Acutely Ill Child

ACUTELY ILL CHILD

Dr. Siasu

Pathways to Pediatric Cardiac Arrest

Precipitating Conditions

Respiratory Circulatory Sudden Cardiac Respiratory Distress Shock Respiratory Failure Cardiopulmonary Failure CARDIAC ARREST

 Timely intervention in seriously ill or injured child is the key to preventing progression toward cardiac arrest

Assess

Act Categorize

Decide

4 Parts to Pediatric Assessment

1. General Assessment – quick visual & auditory observation of appearance, work of breathing, circulation

= General assessment  done only in few seconds

2. Primary Assessment – rapid hands – on ABCDE approach to evaluate cardiopulmonary and neurologic function, vital signs and pulse oximetry

3. Secondary Assessment – medical history using SAMPLE head – to – toe physical examination

4. Tertiary Assessment – laboratory, radiographic, advanced tests that help to establish the child’s physiologic condition and diagnosis

Categorize

TYPE SEVERITY

Respiratory - Upper airway

obstruction - Lower airway obstruction - Lung tissue disease - Disordered control of breathing

- Respiratory distress

- Respiratory failure

Circulatory - Hypovolemic shock - Distributive shock - Cardiogenic shock - Obstructive shock - Compensated shock - Hypotensive shock (before it was called decompensated shock)

 Decide what to do based on your assessment and initial categorization of the clinical condition

ACT

For PALS

 Activate Emergency Response System

 Start CPR

 Obtain code cart, monitor/defibrillator  Place patient on monitor and pulse oximeter  Give oxygen

 Start treatment (nebulizer, IVF)

Reassess the patient as you are providing interventions

General Assessment

Appearance - Muscle tone, interaction, speech, cry

Work Breathing - Increased work of breathing - Decreased or (-) respiratory effort (apneic)

- Abnormal sounds (wheeze, grunting, stridor)

Circulation - Abnormal skin color (pale or mottling), bleeding

Determine if condition is  Life threatening  Not life threatening

Primary Assessment AIRWAY  Look  Listen  Feel Status



Clear – airway open  chest will rise

= with secretions  do suctioning while the head is tilt = obstruction  do tracheostomy

 Maintainable – maintained by simple measures  Not maintainable – needs advanced interventions BREATHING

Check for

 Respiratory rate



Respiratory effort = manifested by retractions  Tidal volume

 Airway and lung sounds



Pulse oximetry = normal O2 sat >90% Normal RR by Age

<1 y.o 30-60/min

1-3 y.o. 24-40

6-12 y.o. 18-30

13-18 y.o. 12-16

CIRCULATION

Assessment cardiovascular function

 Skin color, temperature  Heart rate

 Rhythm

 Blood pressure

 Pulses (both peripheral and central)



CRT = Normal: <2 seconds in a warm environment

End-organ function

 Brain perfusion (mental status) GCS:

= 13-15 – mild head injury = 9-12 – moderate injury = 3-8 – severe head injury  Skin perfusion



Renal perfusion (urine output) = normal: 1cc/kg/hr Normal Heart Rate by Age (per minute)

Age Awake Rate Mean Sleeping Rate

NB to 3 mos 85-205 140 80-160

3 mos to 2 yo 100-190 130 75-160

2 yo to 10 yo 60-140 80 60-90

>10 yo 60-100 75 50-90

Normal Blood Pressure by Age Age

Systolic BP (mm Hg) Diastolic BP (mm Hg)

Female Male Female Male

1 d.o. 60-76 60-74 31-45 30-44 4 d.o. 67-83 68-84 37-53 35-53 1 mo 73-91 74-94 36-56 37-55 3 mos 78-100 81-103 44-64 45-65 6 mos 82-102 87-105 46-66 48-68 1 y.o. 68-104 67-103 22-60 20-58 2 y.o. 71-105 70-106 27-65 25-63 7 y.o. 79-113 79-115 39-77 38-78 15 y.o. 93-127 95-131 47-85 45-85 Hypotension Age Systolic BP (mm Hg) Term (0-28 d.o.) <60 1 mo to 12 mos <70

1 y.o. to 10 y.o. 5th _{BP% <70 + (age in years x 2)}

>10 y.o. <90

DISABILITY

APVU Pediatric Response Scale (evaluate cerebral cortex function)

 Alert

 Voice

 Painful  Unresponsive

Glascow Coma Scale

Responsive Adult Child Infant Code

d Value EYE

OPENING

Spontaneous Spontaneous Spontaneous 4

To speech To speech To speech 3

To pain To pain To pain 2

None None None 1

BEST VERBAL RESPONS

E

Oriented Oriented,

Appropriate Coos and babbles 5

Confused Confused Irritable cries 4

Inappropriate

words Inappropriate words Cries to pain 3 Incomprehensibl

e sounds Incomprehensible words Moans to pain 2

None None None 1

BEST MOTOR RESPONS

E

Obeys Obeys command Moves

spontaneousl y 6 Localizes Localizes painful stimulus Withdraw to touch 5 Withdraws Withdraws to

pain Withdraws to pain 4 Abnormal

flexion Flexion to pain Decorticate to pain 3 Extensor

response Extension to pain Decerebrate 2

None None None 1

TOTAL SCORE 3-15

Signs of Life Threatening Condition

Airway Complete or severe airway obstruction

Breathing Apnea, significant work of breathing

Circulation (-) pulses, poor perfusion, hypotension, bradycardia

Disability Unresponsiveness, depressed consciousness

Exposure Significant hypothermia, bleeding, petechiae with septic shock, abdominal distension with an acute abdomen

Secondary Assessment

 Signs and Symptoms  Allergies

 Medications

 Past Medical History

 Last Meal

 Events

RESPIRATORY DISTRESS

 Clinical state characterized by ↑ RR & ↑ respiratory effort

Signs:

 Tachypnea

 Tachycardia

 Increased respiratory effort (nasal flaring, retractions)

 Abnormal airway sounds  Pale, cool skin

 Changes in mental status (Picture)

Respiratory failure = air hunger Shock = bleeding

RESPIRATORY FAILURE

 Clinical state of inadequate oxygenation, ventilation or both

 End stage of respiratory distress  Probable respiratory failure indications 1. Marked tachypnea (early)

2. Bradypnea (late) 3. Tachycardia (early) 4. Bradycardia (late)

5. Increased, decreased or no respiratory effort 6. Cyanosis

7. Poor to absent distal air movement 8. Stupor, coma

TYPES OF RESPIRATORY PROBLEMS I. Upper Airway Obstruction

 Can occur in nose, pharynx or larynx  Mild to severe

 Causes

o Foreign Body aspiration

o Swelling of tissues lining upper airway (anaphylaxis, hypertrophy, tonsillar, croup, epiglotittis)

o Mass in airway lumen (pharyngeal or peritonsillar abscess or tumor)

o Thick secretions in nasal passages (tracheal rings)

o Congenital airway abnormality

o Iatrogenic (ex subglottic stenosis for ET)  Signs

o Tachypnea

o Increased inspiratory respiratory effort o Change in voice

o Stridor o Poor chest rise o Poor air entry II. Lower Airway Obstruction

 Occur in the lower trachea,

bronchi, bronchioles  Causes o Asthma o Bronchiolitis  Signs o Tachypnea o Wheezing

o Increased in respiratory effort (inspiratory retractions, nasal flaring and prolonged expiration)

o Prolonged expiratory phase with increased expiratory effort

o Cough

III. Lung Tissue Disease

 Affect the substance of the lung

 Causes o Pneumonia o Pulmonary edema o ARDS o Pulmonary contusion o Allergic reaction

o Toxins, vasculitis, infiltrative disease  Signs:

o Tachypnea

o Tachycardia

o Increased in respiratory effort o Grunting sounds

o Hypoxemia

o Crackles

o Diminished breath IV. Disordered Control of Breathing

 Abnormal breathing pattern that

produces symptoms of inadequate respiratory rate, effort, or both

 Causes

o Neurologic disorders (seizures, CNS infections, brain tumor, neuromuscular disease, head injury, hydrocephalus)  Signs

o Variable respiratory rate o Variable respiratory effort o Shallow breathing o Central apnea

Rapid Cardiopulmonary Assessment – Priorities of Initial Management

Potential Respiratory

Failure Probable Respiratory Failure

Keep with caregiver Position of comfort Oxygen as tolerated Nothing by mouth Monitor pulse oximetry Consider cardiac monitor

Separate from caregiver Control airway 100% FIO2 Assist ventilation Nothing by mouth Monitor pulse oximetry Cardiac monitor

Establish vascular access  The earlier you detect respiratory distress or

respiratory failure and start appropriate treatment, the better chance the child has for a good outcome SHOCK

 Condition that results from inadequate delivery of oxygen and nutrients to meet the metabolic demand of the tissue

o

Inadequate blood volume or inadequate oxygen – carrying capacity = hypovolemic

o

Inappropriately distributed blood volume = distributive

o

Impairment of heart contractility = cardiogenic

o

Obstructed blood flow = obstructive

Physiology Shock

 Inadequate tissue perfusion can

lead to

o Tissue hypoxia

o Anaerobic metabolism

o Accumulation of lactic acid and CO2

o Irreversible cell & organ damage  death

Factors Influencing Oxygen Delivery

Preload Cardiac Output Contractility Stroke Volume x X O2 Content Afterload Heart Rate

O2 Delivery = Contractility  inotropic

= Preload, Contractility and afterload problems are managed medically

Compensatory Mechanisms to Maintain Oxygen

 Tachycardia

 Increased Systemic Vascular

Resistance

 Increased contractility

 Increased venous tone

Categorization of Shock by Severity (Effect on Blood Pressure)

1. COMPENSATED

 Normal BP with inadequate tissue perfusion Signs

Increased heat rate Heart Tachycardia

Increased Systemic Vascular Resistance

Skin Cold, pale,

diaphoretic

Circulation Delayed CRT

Pulses Weak peripheral

pulses Narrow pulse

pressure Increased Splanchnic

Vascular Resistance

Kidney Intestine Oliguria, ileus, vomiting 2. HYPOTENSIVE SHOCK

 Decreased BP – inadequate tissue perfusion  Change in mental status

 Late signs of shock

Types of SHOCK

1. Hypovolemic Shock

 Most common cause of shock in children worldwide

 Causes:

o Diarrhea

o Hemorrhage

o Vomiting

o Inadequate fluid intake o Osmotic diuresis o Third – space losses

o Burns

2. Distributive Shock

 Inappropriate distribution of blood volume with inadequate organ and tissue perfusion

 Causes: o Septic shock o Anaphylactic shock o Neurogenic shock Septic Shock  Pathophysiology

o Infectious organisms or byproducts activate immune system and cells (neutrophils, monocytes, macrophages) o Interaction stimulate release of

inflammatory mediators (cytokines) which produce vasodilatation and immune capillary permeability

Consensus Definition & Clinical Characteristics of Pediatric Sepsis

 Systemic Inflammatory Response

Syndrome

 Sepsis

 Severe Sepsis

 Septic Shock

Systemic Inflammatory Response Syndrome (SIRS)

 Presence of 2 of the 4 criteria, one is abnormal temperature or leukocytes count:

o Core temperature >38o_{C or <36}o_C o Tachycardia in absence of external

stimulus, chronic drugs or pain or unexplained persistent elevation ½ - 4 hr period

o Children < 1 year old bradycardia unexplained over ½ - hour time period o Mean RR >2 SD above normal for age or

mechanical ventilation for an acute process not related to underlying neuromuscular disease or general anesthesia

o Leukocytes count ↑ or ↓ for age (not caused by chemotherapy) pr >10% immature neutrophils

Sepsis

Severe Sepsis

 Sepsis + CV dysfunction or ARDS or  Sepsis + 2 or more other organ failures

Septic Shock

 Sepsis + CV dysfunction despite administration of isotonic IVF boluses ≥ 40 mL/kg in 1 hour  CV dysfunction characterized by the following:

- hypotension (SBP <5% for age) or

- need vasoactive drug to maintain BP in normal range or

 2 of the following characteristics of inadequate organ perfusion:

o Unexplained metabolic acidosis, BP >5 mEq/L

o Increased arterial lactate greater than twice the upper limit of normal

o Oliguria: u.o. <0.5 mL/kg/hr o CRT > 5 sec

o Core to peripheral temperature gap > 3o_C 3. Cardiogenic Shock

 Characterized by:

o Decreased cardiac output o Marked tachycardia

o High systemic vascular resistance  Primary Assessment

o Tachypnea

o Increased respiratory effort

o Tachycardia

o Signs of CHF (pulmo edema,

hepatomegaly, jugular venous distention)

o Cyanosis (for cyanotic CHD or pulmo edema)

o Normal or low blood pressure o Weak or absent peripheral pulses o Normal then weak central pulses

o CRT delayed

 Inadequate tissue perfusion from myocardial dysfunction  Causes: o CHD o Myocarditis o Cardiomyopathy o Arrhythmias o Sepsis

o Poisoning or drug toxicity o Myocardial injury 4. Obstructive Shock

 Impaired cardiac output caused by physical obstruction of blood flow

 Types:

o Cardiac tamponade o Tension pneumothorax

o Ductal - dependent congenital heart disease

o Massive pulmonary embolism

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 = isotonic solution @ 20cc/kg bolus

 Monitor oxygenation, heart rate, and urine output  Consider vasoactive infusion

Case No 1:

3 weeks old presents to the emergency department  CC: Vomiting and diarrhea

 PE: Bradycardia, gasping, cyanosis - What is the physiologic status? - What are the initial intervention?

Cardiopulmonary Failure

= Response to intubation and ventilation with FIO2=1.00  HR: 180; BP: 50 mmHg systolic

 Pink centrally; cyanotic peripherally  No peripheral pulses

 No response to venipuncture What is the physiologic status? Hypotensive What is the cause? Hypovolemic shock

Response to Therapy

 Vital signs improved  Perfusion still poor

Chest X-ray: What is the heart size? Case No. 2

A 3-day old infant has a history of irritability and one episode of vomiting

 PE: Gasping, bradycardia, cyanosis What is the physiologic status? What are the initial interventions?

Cardiopulmonary Failure

= Response to oxygenation and ventilation:  HR: 180; BP: 40 mm Hg systolic  Pink centrally

 Cyanotic peripherally  No peripheral pulses

 No response to venipuncture Cause: Cardiogenic shock

What is the physiologic status? What is the next intervention?

Chest X-ray After Fluid Bolus (Picture)