1. Care of the very sick child Morris Earle, Jr. MD, MPH UMASS Memorial Medical School Worcester, MA and Sarah A. Murphy, MD MassGeneral Hospital for Children Boston, MA

2. Care of the very sick child: Presentation Overview This presentation will focus on the principles that are common to: Emergency Triage Assessment and Treatment (ETAT) Pediatric Advanced Life Support (PALS) and the treatment of very sick children

3. Presentation Overview We will focus on: –Recognition of very sick children –Rapid assessment of ABCs –Treatment of A,B, and C according to ETAT guidelines –Next steps in treatment of a very sick child –Rapid differentials for various signs and symptoms

4. Care of the very sick child: ETAT “Emergency Triage Assessment and Treatment” –Deaths in hospital often occur within 24 hours of admission –Many of these deaths could be prevented if very sick children are identified quickly and appropriate treatment started immediately

5. ETAT –ETAT is a set of guidelines developed by the WHO for health care providers –It is meant to aid in the rapid recognition and treatment of very sick children –Based on the principle of recognizing “emergency signs” and beginning appropriate therapy for them when present –Like PALS and other treatment protocols, follows the format of ABC

6. Why does having a system for rapid recognition and treatment matter?

7. “The management of sick young infants at primary health centres in a rural developing country” Archives of Disease in Childhood 2005:90:200-205 Duke, Oa, Mikela et al (Papua New Guinea) Signs predicting death were: –not able to feed –fast respiratory rate –retractions –apnea –cyanosis –“too small” –“skin cold” –severe abdominal distension –bulging fontanelle –hypothermia (<36 axillary)

8. “The management of sick young infants at primary health centres in a rural developing country” Conclusions: signs predictive for death may warrant: –emergency treatment –longer observation –or urgent referral

9. Respiratory compromise was present in 25% of young infants Failure to give oxygen therapy was a modifiable factor in 27% of deaths within health facilities A high proportion of seriously ill young infants were discharged from health facilities early without adequate follow up “The management of sick young infants at primary health centres in a rural developing country”

10. Care of the very sick child 1) Diagnosis: Who is “very sick” ? 2) Management: Airway Breathing Circulation Etc…

11. Recognizing a “very sick child”

12. WHO-identified “Emergency Signs” (ETAT) that require immediate intervention: Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Signs of severe dehydration

13. Respiratory Rate >60 (infant) >40 (toddler) >30 (child) >20 (teen) Heart Rate >160 (infant) >120 (child) > 90 (teen) Early Signs of Severe Illness: Abnormal Vital Signs

14. Abnormal Vital Signs Hypo or hyperthermia Later Signs: Hypotension: < 60 systolic (newborn) < 70 (infant) < 70 +(age x 2) (child) < 90 (teen)

15. Assessment of the Very Sick Child Rapid assessment of a sick child begins with ABC’s… Assess and treat Airway, Breathing, and then Circulation, in that order

16. A = Airway

17. The ten commandments of Pediatric Intensive Care; Airway …Et cetera

18. Complete Airway Obstruction; Either dead or Has a foreign body –needs heimlich maneuver (child) –or five back blows and chest compressions (infant)

20. 5 Back blows: for infant with suspected foreign body and complete airway obstruction

21. Alternate with 5 chest compressions

23. Heimlich Maneuver for a child

24. Partial Airway Obstruction: Look for signs of Partial obstruction! –Stridor –Snoring –Accessory muscle use –Abdominal breathing

25. Partial Airway Obstruction: Child is Conscious: 1. Inspect mouth and remove foreign body if present 2. Clear secretions from mouth and throat 3. Allow child to assume most comfortable position Child is Unconscious: 1. Tilt head (unless concern for trauma to head/neck- then do jaw thrust with 2 nd person stabilizing neck) 2. Inspect mouth, remove foreign bodies 3. Clear secretions from mouth and throat 4. Check airway by feeling for breath, watching for chest rise, listening for breath sounds

27. Positioning airway: 1.Sniffing position

28. The sniffing position

29. Adjust Airway: 2. jaw thrust Should be used if there is any concern about neck trauma or cervical spine injury

31. Adjust Airway: 3. Artificial airway Oral airway if unconscious Nasal airway if conscious

32. Nasopharyngeal Airway:

33. Insertion of oral airway

34. Sizing of oral airway

36. B: Breathing

37. Assessment of Breathing: signs of respiratory distress Tachypnea Retracting Grunting Flaring Use of accessory muscles Stridor

38. Retractions

39. Respiratory Distress If patient exhibits signs of respiratory distress, administer oxygen:

42. Assisted Breathing: bag and mask technique

43. The sniffing position

46. Bag and Mask Ventilation: watch for chest rise

47. Assisted Breathing: Intubation

48. Use of curved blade

49. Use of straight blade

50. View of vocal cords

51. Assisted Breathing: Chest must rise well Check for proper placement of ETT with CO2 detector if available Check for equal breath sounds in axillae Confirm placement with xray Place nasogastric or orogastric tube

52. For the following “emergency signs”: Severe Respiratory Distress, Central Cyanosis, or Obstructed Airway: Emergency Management: –Manage choking if foreign body aspiration –Position airway properly –Administer oxygen –Assist in ventilation if needed –Make sure child is warm

53. C = Circulation

54. Assessment of Circulation: Shock Cold hands AND: –Capillary refill >2 seconds –Weak and fast pulse

55. Signs of Shock Tachycardia Poor perfusion (>2 second capillary refill) Weak pulses Cool extremities Poor mentation, lethargy Poor urine output

56. Shock

57. For the following “emergency signs”: Cold hands, Capillary refill >2 seconds, and Weak and fast pulse: Emergency Management: –Stop any bleeding –Give oxygen –Make sure child is warm –Give fluids (see chart) –Give glucose –Full assessment and treatment

58. For the child in shock it is imperative to give fluids…

59. Obtain IV access! If unable to place IV, place IO

60. Shock Early detection and aggressive management improves survival

61. Vascular Access Consider intraosseous line placement as initial attempt for victims of cardiac arrest No upper age limit for attempt at intraosseous access (Class IIa, LOE 5)

62. Intraosseus needle insertion

63. Alcohol swabs 18G needle with trochar (at least 1.5 cm in length) 5 ml syringe Infusion fluid Local anaesthesia may be required if the patient is conscious.

64. Intraosseus needle: alternative site

65. Treatment of Shock: First! assess if child is severely malnourished If not: –Insert IV or IO –Prepare a bag of Ringers Lactate or Normal Saline –Infuse 20ml/kg as rapidly as possible –Reassess after 1 st infusion and repeat if no improvement –Reassess after 2 nd infusion and repeat if no improvement –Reassess after 3 rd infusion. If no improvement give 20cc/kg of blood transfusion, or a 4 th bolus of fluids if patient has diarrheal illness

66. Treatment of Shock:

67. If a child is severely malnourished it may be difficult to distinguish shock from malnourishment In addition, shock from sepsis and dehydration may coexist Fluids must be given very slowly Monitor pulse and breathing every 5-10 mins Over-hydration can lead to heart failure Treatment of shock in severely malnourished patients

68. If the child is lethargic or unconscious: –Keep warm –Give 10% glucose 5ml/kg –Then give IVF: 15ml/kg over 1 hour –Re-assess every 5-10mins for improvement or worsening –STOP infusion if respiratory rate increases or pulse increases as this means fluids are worsening the child’s condition –If improvement after fluid, may repeat x1 over an hour –Then switch to oral or NG re-hydration and initiate re- feeding Treatment of shock in severely malnourished patients

69. If the child does not improve with first fluid bolus: –Assume child is in septic shock as opposed to dehydration related shock –Give maintenance fluids –Transfuse 10ml/kg of blood, when available, slowly, over 3 hours –Start antibiotic treatment –Initiate re-feeding Treatment of shock in severely malnourished patients

70. If severely malnourished child is NOT lethargic or unconscious, but is alert: –Give 10% glucose: 10ml/kg by mouth or nasogastric tube –Move to assessment and treatment for severe malnourishment Treatment of shock in severely malnourished patients

74. After A, B, C, move on to assess the “other C”, D, and then other organ functions… Assessment of the very sick child:

75. The “other C’s”= coma or convulsions

76. Assess for Coma or Convulsions: AVPU Is the child: –Alert? –Responding to Voice? –Responding to Pain? –Unconscious? A child who is not alert but responding to voice is lethargic A child who does not respond to pain is unconscious

77. Assess for Coma or Convulsions: Is the child having rhythmic movements and unresponsive?

78. For the following “emergency signs”: Coma or Convulsing: Emergency Management: –A, B, C –Give oxygen –Diazepam or Paraldehyde rectally for convulsions (seizures) –Position unconscious child in protective manner –Give IV glucose –Full assessment and treatment

81. D = Dehydration

82. Severe Dehydration in Child with Diarrhea Diarrhea plus –Lethargy –Sunken eyes –Very slow skin pinch

83. For the following “emergency sign”: Diarrhea with lethargy, sunken eyes, or very slow skin pinch: Emergency Management: –Make sure child is warm –If child is NOT severely malnourished Insert IV and give rapid fluid boluses Treat diarrhea –If child is severely malnourished: Do not insert IV Treat per malnourishment guidelines

85. Review: Assessment and treatment of the very sick child After assessing for, and immediately treating “emergency signs”, the caregiver should then move on to looking for “priority” signs which warrant urgent treatment Emergency Signs: –Obstructed Breathing –Severe Respiratory Distress –Central Cyanosis –Signs of Shock –Coma –Convulsions –Signs of severe dehydration

86. Review: Assessment and Treatment of the very sick child: Priority signs: –Sick child less than 2 mos –Very high temperature –Trauma or other surgical condition –Pallor –Poisoning –Severe Pain –Respiratory Distress –Restless/Irritable –Malnutrition –Oedema –Burns

87. Remember: start with assessing and securing A,B, C! Review: Assessment and Treatment of the very sick child:

88. Special Note about: Emergency Findings in a Severely Malnourished Child: All children with severe malnourishment require prompt attention and treatment of malnourishment A severely malnourished child who presents with airway obstruction or severe respiratory distress, coma or convulsions should be treated as you would a non- malnourished child Severely malnourished children who are dehydrated should NOT be re-hydrated by IV unless they are in shock Severely malnourished children in shock should be re- hydrated cautiously with frequent re-assessment of their response to fluids