiratory failure:Inadequate oxygenation or ventilation

13. Cardiovascular Assessment

14. Blood pressure Cardiovascular VariablesAffecting Systemic Perfusion Preload Myocardial contractility Afterload Stroke volume Heart rate Cardiac output Systemic vascularresistance

15. Response to Shock 140 100 60 20 Vascular resistance Percent of control Blood pressure Cardiacoutput Compensated shock Decompensated shock

16. Decompensated Shock Compensatory mechanisms fail to maintain adequate cardiac output and blood pressure

17. Physical Examination: Circulation • Cardiovascular function • Heart rate • Pulses, capillary refill • Blood pressure • End-organ function/perfusion • Brain • Skin • Kidneys

18. Physical Examination: Circulation Typical Assessment Order: • Observe mental status • Feel for heart rate, pulse quality, skin temperature, capillary refill • Measure blood pressure • (Measure urine output later)

19. Physical Examination: Circulation Evaluation of responsiveness • A — Awake • V — responsive toVoice • P — responsive toPain • U — Unresponsive

20. Heart Rates in Children Infant 85 220 300 Normal Compensating? SVT Child 60 180 200 Normal Compensating? SVT

21. Physical Examination: Circulation Evaluation of skin perfusion • Temperature of extremities • Capillary refill • Color • Pink • Pale • Blue • Mottled

22. Palpation of Central and Distal Pulses

23. Capillary Refill Prolonged capillary refill (10 seconds) in a 3-month-old with shock

24. Physical Examination:Circulation Estimate of Minimum Systolic Blood Pressure 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

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

26. Physical Examination:Circulation • Cardiovascular function • Heart rate • Pulses, capillary refill • Blood pressure • End-organ function/perfusion • Brain (Mental Status) • Skin (Capillary Refill Time) • Kidneys

27. Physical Examination: Circulation Evaluation of End-Organ Perfusion Kidneys • Urine Output • Normal: 1 to 2 mL/kg per hour • Initial measurement of urine in bladder not helpful

28. Classification of Physiologic Status: Shock Early signs (compensated) • Increased heart rate • Poor systemic perfusion Late signs (decompensated) • Weak central pulses • Altered mental status • Hypotension

29. Septic 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

30. 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

31. Special Situations: Trauma Spinal Precautions? Pneumothorax? Bleeding control?

32. 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

33. Special Situations: Toxicology Is the Patient Awake enough to maintain airway? Respiratory Effort and Rate? Arrythmias? Vascular Tone? Ischemia?

34. Classification of Physiologic Status: Cardiopulmonary Failure Cardiopulmonary failure produces signs of respiratory failure and shock: • Agonal respirations • Bradycardia • Cyanosis and poor perfusion

35. Classification of Cardiopulmonary Physiologic Status • Stable • Respiratory distress • Respiratory failure • Shock • Compensated • Decompensated • Cardiopulmonary failure

37. 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

38. Checkpoint • Rapidly perform assessment • Use the information to prioritize your resuscitation efforts • Remember the Pediatric Assessment Triangle as we practice cases

39. Rapid Cardiopulmonary Assessment Application A 3-week-old infant arrives in the ED: • 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?

40. What is this Child’s Assessment?

41. Rapid Cardiopulmonary Assessment Application Case Progression • 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?

43. Rapid Cardiopulmonary Assessment Application: Response to Therapy • Vital signs improved

44. Pediatric Intubation Andrew Garrett, MD Division of Transport and Emergency Medicine

45. Goals • 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

46. 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

47. 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

48. Anatomy epiglottis True VC False VC cartilage trachea esophagus

49. Cricoid Cartilage

50. 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