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Fran Lockie on Kids: Just Little Adults?
1. Kids: Just Little Adults?
Dr Fran Lockie
MedSTAR
Paediatric Emergency, Women’s and Children’s
Bedside Critical Care, September 2013
2. Scope
• Case
• Why are we scared?
• Structured approach
– Airway,
– Breathing
– Circulation
• Can we do better?
3. 15 month old male with fever
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NVD at term, BW 2.7kg
Previously fit and well
No meds, NKDA
Immunisations UTD
Family all coryzal
4. Country Hospital
• At triage (17:30)
– Alert and playful
– Temp 39, Hr 160, Rr 40
– Good central perfusion
– Mottled peripherally
5. 18:45 Seen by RMO
• Given panadol with resolution of fever, HR
never < 170 since triage
• Bloods
– VBG pH 7.15, BE -10, B/C 10, lact 5, CO2 25
– BSL 6
• Urine NAD
6. URTI focus for fever identified
• 2 small vomits in waiting room, then a small
area of petechiae
8. 22:00
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A Maintained, No O2
B RR 60, marked increased resp effort
C peripheral CRT: absent, central >5 secs
D alert, talking to mum
24g PIV tissued, further attempts unsuccessful
9. Rapid deterioration
– AVPU
– Increasing respiratory distress
– HR >200, Only femoral pulse palpable
– IO sited
– Aggressive filling
– DA started
14. We are scared of kids!
• Kids need early aggressive treatment
• Failure to diagnose shock
• Failure to resuscitate
– Early access
– Early fluids
– Early Abx
– Early inotropes (peripheral is OK!)
– Early intubation
– Evaluate our actions: lactate and physiology
15. • Audit of 17 PICU’s
• 107 patients with septic shock
• 8% received care c/w ACCM guideline
– 21% not given >60ml/kg despite ongoing shock
– 15% not given dopa/ dobu despite fluid refractory
shock
– 23% not given catechol for dopa/ dobu refractory
shock
– 30% not given steroid despite catechol resistant
shock
Arch Dis Child 2009
16. • FAILURE TO DIAGNOSE SHOCK
• 3 factors
– Not looked after by a paediatrician
– Lack of supervision
– Failure to administer inotropes
BMJ
17. Early Resuscitation of Children with
Moderate to severe TBI
• 299 kids with mod-severe TBI
• 39% became hypotensive
– Of these only 48% were treated
• 44% became hypoxic
– Of these 92% were treated
Pediatrics 2009;124;56
32. “Doctor, He’s Tiring!”
• Diaphragmatic exhaustion
• Lacks type 1 muscle fibres
• Decompress the stomach
– Often results in dramatic improvement!
• Know your vent: wt limits
– Generally TV 4-6 ml/kg
36. •
73 of 1133 treated with vasoactive agents by peripheral IV
•
Primarily Dopamine monotherapy (90%) or Dop + Ad (7%)
• 11/73 (15%) developed infiltration – all resolved without
significant intervention
• Longer duration
• Higher dose of dopamine
Pediatr Emerg Care 2010
37. Sugar and temperature
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Large SA: body wt (2-2.5 x BW)
Thin skin and subcut fat (less insulation)
No shivering
Immature thermoregulatory center
• Sugar ALWAYS goes down in critical illness…
41. Is lactate really the ‘Holy Grail’ of
sepsis biomarkers?
No, but sepsis often masquerades
as respiratory disease in kids
I
42. If you still can’t explain it…
• Always assume ingestion
• Always assume inflicted injury
43. Smaller but the same
• Train together??
• Golden rules
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PEEP
NGT
VBG + Physiology
Early inotropes
Ingestion / inflicted
Pink, warm and sweet