Paediatric Emergencies in the Recovery Room

1. Paediatric Emergencies in the Recovery Room Michelle McNamara

2. Proposed LearningPaediatric Emergencies A.B.C.D.E Airway Breathing Circulation Disability (depressed consciousness, unresponsiveness). Exposure ( significant hypothermia, bleeding, shock).

3. Paediatric Challenges Not ‘Small’ Adults Are Someone's Child Age groups – size, development Opiate use intra-op/Post-op Emergence delirium Families Fear of mistakes

4. Paediatric Considerations Higher Anaesthetic Morbidity & Mortality Higher Intra-operative Bradycardia (Infants) Higher Respiratory Complications (Recovery) Associated outcomes worse Complications occur in healthy children of normal weight

5. Paediatric Anaesthesia ReportPatient specific additions Defer verbal report if condition is unstable or emergency intervention is warranted. Birth history (premature birth, or congenital conditions). Developmental considerations (ensure personal comfort items are present, toy, blanket, religious items). Special needs (e.g. glasses, hearing implants) Pre-operative behaviour, (calm or anxious). Loose teeth (returned for tooth fairy).

6. Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

7. Assessment • General • Primary • Secondary • Tertiary SAMPLE • Signs & Symptoms • Allergies • Medication • Past Medical History • Last Meal • Events

8. Paediatric Definitions Premature Newborn – Birth before 37/40 Newborn – Birth to 72 hours Neonate - Infant during first 28 days of life Infant - 1st year of life (including neonate) Toddler 1-3yrs Preschooler 4-5yrs School Age 6 – 12yrs Adolescent > 13yrs

9. Airway

10. Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

11. Anatomy and Physiology Airway Large Tongue Narrow Nostrils Smaller Airway Opening Short Neck Neonates are obligatory nose breathers More Susceptible to Laryngeal / Bronchospasm Easily Obstructed Airway Post Intubation Oedema

12. Airway problems Tracheal intubation (under 5 years) History of pre-term birth Reactive airway disease Airway surgery Excessive Secretions/Nasal Congestion Parents who smoke.

13. Breathing

14. Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

15. Normal Respiratory Rate by Age Age Breaths Per Minute A respiratory Rate consistently > than 60 bpm in a child of any age is abnormal Infant (< 1yr) Toddler (1 – 3yrs) Preschooler (4 – 5yrs) School Age (6 – 12yrs) Adolesent (13 – 18 years) 30 – 60 24 - 40 22 – 34 18 – 30 12 - 16

16. Normal Spontaneous Ventilation Minimal work Quiet breathing Easy inspiration Passive expiration Rapid in the neonate Decreases in older infants & children

17. Paediatric Considerations(Respiratory) High metabolic rate Oxygen demand is higher Infant Oxygen Consumption is 6-8mls/kg per minute (compared to 4mls/kg for adults) Hypoxaemia more rapid in infants & children A room air Sao2 < 94% in a normal child indicates hypoxaemia.

18. Causes of Respiratory Dysfunction Post Op Residual effects of anesthetic agents Opiate Agents Sedative agents Excessive fluid volume Pain/ Anxiety Hypothermia/Hyperthermia Pre-existing Pulmonary Disease.

19. EarlyRespiratory Distress Increased Respiratory & Heart Rate; Decreased Oxygen Saturation, Nasal Flaring (Infants); Chest Retractions, use of Accessory Muscles; Poor chest rise Poor air entry Grunting Croup Stridor Wheezing Mottled Colour

20. LATE Respiratory Distress Bradypnoea No respiratory effort Apnoea Cyanosis Poor or absent distal air movement Coma

21. Types of Respiratory Distress Upper airway obstruction Lower airway obstruction Lung Tissue Disease Disordered control of breathing

22. Croup Inflammation of the upper airway Post-intubation croup Presentation -'bark-like' cough Mild, Moderate, or Severe

23. Causes of Croup Intubation (Traumatic Prolonged or Repeated) Tight fitting E.T.T. Subglottic Injury Coughing (with E.T.T in place) Change of position (whilst Intubated) Surgery >1 hour Surgical trauma May be accompanied by Stridor Respiratory Distress

24. Stridor Shrill Harsh loud Crowing sounds Heard during inspiration, expiration or both.

25. Management of Croup / Stridor Notify Anaesthetist Nebulised cool mist Steroid IV Humidified oxygen Keep N.P.O. Nebulised Epinepherine Keep Pt > 2hrs Re-intubate (size smaller ETT than calculated for the age of the child)

26. Laryngospasm Involuntary muscle contraction of the laryngeal muscles causing the vocal cords to close. Dyspnoea Crowing sound on Inspiration Aphonia (no sound) Rocking Motion of Chest Use of Accessory Muscles.

27. Laryngospasm Nursing Interventions Notify Anaesthetist Administer 100% Humidified Oxygen Positive Pressure Ventilation by BVM Maintaining PEEP to Open Vocal Chords. Prepare for Intubation Oropharyngral Suction as required

28. Bag Mask ventilation

29. Signs & Symptoms Lower airway obstruction Tachypnoea Wheezing, (expiratory most common) Increased respiratory effort Retractions Nasal flaring Prolonged expiration (with expiration being an active rather than a passive process).

30. BronchospasmCauses Preexisting Airway Disease Asthma, Bronchiolitis Allergy/Anaphalaxis Aspiration Mucous plug Foreign Body Pulmonary Edema.

31. Bronchospasm / AsthmaTreatment Notify Anaesthetist Humidified Oxygen 100% Suction Bronchodilators / Ventolin Support ventilation Intubate if necessary Admission overnight

32. Aspiration Causes Residual gastric volume (intra-op) Post op Nausea & Vomiting Inhalation of foreign body e.g. tooth Inability to protect airway

33. Aspiration Nursing Interventions Position head down & turned to the side to promote drainage Humidified Oxygen/Suction Anti-emetic prophylaxis / rescue Notify anaesthetist Chest x-ray I.V. Antibiotic Prepare to re-intubate if necessary

34. Respiratory ManagementDistress/Failure/Obstruction Notify Anesthetist Reposition/Support the airway Open airway Clear the airway Insert an O.P.A. Or N.P.A. Assist ventilation High concentration O2 Monitor SAO2 / HR Nebulised Medication (Albuterol / Epinepherine) Prepare for Endotreacheal Intubation

35. Circulation

36. Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

37. Normal Heart Rate Age Awake Rate Mean Sleeping Rate Newborn to 3months 85 –205 3 months to 2 yrs 100 –190 2yrs to 10yrs 60 – 140 > 10yrs 60 - 100 140 80 - 160 130 75 - 160 80 60 - 90 75 50 - 90

38. Normal Blood Pressure by Age(mm Hg) Age Systolic Diastolic Neonate (1st day) Neonate (4th day) Infant ( 1 month) Infant ( 3 months) Infant ( 6 Months) Infant ( 1year) Child ( 2 years) Child ( 7years) Adolescent ( 15years) 60 – 75 30 – 45 67 84 35 – 53 73 – 94 36 – 56 78 – 103 44 – 65 82 – 105 46 -68 68 – 104 20 – 60 70 – 106 25 – 65 79 – 115 38 – 78 93 – 131 45 - 85

39. Cardiac Physiology Higher cardiac output Higher baseline heart rate Infants – cardiac output dependent on heart rate DO NOT COMPENSATE for lower B/P Bradycardia in an infant ominous sign (CPR <60) May indicate hypoxaemia B/P lower than adults and increase with age H/R higher than adults and decrease with age

40. Cardiac Arrest AssessmentBroselow PaediatricTape H’s • Hypoxia • Hypovolaemia • Hydrogen Ion • Hyper/Hypokalaemia • Hypoglycaemia • Hypothermia T’s • Toxins • Tamponade • Tension Pneumothorax • Thrombosis • Trauma

41. Circulation AssessmentCardiovascular Vital signs Central and Peripheral Pulses Brain Perfusion (Mental Status) Skin Perfusion (Capillary refill <3 seconds) Renal Perfusion (Urine Output) Infants & Young Children 1.5 – 2ml/kg/hr Older Children & Adolescents 1ml/kg/hr

42. Bradycardia Assess & Support ABC Hypoxemia What is the BP? How is perfusion? Arrhythmias? Adolescent athlete Perform CPR if HR<60/min with poor perfusion

43. Tachycardia Assess & Support ABC Check Perfusion Crying ?Pain Temperature ?Malignant hyperthermia Anxiety Full bladder Fluid overload Medications (glycopyrrolate, atropine) Sinus Tachycardia (Infants <220, Children< 180)

44. Cardiac Arrest Asystole PEA VF Pulseless VT Asystole & PEA most common initial arrest rhythms in under 12yrs Activate Emergency Response, commence CPR per BCLS/PALS guidelines

45. Disability

46. Approach to Paediatric Assessment ASSESS (General, Primary, Secondary, Tertiary) CATEGORIZE (Respiratory, Circulatory) DECIDE (Course of Action) ACT (Initiate Appropriate Treatment for Clinical Condition & Severity REASSESS The Above Process Is Ongoing e.g. reassess after any intervention to ensure effectiveness

47. Depressed ConsciousnessPost op • Anesthetic, Opiates, Sedatives • Hypoglycemia / Hyperglycemia • Hypothermia / Hyperthermia • Sepsis • Seizure • Neurological Disease / Head Injury • Respiratory Depression • Emergence Delirium

48. Paediatric Response Scales Alert Voice Painful Unresponsiveness Modified Glasgow Coma Scale for Infants & children GCS (3 -15) Pupil Response to light PERRL (Pupils Equal Round Reactive to Light)

49. Emergence Delirium Post-Anesthesia Agitation, Emergence Agitation, Post-Anesthetic excitement Non-purposeful movementIncidence 25-80% Preschool children (< 6) Lasts up to 45 minutes Associated with Sevoflurane

50. Emergence Delirium treatment R/o physiologic causes ( ABC / Pain/ Anxiety) Identify Emergence Delirium Include family at bedside promptly Protect from harm Calm environment