Pediatric Code Blue Focus Conference November 2015 Duane C. Williams, MD Pediatric Critical Care Department of Pediatrics Children s Hospital of Richmond at VCU Goals of Resuscitation Ensure organ perfusion Ensure oxygen delivery Meet their oxygen demand Provide for their oxygen consumption Treat underlining insult 1
% Control 9/30/2015 Key to Effective Perfusion Volume status Frequent assessment of vital signs Dellinger R et al Surviving Sepsis Campaign ICM 2013 Change in Vital Signs 140 120 100 80 60 40 20 0 % Blood Volume Loss 2
Markers of Improving Perfusion Improved mental status Urine output of ~1ml/kg/hr Appropriate fall in heart rate Remember blood pressure decrease is late Improvement in respiratory status Cap refill Two second cap refill Too fast? Pulse pressure Are distal pulses present IO Placement Place in need of emergent access for fluid and drug administration Should aim to obtain vascular access w ithin 6-12 hours; may be left in place for 72-96 hours if need be Potential locations: Proximal Flat Broad area of Tibia Distal Femur Anterolateral Proximal Humerus* Distal Radius and Ulna* Medial Distal Tibia* Sternum* * Placement site for older children; more commonly used in adults Contraindications to placement: Fracture of the extremity Previous attempt in that site History of osteogenesis imperfect History of osteopetrosis Overlying infection at proposed site (relative contraindication) Complications of placement: Through and through penetration Subcutaneous or subperiosteal infiltration Fracture of bone Local infection Compartment Syndrome Hematoma Potential for growth plate injury Bone or fat embolus (very rare) Incorrect identification of landmarks Bent needle https://calsprogram.org/manual/volume3/section23/13- PED12IntraossVascAccess13.html 3
Cardiac Arrest Coordinate compressions to ventilation 1 Rescuer < 8 yrs old: 30:2 > 8 yrs old: 30:2 2 Rescuer < 8 yrs old: 15:2 > 8 yrs old: 30:2 Intubated 100 beats/min Respiratory rate age and illness dependent Key to Effective Oxygen Delivery The rate at which oxygen is transported from the lungs to the microcirculation 4
Oxygen Demand Oxygen needed to meet the metabolic requirements of the body Oxygen Consumption Amount of oxygen used and made available to the body tissues 5
Markers of Adequate Oxygen Delivery Improvement in mental status Appropriate decrease in heart rate Rise in oxygen saturation Improvement in respiratory status Correction of acidosis Positive Pressure Ventilation Ensure proper sniff position Look for adequate chest rise Matsumoto T et al Jornal de Pediatria 2007 6
Keys to Treatment What are you treating? Shock Hypovolemic Distributive (Septic, Anaphylactic, and Neurogenic) Obstructive Dissociative Cardiogenic Rapid recognition and therapy Hypovolemic Most common form of shock Result of inadequate circulating blood volume secondary to blood or fluid loss Inquire about decreased fluid intake Replenish volume appropriately 7
Distributive Shock Septic, Anaphylactic, and Neurogenic Decrease in blood flow secondary to loss of vasomotor tone despite a normal or high cardiac output Associated with: Peripheral vasodilation Arterial and capillary shunting past tissue beds Pooling of venous blood Decreased venous return to the heart Categories of Septic Shock Systemic inflammatory response syndrome (need two) Tachypnea Leukocytosis or leukopenia* Tachycardia Hyper- or Hypo-thermia* Sepsis Requires evidence of infection Severe Sepsis Requires signs of end-organ dysfunction Septic shock Requires hypotension refractory to fluid administration 8
Anaphylactic Shock IgE mediated allergic response to an allergen Swelling, hives, hypotension, and vasodilation Therapy Immediate epinephrine and anti-histamines Supportive care May need to address poor vascular tone Neurogenic Shock Occurs after an injury to the spinal cord Most commonly seen with blunt trauma Can last one to three weeks Observe hypotension & bradycardia Skin can be warm and dry with blood shunting to the skin causing excessive heat loss and core hypothermia Bradycardia is a classic finding but not universal Treat by increasing vascular tone 9
Obstructive Shock Uncommon in children Mechanical obstruction impairs cardiac output Seen with cardiac tamponade, pneumothorax, cardiac lesions, and pulmonary embolism Treatment? Relieve the obstruction Dissociative Shock Uncommon in children Results from clinical conditions associated with inadequate tissue oxygenation secondary to abnormal affinity of hemoglobin for oxygen Seen with methemoglobinemia and carbon monoxide poisoning 10
Cardiogenic Shock Occurs when cardiac compensatory mechanisms fail May occur in infants with preexisting cardiac disease or myocardial injury Support as needed 11