Transcript Stabilisation and Retrieval: A Systematic Approach.

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 reestablishing physiologic stability.
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Objectives:
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Discuss the anatomical differences between an
adult and child.
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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 2005
9
9
48
75
<1yr = 75
1-5 yr = 48
5-10 yr = 9
>10yr =9
Retrievals by Diagnosis 2005
resp=69
neuro=27
cardiac=18
metabolic=3
other=7
trauma=1
sepsis=16
Respiratory Illness
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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
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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
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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
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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
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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 amounts of lymphoid
tissue
Larynx higher –risk of aspiration
Large Tongue –
airway obstruction
Diaphragm & intercostal
muscles have fewer type 1
muscle fibres - adaptions for
sustained activity, hence tire
earlier
Airways shorter &
narrower encircled by
cricoid cartilage –
less support
Alveoli still
developing in size
and numbers (95%)
Greater oxygen
consumption due
to higher BMR
Mucous membranes
loosely
attached airway oedema
greater
Anatomical factors which impact
upon the child’s spontaneous
ventilation
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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
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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
Heart Rate
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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
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Tachycardia shortens diastolic period which in
turn reduces ventricular filling time
Anaphylaxis
Coma,
convulsions
raised ICP,
poisoning
Upper airway - epiglottitis,
Croup, foreign body
Empyema
Pneumothorax
Pulmonary oedema
asthma,
,bronchiolitis
pneumonia
Neuromuscular
disorders
Diabetic
ketoacidosis,
Peritonitis
abdominal
distension
Causes of breathing problems in childhood.
Normal values
Age
Resp. rate
HR
Neonate
60
160
Systolic
BP
70
<1 yr.
35-45
110-160
75
1-5yr
23-35
95- 140
80 – 90
5-12 yr
20-25
80 – 120
90 – 110
> 12yr
adult
adult
100 - 120
Assessment Airway
Look, Listen and Feel
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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
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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
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Respiratory rate and pattern, recession/
accessory muscles, nasal flaring , tracheal tug.
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Chest expansion, abdominal excursion, oxygen
saturations, equal air entry.
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Physiological effects upon heart rate, skin colour
mental status
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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
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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
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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
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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
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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
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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
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If signs of shock - fluid bolus 10 – 20 ml/kg
0.9% saline.
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The 1year old is classed as 10kg
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Estimated weight > 1yr = (age + 4) X 2
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Start inotropes after 60ml/kg
administered in conjunction with volume
replacement
Infusion Calculations Dobutamine
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Vial 250 mg / 20mls add to 30 mls of 5%
dextrose to give total volume of 50mls
Use formula “What you want”
“What you’ve got”
X mls
e.g. 5 kg child prescribed 10 mcg/kg/min =
“What you want”
Infusion Calculations Dobutamine
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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
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Disability – Conscious level, behaviour
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Normal, lively, irritable , lethargic.
AVPU / GCS pupillary signs & posture
Exposure
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Rash , fever
Consider anaphylaxis
Summary
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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
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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)