Pediatric Assessment and Resuscitation: Why it s Different

1. Pediatric Assessment and Resuscitation: Why it�s Different April Jaeger MD Paramedic Lecture Series 2008

2. Pediatric Emergencies SIDS, 1mo-12mo Trauma, >6mo-adulthood MVA Other injury Drowning Fire/burn suffocation Progressive arrest Hypoxia, hypercarbia, respiratory arrest, bradycardia, then asystole

3. Pediatric Emergencies Survival from full arrest, 3-17% Respiratory arrest alone, >50% CPR improves outcomes Immediate CPR, �phone fast�, <8yo All submersion, trauma, overdose

4. Recognizing Pediatric Cardiopulmonary Failure Respiratory rate >60bpm Irregular or decreasing RR with altered mental status Increased work of breathing Altered mental status Irritability, lethargy, decreased response to stimuli Seizures Fever with petechiae Cyanosis

5. Recognizing Pediatric Cardiopulmonary Failure Heart rate Newborn: <80bpm, >200bpm 0-1yo: <80bpm, >180bpm 1-8yo: <60bpm, >180bpm >8yo: <60bpm, >160bpm Poor perfusion Blood pressure drops late Multiple trauma Burns >10% body surface

6. Pediatric Shock Hypovolemic shock Leading cause of shock in children Dehydration, hemorrhage, third spacing Cardiogenic shock Resultant from prolonged shock Distributive Sepsis, anaphylaxis Hypovolemic � inadequate intravascular volume in relation to vascular space; third spacing seen in sepsis, burns Cardiogenic � myocardial dysfunction Distributive � inappropriate distribution of blood flowHypovolemic � inadequate intravascular volume in relation to vascular space; third spacing seen in sepsis, burns Cardiogenic � myocardial dysfunction Distributive � inappropriate distribution of blood flow

7. Pediatric Shock Compensated shock � normal SBP with inadequate perfusion Noted tachycardia Evaluate systemic perfusion Pulse volume, skin mottling, capillary refill, CNS function, urine output Decompensated shock Any falls in SBP must be treated rapidly Median SBP = 90mm Hg +(2 x age) Neonates <60mm Hg 1-12mo <70mm Hg 1-10y <70mm Hg+(2 x age) >10y <90mm Hg Compensated � presence of normal SBP with Ss/Sxs of inadequate tissue and organ perfusion pulse volume, skin, CNS function, UOPCompensated � presence of normal SBP with Ss/Sxs of inadequate tissue and organ perfusion pulse volume, skin, CNS function, UOP

8. Pediatric Respiratory Failure Upper airway obstruction Stridor, hoarseness, retractions, flaring Lower airway obstruction Wheezing, retractions, tachypnea Parenchymal lung disease Hypoxemia, retractions, grunting Abnormal ventilatory control Hypoventilation, irregular breathing Upper airway � foreign bodies, croup, epiglottitis Lower airway � asthma, foreign body, aspiration Parenchymal disease � pneumonia, bronchiolitis Abnormal ventiliation � drug overdose, brain injuryUpper airway � foreign bodies, croup, epiglottitis Lower airway � asthma, foreign body, aspiration Parenchymal disease � pneumonia, bronchiolitis Abnormal ventiliation � drug overdose, brain injury

9. Pediatric Respiratory Failure Upper airway Smaller in diameter & shorter Relatively larger tongue Long, floppy, narrow epiglottis Vocal cords are lower anteriorly Funnel shaped airway narrows to the cricoid cartilage Edema or FB cause relatively more obstruction

10. Pediatric Respiratory Failure Keep the obstructed child calm Obstruction may cause dynamic airway collapse - stridor Croup Foreign body Epiglottitis

11. Pediatric Respiratory Failure Lower airway obstruction Bronchiolitis Asthma PEEP improves gas exchange with lower airway disease

12. Pediatric Respiratory Failure Children have higher O2 consumption Causes of hypoxia Poor gas exchange Pneumonia, ARDS Ventilation:perfusion mismatch Asthma, bronchiolitis, aspiration Decreased compliance or increased resistance Asthma, pneumonia, ARDS Impaired CNS Infection, trauma, overdose

13. Pediatric Respiratory Failure Endotracheal intubation Airway positioning is crucial Straight blades better open the visual plane � esp. in younger children Directly lift the epiglottis ETT size=(age/4) + 4; (+3 cuffed) Insertion depth=(age/2) + 12 Or (ETT size) x 3 Audible air leak @ >20-30 cm H2O

14. Pediatric Respiratory Failure Indications for tracheal intubation Inadequate ventilation control Airway obstruction Loss of protective airway reflexes Excessive work of breathing Need for high PIP for gas exchange Need for airway protection during sedation Potential occurrence of any of the above

15. Pediatric Resuscitation Fluids & Medications Intravenous access Median cubital, long saphenous Follow drugs with 5-10ml flushes Intraosseous access All ages - anterior tibia, distal femur Older children � distal tibia, medial malleolus, anterior superior iliac spine, distal radius or ulna

16. Pediatric Resuscitation Fluids & Medications Isotonic crystalloid solutions Only 1/4th volume remains intravascular 20ml/kg RBC transfusion Trauma victims If shocky after 40-60ml/kg crystalloid 10-15ml/kg

17. Pediatric Resuscitation Fluids & Medications Diabetic ketoacidosis 10ml/kg bolus, then continuous fluids Increased risk for cerebral edema Burns Significant third spacing 2-4ml/kg per % body surface, per 24h Poisonings � Ca+ channel blocker, b blockers 5-10ml/kg, watch for hypotension

18. Pediatric Resuscitation Fluids & Medications Glucose Uses: suspected or documented hypoglycemia Infants: <60mg/dl Dose: 0.5-1g/kg IV; 2-4ml/kg of 25% or 5-10ml/kg of 10% do not exceed 12.5% IV in neonates

19. Pediatric Resuscitation Fluids & Medications Calcium Chloride Uses: hypocalcemia, hyperkalemia, hypermagnesemia, Ca+ channel blocker overdose Dose: 20mg/kg of CaCl 10% Administer over 10-20 seconds Flush before and after administration May cause bradycardia

20. Pediatric Resuscitation Fluids & Medications Sodium Bicarbonate Uses: severe metabolic acidosis with effective ventilation, hyperkalemia, hypermagnesemia, tricyclic poisoning Dose: 1mEq/kg (1ml/kg of 8.4%) IV may repeat every 10min Side effects: metabolic alkalosis, impaired O2 release, pseudo-hypokalemia, hypocalcemia, decreased VF threshold, Na+/water overload

21. Pediatric Resuscitation Fluids & Medications Epinephrine (a & b adrenergic stimulator) Actions: vasoconstriction, increases contractility, heart rate, relaxes smooth muscle Uses: cardiac arrest, symptomatic bradycardia, hypotension Dose: 0.01mg/kg (0.1ml/kg of 1:10,000 solution) May repeat every 3-5min Continuous 0.1-1mg/kg/min

22. Pediatric Resuscitation Fluids & Medications Dopamine (dopamine & b adrenergic stimulator) Uses: inadequate cardiac output, hypotension, enhanced splanchnic blood flow & urine output Dose: 2 to 20mg/kg/min May cause tachycardia, arrhythmias, and hypertension Dobutamine � 5-20ug/kg/min; contractility, inadequate output or myocardial dysfxn (tachy, arrhythmias, ectopy) Norepinephrine � 0.1-2ug/kg/min; hypotension, inadequate output, spinal shock, cardiogenic shock (organ ischemia, HTN, arrhythmias)Dobutamine � 5-20ug/kg/min; contractility, inadequate output or myocardial dysfxn (tachy, arrhythmias, ectopy) Norepinephrine � 0.1-2ug/kg/min; hypotension, inadequate output, spinal shock, cardiogenic shock (organ ischemia, HTN, arrhythmias)

23. Pediatric Resuscitation Fluids & Medications Sodium nitroprusside Uses: hypertensive emergencies, inadequate cardiac output with high resistance, cardiogenic shock Dose: 0.1-1mg/kg/min up to 8mg/kg/min Cannot infuse with saline Deteriorates with light exposure May cause hypotension

24. Pediatric Resuscitation Fluids & Medications Prostaglandin E1 Maintains patency of the ductus arteriosus Patients present in profound shock or cyanosis shortly after birth Dose: 0.05-0.1mg/kg/min May cause vasodilation, hypotension, edema, apnea, hyperpyrexia, jitteriness Prepare for tracheal intubation before administration Ductal dependent lesions: transposition of the great vessels, aortic coartctation, tricuspid atresiaDuctal dependent lesions: transposition of the great vessels, aortic coartctation, tricuspid atresia

25. Pediatric Resuscitation Fluids & Medications Naloxone Narcotic antagonist Reverses effects of respiratory depression, sedation, hypotension, hypoperfusion Dose: 0.1mg/kg; 2mg for children over 5yo or 20kg May abruptly reverse narcotic depression Nausea, tachycardia, hypertension, tremulousness, seizures, arrhythmias, asystole, pulmonary edema

26. Pediatric Rhythm Disturbances Arrest is often progression from respiratory distress Asystole, bradyarrhythmia (wide QRS) Sudden witnessed collapse � cardiac Myocarditis, congenital cardiac disease, history of arrhythmias, blow to chest Arrhythmias with shock/collapse should be treated with defibrillation

27. Pediatric Rhythm Disturbances Bradyarrhythmias � 4Hs, 4Ts Treat underlying cause Tachyarrhythmias � SVT, VT Synchronized cardioversion Collapse rhythms � VF, asystole, PEA, pulseless VT Defibrillation for VF or pulseless VT

28. Pediatric Rhythm Disturbances Bradycardia with cardiorespiratory compromise Chest compressions if no improvement despite ventilation & oxygenation No pausing of CPR for drug administration Epinephrine � 0.01mg/kg 0.1ml/kg of 1:10,000 solution May repeat every 3-5 minutes Atropine � 0.02mg/kg May repeat once Max dose 0.5mg in child, 1mg in teens

29. Pediatric Rhythm Disturbances VT � uncommon in children HR normal to 200 bpm Underlying structural heart disease or rhythm abnormalities Wide-QRS tachycardia Differentiate from torsades de pointes

30. Pediatric Rhythm Disturbances SVT � rapid regular rhythm Infants, HR>220 bpm >90% children have narrow QRS complex Often absent or abnormal P waves Lack of beat to beat variability

31. Pediatric Rhythm Disturbances Vagal manuevers if stable VT/SVT Ice to the face � infants & young kids 10-15 seconds, may repeat once Valsalva manuever (blow into straw)

32. Pediatric Rhythm Disturbances Synchronized cardioversion if unstable VT/SVT 0.5-1 J/kg, then 1-2 J/kg Use sedation with analgesia for elective cardioversion Adenosine � treatment of SVT Blocks the AV node 0.1 mg/kg rapid IV bolus May double dose, 0.2 mg/kg, if no effect

33. Pediatric Rhythm Disturbances Amiodarone � VT 5mg/kg IV over 20-60 minutes Procainamide � VT 15mg/kg IV over 30-60 minutes Should not be used together Prolong the QT interval Vasodilators, AV node inhibition

34. Pediatric Rhythm Disturbances Defibrillation � VF, pulseless VT Starting dose 2 J/kg Repeat doses of 4 J/kg AED use Pediatric specific if available Adult AED acceptable for >1yo

35. Pediatric Rhythm Disturbances Drug administration if 3 shocks are unsuccessful � VF/pulseless VT CPR should not pause Epinephrine � VF/pulseless VT 0.01mg/kg (0.1ml/kg of 1:10,000) May repeat every 3-5 minutes Amiodarone � VF/pulseless VT Load 5mg/kg May repeat up to total of 15mg/kg

36. Pediatric Trauma Airway Remove foreign bodies Oropharyngeal airway if unconscious Breathing Hyperventilation is not routine Chest wall injuries may not be obvious Circulation Signs of shock Decompensated shock is a late sign Intra-abdominal hemorrhage is subtle Hyperventilation - increased ICP and signs of clinical deteriorationHyperventilation - increased ICP and signs of clinical deterioration

37. Pediatric Trauma Disability Glasgow Coma Scale Exposure Prevent hypothermia, esp. in infants

38. Pediatric Trauma Spinal injuries Increased frequency of ligamentous injuries Relatively larger head C1-C4 fractures more common, <8yo Spinal board immobilization Padding under the shoulders to avoid flexion on a backboard, <8yo Fill gaps between straps and patient

39. Pediatric Trauma Carseat transportation only in stable children with no evidence of injury Apply pediatric cervical collar Pad the lap & any gaps Tape to secure pelvis and chest Towels on either side of the head with tape across the forehead & collar

40. Pediatric Trauma Non-accidental trauma Injuries out of proportion to history Immersion burns Bruises of different ages Differing history from child Wariness of physical contact Parental apathy or overreaction to child�s actions DOCUMENT THOROUGHLY!

41. Pediatric Toxicology Gastrointestinal decontamination Ipecac � not routinely recommended Activated charcoal Within 30-60 minutes of ingestion Do not give without poison control oversight Up to 1yo: 1g/kg; 1-12yo: 25-50g; teens & adults: 25-100g Contraindicated with an unprotected airway Gastric lavage � not routine

42. Pediatric Toxicology Cocaine ABCs, benzodiazepines ACS: O2, nitroglycerin, ASA, heparin Tricyclic antidepressants ABCs, NaBicarb to treat ventricular arrhythmias (pH>7.45) Calcium channel blockers ABCs, vasopressors

43. Pediatric Toxicology b-Adrenergic Blockers ABCs, epinephrine infusion Opiod toxicity ABCs, naloxone (after ventilation has been established)

44. Pediatric Rapid Sequence Intubation Contraindications: Concern for lack of success Facial or laryngeal edema, trauma, or distortion Spontaneous breathing & adequate ventilation despite distress Upper airway obstruction, epiglottitis

45. Pediatric Rapid Sequence Intubation Premedication Anticholinergic agents Infants <1yo, 1-5yo receiving succinyl-choline Atropine 0.01-0.02mg/kg IV (min 0.1mg, max 1mg) Glycopyrrolate 0.005-0.01mg/kg IV (max 0.2mg) Lidocaine � reduces ICP rise 1-2mg/kg IV, 2-5 min before

46. Pediatric Rapid Sequence Intubation Atropine to minimize bradycardia 0.01mg to 0.02mg/kg IV, max 1mg 0.04mg/kg IM Give 1-2 minutes before intubation May also decrease secretions Common side effect of tachycardia Monitor with pulse oximetry if available

47. Pediatric Rapid Sequence Intubation Sedative-hypnotic agents (no analgesia) Midazolam � 0.1-0.2mg/kg (max 4mg) Respiratory depression, hypotension Diazepam � 0.1-0.2mg/kg (max 4mg) Respiratory depression, hypotension Thiopental � 2-4mg/kg Negative inotrope, hypotension Decreases ICP Etomidate � 0.2-0.4mg/kg Myoclonic activity, cortisol suppression Decreases ICP, minimal CR depression

48. Pediatric Rapid Sequence Intubation Anesthetic Agents Lidocaine � 1-2mg/kg Myocardial & CNS depression, seizures Decreases ICP, less hypotension Ketamine � 1-4mg/kg Increased ICP, BP, secretions; hallucinations Dissociative agent, bronchodilator Propofol � 2-3mg/kg Hypotension, pain with injection Less airway reactivity

49. Pediatric Rapid Sequence Intubation Neuromuscular Blocking Agents Succinyl-choline* � 1-2mg/kg Fasciculations, increased ICP, HTN, hyperkalemia Short duration, use defasciculation agent Vecuronium � 0.1-0.2mg/kg Minimal cardiovascular side effects 2-3 minutes to onset Rocuronium � 0.6-1.2mg/kg Minimal cardiovascular side effects Rapid onset

50. References PALS Provider Manual. Zaritsky et al. 2002 Gewitz, Michael H., Paul K. Woolf. �Cardiac Emergencies.� Textbook of Pediatric Emergency Medicine. 5th ed. Gary R. Fleisher, Stephen Ludwig, and Fred M. Henretig. Philedelphia: Lippincott Williams & Williams, 2006 Kadish, Howard. �Thoracic Trauma.� Textbook of Pediatric Emergency Medicine. 5th ed. Gary R. Fleisher, Stephen Ludwig, and Fred M. Henretig. Philedelphia: Lippincott Williams & Williams, 2006 Torrey, Susan B. �Apnea.� Textbook of Pediatric Emergency Medicine. 5th ed. Gary R. Fleisher, Stephen Ludwig, and Fred M. Henretig. Philedelphia: Lippincott Williams & Williams, 2006. Bachur, Richard G. �Cough.� Textbook of Pediatric Emergency Medicine. 5th ed. Gary R. Fleisher, Stephen Ludwig, and Fred M. Henretig. Philedelphia: Lippincott Williams & Williams, 2006. Schunk, Jeff E. �Foreign Body-Ingestion/Aspiration.� Textbook of Pediatric Emergency Medicine. 5th ed. Gary R. Fleisher, Stephen Ludwig, and Fred M. Henretig. Philedelphia: Lippincott Williams & Williams, 2006. Stevenson, Michelle D., Frederick W. Tecklenburg. �Asthma and Allergic Emergencies.� Textbook of Pediatric Emergency Medicine. 5th ed. Gary R. Fleisher, Stephen Ludwig, and Fred M. Henretig. Philedelphia: Lippincott Williams & Williams, 2006