Stabilisation of the Seriously Ill Child.

Linda DanielPCC Network Educator

January 2007

Aim: Review how a child might commonly present and the role of the healthcare

practitioner in re-establishing physiologic stability.

Objectives:

Discuss the anatomical differences between an adult and child.

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

<1yr = 75

1-5 yr = 48

5-10 yr = 9

>10yr =9

7548

99

Retrievals by Diagnosis Retrievals by Diagnosis 20052005

resp=69 neuro=27 cardiac=18 sepsis=16

metabolic=3 other=7 trauma=1

Respiratory Illness

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

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

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

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

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 Tongue – airway obstruction

Larynx higher –risk of aspiration

Alveoli still developing in size

and numbers (95%)

Airways shorter &narrower encircled

by cricoid cartilage –

less supportMucous membranes

loosely attached airway oedema greater

Diaphragm & intercostal muscles have fewer type 1 muscle fibres - adaptions for sustained activity, hence tire earlier

Large amounts of lymphoidtissue

Greater oxygen consumption due to higher BMR

Anatomical factors which impact upon the child’s spontaneous

ventilation

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

Volume loading achieves little improvement in Volume loading achieves little improvement in cardiac performance unless the infant is cardiac performance unless the infant is clearly hypovolaemicclearly hypovolaemic

Infants are acutely sensitive to after-load due Infants are acutely sensitive to after-load due to myocardial immaturity and their inability to to myocardial immaturity and their inability to enhance contractile performanceenhance contractile performance

Heart Rate 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

Tachycardia shortens diastolic period which in turn reduces ventricular filling time

Causes of breathing problems in childhood.

Upper airway - epiglottitis,

Croup, foreign body

EmpyemaPneumothorax

Pulmonary oedema

asthma,

,bronchiolitis

pneumonia

Coma, convulsions raised ICP, poisoning

Neuromuscular disorders

Diabetic ketoacidosis, Peritonitis abdominal distension

Anaphylaxis

Normal valuesAge Resp.

rateHR Systolic

BP

Neonate 60 160 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

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

AssessmentAirway

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

Respiratory rate and pattern, recession/ accessory muscles, nasal flaring , tracheal tug.

Chest expansion, abdominal excursion, oxygen saturations, equal air entry.

Physiological effects upon heart rate, skin colour mental status

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 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

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

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

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

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 If signs of shock - fluid bolus 10 – 20

ml/kg 0.9% saline.

The 1year old is classed as 10kg

Estimated weight > 1yr = (age + 4) X 2

Start inotropes after 60ml/kg administered in conjunction with volume replacement

Infusion Calculations -Dobutamine

Vial 250 mg / 20mls add to 30 mls of 5% dextrose to give total volume of 50mls

Use formula “What you want” X mls “What you’ve got”

e.g. 5 kg child prescribed 10 mcg/kg/min =

“What you want”

Infusion Calculations -Dobutamine

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 childInfuse at a rate of 0.6 ml/hour

Respiratory Assessment

Disability – Conscious level, behaviour Normal, lively, irritable , lethargic. AVPU / GCS pupillary signs & posture

Exposure Rash , fever Consider anaphylaxis

Summary 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 differencesAdopting a systematic approach to the stabilisation of seriously ill children will allow practitioners to approach their care with confidence.

Drug Calculations 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)