Fran Lockie talks about the similarities and differences in resuscitating sick kids compared to 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
•
•
•
•
•
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

7. 21:00 Advice:
O2,
20ml/kg Fluid bolus,
Antibiotics,
peripheral inotropes

8. 22:00
•
•
•
•
•
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

10. Ketamine, sux, adrenaline bolus

11. PEA Arrest
• Filling, filling, filling
• Dopamine started at 20mcg/kg/min
• Filling, filling, filling
– 4% albumin
– Blood products (packed cells, plts, FFP, cryo)
• Noradrenaline, Adrenaline, infusions
commenced
• Stat dose hydrocortisone

12. 6hrs later….still PEA / ROSC
•
•
•
•
•
Maximal inotropic / pressor support
multiple dextrose, Ca, Mg boluses
Total fluids 180ml/kg
Sustained bradycardia, worsening acidosis
Massive pulmonary haemorrhage

13. • Parents present throughout
• RIP, 03:00

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

18. •
•
•
•
•
ED staff
Anaethetics
Theatre staff
Standardised scenarios
Causes of error
Resuscitation, in Press 2013

19. 75 Simulations
12.4 doctors / nurses per session
194 incidents of subobtimal care
Resuscitation, in Press 2013

20. We are Solutions…
scared of kids!

21. Train together!
• One Base
• Adult teams
– ED
– Intensivists
– Anaesthetists
• Paediatric and neonatal
teams
• Special operations
paramedics

24. •
•
•
•
•
•
Teamwork
Leadership
Crew Resource Management
Resus drills
Intubation drills
Competency frameworks

27. Ann Emerg Med. 2012
Kids have smaller FRC
Greater VO2 than adults
Rapid desaturation (with stress and apnoea)

28. Ann Emerg Med. 2012

29. Ann Emerg Med. 2012

30. Levitan: Dentition, disruption,
disproportion, dysmobility

31. Levitan: 4Ds

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

33. •
•
•
•
•
95 patients
Mean age 5.5
95% success
10 seconds or less
Pain score 2.3
Pediatr Ermerg Care 2008

34. SAFE study
Sepsis resuscitation (FEAST)
Trauma resusitation / massive transfusion

35. Is administering inotropes
peripherally safe?
Inotrope

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
•
•
•
•
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…

38. Lancet 2011; 377: 1011–18
• Listen to the physiology!

39. Lancet 2011; 377: 1011–18

40. Is lactate really the ‘Holy Grail’ of
sepsis biomarkers?
I

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
–
–
–
–
–
–
PEEP
NGT
VBG + Physiology
Early inotropes
Ingestion / inflicted
Pink, warm and sweet