EMERGENCIES IN CHILDHOOD Monika Csóka M.D.
ETIOLOGY OF CARDIAC ARREST IN ADULT • Dysrhytmia • Ventricular fibrillation
ETIOLOGY OF CARDIAC ARREST IN PEDIATRICS • Respiratory failure • Shock not identified and treated in the early stages
ETIOLOGY • Respiratory tract infection (uper and lower) • Bronchospasm • Foreign body aspiration • Drowning • Trauma • Vomiting/diarrhea • Sepsis • Supraventricular tachycardia • Concenital cardiac abnormalities • Seizures
!!! Early recognition and intervention One study revealed that 92% of children resuscitated when respiratory arrest alone was present had no subsequent neurologic impairment.
Approximately 10 % of children who progress to cardiopulmonary arrest are successfully resuscitated.
ADVANCED LIFE SUPPORT Early recognition Early management of respiratory failure and shock
CARDIOPULMONARY ASSESSMENT ABCs • A airway • B breathing • C circulation
CARDIOPULMONARY ASSESSMENT 30-second rapid assessment stuctured around the ABCs
AIRWAY ASSESSMENT Determine child’s ability to ventilate Airway clear Maintainable with repositioning Unmaintainable without intubation or foreign body removal
BREATHING ASSESSMENT Determine child’s ability to oxygenate Respiratory rate Respiratory effort Breath sounds (air entry) Skin color
BREATHING ASSESSMENT A respiratory rate of less than 10 or greater than 60 is an ominous sign of impending respiratory failure in children.
CIRCULATION ASSESSMENT Reflects perfusion Heart rate Pulse quality Level of consciousness Capillary refill Extremity temperature Skin colour Urine output Blood pressure
CIRCULATION ASSESSMENT Heart rate most sensitive parameter for determining perfusion and oxygenation
HEART RATE > 140 beats / minute clinical evaluation to rule out pathologic etiology < 60 beats / minute inadequate cardiac output
Chest compressions should be instituted until therapeutic interventions increase heart rate to more than 60 beats per minute.
PULSE QUALITY Cardiac output Peripheral perfusion comparing pulse quality and skin temperature at a proximal site with that a distal site Capillary refill (< 3 seconds)
VITAL ORGANS BRAIN level of consciousness alert responds to verbal stimuli responds to painful stimuli unresponsive KIDNEYS urine output (1-2 ml / kg / hour = adequate renal perfusion)
BLOOD PRESSURE Reflects the patient’s ability to compensate when in shock Blood pressure depends on child’s age Hypotension (below of fifth percentile) indicates decompensated shock 25 % of blood volume must be lost before drop in blood pressure occurrs. Hypotension occurs late in shock.
PHYSIOLOGIC STATUS RESPIRATORY FAILURE SHOCK CARDIOPULMONARY FAILURE
RESPIRATORY FAILURE Inadequate ventilation / oxigenation Laboratory: PaCO2 ↑ PaO2 ↓ acidosis Clinical signs: lack of response to airway maneuvers and oxygen Therapy: bag- valve-mask ventilation or intubation
SHOCK Abnormalities in the circulation portion of the assessment Clinical signs: blood pressure < fifth percentile for child’s age Therapy: agressive fluid management
CARDIOPULMONARY FAILURE Global deficits in ventilation, oxygenation and perfusion Clinical signs: agonal respirations bradycardia cyanosis
MANAGEMENT PRIORITIES Determine child’s physiologic status Management specific to physiologic status using ABC format
MANAGEMENT PRIORITIES Oxigen in the highest concentration available Cardiac monitoring Pulse oximetry(inaccurate measure of oxygen saturation when peripheral perfusion is impaired)
RESPIRATORY FAILURE Rapid, aggressive airway management Deliver the highest concentration of oxygen available Maintain a comfortable position for the child
RESPIRATORY FAILURE 2. Basic airway maneuvers: 1. Oral/nasopharyngeal airway placement 2. Neutral, in-line position: head, neck, shoulders 3. Anterior displacement: chin/jaw (to facilitate an open mouth) 4. Remove foreign bodies if present
RESPIRATORY FAILURE 3. Bag-valve-mask indication: inadequate previous measures bradypnea/apnea Indication of intubation: if prolonged ventilation requires inadequate response to bag-valve-mask ventilation
RESPIRATORY FAILURE 4. Appropriate tube size: matching to the size of nares or fifth finger charts and lenght-based tapes (more accurate)
RESPIRATORY FAILURE 5. Vascular acces: after meeting ventilation and oxygenation Nasogastric/oral gastric tube: in intubated & in bag-valve-mask ventilation (to ensure maximal ventilation)
SHOCK Assessing shock: 1. vascular access: peripheral (prox. upper extremity): !three attempts or 90 seconds! then intraosseal (dist. femur/prox. tibia): <6 year or central (femoral): >6 year
If intravenous access in the peripheral proximal upper extremity cannot be obtained in three attempts or 90 seconds in a child younger than six years of age, intraosseous vascular access in the proximal tibia or distal femur should be initiated.
SHOCK 2. 2. oxygen 3. monitoring: urine output (to determine organ perfusion)
SHOCK 3. Fluid therapy: crystalloid (saline/lactated Ringer’s): 20ml/kg in <20min repeated boluses until stable condition blood replacement (traumatic blood loss): blood loss hypotension inadequate perfusion parameters
IN SHOCK 4. Septic/cardiogenic shock therapy initially: crystalloid 20ml/kg drugs: inotropes (epinephrine) after intravenous repletion (estimated infusion volume: 40-60ml/kg) corticosteroid: 1 mg/kg/6 hours
CARDIOPULMONARY FAILURE Global deficit in airway breathing circulation Treatment: oxygen ventilation (mask) cardiac monitor vascular access
INOTROPIC AGENTS Epinephrine 0,1-1,0 μg/kg/min bradycardia shock hypotensio Dopamine 2-5 μg/kg/min renal and splanchnic blood flow 10-20 μg/kg/min shock Dobutamine 2-20 μg/kg/min norm. card. shock
GLUCOSE LEVEL Serum glucose level determination Glucose replacement (hypoglycaemia) dextrose (25%) 0.5-1g/kg (2-4ml/kg) over 20-30min neonates: dextrose (10%) 0.5-1g/kg
POSTRESUSCITATION CARE Once a child is resuscitated, medical care and reassessment must be ongoing. Laboratory Radiology Etiology determine