Recognition and management of the seriously ill child

Dr Esyld WatsonConsultant in Adult and Paediatric Emergency Medicine

Learning outcomes

To understand the aetiology of and clinical pathways to cardiorespiratory arrest in children

To use a rapid ABCDE assessment to determine the clinical state

To distinguish between compensated and decompensated respiratory or circulatory failure

To initiate treatment interventions based on ABCDE assessment and reassessment

Aetiology of cardiorespiratory arrest

Children are different to adults

Adults◦Usually a primary cardiac arrest◦Sudden and unpredictable in onset◦Usually due to arrhythmia◦Not usually preceded by hypoxia and

acidosis◦Successful outcome depends on early

defibrillation

Aetiology of cardiorespiratory arrest

Children◦ Most children have secondary arrest◦ Respiratory and/or circulatory failure leads to

hypoxia and acidosis.◦ Myocardial hypoxia results in bradycardia then

asytole◦ Early recognition and treatment of respiratory

and circulatory failure can prevent progression to arrest

◦ 10 - 20% of children have primary cardiac arrest - usually due to congenital or acquired heart disease

Pathways to cardiorespiratory arrest

Compensated circulatory failureCompensated respiratory failure

Cardiorespiratory failure

Cardiorespiratory arrest

Decompensated

circulatory failure

Decompensated

respiratory failure

Normal Values

Recognition of the seriously ill child is based on assessment of:

Airway (c-spine consideration in trauma)

Breathing Circulation Disability Exposure

Oxygenation

Ventilation

Perfusion

A - Airway

Assessing the airway

B - Breathing

Assessing breathingoxygenation and ventilation

Minute ventilation = Tidal volume x RR

Respiratory rate (RR)

Work of breathing

Tidal volume (chest expansion)

Oxygenation (pulse oximetry)

Assessing respiratory rate

Increased RR is often the first sign of respiratory difficulty

RR varies with age, fever, pain and anxiety as well as in respiratory failure

Monitor the trend in RR

Assessing the work of breathing

Assessing tidal volume

Tidal volume (look, listen, feel) ◦Compare one side of chest with the other◦Subjective assessment: breath sounds

should be audible in both bases◦(Feel for trachea; is it central?)

Assessing respiratory sounds

Stridor

Wheeze

Grunting

Assessing oxygenation◦ Cyanosis is unreliable

(SpO2 < 80%)

Any child with a breathing problem must have pulse oximetry

Clinical signs of hypoxia Irritability, agitation,

drowsiness, level of consciousness

Decompensation?

Increasing respiratory rate Sudden fall in respiratory rate Exhaustion Reduced interaction with caregivers,

agitation Diminishing level of consciousness

C - Circulation

Assessing circulatory status

Assessing pulses

Comparison of central and peripheral pulses◦Reflects stroke volume◦As shock progresses peripheral pulses are

lost before central pulses

Assessing heart rate

Increased HR is often the first sign of circulatory compromise

HR varies with age, fever, pain and anxiety as well as in circulatory failure

It is more important to monitor the trend in HR than to rely on absolute value

Assessing skin perfusion

Feel skin temperature ◦Warm / cold line

Skin colour ◦Mottling◦Pallor◦Peripheral cyanosis ◦Rashes

Assessing capillary refill time

CRT > 2 sec is abnormal

Assess peripherally and centrally

Assessing cerebral perfusion

Early signs◦Loss of interest in surroundings◦Irritability, agitation

Late signs◦Drowsiness, loss of consciousness,

hypotonia (floppy)

Assessing renal perfusion

Urine output is an index of organ perfusion

Nappy weights or number of wet nappies

Urinary catheter (> 1 ml kg-1 h-1) How many times passed urine that

day?

Decompensation? Steadily increasing HR Sudden fall in HR Increasing peripheral vasoconstriction Reduced interaction with care givers,

agitation Diminishing level of consciousness Hypotension

D - Disability

Assessing disability

Evaluate the level of responsiveness◦Alert◦Voice◦Pain◦Unresponsive to painful stimulus

Posturing Pupil reaction Glucose

E- Exposure

Exposure

Respect dignity Rashes Bruising Injuries Environment temperature

Cardiorespiratory failure

There is usually some respiratory compensation for decompensated circulatory failure and vice versa

Cardiorespiratory failure is global failure of oxygenation, ventilation and perfusion

If untreated will lead to cardiorespiratory arrest

Management based on initial assessment

Decide on clinical status of the child:

Stable Compensated respiratory failure Decompensated respiratory failure Compensated circulatory failure Decompensated circulatory failure Cardiorespiratory failure

Stable child

Confirm clinical status Take a more detailed history Examination and investigations to

aid diagnosis Begin treatment Reassess

Compensated respiratory failure

Assess ABCDE O2 therapy

(non-threatening)

Monitoring (pulse oximetry, HR, RR)

Specific therapy Reassess Seek expert help

Decompensated respiratory failure

Open and maintain airway

High-flow O2

Ventilate

Assess adequacy of ventilation

Reassess and monitor Seek expert help

Compensated circulatory failure Assess airway High-flow O2 Monitoring IV / IO access Fluid bolus 20 ml kg-1

0.9% NaCl Reassess after any

intervention Seek expert help

Decompensated circulatory failure

Open and maintain the airway High-flow O2

Support ventilation if required Immediate IV / IO access,

fluid bolus 20 ml kg-1 0.9% NaCl

Reassess Repeat fluid boluses Seek expert help

Cardiorespiratory failure Open and maintain the

airway High-flow O2 Support ventilation Immediate IV / IO access,

fluid boluses Reassess and monitor Seek expert help Consider tracheal

intubation and mechanical ventilation

Any questions?

Summary

Airway (c-spine consideration in trauma)

Breathing Circulation Disability Exposure

Oxygenation

Ventilation

Perfusion

• Compensated V Decompensated• Cardiorespiratory Failure