Fran Lockie on Kids: Just Little Adults?
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Fran Lockie on Kids: Just Little Adults?

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

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

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Fran Lockie on Kids: Just Little Adults? Fran Lockie on Kids: Just Little Adults? Presentation Transcript

  • Kids: Just Little Adults? Dr Fran Lockie MedSTAR Paediatric Emergency, Women’s and Children’s Bedside Critical Care, September 2013
  • Scope • Case • Why are we scared? • Structured approach – Airway, – Breathing – Circulation • Can we do better?
  • 15 month old male with fever • • • • • NVD at term, BW 2.7kg Previously fit and well No meds, NKDA Immunisations UTD Family all coryzal
  • Country Hospital • At triage (17:30) – Alert and playful – Temp 39, Hr 160, Rr 40 – Good central perfusion – Mottled peripherally
  • 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
  • URTI focus for fever identified • 2 small vomits in waiting room, then a small area of petechiae
  • 21:00 Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes
  • 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
  • Rapid deterioration – AVPU – Increasing respiratory distress – HR >200, Only femoral pulse palpable – IO sited – Aggressive filling – DA started
  • Ketamine, sux, adrenaline bolus
  • 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
  • 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
  • • Parents present throughout • RIP, 03:00
  • 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
  • • 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
  • • FAILURE TO DIAGNOSE SHOCK • 3 factors – Not looked after by a paediatrician – Lack of supervision – Failure to administer inotropes BMJ
  • 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
  • • • • • • ED staff Anaethetics Theatre staff Standardised scenarios Causes of error Resuscitation, in Press 2013
  • 75 Simulations 12.4 doctors / nurses per session 194 incidents of subobtimal care Resuscitation, in Press 2013
  • We are Solutions… scared of kids!
  • Train together! • One Base • Adult teams – ED – Intensivists – Anaesthetists • Paediatric and neonatal teams • Special operations paramedics
  • • • • • • • Teamwork Leadership Crew Resource Management Resus drills Intubation drills Competency frameworks
  • Ann Emerg Med. 2012 Kids have smaller FRC Greater VO2 than adults Rapid desaturation (with stress and apnoea)
  • Ann Emerg Med. 2012
  • Ann Emerg Med. 2012
  • Levitan: Dentition, disruption, disproportion, dysmobility
  • Levitan: 4Ds
  • “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
  • • • • • • 95 patients Mean age 5.5 95% success 10 seconds or less Pain score 2.3 Pediatr Ermerg Care 2008
  • SAFE study Sepsis resuscitation (FEAST) Trauma resusitation / massive transfusion
  • Is administering inotropes peripherally safe? Inotrope
  • • 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
  • 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…
  • Lancet 2011; 377: 1011–18 • Listen to the physiology!
  • Lancet 2011; 377: 1011–18
  • Is lactate really the ‘Holy Grail’ of sepsis biomarkers? I
  • Is lactate really the ‘Holy Grail’ of sepsis biomarkers? No, but sepsis often masquerades as respiratory disease in kids I
  • If you still can’t explain it… • Always assume ingestion • Always assume inflicted injury
  • Smaller but the same • Train together?? • Golden rules – – – – – – PEEP NGT VBG + Physiology Early inotropes Ingestion / inflicted Pink, warm and sweet