fran lockie on kids: just little adults?

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  1. 1. Kids: Just Little Adults? Dr Fran Lockie MedSTAR Paediatric Emergency, Womens and Childrens Bedside Critical Care, September 2013
  2. 2. Scope Case Why are we scared? Structured approach Airway, Breathing Circulation Can we do better?
  3. 3. 15 month old male with fever NVD at term, BW 2.7kg Previously fit and well No meds, NKDA Immunisations UTD Family all coryzal
  4. 4. Country Hospital At triage (17:30) Alert and playful Temp 39, Hr 160, Rr 40 Good central perfusion Mottled peripherally
  5. 5. 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
  6. 6. URTI focus for fever identified 2 small vomits in waiting room, then a small area of petechiae
  7. 7. 21:00 Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes
  8. 8. 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
  9. 9. Rapid deterioration AVPU Increasing respiratory distress HR >200, Only femoral pulse palpable IO sited Aggressive filling DA started
  10. 10. Ketamine, sux, adrenaline bolus
  11. 11. 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
  12. 12. 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
  13. 13. Parents present throughout RIP, 03:00
  14. 14. 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
  15. 15. Audit of 17 PICUs 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 shock Arch Dis Child 2009
  16. 16. FAILURE TO DIAGNOSE SHOCK 3 factors Not looked after by a paediatrician Lack of supervision Failure to administer inotropesBMJ
  17. 17. 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 treatedPediatrics 2009;124;56
  18. 18. ED staff Anaethetics Theatre staff Standardised scenarios Causes of error Resuscitation, in Press 2013
  19. 19. 75 Simulations 12.4 doctors / nurses per session 194 incidents of subobtimal careResuscitation, in Press 2013
  20. 20. We are Solutions scared of kids!
  21. 21. Train together! One Base Adult teams ED Intensivists Anaesthetists Paediatric and neonatal teams Special operations paramedics
  22. 22. Teamwork Leadership Crew Resource Management Resus drills Intubation drills Competency frameworks
  23. 23. Ann Emerg Med. 2012Kids have smaller FRC Greater VO2 than adults Rapid desaturation (with stress and apnoea)
  24. 24. Ann Emerg Med. 2012
  25. 25. Ann Emerg Med. 2012
  26. 26. Levitan: Dentition, disruption, disproportion, dysmobility
  27. 27. Levitan: 4Ds
  28. 28. Doctor, Hes 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
  29. 29. 95 patients Mean age 5.5 95% success 10 seconds or less Pain score 2.3Pediatr Ermerg Care 2008
  30. 30. SAFE study Sepsis resuscitation (FEAST) Trauma resusitation / massive transfusion
  31. 31. Is administering inotropes peripherally safe?Inotrope
  32. 32. 73 of 1133 treated with vasoactive agents by peripheral IVPrimarily Dopamine monotherapy (90%) or Dop + Ad (7%) 11/73 (15%) developed infiltration all resolved without significant intervention Longer duration Higher dose of dopaminePediatr Emerg Care 2010
  33. 33. 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
  34. 34. Lancet 2011; 377: 101118 Listen to the physiology!
  35. 35. Lancet 2011; 377: 101118
  36. 36. Is lactate really the Holy Grail of sepsis biomarkers?I
  37. 37. Is lactate really the Holy Grail of sepsis biomarkers?No, but sepsis often masquerades as respiratory disease in kids I
  38. 38. If you still cant explain it Always assume ingestion Always assume inflicted injury
  39. 39. Smaller but the same Train together?? Golden rules PEEP NGT VBG + Physiology Early inotropes Ingestion / inflicted Pink, warm and sweet