Penanganan Kasus Emergency Pada Anak

7/23/2019 Penanganan Kasus Emergency Pada Anak

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Penanganan kasus gawat darurat

pada anak

Abdul Chairy

e-mail: [email protected]

Mobile: +6281329375575

@abdul_chairy


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Outline

Pediatric BLS + pediatric cardiac arrest

Primary assesment identify intervene


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approach to a

acutely-ill child


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Pediatric

cardiac arrest

Epinephrine IO/IV 0.01

mg/kg/dose repeat every3-5 minutes or

0.1 mg/kg ET

Defibrillation

1st shock 2 J/kg,

subsequent shock 4 J/kg,max. 10 J/kg or adult dose

Hypovolemia

Hypoxia

Hydrogen ion (acidosis)

Hypoglycemia

Hypo-/hyperkalemia

Hypothermia

Tension pneumothorax

Tamponade, cardiacToxins

Thrombosis


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Rationale for CAB vs ABC Chest compression must be started right away to support

circulation & algorithms too complex needed

simplification (only 30% of children receive bystander

CPR)

Provision of ventilation delays the initiation of chestcompressions & thus circulation often by minutes

CPR was done poorly too slow too shallow & with

excessive ventilations which can impede cardiac output Adults & children who suffer sudden cardiac arrest from V-

fib/V-tach benefit from rapid CPR & defibrillation


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Compression to ventilation

Health care provider if alone 30:2, otherwisecompression to ventilation rate 15:2

Push hard, push fast compress chest in infant 4 cmand 5 cm in children allow chest to recoil compress

at least 100 x/min

Breathe 8-10 x/min avoid excessive ventilation

Switch rescuers every 2 minutes to avoid fatigue whendoing chest compression


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Chest compressions


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BMV vs ET Intubation

LOE 1 study shows no

difference in survival or

neurological outcome

Recommendation is that

BMV recommended over

ET intubation for

ventilatory support in out-

of-hospital settings


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Minute ventilation Avoid excessive ventilation of infants & children

during resuscitation from cardiac arrest; insufficient data

to identify optimal tidal volume or rate

Animal studies show excessive ventilation decreasesCPP, ROSC & survival

Excessive ventilation increases intrathoracic pressureimpedes venous return, reduces CO &

cerebral/coronary blood flow

During CPR ventilate 8-10 times per minute for infants& children

TEKAN LEPAS LEPAS


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Rapid Sequence Intubation

Obtain AMPLE &examine patient

Prepare personnel, medication,

equipment

Monitor & pre-oxygenate

ECG, pulse oximeter

Pre-medicate Give atropine 0.02 mg/kg (min 0.1 mg) iv

Indicated for all children


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Sedate (choose one option based on condition of patient)

Normotensive

Midazolam 0.2 mg/kg

EtomidateThiopental

Propofol 1 mg/kg

Hypotensive/hypovolemic

Mild Severe

Etomidate or Etomidate orKetamine or Ketamine or

Midazolam none

Head injury or status epilepticus

Normotensive Hypotensive

Thiopental or Etomidate orPropofol or Low-dose thiopental

Etomidate

Status asthmaticus

Midazolam orKetamine

Rapid Sequence Intubation (contd ..)


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Apply cricoid pressure

when patient is unconscious

Paralyze

Rocuronium

Vecuronium

Succinylcholine

Intubate trachea

Evaluate & confirm tube placement (eg. exhaled CO2)

Secure tracheal tube

Observe & monitor Administer additional sedation & paralytics PRN

American Academy of Pediatrics /

American Heart Association


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CUFFED VS UNCUFFED ETT Cuffed tubes may be preferred in certain circumstances

poor lung compliance, high airway resistance, or large

glottic air leak, really any sick child (class IIa, LoE B)

Cuffed ETT will not cause pressure on the cricoidcartilage leading to pressure necrosis (class IIa, LoE B)

Reintubation rate in uncuffed ETT is 30.8% vs 2.1% incuffed ETT

Uncuffed (age (yr)/4) + 4 = mmIDCuffed (age (yr)/4) + 3.5 = mmID


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Rapid Sequence Intubation


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TroubleshootingDisplaced ET tube is not in trachea or has moved into a

bronchus (right mainstem most common)

Obstruction Consider secretions or kinking of the tube

Pneumothorax Consider chest trauma, barotrauma ornon-compliant lung disease

Equipment Check oxygen source, BVM and ventilator

15


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The PAT

Circulation to Skin


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Appearance

(TICLS)

Tone

InteractivenessConsolability

Look/Gaze

Speech/Cry


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Appearance

(AVPU)

Alert/Awake

VoicePain

Unresponsive


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Appearance

Seizure?

Exposure? Burns, causticingestion, CO, etc


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AppearanceSeizure management

Diazepam rectal 5-10 mg or IV/IM 0.3-0.5 mg/kg

Phenytoin IV 15-20 mg/kg in 20 minutes

2-3 times

Phenytoin IV 10 mg/kg in 20 minutes

Phenobarbital IV 15-20 mg/kg

Phenobarbital IV 10 mg/kg


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Work of Breathings Abnormal airway sounds

Abnormal positioning

Abnormal respiratory rate Retractions

Nasal flaring

SpO2


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Work of Breathings Upper airway obstruction

Lower airway obstruction

Lung tissue disease Disorder control of

breathing


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Upper Airway Obstruction


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Lower Airway Obstruction


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Intervention: Oxygen


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Oxygen (contd ..) Oxygen increasing evidence for harm limit

hyperoxemia start with 100% - later adjust to achieve

SpO2 >94%

The issues In reperfusion injury, hypoxic cells appear toundergo metabolic changes that prime them to create free

radicals when oxygen is reintroduced

Experimental resuscitation with 100% oxygen has beenassociated with a variety of concerning physiologic changes

when compared with room air resuscitation: increasedgeneration of oxygen radicals, decreased CNS sodium-

potasium ATPase function & decreased dopamine metabolism


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Pallor

Mottling

Cyanosis

Capillary refill timeCirculation to Skin

Circulation to Skin


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HYPOVOLEMI

C

SHOCK

DISTRIBUTIVE/SE

PTIC SHOCKCARDIOGENI

C

SHOCKMEDIATORS

Myocardial

Depression

Vasodilatation

Capilary

Leak

CARDIAC OUTPUT BLOOD PRESSURE

CONTRACTILITY

Sympathetic Discharge

Vasoconstriction

HR

Contractility

Improved

Cardiac Output

and

Blood Pressure

COMPENSATED

Myocardial Perfusion

Myocardial O2 Consumption

Myocardial PerfusionTISSUE ISCHEMIA

MEDIATOR

RELEASE

Cell FunctionLoss of

autoregulator

of microcirculationCell Death

DEATH OF ORGANISM

PRELOAD

UNCOMPENSATE

D

Figure 3.1.

Sequence of pathophysiologic

events in clinical shock states.From White MK, Hill JH, Blumer JL.

Shock in the pediatric patient. Act

Pediatr 1987:34:139-174


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SHOCKTypical signs of compensated

shock include

Tachycardia

Cool and pale distal extremities

Prolonged (>2 seconds)capillary refill (despite warm

ambient temperature)

Weak peripheral pulsescompared with central pulses

Normal systolic blood pressure

As compensatory mechanisms fail,

signs of inadequate end-organ

perfusion develop. In addition to the

above, these signs include

Depressed mental status

Decreased urine output

Metabolic acidosis

Tachypnea

Weak central pulses

Deterioration in color (eg,mottling, see below)

Circulation 2010;122;S876-S908


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Recognize decrease mental status & perfusion

Manage airway, breathing & IV/IO access

Initial resuscitation:

push boluses 20 cc/kg crystalloid or colloid up to 60 cc/kg

Correct hypoglycemia & hypocalcaemia. Begin antibiotics

Fluid refractory shock: Begin inotrope IV/IO

Reverse cold shock titrating dopamine up to 10 mcg/kg/min or, if

resistant, titrating central epinephrine 0.05-0,3 mcg/kg/min

Reverse warm shock titrating norepinephrine 0.5-3 mcg/kg/min

0 min

1 min

15 min

60 min Catecholamine resistant shock

Initial management

Lab work-up CBC, diff count, glucose (rapid), mixed venous GA,

blood culture, CRP/procalcitonin, ALT, SCr, PT/aPTT, electrolytes,

lactate, blood typeBrierley J et al. Crit Care Med 2009; 37:666-668


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EGDT (early target)

1. Regain of consciousness

2. Normal peripheral pulse (malleolus media or dorsalispedis), warm acral, CRT 1 ml/kg/hr

5. Broad-spectrum antibiotics (gram + & -)

6. ScvO2 >70%

7. Minimal Hb 7 (without shock) or 10 g/dL (shock orhypoxemia)

Goldsteinet al. Pediatr Crit Care Med 2005; 6(1):2-8


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Intervention: Vascular access

Peripheral vein

Intraosseus

Often difficult to obtain in small &/or

acutely-ill child


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Intraosseous IO access is a rapid, safe, effective, and acceptable route

for vascular access in children.

All intravenous medications can be administered

intraosseously, including epinephrine, adenosine, fluids,blood products and catecholamines.

Onset of action and drug levels for most drugs arecomparable to venous administration.

IO access can be used to obtain blood samples for analysis

including for type and cross match and blood gases duringCPR

Circulation 2010;122;S876-S908


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Intraosseous infusion


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Intraosseous infusion


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Summary

Primary care physician should be able to detect& manage emergency conditions in children

He/she should have the skill to perform CPR,manage CABs which consist of BMV/RSI,

oxygen therapy, intraosseus infusion

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Penanganan Kasus Emergency Pada Anak