Resuscitation & Stabilisation of the Critically Ill Child

Sandra StarkNurse Consultant ScotSTAR

Resuscitation

Differences Between Adults & Children

LESS THAN YOU THINK!!!!

Paediatric vs Adult Resuscitation

Focus on the similarities

Airway

Breathing

Circulation

Common Presentations Respiratory distress

Usually infective in origin Bronchiolitis, LRTI, croup

Infection/sepsis Large range of support required

Seizures

Trauma

Decreased GCS Intracranial pathology Infection Trauma NAI

DifferencesPathways leading to cardiac arrest in children

are different

Rarely due to primary cardiac disease

Usually due to circulatory +/- respiratory failure

If child arrests, likely to be more decompensated

Airway Differences Head large, neck small- tends to cause neck flexion

Tongue relatively large◦ May obstruct airway in unconscious child◦ Obstructs view at laryngoscopy

Easy to compress airway when holding face mask

Beware the child with airway obstruction who has an oxygen requirement

Head tilt◦ Neutral in the infant◦ Sniffing in the child

Intubation Differences As in adults, often can maintain airway with good bag/mask If need intubation or to assist, have variety of sizes close to

hand ETT size – 4 + age/4 (drop half a size if cuffed) Epiglottis in children horseshoe shaped & projects

posteriorly Larynx high & anterior (C2-3 in infant compared to C5-6 in

adult) Trachea short – tube displacement more likely Pre-oxygenation vital – more likely to desaturate More likely to be bradycardic during intubation

◦ Infants more pronounced vagal response◦ Bradycardia with direct laryngeal stimulation◦ Can be due to hypoxia◦ More likely to stimulate vagal response (vagus nerve) in infant

intubation with direct laryngeal stimulation,

Breathing DifferencesHigher metabolic rate & oxygen consumption so

higher RRWork of breathing – nasal flaring, intercostal &

subcostal recessions due to compliant chest wallInfants rely on diaphragmatic breathing – more

likely to fatigue & cause respiratory failureMore compliant chest wall – may have lung injury

without fractured ribsIf rib # present, implies significant forceImportant to remember when BVM not to use

excessive force (tidal volume 5-10ml/kg)

Circulation DifferencesChild’s circulating blood volume 70ml-

80ml/kg

Higher than an adult but relatively small so easier to dilute

Small SV in infants so CO increased by HR

HR response to fluids can be blunted in infants

Cardiac DecompensationCardiac arrest – likely to be asystole or PEA

Uncommon to require shock

Children will maintain cardiovascular parameters (ie BP) until almost pre-terminal then deteriorate very quickly

Bradycardia/hypotension LATE sign of decompensation

Primary cardiac disease uncommon in children – consider in neonates or children with known cardiac disease

Neurology DifferencesModified GCS??

Hypoglycaemia can be a big problem

Paediatric SpineSpinal injuries relatively rare

More flexible joint capsules & interspinous ligaments

Relatively large head compared with neck – thus movement greater and more injuries at level of occiput to C3

Spinal cord injury without radiological abnormalities more common in children

Paediatric Burns

Paediatric BurnsAdults – rule of 9s

More complex in paeds

Easiest way – palmar surface (including fingers) of patient’s hand represents approximately 1%

Essential Equations

Weight (Age+4) multiplied by 2Formula for weight

◦ Average birth weight 3.5kg◦ Increased to 10kg by 1 year

Broselow tapes◦ Colour coded system for paediatrics

Energy = 4J/kgFluid = 20ml/kg (10ml/kg in trauma or DKA)Sugar = 3ml/kg of 10% dextroseAdrenaline = 0.1ml/kg of 1:10,000

StabilisationDiscussion regarding retrieval to

appropriate centre

Ongoing care & optimisation

Interventions

Airway/intubationVentilationHaemodynamic supportVascular access (arterial/venous)Other – blood, medications

Who Will Perform Interventions?Local team

Retrieval team

Joint

Intubation - Tips If referring team can intubate saves time if they do so

Don’t cut tubes too short

Short ETT◦ Easy to dislodge◦ CXR to confirm position

Many children will maintain A & B with PEEP/oxygen – correct haemodynamics before administering anaesthetic

Common regime◦ Fentanyl (1-2mcg/kg) if required◦ Ketamine 2mg/kg◦ Rocuronium 1mg/kg◦ Resus drugs drawn up-adrenaline/atropine◦ Beware thio/propofol

Ventilation - TipsLow threshold for intubation children for

transfer◦Especially any airway obstruction◦Safer to intubate in good environment before you

leave

Watch tidal volumes – easy to over inflate small lungs

Difficulties with ventilation◦Suction, physio can make a big difference

Circulation - Tips

IO access if unable to get access◦Also remember external jugular vein for access◦Scalp veins in neonates

Inotropes if required (consider when >40ml/kg fluid resuscitation)

Adrenaline or dopamine can be used peripherally

2 points of access before you leave

How to Make up Inotropes

Neurology - TipsBeware of hypoglycaemia

◦3-5ml/kg 10% dextrose

Midazolam/morphine for sedation◦Morphine 20-40mcg/kg/hr◦Midazolam 0.1mg/kg/hr◦Bolus rocuronium for transfer

Small adults◦Use what you are comfortable with!!

Head InjuryMay require time-critical response for

neurosurgical interventionPrevent secondary brain injury with

appropriate ventilation/circulatory support◦Desaturation & low BP very bad for heads◦In child with head injury & raised ICP, even one

episode of hypotension can cause significant morbidity

Other . . . Heat loss more of a problem-packaging

important

Higher body surface area for heat loss

In trauma, energy transmitted to body that has less connective tissue & fat and closer proximity to multiple organs – significant injury may exist in absence of fractures

Cardiac . . .Very rare to have primary cardiac diseaseCardiac compromise often secondary to

other pathologyNeonates

◦Cyanosed◦Cardiac findings ie absent femorals

Older children◦History of cardiac disease/pathology

Cardiac PresentationA, B, C . . .Often breathing can be supported with PEEP

◦May need intubation but optimise other systems first

◦The ‘oxygen’ dilemma . . .Cautious with fluid

◦Use 10ml/kg aliquots & assess response◦In neonates with duct dependent disease, discuss

with tertiary centre & consider prostin◦Sepsis/metabolic other differentials in ‘shut

down’ neonate – sepsis FAR MORE COMMON

www.snprs.scot.nhs.uk

Questions??