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A drowsy child

HKCEM College Tutorial. A drowsy child. Author Dr. T W Wong Revised by Dr. Chang Wai Yin James Oct, 2013. Triage. F/1 year old brought in by maid vomiting + drowsiness ? Fit at home AVPU only P Pulse 140/min RR 12/min. Triage Category I. In Resuscitation Room.

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A drowsy child

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  1. HKCEM College Tutorial A drowsy child Author Dr. T W Wong Revised by Dr. Chang Wai Yin James Oct, 2013

  2. Triage • F/1 year old • brought in by maid • vomiting + drowsiness • ? Fit at home • AVPU only P • Pulse 140/min RR 12/min Triage Category I

  3. In Resuscitation Room How would you assess this child initially?

  4. Check if the kid is in distress Assessment Triangle Appearance: mental status muscle tone Work of breathing RR, retraction, stridor Circulation: color, cap refill, pulse

  5. Check if the kid is in distress Assessment Triangle Appearance: Drowsy (grimace with pain) Tone flaccid Work of breathing RR, retraction, stridor Circulation: color, cap refill, pulse

  6. Check if the kid is in distress Assessment Triangle Appearance: mental status muscle tone RR 12/min shallow no retraction Circulation: color, cap refill, pulse

  7. Check if the kid is in distress Assessment Triangle Appearance: mental status muscle tone Work of breathing RR, retraction, stridor Circulation: pale, cap refill 4sec, pulse weak

  8. What is the physiological status of the child? Airway: patent Breathing: ventilation problem Circulation: shock Mental State: depressed

  9. What is your initial treatment? Stabilize ABC

  10. Immediate Treatment • 100% oxygen by mask • try to start an IV • ECG monitor • pulse oximeter (SpO2 = 90%) • SBP = 70 mmHg

  11. Does this child need intubation? For protection of airway Possible ventilatory failure

  12. SOAP ME How do you prepare for intubation? Induction ? Muscle relaxant ? What size tube ?

  13. Size of ET tube Cuffed: Age/4 + 4 mm Uncuffed: Age/4 + 3mm Size of diameter of little finger

  14. What drug to prepare? Sedating agent? Muscle relaxant: sux or rocuronium atropine lignocaine

  15. Dosage? Refer to... Broselow Tape

  16. As you start bagging the child, IV attempts fail What is your options now?

  17. Start an IO line IO needle insertion

  18. Describe steps in RSI

  19. The tube is insertedHow do you check if tube is in good position and ventilation is adequate ? Chest expansion/movement ETCO2 SpO2 CXR

  20. IO line is inYour fluid order please NS 20 ml/Kg bolus

  21. Maintenance fluid order for children 1/5 solution 100 ml/Kg (0-10 Kg) 50 ml/Kg (10-20 Kg) 20 ml/Kg (> 20 Kg)

  22. Progress • BP 75 mmHg • Pulse 130/min cap refill 3 sec • SpO2 100% • ETCO2: 55 mmHg Now you can do your secondary survey after a targeted history

  23. More history from maid • Unwell for 1/7 • fussy not feeding well • vomit 2x no diarhoea • limb twitching ? Fit before attendance • fever? • FTSVD, well all along Any other questions?

  24. Examination • Ant fontanel tense • Pupil 4 mm reactive • Chest AE Okay no added sound • HS dual no murmur • Abd soft, no mass felt • Limbs flaccid (no lateralising sign) • Babinski equivocal Any more findings you would like to know?

  25. What ddx would you consider CNS infection: meningitis, encephalitis CNS bleeding: shaken baby syndrome Sepsis: meningococcemia Metabolic: hyponatremia, dehydration Drug overdose/Poisoning

  26. Any investigation? H’stix Blood for electrolytes ABG Urine (ketone, micro, culture) Blood culture? CXR CT brain

  27. Progress • Paediatric team now arrives and takes over the case • CT scan of brain is performed • Features suggestive of ICH ? Shaken baby syndrome What physical finding may suggest this dx?

  28. Shaken baby syndrome • Intracranial bleeding • ?shake + impact • retinal hemorrhage is often found

  29. Summary We have covered: 1. Assessment of a critically ill child 2. Resuscitation of a depressed child 3. Ddx of a depressed child 4. Shaken baby syndrome

  30. THE EMD

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