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Stabilisation of the critically ill child

Stabilisation of the critically ill child. Dr Reinout J Mildner Consultant Paediatric Intensivist Birmingham Children’s Hospital. Paediatric retrieval services. Stand alone or linked to regional PICU Funded by Specialist Commissioners Roles: - Source of advice

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Stabilisation of the critically ill child

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  1. Stabilisation of the critically ill child Dr Reinout J Mildner Consultant Paediatric Intensivist Birmingham Children’s Hospital

  2. Paediatric retrieval services • Stand alone or linked to regional PICU • Funded by Specialist Commissioners • Roles: - Source of advice - Transportation of critically ill children who qualify for ICU therapy - Education & training - Audit & feedback

  3. Duties of the referring hospital – Golden Hour will be with you, be prepared • Nominated consultant + lead nurse • Appropriately designed + equipped area • Protocols - admission / discharge - resuscitation + stabilisation - treatment of all major conditions - advice, referral + transport to lead PICU • Initiation and maintenance of intensive care, • including location (ED/ Theatres/Ward/ITU) • Involvement of paediatric nurse / consultant • Arrangements for when: - lead centre full - retrieval team not available - transport to ECMO / burns centre - time critical transfers

  4. Paediatric retrieval services • Stand alone (CATS London, WMPRS) or linked to regional PICU (STRS etc) • Managed Lead Consultant Lead Nurse Responsibilities: Oversee programme + clinical review Budgetary responsibility Protocols / guidelines Equipment procurement and maintenance incl ambulance provision Staff recruitment and rota’s Education and training Audit, Quality Improvement, Safety Feedback / Outreach Service development

  5. West Midlands Paediatric Retrieval Service • Advice about or retrieval of any sick child call 0300 200 1100 • Operational team 1. 24 hour co-ordination centre (stand alone service) – Operator + Consultant receive all PICU referrals advice regarding stabilisation bed finding mobilise team 2. Retrieval team Transport nurse Transport doctor Ambulance crew

  6. Ambulance specifications: - Access ramp / tail lift +/- winch - Floor fixing system - Electrical supply - Oxygen / air supply - Rear / forward facing seats - Equipment storage / restraint (CEN compliant) - Heating Trolley specifications: - Hard wearing, overall weight < 140 kg - Able to take and restrain children of all sizes - Floor fixing system – Ferno / Paraid - Electrical management system 12V / 240 V - Accommodate: ventilator Baby PAC/ VentiPAC monitor – Philips, incl ETCO2 infusion pumps - Braun suction unit - Laerdal NO set up - Comply with ICS guidance

  7. Retrieval equipment – age appropriate Airway Oral airways size 000 – 4 Face masks size 00 – 5 ETT uncuffed: 2.0 mm – 6.0 mm ID ETT cuffed 3.0 mm – 7.5 mm ID LMA’s size 1 – 4 Laryngoscopes: Miller 00 and 0, Magill 1 and 2, Mcintosh 1 – 3 McGill forceps large and small Yankauer suckers large and small Needle cricothyrodotomy set Bougies 5Fr – 15Fr, Stylets 2mm – 5 mm Tape to secure ETT Range of NG tubes 4 – 12 Fr + oral syringes Breathing Laerdal self-inflating bags adult and paediatric Ayre’s T-piece 0.5 L, Mapleson C circuits 1 and 2L Chestdrains sizes 8, 10 and 16 Fr NO ready made ventilator circuit Suction cathters 6 – 12 Fr Circulation IV cannula’s 24G – 14 G Lederflex lines 22G 6 and 8 cm Central Lines 4Fr, 4.5Fr, 5Fr (5,8 and 12 cm), 7.5Fr Guidewires (Baby wire, 0.18 and 0.25) Intraosseus needles Urinary catheters Consumables

  8. Intubation plans and airway management

  9. Upper Airway Anatomy in Infants • Large head • Large tongue • High anterior larynx • Infant epiglottis long, floppy & U shaped • Funnel shaped larynx • Narrow trachea

  10. Airway Differences

  11. Positioning Adapted from Walls et al. Manual of Emergency Airway Management. 2nd Ed. 2004.

  12. Standard airway equipment • Oral airways size 000 – 4, nasopharyngeal airways • Face masks size 00 – 5, round + shaped • ETT uncuffed: 2.0 mm – 6.0 mm ID • ETT cuffed 3.0 mm – 7.5 mm ID • Laryngoscopes: Miller 00 - 3, Magill 1 and 2, Mcintosh 1 – 3 • Magill forceps large and small • Yankauer suckers large and small • Bougies 5Fr – 15Fr, Stylets 2mm – 5 mm • LMA’s size 1 – 4 • Needle cricothyrodotomy set • Tape to secure ETT

  13. Laryngoscope Blades • Straight blades are placed under the epiglottis and used to lift anteriorly to expose the cords. • Curved blades are placed in the valecula and lifted anteriorly to expose the cords. Miller Macintosh Wisconsin

  14. Endotracheal tube size • Newborn wt (kg) ETT ID (mm) Length at lip (cm) < 0.7 2.0 6 < 1.0 2.5 7 1.0 3.0 7.5 2.0 3.0 9 3.0 3.0 10.5 3.5 3.5 11 • 6 months 3.5 12 • Over 1 year: (Age in years/4) + 4 12+age/2 • Have one size smaller and larger

  15. Common Problems • Esophageal Intubation • Blade placed too deep, cords not visualized • Tongue obscures visualization • Sweep tongue to one side with blade • More anterior lift • Pull forward with Magill forceps • Cannot see cords • Head is hyper-extended – reposition • Leak on ETT compromising ventilation: upsize • Facial burn: use uncut ETT to allow for facial swelling

  16. Difficult Airways in Infants • Must always be prepared for something abnormal • Increasing awareness of problems beforehand because of neonatal ultrasound • “Things you can see” versus “Things you may find”

  17. Difficult Airways in Infants • Congenital malformations • “Things you can see” • Predictable from looking at the patient • Down’s syndrome • Cleft lip and palate • Pierre Robin syndrome • Treacher Collins syndrome • Goldenhar syndrome • Apert and Crouzon Syndrome

  18. Congenital Malformations • Cleft Lip and Palate • Most common congenital face malformation • Pierre Robin Sequence • Obstruction is usually at the nasopharyngeal level

  19. Congenital Malformations • Apert and Crouzon • Maxillary hypoplasia • Nasopharyngeal airway compromise • Goldenhar syndrome • Unilateral anomalies • Higher incidence of airway anomalies

  20. Congenital Malformations • Treacher Collins • Choanal atresia/stenosis more common • Down’s Syndrome • Large tongue • Subglottic stenosis more common • Remember atlantoaxial instability

  21. Difficult Neonatal Airways • Congenital or acquired malformations • “Things you may find” • Croup • Epiglottitis • Laryngomalacia • Hemangioma or Lymphangioma • Tracheal web • Laryngeal atresia • Subglotic stenosis

  22. Epiglottitis

  23. Congenital Malformations • Laryngomalacia • A sequence between fully formed to atresia

  24. Congenital Malformations • Laryngeal Web • Tracheal Atresia • Survive only if tracheoesophageal fistula or emergent tracheostomy

  25. Congenital Malformations • Hemangioma or Lymphangioma • Only about 30% present at birth • Get bigger in 1st year of life

  26. Congenital Malformations • Subglottic Stenosis • Can be acquired after prolonged / multiple intubations

  27. Unexpected difficult airway • Return to bag and mask ventilation • Call for help • Consider what problem is • What can be done differently at further attempts? Positioning Tongue Different blade Cricoid pressure Tilt blade tip forward Bougie / NGT guide Smaller size ETT • Can patient be supported awake with NIV? • NB: With every attempt at intubation airway will swell and become more difficult

  28. More recent adjuncts to difficult intubation Airtraq Glidescope

  29. Laryngeal mask airway Patient weight < 6.5 kg 6.5 – 20 kg 20 – 30 kg 30 – 70 kg 70 – 90 kg

  30. Ventilation and ventilatory adjuncts

  31. Indications for intubation1. Worsening respiratory distress 2. Progressive hypercapnia and/or hypoxia 3. Respiratory arrest / prolonged apnoea • Effort: rate, recession, noise, grunting, nasal flaring, accessory muscle use • Efficacy of breathing: • breath sounds, chest expansion • Effects of inadequate breathing: heart rate, skin colour, mental status

  32. Initial ventilation • Control significant ETT leak: upsize / throat pack • Set Pressure control level + PEEP or • Initial tidal volume 10 - 12 ml/kg • Set rate and inspiratory time • Neonate 30 - 60 bpm • Infant 25 - 40 bpm • Child 14 - 25 bpm • I : E ratio 1 : 3 to 1 : 1 • Avoid very short or > 50 % inspiratory time

  33. Aims clear secretions avoid / improve atelectasis improve V- Q matching Techniques saline lavage + suction chest percussion postural drainage consider re-recruitment Chest physiotherapy and suction

  34. sedation + muscle relaxation • Midazolam infusion 2 - 4 cg/ kg/ min 1mg / ml solution in glucose 5% not if < 6 months • Morphine 20 - 60 cg/ kg/ hr 1 mg / kg morphine in 50 ml Glucose 5 %, run at 1 - 3 ml/hr • Rocuronium 0.6 - 1 mg/ kg/ hr (neat solution) Alternatives: Atracurium, intermittent pancuronium

  35. monitoring Alveolar ventilation • chest movement • PaCO2 / ETCO2 • adjust TV or rate (VC) OR PIP or rate (PC) Oxygenation • SpO2 / PaO2 • adjust FiO2 or PEEP CXR

  36. Vascular access

  37. Think intra-osseus anterior tibial plateau, 2-3 cm below the tibial tuberosity

  38. Ultrasound guided central venous access SLA ‘hockey stick’ transducer

  39. bronchiolitis 1. Apnoeas • need for intubation, usually compliant lungs 2. Mixed picture • airway obstruction • copious secretions + atelectasis • diffuse pneumonitis • volume control/ guarantee ventilation, PEEP 5 – 10 cm H2O

  40. asthma Absolute indications for intubation • cardiac / respiratory arrest • severe hypoxia • deteriorating mental state Relative indication • progressive exhaustion Rare, high risk: CVS instability + barotrauma

  41. asthma • main problems  airway resistance + dynamic hyperinflation • use iv salbutamol  aminophylline and iv hydrocortisone, trial of Mg – sulphate • iv ketamine, inhalational anaesthesia • PCV / VCV low rate + long expiratory time, permissive hypercapnia • high PIP tolerable • PEEP below PEEPi • monitor blood electrolytes (K+)

  42. ARDS • Open lung approach with limited TV • Titrate PEEP ( 7 - 16 cm H2O) to FiO2 0.6 and SaO2 > 90%. I : E = 1 : 1 • PCV / PRVC, aim tidal volume 6 ml / kg. Maintain MV by  rate and allow permissive hypercapnia. • Cardiac support with volume  inotropes

  43. focal / unilateral lung disease • Place patient with affected side up postural drainage  V - Q mismatch recruitment affected lung • Avoid overdistention unaffected side limit PEEP accept relative hypoxia

  44. Head injuries

  45. Common causes • RTA: pedestrian cyclist passenger in car • Falls: toddlers teenagers • Non-accidental injury: < 1yr • Mechanism important

  46. Epidemiology • Mortality ± 25 - 30% • 40% of trauma deaths age 1-15 yrs • Trimodal distribution • At scene: airway obstruction bleeding head / spinal injury 2. First hours: all of above aspiration 3. Days - weeks: ARDS Sepsis MODS

  47. PRIMARY INJURY • SKULL # • LINEAR / STELLATE • (NON) – DEPRESSED • BASAL • PERIORBITAL ECCHYMOSES • HEMOTYMPANUM • BATTLE’S SIGN • CSF LEAK DIFFUSE AXONAL INJURY • DURAL SAC TEARS • EXTRADURAL HAEMATOMA • SUBDURAL HAEMATOMA • SUBARRACHNOID HAEMATOMA CEREBRAL LACERATION / CONTUSION

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