Objectives. Objectives 10/12/2011. Case Study: Initial Assessment of the Critically Ill Child. By Rebecca Saul, MSN, CRNP

Transcription

1 Case Study: Initial Assessment of the Critically Ill Child By Rebecca Saul, MSN, CRNP Objectives Define the anatomic variations between children and adults Recognize and implement exam techniques useful in rapidly treating the pediatric patient Recognize critical abnormal findings in the pediatric patient Emphasize the importance of early identification of respiratory failure and shock Objectives Describe the clinical features of shock categories Discuss the initial cardiopulmonary evaluation of the pediatric patient Discuss the importance of early evaluation of the neurological status in pediatric patients Discuss the importance of rapid recognition and treatment of sepsis in children 1

2 Case Study You are called to the bedside of a 2 month old being admitted with respiratory distress: RSV vs. pneumonia vs. bronchiolitis The patient is on humidified oxygen by NC What other assessment findings would you observe when you arrive at the patient s room? General Examination Techniques Sick or Not Sick? Across the room observation Quiet to active exam Quiet to Active Exam Listen before you leap! Breath sounds, bowel sounds Allow a child who is well enough to remain in caregiver s arms/lap, if appropriate Minimizing agitation reduces oxygen consumption and energy expenditure Save the worst for last 2

3 So Let s Test Our Theory! Sick or Not Sick? Sick or Not Sick? 3

4 So, you walk into a room and see this Sick or Not Sick? ABC s General appearance Behavior Interaction with caregivers Positioning/Posture Work of Breathing 4

5 Case Study O2 sat is 83% with humidified oxygen Retracting and wheezing, lethargic and limp in parent s arms Tachypneic and having intermittent itt t episodes of bradycardia on monitor Appears mottled and dusky in color What do you do next? General Appearance Is the patient alert and age appropriate? How is the patient interacting with the environment? What is the skin color? What is your first impression of this child? Behavior Is the child playful or withdrawn? Running around the room/very active? Are they irritable or easily agitated? Anxious or unreasonably fearful? Crying or ominously silent? Limp or inactive? 5

6 Interaction with Caregivers Appropriate for developmental level? Fearful? Clinging? Detached? Not interacting at all? Physical Assessment THE PRIMARY SURVEY Case Study What findings about this patient concerned you? This patient requires immediate intervention!!! What s next? What signs indicate airway instability or inadequate respiratory effort? What would you do prior to intubation? 6

7 Quick Review of Structural Differences of Airway Anatomy ABC s Airway patency Structural differences from adults Potential for obstruction/occlusion Work of breathing Structural differences Positioning Circulation Compensatory mechanisms Adult Airway 1. Larger diameter 2. More rigid cartilage 3. Narrowest point at vocal cords 4. Epiglottis narrower and firmer 5. Tongue smaller in proportion to oropharynx 6. Usually less tonsilar and adenoid enlargement or these structures are absent due to surgical excision 7. Cylinder shape 7

8 1. Large, floppy tongue 2. Higher, more anterior airway 3. Epiglottis is wider, floppier, omega shaped 4. Cricoid ring narrowest part 5. Funnel shaped airway 6. More flexibility in tracheal cartilage 7. Diameter of airway reduced Pediatric Airway Airway What equipment do you have available? BVM with appropriate sized mask LMA ETT, laryngoscope blades (sized), handle, Glidescope, ventilator, oxygen Surgical airway equipment What other resources? PEOPLE!!! Airway Is the airway patent? Is there any history of inhalation injury, thermal or chemical? Is there any suspicion of foreign body aspiration i or persistent, unexplained coughing? Is there drooling or difficulty controlling secretions? 8

9 If you secure the airway. Ventilator settings should be reflective of the disease process Asthma and ARDS vs. pneumonia Age and disease dictate rate Lung protective volume settings 6-8ml/kg Start with 100% oxygen and titrate down PEEP/ Pressure support/ itime/i:e ratio Breathing What is the work of breathing? Retractions Nasal flaring Stridor Tracheal tugging Tachypnea Periods of apnea What is the position of comfort? Are there any underlying medical problems? Absent or abnormal breath sounds? Work of Breathing Tripod position maintains airway Apply supplemental O2 in as inoffensive way as possible Blow by Nasal cannula Mask Be aware of impending respiratory compromise!!! 9

10 Case Study Your patient has been intubated, and is sedated. You are utilizing lung protective ventilator settings You notice the patient is cool, pale and tachycardic on the monitor. A femoral arterial line has been inserted and the patient has a systolic BP of 63mmHg What additional measures are warranted? Circulation What are your relevant indicators of perfusion? Skin color Capillary refill Is there any uncontrolled or obvious bleeding? Pulse rate, rhythm, quality, peripheral vs central Cardiopulmonary Differences Adults: Adults: Compensatory mechanisms vary Increase heart rate Increase cardiac contractility Increase stroke volume Lung compliance may be altered due to underlying co morbidity Compromise often visible Blood pressure a more measurable indicator of circulatory status Cardiac arrest can occur for almost any reason 10

11 Cardiopulmonary Differences Pediatrics Compensatory mechanisms: Increase rate to increase CO Lung compliance may be affected by congenital conditions, prematurity or disease process Serious compromise may appear to occur suddenly, monitor end organ perfusion Cardiac arrest usually a result of underlying respiratory failure Case Study The pediatric intensivist is at the bedside. Dopamine has been added to facilitate improved hemodynamics IV fluids 0.9% NaCl infusing at a maintenance rate following 3 saline boluses-minimal improvement in BP Blood cultures and labs obtained and pending Shock 11

12 Shock Defined Inadequate delivery of oxygen at a cellular level resulting in a failure to meet the metabolic demands of the body. Oxygen stores are depleted, oxyhemoglobin disassociation curve shifts to the right Anaerobic metabolism begins to occur resulting in increased serum lactate and cellular acidosis Compensated Stages of Shock Uncompensated Irreversible Hypovolemic Cardiogenic Obstructive Distributive Shock Categories 12

13 Hypovolemic Shock Causes include: Dehydration Direct fluid losses Vomiting Diarrhea NG Suction Insensible fluid losses Fever Non-humidified oxygen Serum osmolality changes Hemorrhage Trauma/ blood loss Coagulopathic states Cardiogenic Shock Causes Congenital defects Ductal dependant lesions Present when ductus closes s Myocardial depression Dysrhythmia Cardiac contusion Cardiomyopathy Ischemic cardiac disease Causes Obstructive Shock Tension pneumothorax Pulmonary embolism y Obstructive lesions such as aortic stenosis Cardiac tamponade Disruption of great vessels such as dissection 13

14 Distributive Shock Causes Sepsis Bacterial Viral Fungal Anaphylaxis Neurogenic Head injury Spinal cord injury Case Study Patient respiratory status stabilized with intubation and assisted ventilation Patient admitted to PICU from ED to pediatric intensivist service IV fluids, dopamine and IV antibiotics are infused early in course of therapy, corticosteroids begun at 1mg/kg/day after admission to the floor Patient diagnosed with septic shock secondary to pneumonia Sepsis 14

15 Signs of Sepsis Hyperthermia or hypothermia Altered level of consciousness Irritability Respiratory distress Rash Abnormal white blood cell counts Sepsis Warm septic shock High cardiac output Vasodilation Tachycardia Brisk capillary refill and bounding pulses Widened pulse pressure Sepsis Cold septic shock Low cardiac output Poor peripheral perfusion/prolonged capillary refill Tachycardia Mottled skin and weak pulses 15

16 Goals for Therapy in Sepsis Restore and maintain end organ perfusion Aggressive fluid resuscitation Vasoactive agents Empiric antibiotics/antimicrobials Maintain i adequate hemoglobin concentration ti Glucose administration Corticosteroid administration for catecholamine refractory shock Interventions for the Critically Ill Child Early recognition and intervention are key to successful outcomes Maintain ABC s aggressively: Secure an airway Optimize oxygenation n Initiate early IV/IO access and fluid resuscitation Vasoactive drug administration Rapid consultation with an intensivist PICU admission Any Questions? 16