Kids: Just Little Adults?

Dr Fran LockieMedSTARPaediatric Emergency, Women’s and Children’sBedside Critical Care, September 2013

Scope• Case• Why are we scared?• Structured approach

– Airway, – Breathing– Circulation

• Can we do better?

15 month old male with fever

• NVD at term, BW 2.7kg• Previously fit and well• No meds, NKDA• Immunisations UTD• Family all coryzal

Country Hospital

• At triage (17:30)– Alert and playful– Temp 39, Hr 160, Rr 40– Good central perfusion– Mottled peripherally

18:45 Seen by RMO

• Given panadol with resolution of fever, HR never < 170 since triage

• Bloods– VBG pH 7.15, BE -10, B/C 10, lact 5, CO2 25– BSL 6

• Urine NAD

URTI focus for fever identified

• 2 small vomits in waiting room, then a small area of petechiae

21:00 Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes

22:00

• A Maintained, No O2• B RR 60, marked increased resp effort• C peripheral CRT: absent, central >5 secs• D alert, talking to mum• 24g PIV tissued, further attempts unsuccessful

Rapid deterioration

– AVPU

– Increasing respiratory distress– HR >200, Only femoral pulse palpable

– IO sited– Aggressive filling– DA started

Ketamine, sux, adrenaline bolus

PEA Arrest• Filling, filling, filling• Dopamine started at 20mcg/kg/min• Filling, filling, filling

– 4% albumin– Blood products (packed cells, plts, FFP, cryo)

• Noradrenaline, Adrenaline, infusions commenced

• Stat dose hydrocortisone

6hrs later….still PEA / ROSC• Maximal inotropic / pressor support• multiple dextrose, Ca, Mg boluses• Total fluids 180ml/kg• Sustained bradycardia, worsening acidosis• Massive pulmonary haemorrhage

• Parents present throughout• RIP, 03:00

We are scared of kids!

• Kids need early aggressive treatment• Failure to diagnose shock• Failure to resuscitate

– Early access– Early fluids– Early Abx– Early inotropes (peripheral is OK!)– Early intubation– Evaluate our actions: lactate and physiology

• Audit of 17 PICU’s • 107 patients with septic shock • 8% received care c/w ACCM guideline

– 21% not given >60ml/kg despite ongoing shock– 15% not given dopa/ dobu despite fluid refractory

shock– 23% not given catechol for dopa/ dobu refractory

shock– 30% not given steroid despite catechol resistant

shockArch Dis Child 2009

• FAILURE TO DIAGNOSE SHOCK

• 3 factors– Not looked after by a paediatrician

– Lack of supervision

– Failure to administer inotropes

BMJ 2005

Pediatrics 2009;124;56

Early Resuscitation of Children with Moderate to severe TBI

• 299 kids with mod-severe TBI

• 39% became hypotensive– Of these only 48% were treated

• 44% became hypoxic– Of these 92% were treated

• ED staff• Anaethetics• Theatre staff• Standardised scenarios• Causes of error

Resuscitation, in Press 2013

75 Simulations12.4 doctors / nurses per session194 incidents of subobtimal care

Resuscitation, in Press 2013

We are scared of kids!Solutions…

Train together!

• One Base• Adult teams

– ED– Intensivists– Anaesthetists

• Paediatric and neonatal teams

• Special operations paramedics

• Teamwork• Leadership• Crew Resource Management• Resus drills• Intubation drills• Competency frameworks

Ann Emerg Med. 2012

Kids have smaller FRC

Greater VO2 than adults

Rapid desaturation (with stress and apnoea)

Ann Emerg Med. 2012

Ann Emerg Med. 2012

Levitan: Dentition, disruption, disproportion, dysmobility

Levitan: 4Ds

“Doctor, He’s Tiring!”

• Diaphragmatic exhaustion• Lacks type 1 muscle fibres

• Decompress the stomach– Often results in dramatic improvement!

• Know your vent: wt limits– Generally TV 4-6 ml/kg

• 95 patients• Mean age 5.5• 95% success• 10 seconds or less• Pain score 2.3

Pediatr Ermerg Care 2008

SAFE studySepsis resuscitation (FEAST)Trauma resusitation / massive transfusion

Is administering inotropes peripherally safe?

Inotrope

• 73 of 1133 treated with vasoactive agents by peripheral IV

• Primarily Dopamine monotherapy (90%) or Dop + Ad (7%)

• 11/73 (15%) developed infiltration – all resolved without significant intervention

• Longer duration

• Higher dose of dopamine

Pediatr Emerg Care 2010

Sugar and temperature

• Large SA: body wt (2-2.5 x BW)• Thin skin and subcut fat (less insulation)• No shivering• Immature thermoregulatory center

• Sugar ALWAYS goes down in critical illness…

Lancet 2011; 377: 1011–18

• Listen to the physiology!

Lancet 2011; 377: 1011–18

Is lactate really the ‘Holy Grail’ of sepsis biomarkers?

Intensive Care Med 1997

Is lactate really the ‘Holy Grail’ of sepsis biomarkers?

Intensive Care Med 1997

No, but sepsis often masquerades as respiratory disease in kids

If you still can’t explain it…

• Always assume ingestion• Always assume inflicted injury

Smaller but the same

• Train together??• Golden rules

– PEEP– NGT– VBG + Physiology– Early inotropes– Ingestion / inflicted– Pink, warm and sweet