Kids: Just Little Adults?

Dr Fran Lockie MedSTAR

Paediatric Emergency, Women’s and Children’s

Bedside 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 shock

Arch 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 Simulations

12.4 doctors / nurses per session

194 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 study

Sepsis resuscitation (FEAST)

Trauma resusitation / massive transfusion

Is administering inotropes peripherally safe?

Inotro

pe

• 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?

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

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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