1. Resuscitation & Stabilisation of the Critically Ill Child Sandra Stark Nurse Consultant ScotSTA R

2. Resuscitation

3. Differences Between Adults & Children LESS THAN YOU THINK!!!!

4. Paediatric vs Adult Resuscitation Focus on the similarities Airway Breathing Circulation

5. Common Presentations Respiratory distress  Usually infective in origin  Bronchiolitis, LRTI, croup Infection/sepsis  Large range of support required Seizures Trauma Decreased GCS  Intracranial pathology  Infection  Trauma  NAI

6. Differences Pathways leading to cardiac arrest in children are different Rarely due to primary cardiac disease Usually due to circulatory +/- respiratory failure If child arrests, likely to be more decompensated

7. Airway Differences Head large, neck small- tends to cause neck flexion Tongue relatively large ◦ May obstruct airway in unconscious child ◦ Obstructs view at laryngoscopy Easy to compress airway when holding face mask Beware the child with airway obstruction who has an oxygen requirement Head tilt ◦ Neutral in the infant ◦ Sniffing in the child

8. Intubation Differences As in adults, often can maintain airway with good bag/mask If need intubation or to assist, have variety of sizes close to hand ETT size – 4 + age/4 (drop half a size if cuffed) Epiglottis in children horseshoe shaped & projects posteriorly Larynx high & anterior (C2-3 in infant compared to C5-6 in adult) Trachea short – tube displacement more likely Pre-oxygenation vital – more likely to desaturate More likely to be bradycardic during intubation ◦ Infants more pronounced vagal response ◦ Bradycardia with direct laryngeal stimulation ◦ Can be due to hypoxia ◦ More likely to stimulate vagal response (vagus nerve) in infant intubation with direct laryngeal stimulation,

9. Breathing Differences Higher metabolic rate & oxygen consumption so higher RR Work of breathing – nasal flaring, intercostal & subcostal recessions due to compliant chest wall Infants rely on diaphragmatic breathing – more likely to fatigue & cause respiratory failure More compliant chest wall – may have lung injury without fractured ribs If rib # present, implies significant force Important to remember when BVM not to use excessive force (tidal volume 5-10ml/kg)

10. Circulation Differences Child’s circulating blood volume 70ml-80ml/kg Higher than an adult but relatively small so easier to dilute Small SV in infants so CO increased by HR HR response to fluids can be blunted in infants

11. Cardiac Decompensation Cardiac arrest – likely to be asystole or PEA Uncommon to require shock Children will maintain cardiovascular parameters (ie BP) until almost pre-terminal then deteriorate very quickly Bradycardia/hypotension LATE sign of decompensation Primary cardiac disease uncommon in children – consider in neonates or children with known cardiac disease

12. Neurology Differences Modified GCS?? Hypoglycaemia can be a big problem

13. Paediatric Spine Spinal injuries relatively rare More flexible joint capsules & interspinous ligaments Relatively large head compared with neck – thus movement greater and more injuries at level of occiput to C3 Spinal cord injury without radiological abnormalities more common in children

14. Paediatric Burns

15. Adults – rule of 9s More complex in paeds Easiest way – palmar surface (including fingers) of patient’s hand represents approximately 1%

16. Essential Equations Weight (Age+4) multiplied by 2 Formula for weight ◦ Average birth weight 3.5kg ◦ Increased to 10kg by 1 year Broselow tapes ◦ Colour coded system for paediatrics Energy = 4J/kg Fluid = 20ml/kg (10ml/kg in trauma or DKA) Sugar = 3ml/kg of 10% dextrose Adrenaline = 0.1ml/kg of 1:10,000

17. Stabilisation Discussion regarding retrieval to appropriate centre Ongoing care & optimisation

18. Interventions Airway/intubation Ventilation Haemodynamic support Vascular access (arterial/venous) Other – blood, medications

19. Who Will Perform Interventions? Local team Retrieval team Joint

20. Intubation - Tips If referring team can intubate saves time if they do so Don’t cut tubes too short Short ETT ◦ Easy to dislodge ◦ CXR to confirm position Many children will maintain A & B with PEEP/oxygen – correct haemodynamics before administering anaesthetic Common regime ◦ Fentanyl (1-2mcg/kg) if required ◦ Ketamine 2mg/kg ◦ Rocuronium 1mg/kg ◦ Resus drugs drawn up-adrenaline/atropine ◦ Beware thio/propofol

21. Ventilation - Tips Low threshold for intubation children for transfer ◦ Especially any airway obstruction ◦ Safer to intubate in good environment before you leave Watch tidal volumes – easy to over inflate small lungs Difficulties with ventilation ◦ Suction, physio can make a big difference

22. Circulation - Tips IO access if unable to get access ◦ Also remember external jugular vein for access ◦ Scalp veins in neonates Inotropes if required (consider when >40ml/kg fluid resuscitation) Adrenaline or dopamine can be used peripherally 2 points of access before you leave

23. How to Make up Inotropes

24. Neurology - Tips Beware of hypoglycaemia ◦ 3-5ml/kg 10% dextrose Midazolam/morphine for sedation ◦ Morphine 20-40mcg/kg/hr ◦ Midazolam 0.1mg/kg/hr ◦ Bolus rocuronium for transfer Small adults ◦ Use what you are comfortable with!!

25. Head Injury May require time-critical response for neurosurgical intervention Prevent secondary brain injury with appropriate ventilation/circulatory support ◦ Desaturation & low BP very bad for heads ◦ In child with head injury & raised ICP, even one episode of hypotension can cause significant morbidity

26. Other... Heat loss more of a problem-packaging important Higher body surface area for heat loss In trauma, energy transmitted to body that has less connective tissue & fat and closer proximity to multiple organs – significant injury may exist in absence of fractures

27. Cardiac... Very rare to have primary cardiac disease Cardiac compromise often secondary to other pathology Neonates ◦ Cyanosed ◦ Cardiac findings ie absent femorals Older children ◦ History of cardiac disease/pathology

28. Cardiac Presentation A, B, C... Often breathing can be supported with PEEP ◦ May need intubation but optimise other systems first ◦ The ‘oxygen’ dilemma... Cautious with fluid ◦ Use 10ml/kg aliquots & assess response ◦ In neonates with duct dependent disease, discuss with tertiary centre & consider prostin ◦ Sepsis/metabolic other differentials in ‘shut down’ neonate – sepsis FAR MORE COMMON

29. www.snprs.scot.nhs.uk

30. Questions??