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what are the 2 main causes of cardiac arrest?
- respiratory failure
- circulatory failure
what are the 2 main categories of respiratory failure with 3 eg of each?
- respiratory obstruction: foreign body, asthma, croup/acute epiglottitis
- respiratory depression: convulsions, poisoning/drugs, raised ICP
what are the 2 main categories of circulatory failure with 3 eg of each?
- fluid LOSS: blood loss, burns, D&V
- fluid SHIFTS/MALDISTRIBUTION: sepsis, anaphylaxis, cardiac failure (peripheral/pulm oedema)
what is the main difference in cardio-resp arrest between children and adults
- children: it is usually at the end of physiological deterioration. they arrest because they are already so ill.
- so even if defib - very high death rate
how can you tell if A&B are at a cricital state?
- increased work of breathing - ie respiratory distress
- absent or decreased respiratory effort - due to exhaustion or respiratory depression
what are the 3 main key signs to look for in A&B
- effect ie adequacy of oxygenation
what 5 things do you look for - effort of breathing?
- respiratory rate
- inspiratory or expiratory noises (stridor or wheeze)
- nasal flaring
- use of accessory muscles/paradoxical breathing
how do you assess the efficacy of air entry?
- breath sounds
- pulse oximetry
how do you assess the adequacy of oxygenation?
- heart rate
- skin colour
- mental status
what are the 4 signs of potential circulatory failure (shock)?
- pulse volume reduction - weak peripheral, if weak central then
- increased cap refill time >2s
- BP low - preterminal sign
what are the effects of circulatory failure on the body?
- metabolic acidosis with increased respiratory rate (to compensate)
- skin: pale, mottled, cold
- mental state: agitation then drowsy as reduced cerebral perfusion
- urine output: oliguria as reduced renal perfusion
what are the 3 signs of potential CNS failure?
- level of consciousness
- posture: hypotonic
- pupils: dilatation, unreactivity, inequality
what are the effects of CNS failure?
- respiratory depression
- abnormal respiratory patterns
- systemic hypertension with sinus bradycardia - Cushing's response (indicates herniation of cerebellar tonsils through foramen magnum)
what is the most common cardiac arrest rhythm in children?
what is the treatment for cardiorespiratory arrest?
- shout for help
- approach with care
- free from danger
- evaluate ABCs
- check responsiveness: ask loudly as you all right? do not shake in case c-spine injury
- shout for help if unresponsive (if responsive then leave child in same position and reassess regularly, get help if needed)
- turn child to his back
- open airway using head tilt chin lift
- look listen feel for breathing only for 10s
- if breathing normally - then recovery position - get help
- if breathing is NOT normal then
- - remove obvious airway obstruction
- - 5 initial rescue breaths
- - note any gag or cough response to your action.
- assess circulation: signs of life, carotid pulse in neck if >1yo or brachial pulse if <1yo
- if detect signs of circulation then continue rescue breaths
- if no signs of life start chest compression rate of 100-120/min
- 15 compression then 2 effective breaths
- due for 1 minute then call for help
after BLS, what 3 things may you need to do for the child in cardioresp arrest?
- A: intubate
- B: ventialte
- C: circulatory access - venous or intraosseous, ECG monitor
what are the 2 ways of giving chest compressions to an infant?
- 2 finger technique if ALONE
- hand encircling and using thumbs on lower half of sternum
what is method of chest compression for a small child?
- one handed - heel of the hand over lower half of sternum
- lift fingers so pressure not applied to ribs
once you have a heart rhythm, which are the shockable and which are non shockable?
- shockable: VF, pulseless VT - then give 1 shock 4J/kg then immediately CPR 2 minutes
- non shockable: PEA, systole - immediately resume CPR 2 minutes
what are the reversible causes of cardioresp arrest?
- HHHH: hypoxia, hypovolaemia, hypothermia, hyper/hypoK+
- TTTT: thrombosis, tension PT, toxins, tamponade
what are the 4 main causes of upper airway obstruction?
- foreign body inhalation
- acute croup
what is the cardinal sign of upper airway obstruction?
- stridor: noise associated with breathing due to obstruction of extrathroracic airway
- worse on inspiration
what are features of severe upper airways obstruction?
- severe DIB: exhaustion
- poor air entry
- chest wall recession
- decreased conscious level
what are 3 main features of acute croup?
- dry, barking cough
- hoarse voice
- low grade fever <38.5
what age does croup usually affect?
3month - 5yr
which croup differential is difficult to distinguish from croup?
- bacterial tracheitis
- it will become apparent when there is deteriorating course without antibiotics
what is the management of croup?
- gentle confident handling - avoid unnecessary upset for child
- monitor O2 sats and heart rate
- give O2 - wafting
- seek help if intubation and ventilation required
- nebulised budesonide (steroid) or oral dexamethasone
- nebulised adrenaline (5ml of 1:1000): transient relief to buy time for steroids to work or intubation
why is epiglottitis becoming uncommon?
what is management of acute epiglottitis?
- call for help - senior pads, anaesthetist, ENT surgeon
- KEEP CALM, DO NOT LIE DOWN, DO NOT EXAMINE THROAT - any distress can further compromise airway so defer until full support available
- give oxygen
- expert will intubate and ventilate
- then swab epiglottis and take blood cultures
- iv antibiotics - iv ceftriaxone 80mg/kg/day
what are the causes of lower airways obstruction?
what are the RF for acute asthma attack?
- poor control: long duration of symptoms, night wakening
- previous attack needing IV therapy or PIC
- poor response to Rx in current episode
what are the features of acute SEVERE asthma?
- too breathless to talk or feed
- O2 sats < 92%
- recession and accessory muscle use
what is the management of acute SEVERE asthma?
- high flow oxygen
- inhaled SABA: via large volume spacer 10 puffs of salbutamol 100mcg each.
- or nebulised SABA 2.5 (up to 12yo) -5mg (12-18yo).
- repeat SABA 10-20mins
- predisolone 1-2mg/kg, max 40mg. or iv hydrocortisone 4mg/kg
- if poor response give inhaled ipratropium bromide
what are features of life threatening asthma?
- silent chest
- poor respiratory effort, exhaustion
- O2 sats < 92%
- reduced level consciousness
- peak flow <33%
what is Rx of life threatening asthma?
- high flow O2
- nebulised salbutamol
- ipratropium bromide
- (iv salbutamol, Mg, aminophylline)
- burst therapy - back to back bronchodilators. 3 in an hour. reassess after each burst
what is the commonest serious respiratory infection in infancy?
what is bronchiolitis characterised by?
- BREATHING PROBLEMS:
- tachypnoea >60
- irregular breathing
- recurrent apnoea
what causes bronchiolitis?
- direct inflammation of bronchiole walls and mucus plugging
- virus: RSV, metapneumovirus, influenza, parainfluenza
how does bronchiolitis present?
- age <1yo
- acute DIB - SOB, inc effort
- poor feeding
- recurrent apnoea in neonates
- signs of dehydration
what Qs need to ask mother in bronchiolitis?
- ability to feed
- preterm birth
- underlying cardio/resp disease
- preceding coryza
what is the management of bronchiolitis?
- monitor O2 sats, RR, HR
- airway/nasal passage clearance: may reduce respiratory distress (Yankauer suction catheter at nares)
- give humidified O2 by headbox or nasal cannulae to maintain O2 sats >94%
- HYDRATION: oral feed (mild), NG feed (mod), iv fluids (severe)
- can give nebulised hypertonic saline (3%) to draw water into lungs away from airways
- adrenaline can reduce the oedema and buy time
- CPAP can keep airways open and make easier to breathe
which 3 drugs have no role in bronchiolitis?
NO role for bronchodilators, steroids or antibiotics!
what is Rx when there is exhaustion or apnoea?
- as will become hypoxic and hypercapnic
what is the definition of shock?
- acute failure of circulatory function
- leading to poor TISSUE PERFUSION
what are the 2 common causes of shock in chidlren?
- distributive - sepsis/anaphylaxis
what are the early physical signs of shock?
- pallor: due to vasoconstriction
- tachycardia with reduced pulse volume
- poor skin perfusion: cold, long cap refill
- signs of bleeding
what are the late signs of shock? think of END ORGAN FAILURES!
- rapid deep breathing: response to metabolic acidosis
- agitation, confusion due to brain hypoperfusion
- oliguria: <2ml/kg/h in infants and <1ml/kg/h in children
if there is warm shock what does that indicate?
toxin mediated - gut organisms
what is the Rx of circulatory shock?
- 100% O2
- iv access x2
- fluids: 20ml/kg
- if no improvement repeat 20ml/kg normal saline
- reassess if still no improvement
- intubate, ventilate
how do you manage anaphylactic shock?
- ABC, remove allergen
- lie flat, raise legs
- im adrenaline 1:1000 10ug/kg
- 20ml/kg fluid if shocked
- repeat adrenaline, fluids every 5 mins if no improvement
- once stable: iv hydrocortisone
- iv chlorpheniramine
- monitor: pulse, ECG, BP
what are the main causes of septic shock? organisms
- neisseria meningitides
- G+ve: staph, strep
- G-ve bacteria
what shape and gram is n.meningitides?
what are features of early septic shock (ie compensated)
- increased cardiac output
- decreased systemic resistance
- warm extremities
- high fever
- mental confusion
what are features of late ie decompensated septic shock?
- reduced CO
- cool peripheries
- metabolic acidosis
what is the cardinal sign of meningococcal septicaemia?
- petechial or purpuric rash
- in early stage may be blanching
if meningococcal sepsis is suspected what must be done asap?
how do you manage septic shock?
- A&B: give oxygen
- C: HR, BP, cap refuel - iv access, blood tests, fluids 20ml/kg
- antibiotics: iv ceftriaxone
- metabolic: blood glucose, blood gas - acidosis, DIC
- level of consciousness assess
- meningitis: check fontanelles, LP
- may need ITU - continuous monitoring - central venous pressure, UO, pulse O2
in DKA, why do you get production of ketones?
- without insulin, G cant be taken into cells and used
- so fat is used as energy source - leading to ketone production and metabolic acidosis
what are symptoms of DKA in a new diabetic?
- polyuria due to osmotic diuresis
- polydipsia to compensate
- weight loss
- abdominal pain
what is trigger for known diabetic in DKA and symptoms
- intercurrent illness eg infection
- poor control of glucose levels
- may have poor compliance with insulin
what are the 4 essential Ix in DKA?
- blood glucose
- blood gas
- urine: glucose, ketones
what are the typical abnormalities in DKA
- blood glucose > 15mmol/l
- U&E: increased urea, Na low, K can be low/normal/high depends on renal function and degree of acidosis
- ABG: metabolic acidosis low pH, HCO3 low, PaCO2 low as respiratory compensation
what are the 3 main categories of signs in DKA?
- dehydration: dry MM, reduced skin turgor, tachycardia, hypotension
- acidosis: ketones breath, kussmaul
- cerebral oedema: headache, decreased conscious, seizure, high ICP signs
in DKA what is total body K+ like?
how do you prevent cerebral oedema?
slow metabolic correction and rehydration
how do you treat DKA?
- fluids: treat shock, maintenance fluids rehydrate over 48hours (in case cerebral oedema)
- 0.9% saline initially
- insulin: iv 0.1U/kg/h
- avoid drops of G >5mmol/l/h
- when glucose < 14 add dextrose
- add K+ after giving insulin - need ECG monitor
- treat cause - infection
what things need to be monitored in DKA?
- blood glucse
- fluid balance - input, output, weight
- vital signs, near - ceberal oedema
what are the 2 main complications of DKA?
- cerebral oedema: prevent by avoiding rapid falls in glucose or Na
- cardiac dysrhythmias: K+ levels
what is status epilepticus?
- continuous/recurrent seizures >30mints
- where pt doesn't regain normal baseline mental state
what are causes of status epileptics?
- febrile convulsions
- head injury
- meningitis, encephalitis
- metabolic: hypoglycaemia, poison
what is Rx of status epilepticus?
- ABC - may need nasopharyngeal airway
- check BM
- iv access - check glucose, calcium, Mg
- iv lorazepam --> still after 10 mins then more lorazepam
- if no iv access then PR diazepam or buccal midazolam --> still seizing then iv lorazepam or if no iv access then PR paraldehyde mixed with olive oil
- still seizing then iv phenytoin (infusion under ECG and BP monitoring) or phenobarbitone if already on phenytoin
- intraosseous if no iv
- then paralyse and intubate and ventilate
- treat on ICU - thiopentone or BZD infusion
what are causes of high ICP?
what are symptoms of high ICP?
- altered consciousness
- cushig's sign: bradycardia and hypertension
- asympmetrial pupils
what is Rx of ICP?
- 30 degrees head up
- aim is to reduce activity of brain to reduce blood supply and reduce oedema
- intubate, sedate, paralyse
- need to maintain normoCO2
- iv mannitol or 3% saline to reduce oedema