Recognition of Seriously Ill Child

7/25/2019 Recognition of Seriously Ill Child

1/12

1/12

3.2.1here we goM7mmad 7mmdan

Recognition of seriously ill child

Our lecture today is mainly about signs and symptoms of respiratory andcirculatory failure, coz if we detect these S&S we can avoid the morbidity andmortality in the children ,the most common cause of death in children is septic orhypovolumic shock and heart failure.

-seriously ill child : child in rapid need of assessment &is recognized

by symptoms & signs like; tachycardia , tachypnea , irritability , lethargycyanosis, grunting, nasal flaring , chest retractions , .

Aims and Objectives of the lecture

Aetiology of cardiac arrest in children

Reducing mortality and morbidity

Recognising respiratory and circulatory insufficiency and failure

Initial management plan

The most common cause of heart failure in adults is ischemic heart disease

We have primary and secondary cardiac arrest :

Primary Cardiac Arrest Common in adults, less common in children Sudden, unpredictable onset Due to arrhythmia (Ventricular fibrillation or pulseless ventricular tachycardia) Hypoxia and acidosis not initially present Outcome depends on early defibrillation

So the primary is sudden in nature " kan el-zlmeh methl el-wrdeh"But if you were at ICU , NICU or ER and the nurse called you because code blue "cardiac

arrest" and the patient was child , you must know there was wrong in the observation and

monitoring of the patient, because before the cardiac arrest the patient went through tachypnea, tachycardia , hypoxia, acidosis then cardiac arrest ,so if we had good monitoring on the

patient we could save his life.


2/12

2/12

Most cases of cardiac arrest in children are preceded by respiratory failure .

Secondary Cardiac Arrest Most common form in children Heart stops due to ischemia or hypoxia secondary to another condition

Arrest rhythm is usually bradycardia, progressing to asystole "most commonarrhythmia in children"

Hypoxia initially present Outcome depends on prevention or prompt resuscitation " very poor"

so,in children the cardiac arrestcan result from either respiratoryorcirculatorycauses

,both of them progress from compensated stage to decompensated then both of them lead tothe same outcome; cardiorespiratory failurethat progress to cardiorespiratory arrest

Shock: clinical state where we have poor delivery of nutrient and oxygen to thetissue.

THE most common shock is the hypovolemic one that can result fromgastroenteritis ,then septic shock "meningococcemia" , so dont mix b/w

shock &cardiac arrest.

Successful resuscitation in children depends upon

early recognition of respiratory and circulatory

failure and measures to prevent progression to

cardiac arrest

Compensated respiratory

failure

Compensated circulatory

failure

Decompensated circulatoryfailure

Cardiorespiratory failure

Cardiorespiratory arrest

Decompensated respiratoryfailure


3/12

3/12

In acutely ill child always remember:

A - Airway

B - Breathing

C - Circulation

D drugs "from the doc"Assess , change , reassess

Respiratory Failure :-respiratory failure: the loss of ability of the respiratory system tomaintain adequate blood level of Co2 &O2 , the definition that say

PaCo2 >50 mmHg or PaO2


4/12

4/12

We used to say that asthma, bronchiolitis patients etc, come to ER in distress and

tachypnea , but sometimes especially in bronchiolitis and in young age like 6 weeks thefirst and only presentation is apnea "respiratory failure".

Assessment of Respiratory Insufficiency: Airway Chest movement does not imply a clear airway Listen and feel for air movement and noises"sometimes is only transmitted sounds

from upper airway"

Is the airway:Clear and safe? At risk? Obstructed?

Assessment of Respiratory Insufficiency: Breathing1. Respiratory rate2. Tidal volume3. Work of breathing4. Oxygenation

1.Respiratory rate:Varies with age, fever, pain and anxiety as well as respiratory insufficiency,fevereach 1c raise in temperature increase the respiratory rate by 4/min and pulse by10/min.

It is more important to monitor the trend in respiratory rate than to rely

on the absolute value

For example : Guillain-Barre patient enter ER with weakness but then he

stabilize with RR=20 the next day RR=25 then 30 then he died fromrespiratory failure , if the doc noticed the variation with time not the absolute

value then he/she would save the patients life . you can see that all the values

are within normal range in this patient.

Age 12

Resp

rate

30-40 20-30

20-24 12-20

Minute ventilation Tidal volume rate

1400ml/min 140ml 10/min




5/12

5/12

2. Tidal volume; look, listen, feel Compare one side with the other" any bulging or asymmetrical movement" Subjective assessment; breath sounds should be audible in both bases Feel for the trachea; is it central? "collapse or pleural effusion"

Noises Stridor: Inspiratory noise; airway obstruction above the thoracic inlet, can be expiratory

or biphasic .

Wheeze: Expiratory noise; airway obstruction below the thoracic inlet Grunting: Expiratory noise; attempt to raise the end-expiratory lung volume .

Signs of Respiratory Distress (increased work of breathing): Tachypnoea Recession

Head bobbing Anxious demeanour Flared nostrils Grunting Stridor or wheeze Exhaustion

Signs of decompensation

Increasing respiratory rate Respiratory rate 55 Sudden fall in respiratory rate Reduced interaction with carers Exhaustion Decreasing level of consciousness

3.OxygenationCyanosis is an unreliable sign of hypoxia

Absence of cyanosis does not imply good oxygenation

Central cyanosis does imply hypoxia ; baby with TOF will born with cyanosis thatdoesnt relate to oxygen .

Use a pulse oximeter What FIO2 is required to maintain good saturations?" FiO2 ; fraction of inspired O2"

Actually this depends on the age.By using oximeter detect the O2 saturation. the normal range from 95-100% IN ADULTS.

recessions


6/12

6/12

- the child suffer from circulatoryfailure manifested aspurpuric petechial rash on his

skinfrom septic shock "gram organism" .

-hypovolumia , low BP , low or nourine output , increase capillary refill

time .

CardiacOutput

Heart Rate

Strokevolume

Afterload

Preload

SystemicVascular

Resistance

BloodPressure

Contractility

- so as you can see: cardiac output = stroke volume*heart ratechildren they are heart rate dependent; because the stroke volume is toosmall so to get adequate blood heat rate should be high .

- so this is why bradycardia is very bad sign in young children.

blood pressure &systemic vascular resistance SVR.When BP falls in the compensatory range the SVR will increase toCompensate in an attempt to raise the BP , so first the perfusion to thekidney & skin will be reduced . When compensation fail the BP will be

low. But keep in mind the perfusion to the vital organs "brain, heart persist intact till the last moment .

cerebral perfusion pressure should be kept around 50mmHg to avoidhypoxia. Cerebral perfusion pressure = MAP-ICPMAP= mean arterial blood pressure

ICP=internal cerebral pressure "intra cranial pressure"


7/12

7/12

Assessment of Circulatory Failure: Heart rate Blood pressure Systemic vascular resistance Pre-load

Heart rate:Varies with age, fever 1c=10beats/min and anxiety as well as circulatory failure

Normal heart (HR) and respiratory (RR) rates by age

Blood PressureAfterthe 1styear of life , the systolic BP must be AT LEAST 70 and above.But you must know the ranges because they are narrow so the patient become hypotensive OR

hypertensive by a little change in his BP.

Blood pressure is maintained by increases in SVR at the expense of perfusion of:

Skin Kidneys/gut

So you must know that the kidney function is indication of response to fluid treatment inhypovolumic patient, any urine output 5 is polyurea, normal

urine output in children {1-5}ml/kg/hour.

Skin Perfusion"Capillary refill"Gives us idea of circulation in the patient. Gently squeeze a finger (or toe) pulp until it blanches Release and observe the return of capillary blood > 2 seconds is abnormal

7090100130HR

X5X5X5

14182030RR

18125 ears>30Age

90120> 10 ears70 + 2x a e90 + 2x a e1 10 ears

70801 12 months

50600 1 month

Systolic BP(lower limit)

mmHg

Systolic BP(normal) mmHg

Age


8/12

8/12

Skin Perfusion "Continue" Look for colour (mottling"", pallor, peripheral cyanosis or rashes) feel - for peripheral pulses, temperature and the line of demarcation between warm and

cold .

Renal Perfusion

Urine output is an index of organ perfusion Nappy weights Urinary catheter?

Pre-load Jugular venous pulsation "rarely visible coz of short neck in children" Enlargement of liver " in cardiogenic shock" Moist sounds in lungs CXR

Signs of decompensationin circulatory failure Increasing pulse rate Sudden fall in pulse rate Hypotension Oliguria Reduced interaction with carers Decreasing level of consciousness

From ro2ya but the doc didnt mention them:

Types of circulatory failure shock- shock :clinical syndrome of circulatory dysfunction resulting in

inadequate o2 & nutrient delivery, with inability to meet the metabolicdemand of the tissue .

-types :

1-hypovolumic:due to loss of fluid2-relative hypovolumic " distributive ":the problem is not related to

absolute volume but to loss of vessel tone resulting in vasodilatation&larger intravascular space with normal blood volume .

3-cardiogenic:abnormality in cardiac function due to depressed

myocardial contractility .

Cardiogenic

Distributive

Hypovolaemic

Pre-loadSVRBPHR


9/12

9/12

Cardiorespiratory FailureIf we have respiratory or circulatory failure both will in cardiorespiratory arrest.

There is always some respiratory compensation for circulatory failure and viceversa

In severe illness it is not possible to determine which came first If untreated, this phase presages imminent cardio-respiratory arrest

Management; based on initial assessment

Compensated Respiratory Failure

Assess airway O2 therapy (unthreatening) Monitoring (pulse oximetry, pulse and respiratory rate) IV access with topical anaesthesia,to reduce the pain result from iv canula. Reassess

Decompensated Respiratory Failure

Admit to ICU Maintain clear airway 100% O2 Support ventilation with bag/mask system Consider tracheal intubation and mechanical ventilation

Compensated Circulatory Failure

Assess airway

O2 therapy (unthreatening) Monitoring (pulse oximetry, pulse and respiratory rate, blood pressure) IV access Fluid bolus Reassess

Decompensated Circulatory Failure

Airway control 100% O2 Support ventilation if required

Urgent IV/IO access, fluid bolus Reassess and repeat as required Consider inotropes


10/12

10/12

Cardiorespiratory Failure Airway control 100% O2 Support ventilation, initially with bag/mask system Reassess (monitoring) Urgent IV/IO access; fluid boluses if required Reassess

Consider inotropes

Notes:1-AS you see in the previous session that each management consist of:

assessment. Change. reassessment

2-IV fluid boluses in case of hypovolumic shock and septic ;each bolus equal to 20cc/kg ;u can give many boluses till the patient improve ;there is 2 types of IV fluids :

A-crystalloid : effective volume expander but require 2-4 times the volume of bloodloss to restore hemodynamic parameters and doesn't stay for long in the vascular space so

the BP will decrease again . it is of 2 types either :1- normal saline(most available) and the best because of its Na conc , close to

the osmolarity of the blood (285) and we calculate it by = (Na +k )*2

+BUN+SUGAR/22-ringer's lactate(normal saline+Ca+lactate) used in acidosis "from hemma"

B-colloid:one of its constitute is albumin , stay longer but can carry infections incase of"fresh frozen plasma"(type of the colloid) like hepatitis ,HIV

usually the normal saline used in colloid compartment but others can be used aswell.

3-inotrpes:drugs that enhance the cardiac muscle contractility thusincrease the cardiac output and vasopressors :digitalis ,debutamine, dopamine,

Adrenaline, norepinephrine. The under lined not mentioned by the doc

4-whenever u dont find an IV access as soon as possible(nearly 90 sec)give theresuscitation IO(intra-osseous) ; usually in the tibia

Example 1

9 month old with breathing difficulty. On admission; respiratory rate 45/min,heart rate 160/min, temperature 37.80C. Conscious and fully orientated

A: Clear

B: Generalised wheeze both lungs, increased work of breathing

C: Tachycardia, BP normal, good peripheral perfusion

This case is "Compensated respiratory failure" ;if u notice the level ofconsciousness not altered .


11/12

11/12

Management in example 1:

O2 therapy (unthreatening) Monitoring (pulse oximetry, pulse and resp rate) IV access with topical anaesthesia

Reassess regularly

Other Investigations

CXR? FBC & Electrolytes? Blood gases?And this patient is Onward referral

Example 2

11 month old with 2 day history of colic. On admission; respiratory rate 40/min,

heart rate 185/min temperature 37.20C. Drowsy and withdrawnA: Clear

B: Good air entry bilaterally, tachypnoea, quiet respiration

C: BP 65/?, cool mottled peripheries, capillary refill time 5 seconds, dry nappy

This case is a "Decompensated circulatory failure" note that the child is hypotensive ,

has a capillary refill 5 sec AND drowsy .

Management in example 2:

Airway control High flow O2 Support ventilation if required Monitoring (minimum SpO2 and BP) Urgent IV access, fluid bolus Reassess and repeat as required

Fluid boluses,20ml/kg of Balanced salt solutions initially (e.g. 0.9% NaCl, Compound

Sodium Lactate),Reassess.

But If the patient is bleeding give blood .

Assessment of Fluid Boluses

Changes in heart rate, BP, peripheral perfusion

Chest signs Jugular venous pulsation, liver edge

CXR

Other Investigations

CXR CBC, X-match & Electrolytes Blood gases


12/12

Left pic: hypovolumic shock ,heart is small "low blood volume" ,the lungare black "hypoperfusion"

Right pic:CXR for cardiogenic circulatory failure ; there is cardiomegaly ,lung edema , this child was given overload fluid.

Tm be7md Allah

A7la t7yah ela groupi C6 "3dnan ,feras , iyad, m7mmd jehad , yaseen ,m7mmd iyad ,

sleem , 5leel (CR), 5ATOON, ZENAH,N3EEMH, HAJAR, FA6MH, LINA, NUR."W shokr kbeer la Btool abo-3'zal 3la mo7adrt ro2yaT7yah la RASHED W BSHAR , M7MMAD 3LEEMATMY dude "7ussam skaf"

Finally

i'LL BE BACK

Ella roo7 3bd-Allah Abo-6weelh "AL-FAT7EH"

M7MMAD 7AMMDAN

Documents

Recognition of Seriously Ill Child