Managing a child with cardiac instabilityManaging a child with cardiac instability

ผศ.นพ.สรวุฒิ พงศโรจนเผานพ.ชัยสิทธิ์ แสงทวีสิน

นพ.สรศักดิ์ โลหจินดารัตน

รูปที่ 1 Pathway to pediatric cardiac arrest

Precipitating ConditionsRespritatory Circulatory Sudden Cardiac

(Arrhythmia)

RespiratoryDistress

Shock

RespiratoryFailure

Cardiopulmonary Failure

Cardiac Arrest

Outcome of Respiratory Outcome of Respiratory vsvs Cardiopulmonary Cardiopulmonary Arrest in ChildrenArrest in Children

0

10

20

30

40

50

60

70

80

90

Respiratory Cardiopulmonary

Percentage of RecoverPercentage of Recover

Case PresentationCase Presentationเด็กหญิงไทย อายุ 2 ป 2 เดือน ภูมิลําเนา บางคอแหลม กทม.

ประวัติจากบิดามารดา เชื่อถือได

CC. Progressive dyspnea for 1 week

How to approach the seriously ill patient as How to approach the seriously ill patient as

this girl ?this girl ?

รูปที่รูปที่ 22 Approach the seriously ill patient by the method of: Approach the seriously ill patient by the method of:

AssessAssess--CategorizeCategorize--DecideDecide--Act Act

Assess

Categorize

Decide

Act

ตารางที่ 1 ขั้นตอนในการประเมินอาการ ( Assess ) ผูปวยเด็กภาวะวิกฤต

Clinical Assessment Brief Description

General assessment

(Pediatric assessment

Triangle: PAT)

A rapid visual and auditory assessment of the child’s overall

appearance, work of breathing, and circulation completed

within the first seconds of patient encounter

Primary assessment A rapid, hands-on ABCDE approach to evaluate

cardiopulmonary and neurologic function; this step

includes assessment of vital signs and pulse oximetry

Secondary assessment A focused medical history using the SAMPLE mnemonic

and a thorough head-to-toe physical exam

Tertiary assessment Laboratory, radiographic, and other advanced tests that help to

establish the child’s physiologic condition and diagnosis

ตารางที่ 3 The general assessment using the pediatric assessment triangle (PAT)

PAT General Assessment

Appearance Muscle tone, interaction, consolability, look/gaze, or

speech/cry

Work of Breathing Increased work of breathing (eg, nasal flaring, retractions),

decreased or absent respiratory effort, or abnormal sounds

(eg, wheezing, grunting, stridor)

Circulation Abnormal skin color (eg, pallor or motting) or bleeding

Primary assessmentPrimary assessment

-- AAirwayirway

-- BBreathingreathing

-- CCirculationirculation

-- DDisability: isability: neurologicneurologic statusstatus

-- EExposure: PExposure: PE

-- handshands--on evaluation on evaluation

-- assess cardiopulmonary & assess cardiopulmonary & neurologicneurologic functionfunction

-- include : VS, SpOinclude : VS, SpO22

ตารางที่ 5 Normal Respiratory Rates by Age3

Age Breaths per Minutes

Infant (<1 year) 30 to 6060

Toddler (1 to 3 years) 24 to 40

Preschooler (4 to 5 years) 22 to 34

School age (6 to 12 years) 18 to 30

Adolescent (13 to 18 years) 12 to 16

CirculationCirculationIncludes evaluation of1) Cardiovascular function

- skin color & temp- HR- rhythm- BP- pulses (peripheral & central)- capillary refill time

2) End-organ function- brain perfusion (mental status)- skin perfusion- renal perfusion (urine output)

ตารางที่ 7 Normal Heart Rates (per Minute) by Age

Age Awake Rate Mean Sleeping Rate

Newborn to 3 months 85 to 205 140 80 to 160

3 months to 2 years 100 to 190 130 75 to 160

2 years to 10 years 60 to 140 80 60 to 90

>10 years 60 to 100 75 50 to 90

Modified from: Hazinski3 and Gillete6

Basic Relationships of Cardiovascular Basic Relationships of Cardiovascular ParameterParameter

PreloadPreload

MyocardialMyocardialcontractilitycontractility

AfterloadAfterload

Stroke volumeStroke volume

Heart rateHeart rate

Cardiac outputCardiac output

Systemic vascular resistanceSystemic vascular resistance

BloodBloodpressurepressure

Cardiac outputCardiac output

Systemic vascular resistanceSystemic vascular resistance

ตารางที่ 9 Definition of Hypotension by Systolic Blood Pressure and Age

Age Systolic Blood Pressure (mm Hg)

Term neonates

(0 to 28 days)

< 60

Infants

(1 to 12 month)

<70

Children

1 to 10 years

5th BP percentile

<70+ (age in years x 2)

Children

>10 years

<90

Capillary RefillCapillary Refill

• Normal capillary refill < 2 seconds in a warm environment

MottledMottled

ตารางที่ 10 Normal urine output in well-hydrated infants, young children,

older children, and adolescents

Age Normal Urine Output

Infants and young

children

1.5 to 2 mL/kg per hour

Older children and

adolescents

1 mL/kg per hour

ตารางที่ 13 The SAMPLE mnemonic for secondary assessment to identify important

aspects of the child’s history and presenting compliant by focus on history and PE.

Signs and Symptoms Signs and symptoms at onset of illness, such as

Breathing difficulty (eg, cough, rapid breathing, increased

respiratory effort, breathlessness, abnormal breathing pattern,

chest pain on deep inhalation)

Altered level of consciousness

Agitation, anxiety

Fever

Decreased oral intake

Diarrhea, vomiting

Bleeding

Fatigue

Time course of symptoms

Allergies Medications, foods, latex, etc

Medications Medications

Last dose and time of recent medications

Past medical history Health history (eg, premature birth)

Significant underlying medical problems (eg, asthma,

congenital heart disease, seizures, head injury, brain

tumor, diabetes, hydrocephalus, neuromuscular disease)

Past surgeries

Immunization status

Last meal Time and nature of last liquid or food (including breast

or bottle feeding in infants)

Events Events leading to current illness or injury (eg, onset

sudden or gradual, type of injury)

Hazards at scene

Treatment during interval from onset of disease or injury

until your evaluation

Estimated time of arrival (if out-of-hospital onset)

ตารางที่ 13 The SAMPLE mnemonic for secondary assessment to identify important

aspects of the child’s history and presenting compliant by focus on history and PE.

Case PresentationCase Presentationเด็กหญิงไทย อายุ 2 ป 2 เดือน ภูมิลําเนา บางคอแหลม กทม.

ประวัติจากบิดามารดา เชื่อถือไดCC. Progressive dyspnea for 1 weekPI. 2 weeks PTA ไขสูง ไอมาก หอบไปโรงพยาบาลใกล

บาน แพทยตรวจเลือด X-ray บอกวา ปอดบวม พนยา ฉีดยาให ไดยามา 4 ชนิด และนัดไปฉีดยาทุกวัน

1 week PTA ไขหายไป ไอลดลง แตสังเกตวาเด็กเหนื่อยเพิ่มขึ้น กินนมนอยลง พาไปโรงพยาบาลเดิมอีกครั้ง แพทยบอกวาเปน หลอดลมอักเสบ เพิ่มยาใหอีก 1 ชนิด เหนื่อยไมลดลง จึงพามาโรงพยาบาลนี้

Case Presentation (2)Case Presentation (2)

PH. บุตรคนเดียว คลอดรพ.ใกลบาน แรกเกิด 3300 กรัม แข็งแรงดีมาตลอด

กินทุกอยางไมเลือก ขาว 3 มื้อ นมครั้งละ 4 ออนซวันละ 2 ครั้ง พัฒนาการสมวัย

ทั้งบิดา มารดาอายุ 24 ป แข็งแรงดี อยูกัน 3 ครอบครัว 8 คนในบาน

Case Presentation (3)Case Presentation (3)

PE. Alert, active, dyspneaT 37.0°C, RR 52/min, BP 90/66 mmHg, HR

150/minNot pale, no jaundice, no conjunctival

injectionPharynx and tonsils – not injected

Case Presentation (4)Case Presentation (4)

Chest – equal chest movement, subcostalretraction, rhonchi both lungs

Heart – hyperactive precordium,no murmurAbdomen – liver 6 cm below right costal

marginExtremities – no edemaNeuro – normal muscle power, reflex 2+ allSkin – no rash

Positive finding from AssessmentPositive finding from Assessment

•• General assessment : irritableGeneral assessment : irritable

dyspneadyspnea, , subcostalsubcostal retractionretraction

no central cyanosisno central cyanosis

•• Primary assessment : increased RR (>40/min)Primary assessment : increased RR (>40/min)

subcostalsubcostal retractionretraction

increased HR ( >140/min)increased HR ( >140/min)

poor peripheral pulsepoor peripheral pulse

cap refill < 2 sec.cap refill < 2 sec.

•• Secondary assessment:Secondary assessment:

SS&S: Heart; hyperactive &S: Heart; hyperactive precordiumprecordium

Lung; Lung; rhonchirhonchi, , subcostalsubcostal retractionretraction

AbdAbd; liver 6 cm>RCM; liver 6 cm>RCM

AA: no: no

MM: antibiotic and bronchodilator : antibiotic and bronchodilator

PP: no: no

LL: 3 hrs: 3 hrs

EE: Rx as pneumonia for 2 wks: Rx as pneumonia for 2 wks

with antibiotic and bronchodilator with antibiotic and bronchodilator

Positive finding from AssessmentPositive finding from Assessment

Tertiary assessment of circulatory abnormalitiesTertiary assessment of circulatory abnormalities

Lab studies- ABG- central venous oxygen saturation (Svo2) - total serum CO2

- arterial lactateNonlab studies

- ABP monitor- CVP monitor- CXR- ECG- Echocardiography