Recognition and management of the seriously ill child Dr Esyld Watson Consultant in Adult and Paediatric Emergency Medicine

Learning outcomes To understand the aetiology of and clinical pathways to cardiorespiratory arrest in children To use a rapid ABCDE assessment to determine the clinical state To distinguish between compensated and decompensated respiratory or circulatory failure To initiate treatment interventions based on ABCDE assessment and reassessment Emphasise the ABCDE approach

Aetiology of cardiorespiratory arrest Children are different to adults Adults Usually a primary cardiac arrest Sudden and unpredictable in onset Usually due to arrhythmia Not usually preceded by hypoxia and acidosis Successful outcome depends on early defibrillation

Aetiology of cardiorespiratory arrest Children Most children have secondary arrest Respiratory and/or circulatory failure leads to hypoxia and acidosis. Myocardial hypoxia results in bradycardia then asytole Early recognition and treatment of respiratory and circulatory failure can prevent progression to arrest 10 - 20% of children have primary cardiac arrest - usually due to congenital or acquired heart disease Emphasise that in children there is not usually an underlying cardiac disorder. Acidosis and hypoxia due breathing or circulation problems are common. If left untreated lead to myocardial ischaemia and CRA. Primary cardiac arrest does occur, although rarely Must intervene to prevent this occurring. Outcome is very poor if CPA occurs.

Pathways to cardiorespiratory arrest Compensated circulatory failure Compensated respiratory failure Decompensated circulatory failure respiratory failure Cardiorespiratory failure Cardiorespiratory arrest Summary slide Successful resuscitation in children depends upon early recognition of respiratory and circulatory failure and measures to prevent progression to cardiorespiratory arrest

Normal Values

Recognition of the seriously ill child is based on assessment of: Airway (c-spine consideration in trauma) Breathing Circulation Disability Exposure Oxygenation Ventilation Perfusion The aim of the rapid clinical assessment is to provide information on the child’s oxygenation, ventilation and perfusion. This will determine whether there is a breathing or circulatory problem or both Treatment will be based on this assessment. Can be done in 30 seconds.

A - Airway

Assessing the airway An assessment of the airway can only be made if the child is attempting to breath or the child is receiving assisted ventilation. The airway of children and infants is more susceptible to obstruction secondary to oedema as it is proportionately narrower than in adults Stridor is an inspiratory noise indicating extrathoracic obstruction of the upper airway

B - Breathing

Assessing breathing oxygenation and ventilation Minute ventilation = Tidal volume x RR Respiratory rate (RR) Work of breathing Tidal volume (chest expansion) Oxygenation (pulse oximetry)

Assessing respiratory rate Increased RR is often the first sign of respiratory difficulty RR varies with age, fever, pain and anxiety as well as in respiratory failure Monitor the trend in RR

Assessing the work of breathing Play video clip and ask candidates to identify features of respiratory distress. They will appear with the next click of the mouse. Head bobbing – in infants when sternocleidomastoid muscles brought into use as accessory respiratory muscles

Assessing tidal volume Tidal volume (look, listen, feel) Compare one side of chest with the other Subjective assessment: breath sounds should be audible in both bases (Feel for trachea; is it central?) Tidal volume can be assessed by observation of chest movement, palpation, auscultation and percussion.

Assessing respiratory sounds Stridor Wheeze Grunting Volume of noises does not correspond to severity of respiratory compromise

Assessing oxygenation Cyanosis is unreliable (SpO2 < 80%) Any child with a breathing problem must have pulse oximetry Clinical signs of hypoxia Irritability, agitation, drowsiness, level of consciousness Cyanosis is not a reliable indicator of the degree of hypoxia; it may never be observed in a profoundly hypoxic child if there is significant anaemia SpO2 of < 90% in air or < 95% in supplemental oxygen indicates respiratory failure When SpO2 is < 70% pulse oximetry is inaccurate, although trends will still be reliable

Decompensation? Increasing respiratory rate Sudden fall in respiratory rate Exhaustion Reduced interaction with caregivers, agitation Diminishing level of consciousness Ask candidates for the signs of decompensation

C - Circulation

Assessing circulatory status Target organs most easily assessed are brain and kidneys. Assessing liver edge can be very important in children with suspected cardiac failure. This baby survived and left hospital with all limbs intact.

Assessing pulses Comparison of central and peripheral pulses Reflects stroke volume As shock progresses peripheral pulses are lost before central pulses Consider which pulses are central and peripheral in infants and children and easily accessible

Assessing heart rate Increased HR is often the first sign of circulatory compromise HR varies with age, fever, pain and anxiety as well as in circulatory failure It is more important to monitor the trend in HR than to rely on absolute value

Assessing skin perfusion Feel skin temperature Warm / cold line Skin colour Mottling Pallor Peripheral cyanosis Rashes Skin temperature much more useful than skin colour.

Assessing capillary refill time CRT > 2 sec is abnormal Assess peripherally and centrally Play video clip. Caution if the child has been in cold weather, consider central CRT

Assessing cerebral perfusion Early signs Loss of interest in surroundings Irritability, agitation Late signs Drowsiness, loss of consciousness, hypotonia (floppy)

Assessing renal perfusion Urine output is an index of organ perfusion Nappy weights or number of wet nappies Urinary catheter (> 1 ml kg-1 h-1) How many times passed urine that day? Regular measurement of urine output very helpful in assessing perfusion Can be a relatively early sign of circulatory failure Normal infant usually has six wet nappies a day

Decompensation? Steadily increasing HR Sudden fall in HR Increasing peripheral vasoconstriction Reduced interaction with care givers, agitation Diminishing level of consciousness Hypotension Ask candidates for the signs of decompensation Emphasise that hypotension is a late sign and it should be possible to determine decompensation before hypotension occurs.

D - Disability

Assessing disability Evaluate the level of responsiveness Posturing Alert Voice Pain Unresponsive to painful stimulus Posturing Pupil reaction Glucose Painful stimulus can be delivered by applying sternal pressure. A child who is unresponsive to painful stimuli has a significant degree of neurological derangement equivalent to a Glasgow coma scale score of 8 or less. Seriously ill children become floppy If there is serious brain dysfunction, stiff posturing may be demonstrated.

E- Exposure

Exposure Respect dignity Rashes Bruising Injuries Environment temperature Complete exposure whilst maintaining dignity is important to collect all clinical information

Cardiorespiratory failure There is usually some respiratory compensation for decompensated circulatory failure and vice versa Cardiorespiratory failure is global failure of oxygenation, ventilation and perfusion If untreated will lead to cardiorespiratory arrest

Management based on initial assessment Decide on clinical status of the child: Stable Compensated respiratory failure Decompensated respiratory failure Compensated circulatory failure Decompensated circulatory failure Cardiorespiratory failure Ask the candidates what are the types of clinical status one an deterime? Once assessment has been performed and the clinical status decided then the management plan can be instituted In reality assessment and treatment will occur at the same time.

Stable child Confirm clinical status Take a more detailed history Examination and investigations to aid diagnosis Begin treatment Reassess For a stable patient more time can be taken in getting a more detailed history and enlisting further expert help to make a diagnosis Remember to reassess however as the child may deteriorate at any time

Compensated respiratory failure Assess ABCDE O2 therapy (non-threatening) Monitoring (pulse oximetry, HR, RR) Specific therapy Reassess Seek expert help Non-threatening O2 therapy is important as upsetting the child will increase oxygen demand and worsen respiratory distress. If a child has narrowed upper airways this will also cause turbulent air flow and increasing airway resistance Pulse oximetry is important to assess effect of oxygen therapy.

Decompensated respiratory failure Open and maintain airway High-flow O2 Ventilate Assess adequacy of ventilation Reassess and monitor Seek expert help BMV if inadequate ventilation. Always reassess.

Compensated circulatory failure Assess airway High-flow O2 Monitoring IV / IO access Fluid bolus 20 ml kg-1 0.9% NaCl Reassess after any intervention Seek expert help Reassess after each fluid bolus – CRT, pulse volume, skin temperature, HR, BP

Decompensated circulatory failure Open and maintain the airway High-flow O2 Support ventilation if required Immediate IV / IO access, fluid bolus 20 ml kg-1 0.9% NaCl Reassess Repeat fluid boluses Seek expert help

Cardiorespiratory failure Open and maintain the airway High-flow O2 Support ventilation Immediate IV / IO access, fluid boluses Reassess and monitor Seek expert help Consider tracheal intubation and mechanical ventilation Urgent management is required to avoid cardiorespiratory arrest

Any questions?

Oxygenation Ventilation Perfusion Summary Airway (c-spine consideration in trauma) Breathing Circulation Disability Exposure Oxygenation Ventilation Perfusion The aim of the rapid clinical assessment is to provide information on the child’s oxygenation, ventilation and perfusion. This will determine whether there is a breathing or circulatory problem or both Treatment will be based on this assessment. Can be done in 30 seconds. Compensated V Decompensated Cardiorespiratory Failure