Pediatric advanced life support. Management of decreased conscious level in children Virgi ija Žili skaitė 2017
Life threatening conditions: primary assessment, differential diagnostics and emergency care. Pediatric advanced life support. Management of decreased conscious level in children
Pediatric advanced life support
V.Žili skaitė, 7 4
Causes of sudden cardiac arrest Causes Children and adult Management differences Asphyxial cardiac arrest More common in infant and children In adults: drowning, drug abuse, trauma (hipoventilation) CPR 1min., then call for help or use AED (if 1 rescuer) VF cardiac arrest More common in adults. In children - acute collapse in prehospital settings (about 15% of SCA) If 1 rescuer, call for help first, get and use AED, and start CPR Call for help - immediately activate the emergency response system (ERS) Differences of sudden cardiac arrest (SCA) in Children and Adults: Asphyxial cardiac arrest is more common than VF cardiac arrest in infants and children, and ventilation is extremely important in pediatric resuscitation SCA in children more common is due to respiratory distress or shock, than cardiac disturbances Therefore, cardiac arrest is the result of bradycardia and asystole (not VF)
Child age for resuscitation Child age for resuscitation Causes of sudden cardiac arrest Newborn From birth until discharge from the hospital Insufficiency of breathing Infant From discharge from the hospital until 1 year Child From 1 year until puberty (puberty is Asphyxia: tachycardia bradycardia asystole defined as breast development in females and the presence of axillary hair in males) Adolescent Adult From puberty until 18 years From 18 years until end of life Ventricular fibrillation cardiac arrest Pediatric patient: Infant, child, adolescent
Pediatric advanced life support The order of assessment and intervention for any seriously ill child follows the ABCDE principles: indicates airway head and chin position airway suctioning oropharyngeal tube endotracheal tube, laryngeal mask tracheostomy indicates breathing. Take no more than 10 s to: Look for this includes any movement, coughing or normal breathing (not abnormal gasps or infrequent, irregular breaths). In a child over 1 year feel for the pulse in the neck. pulse or the pulse In an infant feel for the bag-mask ventilation respiratory monitoring (first line pulse oximetry/peripheral oxygen saturation SpO2), end tidal carbon dioxide monitoring artificial ventilation with special devices give oxygen at the highest concentration (i.e. 100%) during initial resuscitation indicates circulation chest compressions cardiac monitoring (first line pulse oximetry/spo2,electrocardiography (ECG) intravascular access (peripheral intravenous (IV) or intraosseous (IO) route), endotracheal route if IV/IO is imposiblle indicates disability indicates exposure Each step is evaluated and the intervention is performed
Resuscitation team: at least 4 rescuers CPR + monitor/defibrillator + IV/IO access Two rescuers Breathing Chest compressions Fourth rescuer Intravascular access IV or IO Fluids and drugs Third rescuer Documentation Defibrillation / cardioversion V.Žili skaitė, 7 8
https://www.youtube.com/watch?v=0rodpk-vpao V.Žili skaitė, 7 9
Asystole CPR + monitor/defibrillator + IV/IO access Give adrenaline IV or IO (0.01 mg/kg) and repeat every 3 5 min (every 2nd cycle) ET Adrenaline 0,1 mg/kg until IV/IO access has been established Identify and treat any reversible causes (4Hs & 4Ts) V.Žili skaitė, 7 11
Defibrillation CPR + monitor/defibrillator + IV/IO access Ventricular fibrillation or ventricular tachycardia without central pulse Give one shock, energy dose 4 J/kg Resume CPR as soon as possible without reassessing the rhythm After 2 min, check briefly the cardiac rhythm on the monitor Give second shock (4 J/kg) if still in VF/pVT Give CPR for 2 min as soon as possible without reassessing the rhythm Pause briefly to assess the rhythm; if still in VF/pVT give a third shock at 4 J /kg Give adrenaline 0.01 mg/kg and amiodarone 5 mg/kg after the third shock once CPR has been resumed Give adrenaline every alternate cycle (i.e. every 3 5 min during CPR) Give a second dose of amiodarone 5 mg/kg if still in VF/pVT after the fifth shock V.Žili skaitė, 7 13
Unstable arrhythmias Open the airway Give oxygen and assist ventilation as necessary Attach ECG monitor or defibrillator and assess the cardiac rhythm Evaluate if the rhyth is slow or fast for the child s age Evaluate if the rhythm is regular or irregular Measure QRS complex (narrow complexes: <0.08 s duration; wide complexes: >0.08 s) The treatment options are dependent on the child s haemodynamic stability
Unstable arrhythmias Bradycardia If a child with decompensated circulatory failure has a heart rate <60 beats min, a d they do ot respo d rapidly to ventilation with oxygen, start chest compressions and give adrenaline Tachycardia Narrow complex tachycardia Vagal manoeuvres (Valsalva or diving reflex) may be used in haemodynamically stable children Chemical (adenosine) or electrical cardioversion (1 J/kg and the second dose is 2 J/kg) Wide complex tachycardia Synchronized cardioversion is the treatment of choice for unstable VT with signs of life Consider anti-arrhythmic therapy (amiodarone) if a second cardioversion attempt is unsuccessful or if VT recurs
AHA PALS Systematic Approach Algorithm
Drugs for resuscitation Drug Adrenaline 0,1% 1mg/ml (1:1000) Indication Dose IV bolus therapy: - asystole - heart rate <60 beats min 1 with decompensated circulatory failure and it does not respond rapidly to ventilation with oxygen 1:10.000 0,1mg/ml Asystole: - IV, IO: 0,01mg/kg (0,1ml/kg 1:10.000, 1 ml / 10 kg) - every 3-5 minutes - ET (endotracheal): 0,1mg/kg (0,1ml/kg 1:1.000) - every 3-5 min., until venipuncture is performed Bradycardia: - IV 0,01mg/kg (0,1ml/kg 1:10.000) - ET : 0,1mg/kg (0,1ml/kg 1:1.000) V.Žili skaitė, 7 20
Reduced level of consciousness Children may present with reduced level of consciousness for many different reasons. Coma is not a disease, but syndrome caused by various causes. Reduced level of consciousness may show: the child is seriously ill there is the first sign of sepsis or other type of shock the sign of direct CNS injury trauma, hemorrhage, infection, stroke etc. The approach to a child with altered mental status requires an process of stabilization, assessment, differential diagnosis, and definitive management The degree of altered consciousness can be quantified by various scales including AVPU (Alert, Voice, Pain, Unresponsive) and GCS (Glasgow Coma Scale), modified when necessary for the child under five years of age
Assessment and management (1) Prior headaches, vomiting or diplopia (double vision) suggest raised intra-cranial pressure. In the absence of specific pointers or a history of previous similar episodes, blood sugar should be measured without delay. Key components of the neurological examination: Level of consciousness Muscle tone, posture, movement and reflexes Brainstem reflexes including pupillary responses and corneal reflexes. Infection represents the most common cause after trauma.
Assessment and management (2) Assessment and management should follow the structured approach of ABCDEFG. In particular determine Glasgow Coma Score (GCS) or modified GCS for the child under five. Assess for: Ask about: Raised intra-cranial pressure (ICP) - Cushing's triad of bradycardia, raised blood Pressure and irregular respiration (note that these are late signs of raised ICP); Abnormal pupillary responses Loss of conjugate gaze Abnormal posture Ocular fundi for papillodema and retinal haemorrhage. Previous similar presentations Trauma Seizures Fevers Recent illnesses, including rashes Diarrhea and vomiting Exposure to drugs and medications, including: Accidental overdose/poisons Alcohol, recreational drugs Oncology treatment
First line investigation and diagnostic tests Intravenous (IV) or intraosseous (IO) blood should be collected if possible, at cannulation, for: Culture Electrolytes, Sodium, Urea, Creatinine, Glucose (EUCG) full blood count (FBC) Blood gas analysis, including lactate Calcium Magnesium Ammonia requires a fresh sample on ice for immediate analysis Creatine phosphokinase (CPK). Blood should be taken for storage of serum, plasma and EDTA (for DNA storage) CT scan should be performed, as soon as the child is stable with adequate airway protection, if the diagnosis remains unclear
Emergency management of children with altered consciousness Assessment and correction of breathing (AB) Assessment and correction of circulation(c) Assessment and correction of glycaemia (D) Assessment and correction of raised intracranial pressure V.Žili skaitė, 7 28