Why are cardiac children so vulnerable?Immunologically immatureAirway size Chest wall complianceRespiratory musclesControl of breathingLess reserve

Hyoid BoneThyrohyoid Membrane & CartilageEpiglottisTracheaCricoid CartilageVocal CordsArytenoid CartilageThe LarynxPosterior Crycoarytenoid Cartilage

1. Hyoid Bone 2. Thyroid Cartilage 3. Cricoid Cartilage 4. Tracheal Cartilages

More rostral pediatric larynx

Laryngeal apparatus develops from brachial clefts and descends caudallyInfants larynx is higher in neck (C2-3) compared to adults (C4-5)

Surely Its Just a Cold? Why Kids Crash So Quickly.

Pointers.Beware of the Good Blood Gas.SaO2 Monitor burns. 4 Hourly move.Flaring, Grunting, Recession, Head Bobbing. AVPUProning, Positioning, OXYGEN!Calming, Paracetomol. Chloral Hydrate. Vallergan.Higher BMR. Less Reserve.

Asthma They Also Get It! Pathophysiology

Child with severe asthmaC:\Documents and Settings\watersonja\Desktop\13 july\status asthmaticus.avi

Bronchiolitis: They Also Get It!Children < 2 years old80% of patients < 1 year oldEpidemics January through May

Breathing: Respiratory rate Evaluate before you wake a child

Look at rate to assess if abnormal: Fast Slow ALERT, ALERT, ALERT Apnea

Age

Breaths per minute

Infant (< 1 year)

30 to 60

Toddler (1 to 3 years)

24 to 40

Preschooler (4 to 5 years)

22 to 34

School age (6-12 years)

18 to 30

Adolescent (13 to 18 years)

12 to 16

Breathing: Respiratory Effort

Breathing: Respiratory effortNasal flaring

Retractions

Seesaw breathing

Head bobbing

Respiratory effort: Nasal flaring Sign of respiratory distress Enlargement of nostrils helps to reduce nasal resistance and maintains airway patency Can be intermittent or continuous Described as minimal or marked

Respiratory effort: retraction

Respiratory effort: Retractionsrecession mild severe.avi

Respiratory effort: Head bobbing or seesaw respirationsHead bobbingBobs forward with each inspirationCaused by contraction of scalene and sternocleidomastoid muscles; respiratory failureInfants and young children

See-Saw breathingSevere chest retractions during inspiration accompanied by expansion of the abdomenOften sign of upper airway obstructionQuickly lead to fatigue and progress to resp failure

Breathing: Air movement

Chest wall movementBreath soundsAnterior, Lateral, PosteriorNormal Inspiration soft and quiet, Expiration shorter and quieterWHY??? Reverberating breath sounds

Breathing: Airway & breath coundsStridor upper airway obstructionGrunting find real grunt soundsGurglingProlonged expiration d/t lower airway ostrWheezing lower airway obstructionCrackles

Breathing: Pulse oximetryMeasures % of the childs hgb that is saturated with oxygen

Oxygen saturation readingAction= or > 94% on R/AAdequate oxygenation< 94% (hypoxemia) when on R/AConsider giving oxygenLess than 90% in child receiving 100% by non rebreathing mask (severe hypoxemia)CALL FOR HELPAdditional actions are usually required

Respiratory Distress

Respiratory Distress

Respiratory Distress: EarlyTachycardia TachypnoeaAny retractions or tracheal tugStridorNiosy breathingWheezeProlonged expiration

Respiratory Distress: LateHead bobbingGruntingPoor skin perfusion/colourSilent chestNasal flaringSee-Saw chest movementsBradycardiaPoor social interactions

Signs of DeteriorationIncreasing recessionIncreasing respiratory rateIncreasing pulse rateFatigueAltered mental statusCyanosis

And It Gets Worse2. bronchiolitis.avi8 respiratory distress.avisevere preterminal respiratory distress.avi

BreathingEnhanced oxygen

Mask with reservoir Nasal prongs [spectacles]Head boxneonate with severe respiratory distress.avi

THE HIGHEST AVAILABLE OXYGEN CONCENTRATION SHOULD BE GIVEN

Vital Signs. Note Frank Shann Page 1 [MAP]

Cardiovascular Assessment and Management.

Effects of Circulatory Inadequacy

Respiratory Rate and Character

Skin Temperature/Color.

Mental Status AVPU

Cardiovascular signsCapillary refillSlightly above level of heart.

press for 5s release colour should return

Cardiovascular signsCapillary refill

Like this Little Fellacapillary refill.avi

DEFINITION OF SHOCK

AN ABNORMALITY OF THE CIRCULATORY SYSTEM THAT RESULTS IN INADEQUATE ORGAN PERFUSION AND TISSUE OXYGENATION.

Shock is a syndrome that results from inadequate oxygen delivery to meet metabolic demandsDO2 < VO2

Untreated this leads to metabolic acidosis, organ dysfunction and deathNow tell me all about ATP..

Initial Evaluation: Physical ExamNeurological: Fluctuating mental status, sunken fontanelSkin and extremities: Cool, pallor, mottling, cyanosis, poor cap refill, weak pulses, poor muscle tone.Cardio-pulmonary: Hyperpnea, tachycardia.Renal: Scant, concentrated urine ADH though

Something Like Thisdehydration response to fluids.avi

Outcome of Pediatric ShockChang 1999

Stages of ShockCompensatedVital organ function maintained, BP remains normal.Uncompensated Microvascular perfusion becomes marginal. Organ and cellular function deteriorate. Hypotension develops.Irreversible

Hypovolemic ShockClinically, history of vomiting/diarrhea or trauma/blood lossSigns of dehydration: mucous membranes, tears, skin turgorHypotension, tachycardia without signs of congestive heart failure

CARDIOGENIC SHOCK

MYOCARDIAL DYSFUNCTION

Remember those Hs and Ts!

OBSTRUCTIVE SHOCK CARDIAC TAMPONADE TENSION PNEUMOTHORAX PULMONARY EMBOLISM DUCTAL-DEPENDENT EMBOLISMTHROMBOSIS

CARDIAC PHYSIOLOGY RE-VISITED Cardiac output is defined as the volume of blood pumped by the heart per minute.This is determined by the product of heart rate and stroke volume

CARDIAC OUTPUT= STROKE VOLUME X HEART RATE

STROKE VOLUMEStroke volume is the amount of blood pumped with each cardiac contraction and this is determined by- I. PRELOAD II. MYOCARDIAL CONTRACTILITY III. AFTERLOAD

COMPENSATORY PROGRESSIVE VASOCONSTRICTION-- To preserve flow to the major organs

TACHYCARDIA: Increase in heart rate to preserve cardiac output

SHIFT FROM AEROBIC TO ANAEROBIC METABOLISM Due to poor perfusion and oxygenation. Anaerobic metabolism results in the build up of lactic acid and hence a Metabolic acidosis

Hemodynamic Response to Hemorrhage [and Failure]25%50% % Plasma Loss

% ofControl100Vasc ResistanceCardiac OutputBlood Pressure

SYSTEMIC RESPONSE TO SHOCK IN THE PEDIATRIC PATIENT.CARDIOVASCULAR

< 30% = Increase Heart Rate, Thready peripheral pulses

30-45%= Low Blood Pressure [Note that >45% is very late- BP therefore a late sign] Narrow Pulse Pressure Marked increase in HR Absent Peripheral

>45% = Hypotension, Tachycardia, then Bradycardia.Why the bradycardia????

CENTRAL NERVOUS SYSTEM

< 30%= Anxious, Irritable, Confused

30%-45%= Lethargic, Dulled response to pain

> 45% = Comatose

SKIN

< 30%= Cool , Mottled, Prolonged cap re-fill.

30%-45%= Cyanotic, Markedly prolonged capillary re-fill.

45% = Pale , cold.

URINARY OUTPUT

45%= NONE

So.AVPUCap RefillColour

Then RR and HRMore important than BP

AIRWAY CLEAR and PATENT for good Oxygenation

Position the child= if stable consider leaving with caregiver, it allows for comfort and assurance to the child.

BREATHING acidotic breathing DKA.aviChoose the appropriate mode of delivering high flow oxygen.NON-REBREATHER MASKBAG-VALVE MASKDEFINITIVE AIRWAY

REMEMBER SEEK EXPERT HELP EARLY, if child is not oxygenating and ventilating adequately.

CIRCULATION

Obtain IV access (blood investigation)

Consider Intraoessous Access [After X 2 failed attempts at IV, 1 attempt only if child deteriorating fast]

CENTRAL ACCESS?

IO Accessintraosseous needle insert.avi

Management-GeneralGoal: increase oxygen delivery and decrease oxygen demand:Oxygen FluidTemperature controlAntibioticsCorrect metabolic abnormalities Inotropes

Management - Cardiotonics IIEpinephrine0.05-1.5 ug/kg/minincrease HR, SVR, contractilityEnd point: adequate BP; acceptable tachycardiaNorepinephrine0.05-1.0 ug/kg/minIncrease SVREnd point: adequate BPDopamine2-20 ug/kg/minLower doses, increases renal and splanchnic blood flow, & contractility. Higher doses increases HR and SVREnd Point: Improved perfusion, BP, Urine

Management-General (cont)Laboratory studies:ABGBlood sugarElectrolytesCBCPT/PTTType and crossCultures

Rates of Delivery Guide to Fluid Bolus Based on Underlying Cause of Shock

ASSESS CHILDS RESPONSE TO TREATMENTMONITOR HEART RATE CAPILLARY RE-FILLNEUROLOGICAL FUNCTIONTEMPERATUREBLOOD PRESSUREURINARY OUTPUTOXYGEN SATURATION CAPILLARY BLOOD GLUCOSE

CONSIDER PAIN MANAGEMENT. BLOOD GASES. ECG.

Final ThoughtsRecognize compensated shock quickly- have a high index of suspicion, remember tachycardia is first sign. Hypotension is late and ominous.Gain access quickly- if necessary use an IO line.Administer adequate amounts of fluid rapidly. Remember ongoing losses.Correct electrolytes and glucose problems quickly.If the patient is not responding the way you think he should, broaden your differential, think about different types of shock.

*Work of breathing for each kilogram of body weight is similar in infants and adultOxygen consumption of infant (6 ml/kg/min) is twice that of an adult (3 ml/kg/min)Greater oxygen consumption = increased respiratory rate Tidal volume is relatively fixed due to anatomic structureMinute alveolar ventilation is more dependent on increased respiratory rate than on tidal volumeLack Type I muscle fibers, fatigue more easilyFRC of an awake infant is similar to an adult when normalized to body weight Ratio of alveolar minute ventilation to FRC is doubled, under circumstances of hypoxia, apnea or under anesthesia, the infants FRC is diminished and desaturation occurs more precipitouslyAlveoli still growing therefore less room for gas exchange this also increases anatomical dead space which doesnt participate in gas exchange increased BMR also leads to increase O2 consumption and with less alveoli can lend to hypoxia quicker

*Larynx still soft and easily compress to occlude airway ie. when child falls asleep and head falls over can occludeNon-intubated sick kids roll under head shoulders/neck to prevent flexion or hyperextensionCricoid cartilage narrowest part for kids in adults its the vocal cords natural seal around the ett for kids hence uncuffed tubesTrachea shorter and narrower therefore easier to aspirate/infection down shorter trach, less humidification d/t shortness, **Shorter trachea in kidsNotice the angle for kidsmuch more severe when positioning the airway the hyperextension can in fact occlude the airwaySmaller the child the larger the tongue in relation to mouth size**Infant airways are much narrower therefore increase resistance, this increase resistance requires breathing at a faster rate which requires greater energy expansion

Due to smaller airway resistance small amount of mucous or edema can obstruct airways*****Angle of ribs horizontal from sternum in kids adults they go downwardsCompliance of ribs (softer in kids) in adults these are hard

Intercoastal muscles poorly developed, inability to hold rib cage expanded therefore get retractions easier

Diaphragm works same as adults but.instead of ribs being pulled out they are pulled in d/t being sift in fact diaphragm doesnt great bigger lung spacenow add in the weak intercostal muscles as are poorly developeddoesnt increase lung expansion eitherleads to small tidal volume for minute volume

IMPORTANT anything that compromised diaphragm function can lead to resp distress ie. Gastric dissention therefore prevent this at all cost*Kids are nose breathers for 1 month from birth any nasal occlusion (ie NG tubes) can casue distress***This is a video clip which you can play by changing to slide show view and then clicking on the video.****Assess for signs of effort Increased respiratory effortNasal flaringChest retractionsHead bobbing or seesaw respirations*Remind candidates that increased effort may not be apparent in the exhausted child; the child with neuromuscular disease; the child with reduced conscious level from eg poisoning, post-ictal, meningitis, raised intra-cranial pressure.*Sinking of soft tissueSubcostal retraction indicates a flattenned diaphragm cuz it not only lowers the floor of the thorax, but also pulls on the rib cage in response to the greater than normal decrease in intrathroacic pressure

Intercostal missing off the picture**Inward movement of sternun or the soft tissue of chest during inspirationSign of increasing resp effort child is using chest muscles to try and move air into the lungs impaired due to narrow airways oro o by stiff lungs

Severe restractions will see seesawing or headbobbing*Head bobbing use of neck muscles to breathSeesaw- abdominal breathing*Want to see equal movementReasons for unequal movement: inadequate effort, airway obstruction, aspiration of a foreign body,, collapse of all or part of the lungs, thick secretions that block the airways, collection of air blood or other fluid

Inspiration soft and quiet, Expiration shorter and quieterWHY??? cuz I:e is 2:1Reverberating breath sounds childs chest wall is thintherfore its easier to hear lung sounds from 1 part of the chest when your stehoscope is over another area

*Stridor coarse and high pitched typically on inspiration although sometimes on inspiration and expirationCauses: croup(infection0, tumour, cysts, upper airway edema ( allergic reaction0, FBAOGrunting short low pitched sound during expiration, may sound like small cry SIGN OF SEVERE DISTRESS HELP!!Causes pneumonia, ARDS, bleeding into lungs, adb conditions causing pain and abd splinting ie perfed bowel, bowel obstruction, appyGurgling bubbling sound heard during inspir or expir due ot obstructed airway d/t airway secretions, vomit or bloodWheezing

Key features give a first clue as to the emergency treatment neededBe prepared to consider other causes if poor response to a treatment option

Is an estimate not always accurate ensure good waveforms as can be effected by cool fingers, limbs*******The headbox image is also a video*NC mouth breathers will dilute O2 with air so keep that in mind use 2 l/min only, will more likely tolerate than FM, also in infants can nasal obstruction

Run high flow is concerned re: oxygenation/hypoxia low flow: 23 80%

Partial re-breather 35 60% (6 -10 litres)Non-rebreather 60-100% (10-15 litres)Venturi 24 25% (4-8 litres)Hood 40 60% (>10 litre)Face tent never > than 40% ( 10 15 l)

Younger kids are more susceptible to air drying therefore need humidificationConscious have to balance between irritating child and increasing WOB with mask etc let them sit with primary care giver, if it keeps em settled, use blow by oxygen, hold mask toward face but not on it, try and prevent further agitationUnconscious maintain paten airway with oral airway or jaw thrust etc, lateral positioning*DONT FORGET TO READ THE NOTES UNDER THE SLIDES!

Capillary refill should not be used in isolation as a measure of shock, nor to assess the effectiveness of treatment. It is alone neither sensitive nor specific it may be normal in early septic shock, and abnormal in the absence of shock, eg cold or feverish child. Capillary refill should be used alongside heart rate, pulse volume and BP Best done on sternum especially in cold environment.Also mention skin colour & temperature, with a progressive line moving up / down the foot and shin as the clinical situation changes.The video clip (top right) shows capillary refill in a newborn on the sternum, which is a preferable site when the child may be peripherally coldThis picture was taken six seconds after release of skin pressureIn the child who has recently been in low ambient temperature, pressing on the sternal skin rather than a peripheral digit may give a more accurate response.