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EMERGENCIES IN CHILDHOOD Monika Csóka M.D. ETIOLOGY OF CARDIAC ARREST IN ADULT Dysrhytmia Ventricular fibrillation ETIOLOGY OF CARDIAC ARREST IN PEDIATRICS Respiratory failure Shock not identified and treated in the early stages ETIOLOGY Respiratory tract infection (uper and lower)

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emergencies in childhood

EMERGENCIES IN CHILDHOOD

Monika Csóka M.D.

etiology of cardiac arrest in adult
ETIOLOGY OF CARDIAC ARREST IN ADULT
  • Dysrhytmia
  • Ventricular fibrillation
etiology of cardiac arrest in pediatrics
ETIOLOGY OF CARDIAC ARREST IN PEDIATRICS
  • Respiratory failure
  • Shock

not identified and treated in the early stages

etiology
ETIOLOGY
  • Respiratory tract infection (uper and lower)
  • Bronchospasm
  • Foreign body aspiration
  • Drowning
  • Trauma
  • Vomiting/diarrhea
  • Sepsis
  • Supraventricular tachycardia
  • Concenital cardiac abnormalities
  • Seizures
early recognition and intervention
!!! Early recognition and intervention

One study revealed that 92% of children resuscitated when respiratory arrest alone was present had no subsequent neurologic impairment.

slide7
Approximately 10 % of children who progress to cardiopulmonary arrest are successfully resuscitated.
advanced life support
ADVANCED LIFE SUPPORT

Early recognition

Early management of respiratory failure and shock

cardiopulmonary assessment
CARDIOPULMONARY ASSESSMENT

ABCs

  • A  airway
  • B breathing
  • C  circulation
cardiopulmonary assessment11
CARDIOPULMONARY ASSESSMENT

30-second rapid assessment stuctured around the ABCs

airway assessment
AIRWAY ASSESSMENT

Determine child’s ability to ventilate

Airway clear

Maintainable with repositioning

Unmaintainable without intubation or foreign body removal

breathing assessment
BREATHING ASSESSMENT

Determine child’s ability to oxygenate

Respiratory rate

Respiratory effort

Breath sounds (air entry)

Skin color

breathing assessment14
BREATHING ASSESSMENT

A respiratory rate of less than 10 or greater than 60 is an ominous sign of impending respiratory failure in children.

circulation assessment
CIRCULATION ASSESSMENT

Reflects perfusion

Heart rate

Pulse quality

Level of consciousness

Capillary refill

Extremity temperature

Skin colour

Urine output

Blood pressure

circulation assessment16
CIRCULATION ASSESSMENT

Heart rate

most sensitive parameter for determining perfusion and oxygenation

heart rate
HEART RATE

> 140 beats / minute

clinical evaluation to rule out pathologic

etiology

< 60 beats / minute

inadequate cardiac output

slide18
Chest compressions should be instituted until therapeutic interventions increase heart rate to more than 60 beats per minute.
pulse quality
PULSE QUALITY

Cardiac output

Peripheral perfusion

comparing pulse quality and skin temperature at a proximal site with that a distal site

Capillary refill (< 3 seconds)

vital organs
VITAL ORGANS

BRAIN

level of consciousness

alert

responds to verbal stimuli

responds to painful stimuli

unresponsive

KIDNEYS

urine output (1-2 ml / kg / hour = adequate renal perfusion)

blood pressure
BLOOD PRESSURE

Reflects the patient’s ability to compensate when in shock

Blood pressure depends on child’s age

Hypotension (below of fifth percentile) indicates

decompensated shock

25 % of blood volume must be lost before drop in blood pressure occurrs. Hypotension occurs late in shock.

physiologic status
PHYSIOLOGIC STATUS

RESPIRATORY FAILURE

SHOCK

CARDIOPULMONARY FAILURE

respiratory failure
RESPIRATORY FAILURE

Inadequate ventilation / oxigenation

Laboratory: PaCO2 ↑

PaO2 ↓

acidosis

Clinical signs: lack of response to airway maneuvers and oxygen

Therapy: bag- valve-mask ventilation or intubation

shock
SHOCK

Abnormalities in the circulation portion of the assessment

Clinical signs: blood pressure < fifth percentile for child’s age

Therapy: agressive fluid management

cardiopulmonary failure
CARDIOPULMONARY FAILURE

Global deficits in ventilation, oxygenation and perfusion

Clinical signs: agonal respirations

bradycardia

cyanosis

management priorities
MANAGEMENT PRIORITIES

Determine child’s physiologic status

Management specific to physiologic status using ABC format

management priorities27
MANAGEMENT PRIORITIES

Oxigen in the highest concentration available

Cardiac monitoring

Pulse oximetry(inaccurate measure of oxygen saturation when peripheral perfusion is impaired)

respiratory failure28
RESPIRATORY FAILURE

Rapid, aggressive airway management

Deliver the highest concentration of oxygen available

Maintain a comfortable position for the child

respiratory failure 2
RESPIRATORY FAILURE 2.

Basic airway maneuvers:

1. Oral/nasopharyngeal airway placement

2. Neutral, in-line position: head, neck, shoulders

3. Anterior displacement: chin/jaw (to facilitate an open mouth)

4. Remove foreign bodies if present

respiratory failure 3
RESPIRATORY FAILURE 3.

Bag-valve-mask indication:

inadequate previous measures

bradypnea/apnea

Indication of intubation:

if prolonged ventilation requires

inadequate response to bag-valve-mask ventilation

respiratory failure 4
RESPIRATORY FAILURE 4.

Appropriate tube size:

matching to the size of nares or fifth finger

charts and lenght-based tapes (more accurate)

respiratory failure 5
RESPIRATORY FAILURE 5.

Vascular acces:

after meeting ventilation and oxygenation

Nasogastric/oral gastric tube:

in intubated & in bag-valve-mask ventilation

(to ensure maximal ventilation)

shock39
SHOCK

Assessing shock:

1. vascular access:

peripheral (prox. upper extremity):

!three attempts or 90 seconds!

then

intraosseal (dist. femur/prox. tibia): <6 year

or

central (femoral): >6 year

slide40
If intravenous access in the peripheral proximal upper extremity cannot be obtained in three attempts or 90 seconds in a child younger than six years of age, intraosseous vascular access in the proximal tibia or distal femur should be initiated.
shock 2
SHOCK 2.

2. oxygen

3. monitoring:

urine output (to determine organ perfusion)

shock 3
SHOCK 3.

Fluid therapy:

crystalloid (saline/lactated Ringer’s):

20ml/kg in <20min

repeated boluses until stable condition

blood replacement (traumatic blood loss):

blood loss

hypotension

inadequate perfusion parameters

in shock 4
IN SHOCK 4.

Septic/cardiogenic shock therapy

initially: crystalloid 20ml/kg

drugs: inotropes (epinephrine)

after intravenous repletion

(estimated infusion volume: 40-60ml/kg)

corticosteroid: 1 mg/kg/6 hours

cardiopulmonary failure44
CARDIOPULMONARY FAILURE

Global deficit in airway

breathing

circulation

Treatment: oxygen

ventilation (mask)

cardiac monitor

vascular access

inotropic agents
INOTROPIC AGENTS

Epinephrine 0,1-1,0 μg/kg/min bradycardia

shock

hypotensio

Dopamine 2-5 μg/kg/min renal and splanchnic blood flow

10-20 μg/kg/min shock

Dobutamine 2-20 μg/kg/min norm. card. shock

glucose level
GLUCOSE LEVEL

Serum glucose level determination

Glucose replacement (hypoglycaemia)

dextrose (25%) 0.5-1g/kg (2-4ml/kg) over 20-30min

neonates: dextrose (10%) 0.5-1g/kg

postresuscitation care
POSTRESUSCITATION CARE

Once a child is resuscitated, medical care and reassessment must be ongoing.

Laboratory

Radiology

Etiology determine