Stabilisation of the Seriously Ill Child. Linda Daniel PCC Network Educator January 2007

Aim: Review how a child might commonly present and the role of the healthcare practitioner in re- establishing physiologic stability. Objectives: Discuss the anatomical differences between an adult and child. Using case scenarios as appropriate identify the types of problems that commonly cause a child to exhibit breathing problems. Utilises a systematic approach to the assessment & management of the child with breathing problems.

Numbers of Retrievals by Age Group

Retrievals by Diagnosis 2005

Respiratory Illness The most common cause of illness in infancy and childhood is acute disease of the respiratory tract. The younger the child / infant the more susceptible they are to respiratory difficulties due to anatomical differences

Anatomical factors which impact upon the child’s spontaneous ventilation Airways are shorter and narrower, any increased mucous production results in a reduction in airway diameter. Consequently airway resistance increases. Infants have large heads coupled with short trachea’s comprised of more compliant cartilage consequently airway occlusion may occur if the neck is hyper-extended.

Anatomical factors which impact upon the child’s spontaneous ventilation The infants diaphragm inserts more horizontally in conjunction with their ribs, which causes lower rib retraction especially when supine.Infants are dependent on good diaphragmatic function

Anatomical factors which impact upon the child’s spontaneous ventilation The cricoid ring is the narrowest part of the child’s airway. As cuffed tubes lie in this position uncuffed tubes are preferred in children to minimise oedema and sub- glottic stenosis

Anatomical factors which impact upon the child’s spontaneous ventilation The infant’s chest wall is more compliant / less rigid due to cartilaginous sternum and ribs. The inter-costal muscles do not assist the infant in elevating the rib cage but act a a stabiliser.

Differences in the infants respiratory system compared to an adults Large Tongue – airway obstruction Larynx higher –risk of aspiration Alveoli still developing in size and numbers (95%) Airways shorter & narrower encircled by cricoid cartilage – less support Mucous membranes loosely attached airway oedema greater Diaphragm & intercostal muscles have fewer type 1 muscle fibres - adaptions for sustained activity, hence tire earlier Large amounts of lymphoid tissue Greater oxygen consumption due to higher BMR

Anatomical factors which impact upon the child’s spontaneous ventilation  The lack of pores of Kohn, Channels of Martin and Lambert which allow ventilation be it interalveolar, interbronchiolar and bronchioli-alveolar to occur distal to an obstruction means that infants are prone to atelectasis.

Differences in haemodynamic’s compared with an adult Cardiac output (CO) measures the efficiency and performance of the heart. CO = HR X SV Volume loading achieves little improvement in cardiac performance unless the infant is clearly hypovolaemic Volume loading achieves little improvement in cardiac performance unless the infant is clearly hypovolaemic Infants are acutely sensitive to after-load due to myocardial immaturity and their inability to enhance contractile performance Infants are acutely sensitive to after-load due to myocardial immaturity and their inability to enhance contractile performance

Heart Rate Crucial in infants & young children at maintaining adequate cardiac output In basal conditions myocardial performance in the young is near maximal Parasympathetic innervation is complete at birth unlike sympathetic consequently vagal induced bradycardia is inadequately balanced

Heart Rate Tachycardia shortens diastolic period which in turn reduces ventricular filling time

Causes of breathing problems in childhood. Upper airway - epiglottitis, Croup, foreign body Empyema Pneumothorax Pulmonary oedema asthma,,bronchiolitis pneumonia Coma, convulsions raised ICP, poisoning Neuromuscular disorders Diabetic ketoacidosis, Peritonitis abdominal distension Anaphylaxis

Normal values AgeResp. rateHRSystolic BP Neonate <1 yr yr – yr – – 110 > 12yradult

Assessment Airway Look, Listen and Feel Vocalisations suggest airway patency Noisy “ bubbly” breathing, suggest secretions requiring clearance, consider fatigue or depressed conscious level Snoring respiratory noises suggest partial obstruction of the airway due to depressed conscious level Inspiratory wheeze points to upper airway obstruction Expiratory wheeze points to lower airway obstruction

Assessment Airway Stridor suggests upper airway obstruction - croup Grunting is exhalation against a partially closed glottis to increase end expiratory pressure Opening manoeuvres should be used in a child with a compromised airway – consider use of adjuncts (Guedal, nasopharngeal or intubation) N.B. A child with a compromised airway may quickly become obstructed if distressed

Airway Adjuncts & Sizing  From the incisors to the angle of the mandible Measure from the tip of the nose to the tragus of the ear

Assessment Breathing – Effort, Efficacy Effects Respiratory rate and pattern, recession/ accessory muscles, nasal flaring, tracheal tug. Chest expansion, abdominal excursion, oxygen saturations, equal air entry. Physiological effects upon heart rate, skin colour mental status Hypoxic tachycardia may be exacerbated by anxiety and fever. Severe or prolonged hypoxia leads to pre terminal sign of bradycardia

Assessment Breathing – Effort, Efficacy Effects Tachyapnoea indicates increased ventilation requirements associated with lung or airway disease or metabolic acidosis. A slow respiratory rate indicates fatigue, cerebral depression or pre-terminal state. Hypoxia produces vasoconstriction and skin pallor. Cyanosis is a pre-terminal sign of hypoxia, with the exception of cyanotic heart disease

Bag Valve – Mask Ventilation If hypoventilating with slow respiratory rate or weak effort support is required via bag-valve mask device Face mask application with one hand as head tilt-chin lift manoeuvre is performed Avoid pressure on the soft tissues of the neck which could cause laryngeal/ tracheal compression

Sizing & Placement of Face Masks The face mask size is selected to provide an airtight seal The mask should extend from the bridge of the nose to the cleft of the chin enveloping nose & mouth but avoiding compression of the eyes

Rapid Sequence Induction Prepare intubation equipment Endotracheal tubes diameter size < 1year 3.0, 3.5, 4.0 > 1yr = age / 4 + 4) i.e. 4yrs/4 +4 = 5.0 plus 4.5 & 5.5

Assessment Circulation Heart rate, pulse volume, capillary refill, peripheral temp and colour (BP - compensated in child) IV or IO access X2 & bloods Don’t forget glucose 5mls/kg 10% dextrose Resuscitation – Adrenaline 10mcg/kg (0.1ml/kg of 1:10,000) Intraosseous placement

Assessment Circulation If signs of shock - fluid bolus 10 – 20 ml/kg 0.9% saline. The 1year old is classed as 10kg Estimated weight > 1yr = (age + 4) X 2 Start inotropes after 60ml/kg administered in conjunction with volume replacement

Infusion Calculations - Dobutamine Vial 250 mg / 20mls add to 30 mls of 5% dextrose to give total volume of 50mls Use formula “What you want” X mls “What you’ve got” e.g. 5 kg child prescribed 10 mcg/kg/min = “What you want ”

Infusion Calculations - Dobutamine How to calculate “What you’ve got” Divide 250mg by 50mls = 5 mg/ml Multiply 5 mg by 1000 = 5000 mcg/ ml Divide 5000 mcgs by weight of child (5000 / 5kg) = 1000 micrograms / kg 1 ml = 1000 micrograms/kg Divide 1000 by 60 = micrograms / kg /min 1 ml = 16.6 micrograms /kg/min Therefore “What you want” X mls “What you’ve got” 10 X 1 = 0.6 mls / hour 16.6 To administer the prescription 10mcg/kg/min to a 5kg child Infuse at a rate of 0.6 ml/hour

Respiratory Assessment Disability – Conscious level, behaviour Normal, lively, irritable, lethargic. AVPU / GCS pupillary signs & posture Exposure Rash, fever Consider anaphylaxis

Summary The most common cause of illness in infancy and childhood is acute disease of the respiratory tract. The younger the child / infant the more susceptible they are to respiratory difficulties due to anatomical differences Adopting a systematic approach to the stabilisation of seriously ill children will allow practitioners to approach their care with confidence.

Drug Calculations Calculate a morphine infusion for a 3.5 Kg infant at 20mcg/kg/hr (3.5 mg in 50mls dex 5%) Calculate an adrenaline infusion for a 8kg child at 0.08mcg/kg/min (5mg in 50mls dex 5%) Alprostadil 50nannograms /kg/min for a 3kg infant (225mcg in 50 mls 5% dex)