Recognition of the seriously ill child

23/03/11Dr. John Twomey,

Consultant Paediatrician,Department of Paediatrics/ Emergency Department

Medical Students

Describe what you see

15th century, unknown artist

1664, Gabriel Metsu

1885, Eugene Carriers

2006, Life magazine

The sick child

Some Ground Rules!

Diverse range from infancy to adolescence

Children Are Not “Little Adults”

What are the key differences to consider in children?

• Weight

• Anatomical

• Physiological

• Psychological

Weight

• Centile Charts• Broselow Tape• Formula (1-10yrs): Wt (kg) = (age + 4)2• Estimate (0-1 yrs): Newborn = 3.5 kg 6/12 = 7 kg 12/12 = 10 kg• Estimate (>10 yrs): 10 yrs = 30 kg 12 yrs = 40 kg 14 yrs = 50 kg 16 yrs = 60 kg

Anatomical

Airway - Large head- Short & soft trachea- Small face & mandible- Loose teeth & Large tongue- Easily compressible floor of the mouth- Obligate nasal breathers (<6/12)- Adenotonsillar hypertrophy- Horse-shoe shaped epiglottis projecting posteriorly- High & anterior larynx (straight bladed laryngoscope)- Cricoid ring = narrowest part of the airway (Larynx in

adults) & is susceptible to oedema (uncuffed ett)- Symmetry of carinal angles

Anatomical

Breathing - Lung immaturity- Small air-surface interface (<3m²)- Less small airways (1/10 of adult)- Small upper & lower airways- R 1/r4- Diaphragmatic Breathing- More horizontal ribs

Anatomical

Circulation- RV>LV (0-6/12) => LV>RV- Blood circulating volume/body weight = 70-80 mls/kg- Absolute volume is small (critical importance of relatively

small amounts of blood loss)

Body Surface Area- BSA:Wt ↓ with ↑ age- Small children have a high ratio => relatively more prone

to hypothermia

Physiological

Respiratory- Infant - ↑ BMR & O2

Consumption => ↑ RR

Age (yrs) RR (bpm)

<1 30-40

1-2 25-35

2-5 25-30

5-12 20-25

>12 15-20

Physiological

Cardiovascular- CO = SV x HR- Infant – small stoke

volume => ↑ HR

Age (yrs) HR (bpm)

<1 110-160

1-2 100-150

2-5 95-140

5-12 80-120

>12 60-100

Physiological

Cardiovascular- Infant - ↓ systemic

resistance => ↓ BP- SBP = 80 + (age x 2)

Age (yrs) SBP(mmHg)

<1 70-90

1-2 80-95

2-5 80-100

5-12 90-110

>12 100-120

Physiological

Immune system

- Immature immune system

- Maternal antibodies (x 1st 6/12)

- Protective effect of breast feeding

Psychological

Communication- No or limited verbal communication- Many non-verbal cues- Age-appropriate communication

Fear- Additional distress to the child and adds to parental

anxiety => altered physiological parameters => difficult to interpret

- Explain as clearly as possible (Knowledge allays fear)- Parental presence at all times

A Structured Approach

• 1º Assessment - Resuscitation – identifying & treating the immediate threats to life – closed or obstructed airway, absent or distressed respiration, pulselessness, shock

• 2º Assessment - Emergency Treatment – to start to treat the underlying cause of the child’s condition

• Reassessment - Stabilisation – achieving homeostasis and system control

• Transfer – to a definitive care environment (PICU)

A Structured Approach

• Preparation (before the child arrives)

• Teamwork (with a designated team leader)

• Communication (with contemporaneous recording of history, clinical findings, treatments)

• Consent (assumed if acting in the best interests of the child)

WETFAG• Weight = (Age + 4)2

• Energy = 4 J/kg asynchronous shock

• Tube = (Age/4) + 4 ---- +/- 0.5

• Fluids = 20 mls/kg 0.9% NaCl

• Adrenaline = Adrenaline 10 μg/kg IV/IO (0.1ml/kg of 1:10,000); 100 μg/kg (0.1ml/kg of 1:1,000) ETT

• Glucose = Dextrose 10% 5ml/kg IV

1º Assessment

&

Resuscitation

ABCD(E)

• Airway

• Breathing

• Circulation

• Disability

• (Exposure)

Airway & Breathing

Effort of breathing:• RR/Recession/Inspiratory & expiratory

noises/Grunting/Use of accessory muscles/Nasal flaring/Gasping

Efficacy of breathing:• Chest expansion/Abdominal excursion/ Chest

auscultation/Pulse oximetryExceptions:• Exhaustion/↑ICP/NM d/oEffect of respiratory inadequacy on other organs:• ↑/↓ HR/Pallor/Cyanosis {NB anaemia}/Agitation/

Drowsiness/LOC/Hypotonia

=> BLS & Advanced Airway Support

Basic Life Support (BLS)

EMS activation before BLS:

• witnessed sudden collapse with no apparent preceding morbidity

• witnessed sudden collapse in a child with a known cardiac condition and in the absence of a known or suspected respiratory or circulatory cause of arrest

Call emergencyservices

SAFEapproach

CPR15:2

x 1min

Check pulseCheck for signsof circulation

5 rescuebreaths

Look, listen,feel

Airwayopening

manoeuvres

Are youall right?

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BLSInfant (<1) Child (1-14)

Head tilt position Neutral Sniffing

Initial rescue breaths 5 5

Pulse

Landmark

Technique

Brachial/femoral

1 finger’s breadth above xiphisternum

2 fingers/2 thumbs

Carotid

1 finger’s breadth abovexiphisternum

1 or 2 hands

CPR ratio 15:2 15:2

Circulation

Cardiovascular status:• HR/Pulse volume/CRT/BPEffect of circulatory inadequacy on other organs: • ↑RR (2º to metabolic acidosis)/Pallor/

Cyanosis/Agitation/Drowsiness/LOC/↓ UO (<1ml/kg/hr in children; <2ml/kg/hr in infants)

Cardiac failure:• Cyanosis not correcting with O2/Tachycardia out of

proportion to respiratory difficulty/↑JVP/Gallop rhythm/Murmur/Enlarged liver/ Absent femoral pulses

=> IV/IO access x2; bloods incl. G&X-match; fluid bolus (20ml/kg); inotropes, intubation & CVP monitoring if >3 boluses

DisabilityConscious level:• P ~ GCS </= 8/15Posture:• Decorticate/DecerebratePupils:• Dilatation/Unreactivity/

InequalityEffect of central neurological

failure on other organs:• Hyperventilation/Cheyne-

Stokes/Apnoea• ↑BP, ↓HR, abnormal

breathing (Cushing’s Triad)

=> Intubation if “P” or “U”; Rx hypoglycaemia; Rx seizure

A ALERT

V responds to VOICE

P responds only to PAIN

U UNRESPONSIVE

(Exposure) – Not part of 1º Assessment but do early

ABC - DEFG

Don’t Ever Forget Glucose

Reassessment of ABCD(E) at

frequent intervals

2º Assessment &

Emergency Treatment

Airway & Breathing

Symptoms:• Breathlessness/Coryza/Cough/Grunting/Stridor/Wheeze/

Hoarseness/Drooling & inability to drink/Abdominal pain/ Chest pain/Apnoea/Feeding difficulties

Signs:• Cyanosis/Tachypnoea/Recession/Grunting/Stridor/

Wheeze/Chest wall crepitus/Tracheal shift/Abnormal percussion note/Crepitations on auscultation/Acidotic breathing

Investigations:• O2 sats/Peak flow/End-tidal or trans-cutaneous CO2/

Blood culture/CXR/ABG

Airway & Breathing↑ Respiratory secretions – • Suction - ? Fatigued/depressed conscious level Barking Cough in a well child – • ?Croup – PO/IM Dexamethasone (0.6mg/kg stat or 0.15mg/kg BD

x 2-3/7)/Nebulised budesonide (2mg)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2) – NB TRANSIENT ↑HR; REBOUND

Quiet stridor, drooling, sick-looking child – • ?Epiglottitis/Bacterial Tracheitis (Pseudomembranous Croup) -

Intubation & IV ceftriaxone NB AVOID VENEPUNCTURE (BEFORE INTUBATION) AND X-RAYS

Sudden onset of respiratory distress leading to apnoea in a conscious toddler –

• ?Inhaled foreign body -“choking child” manoeuvre/direct laryngoscopy & use of Magill’s forceps ONLY IN EXTREME CASES OF A THREAT TO LIFE

• ?Anaphylaxis

Airway & BreathingCough, wheeze & ↑SOB – • ?Acute exacerbation of asthma – Inhaled Salbutamol

(2.5mg{<5yo}; 5mg {>5yo}) & O2/PO prednisolone (2mg/kg) or IV hydrocortisone (4mg/kg then 2mg/kg QDS)

• ?IFB• ?AnaphylaxisInfant with wheeze and respiratory distress – • ?Bronchiolitis – Supportive Mx – PO/NG/IV fluids/O2• ?IFB • ?AnaphylaxisPyrexia, breathing difficulties but no stridor/wheeze – • ?Pneumonia – Antibiotics/Adequate hydration/ +/- chest drainStridor following ingestion of a new food – • ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of

1:1,000)/Nebulised adrenaline (5ml of 1:1,000 nebulised in O2)/Chlorphenaramine/Prednisolone

• ?IFB

Management of a Choking Child

Assess

IneffectiveCough

EffectiveCough

Unconscious

5 BackBlows

Assess &repeat

Conscious

OpenAirway

5 RescueBreaths

CPR 15:2Check for

FB

5Chest/abdo

Thrusts

EncourageCoughing

Support &Assess

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Ineffective Cough & Conscious

Infants (<1)• Back Blows (x5) and

Chest Thrusts (x5) (1/second)

Ineffective Cough & Conscious

Children (1-14)• Back Blows (x5)

and Abdominal Thrusts (x5) (1/second) (Heimlich Manoeuvre)

Circulation

Symptoms:• Breathlessness/Fever/Palpitations/Feeding difficulties/

Drowsiness/Pallor/Fluid loss/Poor urine outputSigns:• Tachy -or bradycardia/Hypo- or hypertension/Abnormal

pulse volume or rhythm/Abnormal skin perfusion or colour/ Cyanosis/Pallor/Hepatomegaly/Auscultatory crepitations/Murmur/Peripheral oedema/↑JVP/Hypotonia/Purpura

Investigations:• U&E/FBC/ABG/Coag screen/Blood culture/ECG/CXR

Shock

Acute failure of circulatory function

Shock

Types:• Cardiogenic – heart defects - arrhythmias• Hypovolaemic – fluid loss – haemorrhage, GE• Distributive – vessel abnormalities –

septicaemia, anaphylaxis• Obstructive – fluid restriction – tension pnuemo,

cardiac tamponade• Dissociative – inadequate O2-releasing

capacity of blood – CO poisoning, methaemoglobinaemia

Shock

Types:

• Phase 1 - Compensated

• Phase 2 - Decompensated

• Phase 3- Irreversible

Phase 1- Compensated

• Compensatory mechanisms to preserve vital organ function

• Sympathetic + => ↑Systemic Arterial Resistance; ↑HR; ↑secretion of angiotensin & vasopressin

Clinical Features:

• agitation/confusion, pallor, ↑HR, cold peripheries, ↑CRT

Phase 2 - Decompensated

• Compensatory mechanisms start to fail• Aerobic => anaerobic metabolism => lactic

acidosis• Sluggish blood flow => platelet adhesion• Release of numerous chemical mediators

=> ↑capillary permeability & other deleterious consequences

Clinical Features:• ↓BP, ↓LOC, acidotic breathing, ↓/no UO

Phases 3 - Irreversible

• Retrospective Dx

• Death is inevitable despite therapeutic intervention resulting in adequate restoration of circulation

• EARLY RECOGNITION & EFFECTIVE TREATMENT OF SHOCK IS VITAL

Circulation

Shocked child with no obvious fluid loss – • ?sepsis - IV ceftriaxone Shock with rash & stridor – • ?Anaphylaxis - IM adrenaline (10μg/kg =

0.01ml/kg of 1:1,000)Neonate with unresponsive shock – • ?duct-dependent CHD – Prostaglandin

(Alprostadil 0.05μg/kg/min)Pallor with dark brown urine – • ? Haemolysis ?SCD – O2, rehydration +/-

Transfusion, antibiotics, analgesia

Circulation

No pulse – • ?Cardiac Arrhythmia - Assess cardiac rhythm –

asystolé, PEA, VF, PLVTPoor feeding with HR 230bpm – • ?SVT Algorithm – vagal stimulation, If IV access - IV

adenosine (100μg/kg; ↑x100μg/kg every 2 min to a max of 500μg/kg {300μg/kg in < 1/12}), If No IV access & shocked – DC cardioversion (1J/kg then 2J/kg)

Infant/young child with Hx vomiting, drawing up legs & pallor ++ +/- abdominal mass –

• ?intussusception/malrotation/volvulus etc. - Surgical advice – Paediatric Surgeon - Dublin/Abdominal USS, stabilisation & transfer

What is this rhythm?

Supraventricular Tachycardia (SVT)

• Commonest non-arrest arrhythmia in childhood• HR >220bpm• Narrow QRS complex (< 0.08 sec)

• Palpitations• Lightheadedness• Dizziness• Chest discomfort • Shock (if prolonged - younger)

SVT• Vagal stimulation – glove containing ice over face;

immersion in iced water; unilateral carotid sinus massage; valsalva (blow through a straw!)

• If IV access - IV adenosine (100μg/kg; ↑x100μg/kg every 2 min to a max of 500μg/kg {300μg/kg in < 1/12})

• If No IV access & shocked – DC cardioversion (1J/kg then 2J/kg)

• No response – SEEK SPECIALIST PAEDIATRIC CARDIOLOGY ADVICE

• Amiodarone (5mg/kg over 20-60 min)• Procainamide (15mg/kg over 30-60 min)• Flecainide (2mg/kg over 20 min)

Intussusception – A Medical Emergency!

• Infant/young child with Hx vomiting, drawing up legs & pallor ++ +/- abdominal mass

• ABC• High-flow O2• IV fluid resuscitation• PFA• Abdominal USS• Inform Paediatric Consultant• Stabilisation & Transfer for definitive Mx

Fluids in Resuscitation

• 0.9% NaCl 20 ml/kg (10ml/kg in DKA or Trauma)• >/= 3 boluses (60ml/kg = ¾ of total circulating blood

volume!) = consider RSI• Larger volumes => haemodilution - Albumin??• Use CVP (~cardiac preload) as a guide• Blood – fully cross-matched = 1º type-specific non-cross –matched = 15 min O-negative = 0 min

• NOT dextrose because => hyponatraemia

Disability

Symptoms:• Headache/Fits or Seizures/Change in behaviour/Change

in conscious level/Weakness/Visual disturbance/FeverSigns:• Altered level of consciousness/Convulsions/Altered pupil

size & reactivity/Abnormal posture/abnormal oculo-cephalic reflexes/ Meningism/Papilloedema or retinal haemorrhage/Altered deep tendon reflexes/↑BP/↓HR/ Irregular breathing pattern

Investigations:• U&E/blood glucose/ABG/Coag screen/Blood culture/Blood

& urine toxicology – salicylate/Neuroimaging

Disability

Seizure – 1st Ix – • hypoglycaemia - IV glucose (5ml/kg of Dextrose 10%)Seizure > 5 min duration –• IV lorazepam (0.1mg/kg)/PR diazepam (0.5mg/kg {max

4mg})/Buccal midazolam (0.5mg/kg)Decreasing level of consciousness/abnormal

posturing/abnormal ocular motor reflexes – • ? ↑ICP - Intubation & ventilation/head in-line & 20-30º

head-up position/IV mannitol (0.25-0.5g/kg {1.25-2.5ml/kg of mannitol 20 %} over 20 min) + IV frusemide (1mg/kg)/+/- Dexamethasone (0.5mg/kg BD) Neurosurgery input

Depressed level of consciousness/irritability/convulsions – • ?meningitis/encephalitis - IV ceftriaxone/acyclovir

Disability

Drowsiness with sighing respirations – • ?DKA - IV Normal saline (0.9%) & insulinVomiting, hypoglycaemia & coma – • ?metabolic encephalopathy – IV glucose,

ABCD & send metabolic screen esp ammonia – Metabolic Team input

Unconscious with inconsistent history – • ? NAI – Mx as per any unconscious child,

ophthalmology, bloods, skeletal survey, neuroimaging (if not already done)

Unconscious with pin-point pupils – • ? Opiate poisoning - IV naloxone (10μg/kg); IM

naloxone (100μg/kg)

Exposure

Symptoms:• Rash/Swelling of lips/tongue/Fever

Signs:• Purpura/Urticaria/Angio-oedema

Exposure

Shock/↓LOC/Purpuric rash

• ?Meningococcal septicaemia – Blood culture, PCR & IV ceftriaxone

Shock/Stridor/Urticarial rash

• ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of 1:1,000)

Reassessment,

Stabilisation

&

Transfer

A Structured Approach

• 1º Assessment - Resuscitation – identifying & treating the immediate threats to life – closed or obstructed airway, absent or distressed respiration, pulselessness, shock

• 2º Assessment - Emergency Treatment – to start to treat the underlying cause of the child’s condition

• Reassessment - Stabilisation – achieving homeostasis and system control

• Transfer – to a definitive care environment (PICU)

The Hypocratic Oath! Epiglottitis • Don’t lie patient down!• Don’t do a lateral x-rayManagement of shock• Too much fluid too quickly can => cerebral oedema• No dextrose as resuscitation fluid (=> hyponatraemia)Duct-dependent CHD• Avoid excessive O2 (sats @ 88-92%)No LP if altered level of consciousness• ↑BP, ↓HR, irregular respirations (Cushing’s Triad)Normal fundoscopy does not exclude acute ↑ICPNaHCO3 has NO role in initial management of DKASteriods have NO role in the initial management of Meningococcal Septicaemia (√refractory hypotension)

“Don’t Ever Forget Glucose”