RESUS, TRAUMA, CRISIS in KIDS

Indicators of a critically ill infant

Describe the aetiology of arrest in paeds pts

• Resp pathology

  • most cardioresp arrests in children are secondary to hypoxia due to respiratory pathology (e.g. birth asphyxia, bronchiolitis, asthma, inhalation of foreign body)

  • Thus in ALS/BLS, oxtgen delivery rather than defibrillation is the critical first step

  • In the context of anaesthesia, hypoxia due to laryngospasm may lead to bradycardia then asystole

• Neurological dysfunction may also lead to resp arrest

  • (e.g. convulsion, poisoning)

• Circulatory failure

  • small proportion of cardiac arrests

• Fluid loss or blood loss

  • gastroenteritis, burns, truma

• Maldistribution of fluid

  • sepsis, anaphylaxis

• Primary cardiac cause

  • UNCOMMON in kids

Discuss the assessment of blood loss in kids

• Weight lost

• Clinical signs

• Labs

Clinical

• Pulse

  • Brachial < 1yr

  • Carotid or femoral > 1 yr

• CRT

  • sens but not specific

• Skin colour/temp

  • Mottling indicates porr perfusion

• BP

  • VERY LATE SIGN

• UO decreased

• Drowsy

How are children different in the assessment of this

• Vital signs vary with age

• Blood vol is larger 80-90 ml/kg

• Bloood vol is smaller in ABSOLUTE TERMS

• Children compensate for LARGE IV losses before beocming hypotensive

• UO is rel greater 1-2 ml/kg/hr

Describe fluid resus in kids with blood loss

How to give

What vol of PRBC to kids who are not actively bleeding

• 3 way tap in order to rapidly syringe in fluid boluses

• 20 ml/kg bolus

• REASSESS

• 20 ml/kg bolus

• REASSESS

• PRBC

In children who are anaemic but not actively bleeding, volume of PRBC is:

o 10ml/kg of PRBC increases Hb by 3g/dL
o 4ml/kg of PRBC increases Hb by 1g/dL

Assessment and Mx of dehydration

Three types of fluids for kids

How to assess

Severity

RESUS - 10-20 ml/kg

MAINTENANCE - 4, 2, 1 (if unwell 2/3 of maintenance because kids secrete more ADH)

REPLACEMENT - Before used a clinician estimate but this is inaccurate. See RCH guideline. A constant fluid rate based on premorbid weight then just adjust the duration. Replace over 24h (if < 5%) but if larger deficit and sicker child then replace over 48h

eg. Vol in ml needed for replacement =

% deficit x BW x 10

5 × 10 × 10 = 500 ml

Use IBW

• Weight lost

• Clinical signs

• Labs

• Degree of dehydration expressed as % of bw

• 3 MILD

• 6 MOD

• 9 SEVERE

How to gain access in shocked paeds pt

What are the options

IO where

How to confirm IO

What bloods

It is extremely difficult

• IO

• EXT JUG

• FEMORAL VEIN using seldinger

• Cutdown to long saphenous

• Sagittal sinus cannulation in babies

Anteromedial surface of tibia

• 2-3 cm below tibial tuberosity

• ie. away from growth plate

• Aspiration of blood or BM

• Free flow of fluid by gravity

• Blood culture

• Blood group

• Biochem

Mx of choking child

Paed ALS

• bpm

• 30:2

• 15:2

• Drug doses

• Joules

Post resus

• Compress 100-120 bpm

• single person 30

• 2 people 15

• Adrenaline 10 mcg/kg

• Amiodarone 5 mg/kg

• 4 JOULES/kg

Post resus

• A-E

• Optimise oxygen delivery

• offload ventricle

• maximise cerebral perfusion pressure

• ECG, bloods, CXR, BSL

Anaphylaxis

Common causes

• NMB

• Latex

• Abx

• Contrast

Sepsis

Major pathogens < 2 months old

Major pathogens in older kids

What % present cold shock

What % present warm shock

Every hr they remain in shock their mort

Key features of sepsis on assessment

• 2/3 children present in ‘cold’ shock (normal/low CO and high SVR)

• 1/3 children (and adults) present in ‘warm shock (normal/high CO and low SVR)

DOUBLES

RCH sepsis flowchart

Aspiration

Severe bronchospasm

• what can trigger

• stable asthma pts?

• What about wheeze preop?

Mx

• Procedures commonly performed during anaesthesia (e.g. laryngoscopy, intubation, suctioning) are intense and potent stimuli that can trigger bronchospasm

• In stable asthmatic patients, peri-op risk for bronchospasm is low and is not assoc with significant increase in morbidity

• In the child with wheeze at time of pre-op assessment, there is a very high risk for intra-op bronchospasm

• Severe bronchospasms requires more aggressive, IV bronchodilator therapy

Mx is as per adult but more frightening

POST Tonsillectomy bleed

• Incidence

• Primary

• Secondary

• Factors that affect bleed rates

• Assessment

• KEY PROBLEMS

• MANAGEMENT

Incidence

• 3.5% get bleed

• 0.9% RTT

FACTORS THAT AFFECT BLEED

• Age (lower rates in kids)

• Highest with quinsy and recurrent tonsillitis

• Surg technique - highest with diathermy, lowest with blunt technique

KEY PROBLEMS - PPASHA

• Hypovolaemia

• Potential coagulopathy

• Aspiration risk

• Difficult and Soiled airway

• Shared airway

• Paediatric patient

Gas Embolus

Why head down left laft with venous gas embolus

A head-down (Trendelenburg) position helps manage a venous gas embolism by using gravity to trap air bubbles away from the pulmonary artery outflow tract. This relieves the "air lock" in the heart so blood can keep pumping. Combined with a left lateral decubitus tilt, it prevents air from traveling to the brain or lungs

• Venous Gas Embolism: Head-down and left-side positioning are recommended. This traps air in the apex of the right ventricle, keeping the outflow tract clear

• Arterial Gas Embolism: The head-down position should be avoided. It increases intracranial pressure and can worsen cerebral edema. Patients with arterial bubbles should remain flat (supine)

LAST

Malignant hyperthermia

• Muscle diseases assoc with MH

• v rare in 1st year of life

• King denborough

• myotonia fluctuans

PYLORIC STENOSIS

• What will kill them on induction?

BG

• What is it

• Med or surgical emerg?

• Three stages?

• Incidence?

• % male or female

• Peak pres?

PATHOPHYSIOL

• three aspects

=== DEHYDRATION KILLS ON INDUCTION NOT ELECTROLYTE IMBALANCE

BG

• Hypertrophy of outlet of stomach

• MEDICAL EMERGENCY

• Three stages

  • Hypochloraemic, hypoNa, MET ALK, DEHYDRATION, Alk urine

  • K depletion, paradoxical ACIDIC urine

  • SHOCK, Lactic acidosis, starvation ketosis

• 1 in 350

• 80% male

• PEAK 2-5 weeks of age

PATHOPHYSIOL

• Vomiting causes loss of HCl, water, small amount Na and K 

• Pancreatic bicarb is produced not secreted

• → Metabolic ALK

• So much bicarb then overwhelms the resorptive capacity of PCT → alkaline urine

• ECF vol depletion stims the RAAS

• Na is retained and (K is lost and H+ is lost)

• URINE becomes acidic

• Total body K+ drops

• Lose K in vomit but also shift from ECF to ICF due to alkalosis

  • (H+ moves out and K+ moves in)

• Problem is - there is insufficient Cl in the glom filtrate

• Cannot exchange with bicarb

• Kidney cannot correct the acidosis (cant retain bicarb)

—→ ACIDIC URINE

—→ METABOLIC ALK

—→ IN EXTREME UNCORRECTED CASES THEN SHOCK, REDUCED TISSUE PERFUSION → METABOLIC ACIDOSIS

• —> COMP RESP ALKALOSIS (Hyperventilation)

Clinical features

Diagnosis

Mx

• Is surgery urgent

• What must happen prior?

• Briefly what do the surgeons do

Anaesthetic Implications

PREP

• Vol depletion

• Electrolyte abnormalities

• Pre-op wide bore NGT decompression

INDUCTION - controversial

• Many paeds anaes use sevo and atrac - avoiding sux brady

• OR propofol and sux

• Very few know how to do cricoid in neonate

MAINTENANCE

• Non-opioid or small amount of fentanyl

• Risk of apnoeas

• Hypoglycaemia

EMERGENCE

• Extubate light

DISPOSITION

• Post-op ventilatory depression common

How is severity assessed?

Fluid resus and replacement in PS

Outline special preparations in the emergency department prior to the arrival of a paediatric trauma patient

• TEAM

• EQUIPMENT

• IV DRUGS

• PATIENT

PAEDS TRAUMA PT ARRIVED

1. Control of exsanguinating external haemorrhage

2. AIRWAY AND CSPINE

3. BREATHING

4. CIRCULATION

5. DISABILITY

Paeds trauma continued

1. Control of exsanguinating external haemorrhage

2. AIRWAY AND CSPINE

3. BREATHING

4. CIRCULATION

5. DISABILITY

Paeds Trauma

1. Control of exsanguinating external haemorrhage

2. AIRWAY AND CSPINE

3. BREATHING

4. CIRCULATION

5. DISABILITY

6. EXPOSURE

Outline the use of the Broselow tape in paediatric trauma

•  Uses child’s height or length to estimate weight

• If the weight is not known, some centres use the Broselow tape to estimate the child’s weight and to determine drug doses, equipment sizes (e.g. ETT) and energy for DC shock without any calculations

• Ensure the tape is rolled out on the receiving bed, ready to use

• Tape is laid alongside the child and estimated weight read from the tape

Describe traumatic injury patterns in children that differ from adults, including spinal cord injury without radiological abnormality (SCIWORA) and tension pneumothorax

• Kids are small

• Trauma affects more organs

• Greater dist of force

• Connective tissues more elastic therefore shearing forces may tear major blood vessels

• Flexible skeletal system means significant organ damage with no overlying fractures

• Abdo wall less protected by fat and subcut tissue

• LARGE head in comparison to body

• Little evidence of external injury

• PLUS physiological compensatory mechanisms masks deterioration

  • remember BP maintained until 30% lost

Common causes of paed trauma

• MVA

• drown

• burns

• NAI

• Firearms

• Falls

Types of injury set patterns according to age

• Infant → head injury, big head, thin skull

• Young kids → thoracic and abdo - low c of grav

• Children < 5y → falls and drowning

• Older kids → Limb injuries - higher c of grav

Spinal cord injury without radiological abnormality (SCIWORA)

• What

• Causes

• Ix

• Mx

• An injury that presents with objective signs of cervical spinal cord damage, but no radiological evidence of fracture or ligamentous instability of the cervical spine

• Flex and extension injuries

• Fall, MVA

• MRI

• MTD care and immobilise C Spine up to 3 months

Describe indicators of non-accidental injury in paediatric populations and outline an appropriate course of action when non- accidental injury is suspected

Indicators

Obligations of anaesthetist

Features suspicious of NAI

• Injuries inconsistent with history

• Child reports adult harm

• Multiple injures of differing ages

•  Delayed presentation

• Unusual injuries

  • Significant bruising, especially in children too young to walk

  • Fractures in children too young to walk, rib fractures, multiple fractures or long bone fractures in young children

  • Cigarette burns, well demarcated burns or bite marks

  • Injuries in inaccessible places such as neck, ear, hands, feet and buttocks

  • Intra-oral trauma, damage to frenulum, esp in children too young to walk

  • Genital or anal trauma

• Subdural haematoma, retinal haemorrhages

• Injury to internal organs with no history of major trauma

Mx of burns

See colourful page

Fluid Mx in burns

• Fluid needs to be replaced

• Greatest amount is in first 24h

  • First 8-12h IV to interstitial comps therefore any fluid given will rapidly leave IV comp

• AIM MAINTAIN ADEQUATE CIRC VOL

  • Too little hypoperf

  • Too much then oedema and tissue hypoxia

MODIFIED PARKLAND FORMULA

• 3-4 ml x kg x % burn

• this gives you ml to give in 24h of Hartmanns

• Give half over 8h

• Remaining half over 16h

MATINTENANCE FLUID - added to above for kids < 30 kg

• 4, 2, 1

Analgesia in Burns

• Multimodal

• Regional block - can be hard infection, gen sepsis

• OPIOIDS

• Ketamine but beware delirium

• Role of gabapentin expanding

• IV better than PO

• PSYCHOLOGICAL MX

Pathophys of burns

• Burns cause thermal injury to the skin, which in turn compromises its protective functions. By doing so, this effective barrier is lost and complications, such as hypothermia and infection, can occur

• Massive inflammatory response  

  • Dead tissue 

  • Massive energy demand for temperature and wound healing 

  • Sympathetic response 

  • TO TREAT RESPONSE 

    • Debridement / remove source 

    • No evidence for steroids  

• Gut may stop working 

  • Feeding issues are possible  

• Increasing metabolic demands due to dead tissue and wound healing 

  • Increase CO (7x normal) 

  • Need to have adequate nutritional support for severe burns 

  • Raised temp (altered set point - constant high temp) 

• Respiratory system will +++ to get rid of CO2 being produced everywhere 

• Loss of skin 

• Brain should be normal 

• Renal dysfunction 

  • Muscle breakdown 

Key anaesthetic issues of a Burns pt

• TEMP MX

• ANALGESIA

• FLUID MX

• ACCESS

Drowning

• Def

• Hx

• Exam

• Ix

• Mx

Def

• is the process of experiencing respiratory impairment from submersion/immersion in a liquid

Mx - key things go think about

• VOM is common - Aspiration of vomit is a major comp - place spont breathing kids in left lateral

• Hypothermia is a common comp

Immediate Mx

Active rewarming

Subsequent Mx