THE CHILD WITH  CIRCULATORY PROBLEMS Jamie Ranse :  Critical Care Education Coordinator, Staff Development Unit, ACT Health.
<ul><li>Differences in children </li></ul><ul><li>Circulatory assessment </li></ul><ul><ul><li>General </li></ul></ul><ul>...
<ul><li>Myocardium </li></ul><ul><li>Compensation </li></ul><ul><li>Body water </li></ul><ul><li>Surface area </li></ul><u...
<ul><li>Less compliant  </li></ul><ul><li>Has less contractile tissue </li></ul><ul><li>Significance: </li></ul><ul><ul><l...
<ul><li>Normotensive until 25% of their blood volume is lost </li></ul><ul><ul><li>Circulating volume </li></ul></ul><ul><...
<ul><li>60% of body weight of an adolescent </li></ul><ul><li>65% of the preschooler </li></ul><ul><li>80% of the infant <...
<ul><li>Intracellular fluid compartment </li></ul><ul><li>Extracellular fluid compartments </li></ul><ul><ul><li>Intravasc...
differences in children: body water
<ul><li>Larger surface area / volume ratio </li></ul><ul><li>Significance: </li></ul><ul><ul><li>Greater risk of dehydrati...
<ul><li>Intraosseous cannulation threshold </li></ul>differences in children: venous access
<ul><li>Myocardium </li></ul><ul><li>Body water </li></ul><ul><li>Metabolic rate </li></ul><ul><li>Distribution of body fl...
<ul><li>Observation </li></ul><ul><li>Palpation </li></ul><ul><li>(Percussion) </li></ul><ul><li>Auscultation </li></ul>ci...
<ul><li>Observe </li></ul><ul><ul><li>Skin colour </li></ul></ul><ul><ul><li>Work of breathing </li></ul></ul><ul><ul><li>...
<ul><li>Broad categories </li></ul><ul><li>Hypovolaemic </li></ul><ul><li>Cardiogenic </li></ul><ul><li>Distributive </li>...
<ul><li>Hypovolaemia </li></ul><ul><li>Hypovolaemia most common cause of shock in children </li></ul><ul><li>Gastroenterit...
<ul><li>Dehydration results from </li></ul><ul><ul><li>Reduced intake </li></ul></ul><ul><ul><li>Increased fluid loss </li...
<ul><li>Steiner et al 2003 </li></ul><ul><ul><li>Prolonged CR  </li></ul></ul><ul><ul><li>Abnormal skin turgor </li></ul><...
circulatory assessment: hydration status – estimating deficit Mild 3% Reduced urine output Thirst Dry mucous membranes Mil...
<ul><li>Broad categories </li></ul>management of circulatory alterations
management of circulatory alterations
<ul><li>Calculation of fluid replacement </li></ul><ul><ul><li>10mls/kg isotonic solution </li></ul></ul><ul><li>Calculati...
DVD of circulatory assessment
<ul><li>1010: Called to an infant with 3/7 history of diarrhoea  </li></ul><ul><li>1015: On arrival 6/12  ♀ named Mary : <...
<ul><li>1020: During your initial examination, you notice Mary’s condition deteriorate… </li></ul><ul><li>  A: clear  </li...
<ul><li>What are Mary’s problems? </li></ul><ul><li>What else do we need to know to assist her? </li></ul>case study
<ul><li>Foetal problem – nil </li></ul><ul><li>Illnesses / injuries since birth – nil  </li></ul><ul><li>Immunisation stat...
<ul><li>Observe </li></ul><ul><ul><li>Skin colour </li></ul></ul><ul><ul><li>Work of breathing </li></ul></ul><ul><ul><li>...
THE CHILD WITH  CIRCULATORY PROBLEMS Jamie Ranse :  Critical Care Education Coordinator, Staff Development Unit, ACT Health.
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The child with circulatory probelms

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  • The total circulating volume of a 1 year old is roughly the same as the amount of water you pour on your indoor pot plant. At about 80mls/kg it doesn’t take much loss before you have a significantly shocked baby on your hands. With circulatory function failing, oxygen and nutrients are not reaching the cells and cellular waste products are not being cleared. Circulatory assessment is therefore a very important skill to develop in order to recognise the early signs of a shocked child. heart rate: Increased heart rate may indicate shock, or hypoxia. or fever, or anxiety. Bradycardia is defined as a heart rate less than 60 or a rapidly falling heart rate with poor systemic perfusion. Bad, bad, bad. Cardiac compressions will need to be commenced in infants with HR&lt;60 and poor perfusion. You will probably be experiencing a holy crap moment at this time and be hesitant to begin CPR. If in doubt, just do it. *Unnecessary* chest compressions are almost never damaging. pulse volume and blood pressure: A good indicator of general perfusion can be made by palpating peripheral and central pulses. A poor central pulse with absent peripheral pulses is a sign of significant shock. Remember: when fitting a blood pressure cuff to a childs arm it is vital to select the correct cuff size. The width of the cuff should cover no less than 80% the length of the upper arm. The child’s blood pressure is a much less sensitive indicator, as it may remain *compensated* until circulatory collapse is imminent. You can estimate the expected systolic blood pressure with the following formula: BP= 80+(age in years * 2) . A very low BP is a warning of imminent cardiac arrest, get busy! capillary refill: A slow capillary refill time indicates poor skin perfusion. Press down firmly with your finger on the sternum for 5 seconds and release. ( alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds. Capillary refill time is not a useful indicator in the hypothermic patient. Other effects: Decreased perfusion will lead to an inability of the cells to *take out the trash*. The resulting metabolic acidosis will result in an increased respiratory rate and tidal volumes (without other signs of respiratory distress such as recession) as the lungs try and blow off carbonic acid. The skin may appear mottled or marbled and cold to touch. Decreased level of consciousness. Drowsiness and/or agitation may increase as cellular perfusion decreases. The most sensitive indicator of changes in mental state is of course the parents. Decreased urine output due to decreased perfusion of the kidneys. Less than 2ml/kg/hour in infants and 1 ml/kg/hour in children is a red flag. Once again ask the parents for any history of decreased output. As babies and infants develop significant circulatory compromise it is not exactly rocket science to pick that they are sick. As they begin to die they begin to look dead. But the sensitivity to pick up on early signs of shock is more of an art, and will make a big difference in outcome. Here is a pretty good summation from the Emergency Medicine Journal for you to print out and leave in the toilet for reading. What… you don’t do your best study in the toilet?
  • HR dependent, Tachycardia is the earliest clinical manifestation in compensated shock, but is also may be a result of pain, anxiety, etc… If other signs of compensated shock (decreased Cap refil, cool, mottling skin, decreased peripheral pulses, narrowing pulse pressure, tachyponea)
  • Circulating volume ~80ml/kg in children v ~70ml/kg in adults  little loss = big effect Begin fluid resuscitation early, Mild hyotension should be treated early
  • Extracellualr fluid Infant - ~50% Tolder - ~30% Adolecent ~20%
  • Due to small anatomy, IO insertion threshold is lower in children then in adults
  • Myocardium – HR dependent Body water - GIT proportionally longer therefore greater losses, Metabolic rate greater - greater metabolic wastes therefore greater need for water for excretion BSA - greater therefore greater insensible loss - infant 2 - 3 times greater than adult - - greater heat production and therefore water loss Fluid requirements - greater proportion of ECF exchanged daily in infants than older children because of the above needs for water. This leaves the infant with little reserve in dehydration Renal function - difficulty in concentrating or diluting urine - conserving or excreting Na and acidifying urine - therefore more prone to dehydration or over hydration
  • Pulse characteristics (peripheral rate v heart rate) Cap refil central v peripheral
  • Distributive – sepsis / spinal injury Obstructive – pneumothorax, temponarde
  • Steiner Systematic review – small number of studies Clinical assessment is best Prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern are the most useful signs for detecting dehydration in children. Combinations of signs perform better than individual signs. RCH protocol Clinical findings Mild &lt;4% - no clinical signs Moderate 4-6% Some physical signs Severe &gt;7% multiple physical signs – may also have acidosis and hypotension
  • Skin and respiratory systems – children have higher insensible losses then adults
  • Everyone gets O2 Everyone gets IV access Consider: Volume expansion Inotropic drugs
  • Anatomy and physiology of water electrolyte balance in infants - factor effecting fluid requirements recognizing the seriously ill child structured approach to the seriously ill child resuscitation of infant assessment of cardiovascular system and fluid status management of fluid and electrolyte imbalance - potassium why is the infant so prone to dehydration normal vital signs - BP IV access or IO appropriate IV fluids equipment for infant and child psychosocial needs of an infant and family causes of diarrhoea in infants management of diarrhoea - nutrition infection control investigations - initial and ongoing possible complications - cerebral oedema history
  • The total circulating volume of a 1 year old is roughly the same as the amount of water you pour on your indoor pot plant. At about 80mls/kg it doesn’t take much loss before you have a significantly shocked baby on your hands. With circulatory function failing, oxygen and nutrients are not reaching the cells and cellular waste products are not being cleared. Circulatory assessment is therefore a very important skill to develop in order to recognise the early signs of a shocked child. heart rate: Increased heart rate may indicate shock, or hypoxia. or fever, or anxiety. Bradycardia is defined as a heart rate less than 60 or a rapidly falling heart rate with poor systemic perfusion. Bad, bad, bad. Cardiac compressions will need to be commenced in infants with HR&lt;60 and poor perfusion. You will probably be experiencing a holy crap moment at this time and be hesitant to begin CPR. If in doubt, just do it. *Unnecessary* chest compressions are almost never damaging. pulse volume and blood pressure: A good indicator of general perfusion can be made by palpating peripheral and central pulses. A poor central pulse with absent peripheral pulses is a sign of significant shock. Remember: when fitting a blood pressure cuff to a childs arm it is vital to select the correct cuff size. The width of the cuff should cover no less than 80% the length of the upper arm. The child’s blood pressure is a much less sensitive indicator, as it may remain *compensated* until circulatory collapse is imminent. You can estimate the expected systolic blood pressure with the following formula: BP= 80+(age in years * 2) . A very low BP is a warning of imminent cardiac arrest, get busy! capillary refill: A slow capillary refill time indicates poor skin perfusion. Press down firmly with your finger on the sternum for 5 seconds and release. ( alternatively you can use the nail bed or soles of the feet.) A normal capillary refill should occur within 2-3 seconds. Capillary refill time is not a useful indicator in the hypothermic patient. Other effects: Decreased perfusion will lead to an inability of the cells to *take out the trash*. The resulting metabolic acidosis will result in an increased respiratory rate and tidal volumes (without other signs of respiratory distress such as recession) as the lungs try and blow off carbonic acid. The skin may appear mottled or marbled and cold to touch. Decreased level of consciousness. Drowsiness and/or agitation may increase as cellular perfusion decreases. The most sensitive indicator of changes in mental state is of course the parents. Decreased urine output due to decreased perfusion of the kidneys. Less than 2ml/kg/hour in infants and 1 ml/kg/hour in children is a red flag. Once again ask the parents for any history of decreased output. As babies and infants develop significant circulatory compromise it is not exactly rocket science to pick that they are sick. As they begin to die they begin to look dead. But the sensitivity to pick up on early signs of shock is more of an art, and will make a big difference in outcome. Here is a pretty good summation from the Emergency Medicine Journal for you to print out and leave in the toilet for reading. What… you don’t do your best study in the toilet?
  • The child with circulatory probelms

    1. 1. THE CHILD WITH CIRCULATORY PROBLEMS Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health.
    2. 2. <ul><li>Differences in children </li></ul><ul><li>Circulatory assessment </li></ul><ul><ul><li>General </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><li>Management of circulatory alterations </li></ul><ul><li>DVD of circulatory assessment </li></ul><ul><li>Case study </li></ul>overview
    3. 3. <ul><li>Myocardium </li></ul><ul><li>Compensation </li></ul><ul><li>Body water </li></ul><ul><li>Surface area </li></ul><ul><li>Venous access </li></ul>differences in children
    4. 4. <ul><li>Less compliant </li></ul><ul><li>Has less contractile tissue </li></ul><ul><li>Significance: </li></ul><ul><ul><li>CO = HR x SV </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Other signs of shock  rapid venous access </li></ul></ul>differences in children: myocardium
    5. 5. <ul><li>Normotensive until 25% of their blood volume is lost </li></ul><ul><ul><li>Circulating volume </li></ul></ul><ul><ul><li>Hypotension late / sudden sign of decompensation </li></ul></ul>differences in children: compensation
    6. 6. <ul><li>60% of body weight of an adolescent </li></ul><ul><li>65% of the preschooler </li></ul><ul><li>80% of the infant </li></ul><ul><li>Is distributed between two body compartments </li></ul><ul><ul><li>Intraceullular </li></ul></ul><ul><ul><li>Extracellular </li></ul></ul>differences in children: body water
    7. 7. <ul><li>Intracellular fluid compartment </li></ul><ul><li>Extracellular fluid compartments </li></ul><ul><ul><li>Intravascular </li></ul></ul><ul><ul><li>Interstitial </li></ul></ul><ul><ul><li>Transcellular </li></ul></ul><ul><ul><ul><li>CSF </li></ul></ul></ul><ul><ul><ul><li>Synovial </li></ul></ul></ul><ul><ul><ul><li>Pleural </li></ul></ul></ul>differences in children: body water
    8. 8. differences in children: body water
    9. 9. <ul><li>Larger surface area / volume ratio </li></ul><ul><li>Significance: </li></ul><ul><ul><li>Greater risk of dehydration </li></ul></ul><ul><ul><li>Maintenance fluid requirements higher </li></ul></ul>differences in children: surface area
    10. 10. <ul><li>Intraosseous cannulation threshold </li></ul>differences in children: venous access
    11. 11. <ul><li>Myocardium </li></ul><ul><li>Body water </li></ul><ul><li>Metabolic rate </li></ul><ul><li>Distribution of body fluids </li></ul><ul><li>Surface area </li></ul><ul><li>Venous access </li></ul><ul><li>Immature renal function </li></ul><ul><li>Rely on others to give them fluid </li></ul>summary
    12. 12. <ul><li>Observation </li></ul><ul><li>Palpation </li></ul><ul><li>(Percussion) </li></ul><ul><li>Auscultation </li></ul>circulatory assessment: general
    13. 13. <ul><li>Observe </li></ul><ul><ul><li>Skin colour </li></ul></ul><ul><ul><li>Work of breathing </li></ul></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><li>Hydration status </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Pulse characteristics </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><li>Auscultation </li></ul><ul><ul><li>Chest / heart </li></ul></ul>circulatory assessment: general
    14. 14. <ul><li>Broad categories </li></ul><ul><li>Hypovolaemic </li></ul><ul><li>Cardiogenic </li></ul><ul><li>Distributive </li></ul><ul><li>Obstructive </li></ul>circulatory assessment: general
    15. 15. <ul><li>Hypovolaemia </li></ul><ul><li>Hypovolaemia most common cause of shock in children </li></ul><ul><li>Gastroenteritis most common cause of hypovolaemia in children </li></ul>circulatory assessment: general
    16. 16. <ul><li>Dehydration results from </li></ul><ul><ul><li>Reduced intake </li></ul></ul><ul><ul><li>Increased fluid loss </li></ul></ul><ul><ul><li>Excessive renal loss </li></ul></ul><ul><ul><li>From skin and respiratory systems </li></ul></ul>circulatory assessment: hydration status
    17. 17. <ul><li>Steiner et al 2003 </li></ul><ul><ul><li>Prolonged CR </li></ul></ul><ul><ul><li>Abnormal skin turgor </li></ul></ul><ul><ul><li>Abnormal breathing </li></ul></ul><ul><li>Useful clinical signs include </li></ul><ul><ul><li>Cool pale peripheries & prolonged CR </li></ul></ul><ul><ul><li>Decreased skin turgor </li></ul></ul><ul><ul><li>Deep breathing </li></ul></ul><ul><ul><li>Increased thirst </li></ul></ul>circulatory assessment: hydration status
    18. 18. circulatory assessment: hydration status – estimating deficit Mild 3% Reduced urine output Thirst Dry mucous membranes Mild tachycardia Moderate 5% Dry mucous membranes Tachycardia Abnormal respiratory pattern Lethargy Reduced skin turgor Sunken eyes Severe 10% As above plus Poor perfusion (mottled, slow CR, altered LOC) Shock (poor perfusion, weak pulses, tachycardia)
    19. 19. <ul><li>Broad categories </li></ul>management of circulatory alterations
    20. 20. management of circulatory alterations
    21. 21. <ul><li>Calculation of fluid replacement </li></ul><ul><ul><li>10mls/kg isotonic solution </li></ul></ul><ul><li>Calculation of fluid maintenance </li></ul><ul><ul><li>TKVO – 10mls/hr </li></ul></ul><ul><li>IV / IO </li></ul>management of circulatory alterations
    22. 22. DVD of circulatory assessment
    23. 23. <ul><li>1010: Called to an infant with 3/7 history of diarrhoea </li></ul><ul><li>1015: On arrival 6/12 ♀ named Mary : </li></ul><ul><ul><li>A: clear and open </li></ul></ul><ul><ul><li>B: dyspnoeic </li></ul></ul><ul><ul><li>C: skin pale </li></ul></ul><ul><ul><li>D: awake and interactive </li></ul></ul>case study
    24. 24. <ul><li>1020: During your initial examination, you notice Mary’s condition deteriorate… </li></ul><ul><li> A: clear </li></ul><ul><ul><li>B: ↑ effort, ↑ efficacy </li></ul></ul><ul><ul><li>C: sunken fontanel and eyes, poor peripheral circulation, dry mucous membranes, doughy skin, cyanosed </li></ul></ul><ul><ul><li>D: flaccid, no response to stimuli, fixed stare </li></ul></ul>case study
    25. 25. <ul><li>What are Mary’s problems? </li></ul><ul><li>What else do we need to know to assist her? </li></ul>case study
    26. 26. <ul><li>Foetal problem – nil </li></ul><ul><li>Illnesses / injuries since birth – nil </li></ul><ul><li>Immunisation status – fully immunised for her age </li></ul><ul><li>Developmental status – normal for her age </li></ul><ul><li>Allergies – nil </li></ul><ul><li>Events leading up to your arrival </li></ul><ul><ul><li>3/7 history of diarrhoea </li></ul></ul><ul><ul><li>No oral intake for previous 12/24 </li></ul></ul><ul><ul><li>Unknown urine output </li></ul></ul>case study
    27. 27. <ul><li>Observe </li></ul><ul><ul><li>Skin colour </li></ul></ul><ul><ul><li>Work of breathing </li></ul></ul><ul><ul><li>Mental status </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Pulse rate v heart rate </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><li>Auscultation </li></ul><ul><ul><li>Chest / heart </li></ul></ul>case study: your circulatory assessment
    28. 28. THE CHILD WITH CIRCULATORY PROBLEMS Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health.
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