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Kids: Just Little Adults?
Dr Fran Lockie
MedSTAR
Paediatric Emergency, Women’s and Children’s
Bedside Critical Care, Septe...
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
Fami...
Country Hospital
• At triage (17:30)
– Alert and playful
– Temp 39, Hr 160, Rr 40
– Good central perfusion
– Mottled perip...
18:45 Seen by RMO
• Given panadol with resolution of fever, HR
never < 170 since triage
• Bloods
– VBG pH 7.15, BE -10, B/...
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 ale...
Rapid deterioration
– AVPU
– Increasing respiratory distress
– HR >200, Only femoral pulse palpable
– IO sited
– Aggressiv...
Ketamine, sux, adrenaline bolus
PEA Arrest
• Filling, filling, filling
• Dopamine started at 20mcg/kg/min
• Filling, filling, filling
– 4% albumin
– Blood...
6hrs later….still PEA / ROSC
•
•
•
•
•

Maximal inotropic / pressor support
multiple dextrose, Ca, Mg boluses
Total fluids...
• Parents present throughout
• RIP, 03:00
We are scared of kids!
• Kids need early aggressive treatment
• Failure to diagnose shock
• Failure to resuscitate
– Early...
• Audit of 17 PICU’s
• 107 patients with septic shock
• 8% received care c/w ACCM guideline
– 21% not given >60ml/kg despi...
• FAILURE TO DIAGNOSE SHOCK
• 3 factors
– Not looked after by a paediatrician
– Lack of supervision
– Failure to administe...
Early Resuscitation of Children with
Moderate to severe TBI
• 299 kids with mod-severe TBI
• 39% became hypotensive
– Of t...
•
•
•
•
•

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 op...
•
•
•
•
•
•

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 i...
•
•
•
•
•

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%)

•...
Sugar and temperature
•
•
•
•

Large SA: body wt (2-2.5 x BW)
Thin skin and subcut fat (less insulation)
No shivering
Imma...
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
...
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 / ...
Fran Lockie on Kids: Just Little Adults?
Fran Lockie on Kids: Just Little Adults?
Fran Lockie on Kids: Just Little Adults?
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

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Transcript of "Fran Lockie on Kids: Just Little Adults?"

  1. 1. Kids: Just Little Adults? Dr Fran Lockie MedSTAR Paediatric Emergency, Women’s and Children’s Bedside Critical Care, September 2013
  2. 2. Scope • Case • Why are we scared? • Structured approach – Airway, – Breathing – Circulation • Can we do better?
  3. 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. 4. Country Hospital • At triage (17:30) – Alert and playful – Temp 39, Hr 160, Rr 40 – Good central perfusion – Mottled peripherally
  5. 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. 6. URTI focus for fever identified • 2 small vomits in waiting room, then a small area of petechiae
  7. 7. 21:00 Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes
  8. 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. 9. Rapid deterioration – AVPU – Increasing respiratory distress – HR >200, Only femoral pulse palpable – IO sited – Aggressive filling – DA started
  10. 10. Ketamine, sux, adrenaline bolus
  11. 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. 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. 13. • Parents present throughout • RIP, 03:00
  14. 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. 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. 16. • FAILURE TO DIAGNOSE SHOCK • 3 factors – Not looked after by a paediatrician – Lack of supervision – Failure to administer inotropes BMJ
  17. 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. 18. • • • • • ED staff Anaethetics Theatre staff Standardised scenarios Causes of error Resuscitation, in Press 2013
  19. 19. 75 Simulations 12.4 doctors / nurses per session 194 incidents of subobtimal care Resuscitation, in Press 2013
  20. 20. We are Solutions… scared of kids!
  21. 21. Train together! • One Base • Adult teams – ED – Intensivists – Anaesthetists • Paediatric and neonatal teams • Special operations paramedics
  22. 22. • • • • • • Teamwork Leadership Crew Resource Management Resus drills Intubation drills Competency frameworks
  23. 23. Ann Emerg Med. 2012 Kids have smaller FRC Greater VO2 than adults Rapid desaturation (with stress and apnoea)
  24. 24. Ann Emerg Med. 2012
  25. 25. Ann Emerg Med. 2012
  26. 26. Levitan: Dentition, disruption, disproportion, dysmobility
  27. 27. Levitan: 4Ds
  28. 28. “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
  29. 29. • • • • • 95 patients Mean age 5.5 95% success 10 seconds or less Pain score 2.3 Pediatr Ermerg Care 2008
  30. 30. SAFE study Sepsis resuscitation (FEAST) Trauma resusitation / massive transfusion
  31. 31. Is administering inotropes peripherally safe? Inotrope
  32. 32. • 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
  33. 33. 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…
  34. 34. Lancet 2011; 377: 1011–18 • Listen to the physiology!
  35. 35. Lancet 2011; 377: 1011–18
  36. 36. Is lactate really the ‘Holy Grail’ of sepsis biomarkers? I
  37. 37. Is lactate really the ‘Holy Grail’ of sepsis biomarkers? No, but sepsis often masquerades as respiratory disease in kids I
  38. 38. If you still can’t explain it… • Always assume ingestion • Always assume inflicted injury
  39. 39. Smaller but the same • Train together?? • Golden rules – – – – – – PEEP NGT VBG + Physiology Early inotropes Ingestion / inflicted Pink, warm and sweet
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