CIRCULATION

2. CIRCULATION

3. Rapid assessment • The circulatory status reflects the effectiveness of cardiac output as well as end-organ perfusion • The rapid assessment includes: • Cardiovascular function • End-organ perfusion (systemic circulation)

4. For age based vitals Refer SOS - HOPE APP Cardiovascular function • Heart rate: age-dependent • Ranges • Central and peripheral pulses: compare the femoral, brachial, and radial pulses

5. For age based vitals Refer SOS-HOPE APP Blood Pressure • Blood pressure: age-dependent • Use the following guidelines to estimate the lowest acceptable (5th percentile) systolic BP (SBP) • Newborn – 1 month < 60 mmHg SBP • 1 month – 1 year < 70 mmHg SBP • 1–10 years < 70 mmHg + (2 X age in years) SBP • > 10 years < 90 mmHg SBP

6. End-organ perfusion • Skin perfusion: capillary refill (<2 sec normal), color, extremity temperature (relative to ambient temperature) • Demonstrate Capillary refill

7. Behavior and appearance indicate CNS perfusion • CNS perfusion: mental status, level of consciousness, irritability, consolablity • Level of consciousness • A - Alert • V - Verbal responsiveness • P - Painful responsiveness • U - Unresponsive

8. Compensated Shock • Tachycardia • Cool and pale distal extremities • Prolonged capillary refill (>2 seconds) despite warm ambient temperature • Weak peripheral pulses compared with central pulses • Normal systolic blood pressure

9. Decompenated Shock • Depressed mental status • Decreased urine output • Tachypnea • Weak central pulses • Deterioration in color/Mottling • Falling systolic blood pressure

10. Case -1 • A 10 month old AYUSH • Brought to the Clinic On mother’s lap • The nurse observed that • The baby is not active & eyes are sunken • Immediately the nurse asks for the history, Mother says the child has continuous diarrhea & vomiting since 48hours

11. On ExaminationInteract! • The attending Pediatrician quickly examines the child • What to look for ? • Look for signs of dehydration • Whether the child has signs of shock?

12. Signs of Severe Dehydration GC : Lethargic, floppy EYES : very much sunken MOUTH & TONGUE : very dry SKIN PINCH : goes back very slowly

13. Signs of shock Pulse –fast, low volume (feeble) Extremities– cold & mottled CFT – Prolonged >2secs BP –Normal or low or not recordable

14. Case 1 contdInteract! AYUSH is lethargic, wt 10 kg. Eyes : very much sunken Skin pinch : goes back very slowly Pulse : fast ,feeble Extremities : cold ,mottled CFT : Prolonged >2secs BP : Normal What is your assessment?

15. Assess, Decide & Act • Ayush Has signs of severe dehydration & In shock • BP normal- compensated shock • Hypovolaemic shock

16. How do you manage? Interact!

17. Golden hour Management of shock • GOAL Restoration Of Tissue Perfusion And Oxygenation. • PRINCIPLES • A - establishment of Airway. • B - maintenance of Breathing. • C -restoration of Circulatory blood volume - fluid resuscitation

18. Management of Shock • Airway-clear & patent • Breathing-Provide O2 to Maintain SaO2>92% • Establish peripheral IV line/ IO • Start Ringer’s Lactate or Normal saline 20 ml/kg bolus (Ayush is 10kg needs 200ml over 5-10 min) • Reassess for signs of improvement

19. Response after 20 ml/kg (NS)bolus Interact! • Pulse well felt HR 140/min • BP - 90/66 • CFT<2sec • WHAT NEXT?

20. Next step? • Ayush needs Dehydration correction • Continue IV fluid-100ml/kg over 6hrs - RL/ NS. • Ayush needs 1000ml of fluid over 6 hours for correction of dehydration (300ml over 1 hour & remaining 700ml over 5 hrs) • Reassess & If able to take orally give ORS.

21. Case 2 • Master A • 5 year old weight of 20 kg • Short 3 day history of fever and ARI • Brought with difficulty breathing and increased sweating from last night

22. On Evaluation • Appears apprehensive • Well hydrated • Tachypnea rate about 40/min • Tachycardia 180/min • Peripheral pulses feeble • BP 60/40 mmhg • Liver 3 cm • Pulse Oximeter saturation 90%

23. Assessment • Careful evaluation of the CVS/RS • JVP/Hepatomegaly • Gallop rhythm • Tender hepatomegaly • Probably myo-pericarditis Triage category –

24. Management • Stabilize ABC • Oxygen • Vascular access • IV fluids • Transport consider inotropes if hypotensive or time to shift > 4 hrs • Monitoring

25. Case 3 • A 5 yr old Ashwini, 20kg • Brought with h/o tiredness, headache since 6 hrs • Had h/o fever, headache since 5 days

26. On Examination Interact! • Restless, irritable. Flushing present • Pulse- 180/min weak & thready • extremities cold & mottled • CFT> 6sec • BP 70/50mm Hg • What is your assessment?

27. Assessment • Ashwini is in shock • Hypotensive shock • ?Dengue shock syndrome.

28. Dengue shock syndrome Management A - clear B - good C - IV/IO access Send for Hematocrit, platelet count & Dengue serology

29. Fluid Therapy in DSS ( WHO guidelines ) • IV fluid RL bolus 100ml stat (10ml/kg over 15 minutes) • Reassess • If improves, Continue IV Fluid RL/NS 10 ml/kg/hr for one hour, • Then continue at the rate of 5-7ml/kg/ hr for next 1-2 hour, then reduce to 3-5ml/kg/hr for next 2-4 hour, & then to 2-3 ml/kg for 24 – 48 hours.

30. Case - 4 • 4 year old, fever 3 days • Rapid breathing, “not his usual self” • Not taking feeds since previous night • Has not passed urine that day

31. Assessment • Looks sick, dusky • Grunting, RR 50/min • Pulse 180/min, low volume • Capillary refill 5 sec • BP 80/50 mm Hg • Saturation 80% • Decreased breath sounds left side • CBG 100 mg/dl

32. Response • Free flow oxygen with nonrebreathing mask • IV access, 20 ml/kg normal saline bolus, reassess CRT,HR,BP • Up to 3 boluses if needed • Monitor cirulation constantly – HR,CRT,BP,Sats • Ceftriaxone 100 mg/kg after collecting blood for culture • Transport with medical supervision

33. Conclusion • Assess circulation in orderly fashion • Follow protocol for resuscitation • Monitor continuously until stable , including during transport • Communicate with receiving hospital, document what you have done