Care of the very sick childCare of the very sick child

Morris Earle, Jr. MD, MPHMorris Earle, Jr. MD, MPHUMASS Memorial Medical SchoolUMASS Memorial Medical School

Worcester, MAWorcester, MA

and Sarah A. Murphy, MDand Sarah A. Murphy, MDMassGeneral Hospital for ChildrenMassGeneral Hospital for Children

Boston, MABoston, MA

Care of the very sick child: Care of the very sick child: Presentation OverviewPresentation Overview

• This presentation will focus on the principles that are common to:

• Emergency Triage Assessment and Treatment (ETAT)

• Pediatric Advanced Life Support (PALS)• and the treatment of very sick children

Presentation OverviewPresentation Overview

• We will focus on:– Recognition of very sick children– Rapid assessment of ABCs– Treatment of A,B, and C according to ETAT

guidelines– Next steps in treatment of a very sick child– Rapid differentials for various signs and

symptoms

Care of the very sick child: ETATCare of the very sick child: ETAT

• “Emergency Triage Assessment and Treatment”

– Deaths in hospital often occur within 24 hours of admission

– Many of these deaths could be prevented if very sick children are identified quickly and appropriate treatment started immediately

ETATETAT

– ETAT is a set of guidelines developed by the WHO for health care providers

– It is meant to aid in the rapid recognition and treatment of very sick children

– Based on the principle of recognizing “emergency signs” and beginning appropriate therapy for them when present

– Like PALS and other treatment protocols, follows the format of ABC

Why does having a system for rapid recognition and Why does having a system for rapid recognition and treatment matter?treatment matter?

““The management of sick young infants at The management of sick young infants at primary health centres in a rural developing primary health centres in a rural developing

country”country” Archives of Disease in Childhood 2005:90:200-205Archives of Disease in Childhood 2005:90:200-205 Duke, Oa, Mikela et al (Papua New Guinea) Duke, Oa, Mikela et al (Papua New Guinea)

• Signs predicting death were: – not able to feed– fast respiratory rate– retractions– apnea– cyanosis– “too small”– “skin cold”– severe abdominal distension– bulging fontanelle– hypothermia (<36 axillary)

““The management of sick young infants at The management of sick young infants at primary health centres in a rural developing primary health centres in a rural developing

country”country”

Conclusions:

• signs predictive for death may warrant:– emergency treatment – longer observation – or urgent referral

• Respiratory compromise was present in 25% of young infants

• Failure to give oxygen therapy was a modifiable factor in 27% of deaths within health facilities

• A high proportion of seriously ill young infants were discharged from health facilities

early without adequate follow up

““The management of sick young infants at The management of sick young infants at primary health centres in a rural developing primary health centres in a rural developing

country”country”

Care of the very sick childCare of the very sick child

1) Diagnosis: Who is “very sick” ?

2) Management:Airway

Breathing Circulation

Etc…

Recognizing a “very sick Recognizing a “very sick child”child”

WHO-identified “Emergency Signs” (ETAT) WHO-identified “Emergency Signs” (ETAT) that require immediate intervention:that require immediate intervention:

• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Signs of severe dehydration

Respiratory Rate >60 (infant)>40 (toddler)

>30 (child) >20 (teen)

Heart Rate >160 (infant) >120 (child) > 90 (teen)

EarlyEarly Signs of Severe Illness: Signs of Severe Illness: Abnormal Vital SignsAbnormal Vital Signs

Abnormal Vital SignsAbnormal Vital Signs

Hypo or hyperthermia

Later Signs:

Hypotension:

< 60 systolic (newborn)

< 70 (infant)

< 70 +(age x 2) (child)

< 90 (teen)

Assessment of the Very Sick Assessment of the Very Sick ChildChild

Rapid assessment of a sick child begins with ABC’s…

Assess and treat Airway, Breathing, and then Circulation, in that order

A = AirwayA = Airway

The ten commandments of The ten commandments of Pediatric Intensive Care; Pediatric Intensive Care;

• Airway

• Airway

• Airway

• Airway

• …Et cetera

Complete Airway Obstruction;Complete Airway Obstruction;

• Either dead

or

• Has a foreign body – needs heimlich maneuver (child)– or five back blows and chest compressions

(infant)

5 Back blows:5 Back blows: for infant with for infant with

suspected suspected foreignforeign

body and body and complete complete

airway airway obstructionobstruction

Alternate with 5 chest compressionsAlternate with 5 chest compressions

Heimlich Maneuver for a childHeimlich Maneuver for a child

Partial Airway Obstruction:Partial Airway Obstruction:

• Look for signs of Partial obstruction!– Stridor– Snoring– Accessory muscle use– Abdominal breathing

Partial Airway Obstruction:Partial Airway Obstruction:

Child is Conscious:

1. Inspect mouth and remove foreign body if present

2. Clear secretions from mouth and throat

3. Allow child to assume most comfortable position

Child is Unconscious:

1. Tilt head (unless concern for trauma to head/neck- then do jaw thrust with 2nd person stabilizing neck)

2. Inspect mouth, remove foreign bodies

3. Clear secretions from mouth and throat

4. Check airway by feeling for breath, watching for chest rise, listening for breath sounds

Positioning airway: Positioning airway: 1.Sniffing position1.Sniffing position

The sniffing positionThe sniffing position

•

Adjust Airway:Adjust Airway:2. jaw thrust2. jaw thrust

• Should be used if there is any concern about neck trauma or cervical spine injury

Adjust Airway:Adjust Airway:3. Artificial airway3. Artificial airway

• Oral airway if unconscious

• Nasal airway if conscious

Nasopharyngeal Airway:

Insertion of oral airwayInsertion of oral airway

Sizing of oral airwaySizing of oral airway

B: BreathingB: Breathing

Assessment of Breathing:Assessment of Breathing:signs of respiratory distresssigns of respiratory distress

• Tachypnea

• Retracting

• Grunting

• Flaring

• Use of accessory muscles

• Stridor

RetractionsRetractions

Respiratory DistressRespiratory Distress

• If patient exhibits signs of respiratory distress, administer oxygen:

Assisted Breathing:Assisted Breathing:bag and mask techniquebag and mask technique

The sniffing positionThe sniffing position

•

Bag and Mask Ventilation:Bag and Mask Ventilation:watch for chest risewatch for chest rise

Assisted Breathing: IntubationAssisted Breathing: Intubation

Use of curved bladeUse of curved blade

Use of straight bladeUse of straight blade

View of vocal cordsView of vocal cords

Assisted Breathing: Assisted Breathing:

• Chest must rise well

• Check for proper placement of ETT with CO2 detector if available

• Check for equal breath sounds in axillae

• Confirm placement with xray

• Place nasogastric or orogastric tube

For the following “emergency signs”:For the following “emergency signs”:

Severe Respiratory Distress,Severe Respiratory Distress,Central Cyanosis,Central Cyanosis,

oror Obstructed Airway: Obstructed Airway:

• Emergency Management:– Manage choking if foreign body aspiration– Position airway properly– Administer oxygen– Assist in ventilation if needed– Make sure child is warm

C = CirculationC = Circulation

Assessment of Circulation: Assessment of Circulation: ShockShock

• Cold hands AND:– Capillary refill >2 seconds– Weak and fast pulse

Signs of ShockSigns of Shock

• Tachycardia

• Poor perfusion (>2 second capillary refill)

• Weak pulses

• Cool extremities

• Poor mentation, lethargy

• Poor urine output

ShockShock

For the following “emergency signs”:For the following “emergency signs”:

Cold hands,Cold hands,Capillary refill >2 seconds,Capillary refill >2 seconds,andand Weak and fast pulse: Weak and fast pulse:

• Emergency Management:– Stop any bleeding– Give oxygen– Make sure child is warm– Give fluids (see chart)– Give glucose– Full assessment and treatment

For the child in shock it is For the child in shock it is imperative to give fluids…imperative to give fluids…

Obtain IV access!Obtain IV access!If unable to place IV, place IOIf unable to place IV, place IO

ShockShock

• Early detection and aggressive management improves survival

Vascular AccessVascular Access

• Consider intraosseous line placement as initial attempt for victims of cardiac arrest

• No upper age limit for attempt at intraosseous access (Class IIa, LOE 5)

Intraosseus needle insertionIntraosseus needle insertion

Intraosseus needle insertionIntraosseus needle insertion• Alcohol swabs• 18G needle with trochar (at least 1.5 cm in length)• 5 ml syringe• Infusion fluid• Local anaesthesia may be required if the patient is

conscious.

Intraosseus needle: alternative siteIntraosseus needle: alternative site

Treatment of Shock:Treatment of Shock:

• First! assess if child is severely malnourished• If not:

– Insert IV or IO– Prepare a bag of Ringers Lactate or Normal Saline– Infuse 20ml/kg as rapidly as possible– Reassess after 1st infusion and repeat if no

improvement– Reassess after 2nd infusion and repeat if no

improvement– Reassess after 3rd infusion. If no improvement give

20cc/kg of blood transfusion, or a 4th bolus of fluids if patient has diarrheal illness

Treatment of Shock:Treatment of Shock:

• If a child is severely malnourished it may be difficult to distinguish shock from malnourishment

• In addition, shock from sepsis and dehydration may coexist

• Fluids must be given very slowly • Monitor pulse and breathing every 5-10 mins• Over-hydration can lead to heart failure

Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients

• If the child is lethargic or unconscious:– Keep warm– Give 10% glucose 5ml/kg– Then give IVF: 15ml/kg over 1 hour– Re-assess every 5-10mins for improvement or

worsening– STOP infusion if respiratory rate increases or pulse

increases as this means fluids are worsening the child’s condition

– If improvement after fluid, may repeat x1 over an hour– Then switch to oral or NG re-hydration and initiate re-

feeding

Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients

• If the child does not improve with first fluid bolus:– Assume child is in septic shock as opposed to

dehydration related shock– Give maintenance fluids– Transfuse 10ml/kg of blood, when available,

slowly, over 3 hours– Start antibiotic treatment– Initiate re-feeding

Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients

• If severely malnourished child is NOT lethargic or unconscious, but is alert:– Give 10% glucose: 10ml/kg by mouth or

nasogastric tube– Move to assessment and treatment for severe

malnourishment

Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients

Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients

Treatment of shock in severely Treatment of shock in severely malnourished patientsmalnourished patients

After A, B, C, move on to assess After A, B, C, move on to assess the “other C”, D, and then other the “other C”, D, and then other

organ functions…organ functions…

Assessment of the very sick Assessment of the very sick child:child:

The “other C’s”= coma or The “other C’s”= coma or convulsionsconvulsions

Assess for Coma or Assess for Coma or Convulsions: AVPUConvulsions: AVPU

• Is the child:– Alert?– Responding to Voice?– Responding to Pain?– Unconscious?

• A child who is not alert but responding to voice is lethargic

• A child who does not respond to pain is unconscious

Assess for Coma or Assess for Coma or Convulsions:Convulsions:

• Is the child having rhythmic movements and unresponsive?

For the following “emergency signs”:For the following “emergency signs”:

ComaComaoror

Convulsing:Convulsing:

• Emergency Management:– A, B, C– Give oxygen– Diazepam or Paraldehyde rectally for

convulsions (seizures)– Position unconscious child in protective

manner– Give IV glucose– Full assessment and treatment

D = DehydrationD = Dehydration

Severe Dehydration in Child Severe Dehydration in Child with Diarrheawith Diarrhea

• Diarrhea plus– Lethargy– Sunken eyes– Very slow skin pinch

For the following “emergency sign”:For the following “emergency sign”:

Diarrhea with Diarrhea with lethargy, sunken eyes, or very slow lethargy, sunken eyes, or very slow

skin pinch:skin pinch:

• Emergency Management:– Make sure child is warm– If child is NOT severely malnourished

• Insert IV and give rapid fluid boluses• Treat diarrhea

– If child is severely malnourished:• Do not insert IV• Treat per malnourishment guidelines

Review: Assessment and treatment Review: Assessment and treatment of the very sick childof the very sick child

• After assessing for, and immediately treating “emergency signs”, the caregiver should then move on to looking for “priority” signs which warrant urgent treatment

• Emergency Signs:– Obstructed Breathing– Severe Respiratory Distress– Central Cyanosis– Signs of Shock– Coma– Convulsions– Signs of severe dehydration

Review: Assessment and Review: Assessment and Treatment of the very sick child:Treatment of the very sick child:

• Priority signs:– Sick child less than 2 mos– Very high temperature– Trauma or other surgical condition– Pallor– Poisoning– Severe Pain– Respiratory Distress– Restless/Irritable– Malnutrition– Oedema– Burns

• Remember: start with assessing and securing A,B, C!

Review: Assessment and Review: Assessment and Treatment of the very sick child:Treatment of the very sick child:

Special Note about: Emergency Findings in Special Note about: Emergency Findings in a Severely Malnourished Child:a Severely Malnourished Child:

• All children with severe malnourishment require prompt attention and treatment of malnourishment

• A severely malnourished child who presents with airway obstruction or severe respiratory distress, coma or convulsions should be treated as you would a non-malnourished child

• Severely malnourished children who are dehydrated should NOT be re-hydrated by IV unless they are in shock

• Severely malnourished children in shock should be re-hydrated cautiously with frequent re-assessment of their response to fluids