Dr. Lilia Dewiyanti, SpA, MSiMed.
Many etiologiesRespiratory failure                       Shock                Cardiopulmonary failure               Cardio...
Outcome of respiratory vs Cardiopulmonary Arrest in                     Children      100%          75 – 90 %Survival rate...
Core Knowledge and Skills1. Recognize respiratory distress and   potensial respiratory failure2. Recognize shock3. Describ...
Is this child in respiratory failure                               or shock ?Is this child in respiratoryfailure or shock?...
The Three Phases ofRapid Cardiopulmonary Assessment 1. Physical examination 2. Classification of physiologic status 3. Ini...
The ABCsNormal Vital Functions Are Maintained    By                   To Provide    Airway               Ventilation    Br...
Primary Abnormalities in Respiratory Failure                       Ventilation Airway   AndBreathing                      ...
Classification of Respiratory Failure                    Potential respiratory failure                                 The...
Initial Assessment     Pediatric Assessment Triangle :           Circulation to Skin                                      ...
Appearance (“Tickles” =TICLS)       Tonus       Interactiveness       Consolability       Look/Gaze       Speech/Cry ...
Potential respiratory failure                                12
Work of Breathings                 Abnormal airway sounds                 Abnormal positioning                 Retracti...
The sniffing position                                  The abnormal tripod position                    Retractions        ...
Circulation to SkinCharacteristic of Circulation to Skin              Pallor (putih pucat)              Mottling (bercak...
PAT: Potential Respiratory Failure      Normal                                    Increased                          Circu...
PAT: Respiratory Failure                                                 Increased   Abnormal                             ...
Rapid Cardiopulmonary AssessmentPhysical Examination - Airway    1. Clear    2. Maintainable    3. Unmaintanable without i...
Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing    1. Rate    2. Effort / mechanics    3. Air entry    4....
Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing     Evaluation of rate, effort, and mechanics        • Ti...
Rapid Cardiopulmonary AssessmentPhysical Examination : Breathing                                   21
Primary Abnormalities in Shock                               Ventilation Airway   AndBreathing                            ...
PAT: Shock   Abnormal                         Normal              Circulation to Skin                   Abnormal          ...
Basic Relationships of Cardiovascular Parameters                                     Preload                         Strok...
Cardiac Output = Heart Rate X Stroke VolumeInadequate         Compensation                   • Increased heart rate       ...
re s is te n s i v a s k u la r             140             100% kon trol              60                            C u r...
Child in shock                 27
Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation     1. Heart rate     2. Systematic perfusion          ...
Heart rates in Normal Children             Age                   RangeNewborn – 3 Mos             85 – 200 bpm3 mos – 2 yr...
Palpation of Central dan Distal Pulses                                         30
Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation  Skin perfusion            • Extremity temperature     ...
Normal capillary refill is < 2                   seconds in a warm                   environmentCapillary refill          ...
Rapid Cardiopulmonary AssessmentPhysical Examination - CirculationLevel of consciousness       •A   = Awake       •V   = R...
Renal perfusion     • Urine output (Normal: 1 to 2 mL/kg/hour) reflects              • Glomerular filtration rate reflects...
Rapid Cardiopulmonary Assessment    Physical Examination - Circulation           Age      Fifth percentile mmHg           ...
Review of the Physical Findings in ShockEarly signs (compensated)       • Increased heart rate       • Poor systemic perfu...
Child dying with anasarca , MOSFdespite resuscitation efforts                                   37
Definition of Cardiopulmonary Failure    Deficits in                   • Ventilation                   • Oxygenation      ...
Rapid Cardiopulmonary Assessment                           Ventilation Airway   AndBreathing                           Oxy...
The Three Phases ofRapid Cardiopulmonary Assessment      1. Physical examination      2. Classification of physiologic sta...
Rapid Cardiopulmonary AssessmentClassification of Physiologic status           • Stable           • Respiratory failure   ...
The Three Phases ofRapid Cardiopulmonary Assessment      1. Physical examination      2. Classification of physiologic sta...
Rapid Cardiopulmonary Assessment -Priorities of Initial Management Stable  • Begin further workup  • Provide specific ther...
Rapid Cardiopulmonary Assessment -      Priorities of Initial ManagementPotential RF               Probable RFKeep with ca...
45
Rapid Cardiopulmonary Assessment -Priorities of Initial Management Shock    • Administer oxygen (FiO2 = 1.00) and ensure  ...
Rapid Cardiopulmonary Assessment -Priorities of Initial Management  Cardiopulmonary failure           • Oxygenate, ventila...
Case No 1 A 3-week-old infant arrives at the emergency department. • CC : Vomiting and diarrhea • PE : Gasping respiration...
Case No 1 - Cardiopulmonary failure     Response to intubation and ventilation with FiO2 1.00      • HR : 180; BP 50 mm Hg...
Case No 1 - Response to Therapy         • Vital sign improved         • Perfusion still poor                              ...
What is the heart size ?                           51
Case No 2     A 3-day-old infant has a history of irritability and                         one episode of vomiting     PE ...
Case No 2 - Cardiopulmonary failure     Response to oxygenation and ventilation with FiO2 1.00      • HR : 180; BP 40 mm H...
Chest X-ray after fluid bolus                                54
Upcoming SlideShare
Loading in …5
×

Recognition of pediatric emergencies

1,517 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,517
On SlideShare
0
From Embeds
0
Number of Embeds
7
Actions
Shares
0
Downloads
164
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Recognition of pediatric emergencies

  1. 1. Dr. Lilia Dewiyanti, SpA, MSiMed.
  2. 2. Many etiologiesRespiratory failure Shock Cardiopulmonary failure Cardiopulmonary arrest 2
  3. 3. Outcome of respiratory vs Cardiopulmonary Arrest in Children 100% 75 – 90 %Survival rate 75% 7 – 11 % Respiratory arrest Cardiopulmonary arrest 3
  4. 4. Core Knowledge and Skills1. Recognize respiratory distress and potensial respiratory failure2. Recognize shock3. Describes priorities for management of respiratory distress, failure, and shock 4
  5. 5. Is this child in respiratory failure or shock ?Is this child in respiratoryfailure or shock? 5
  6. 6. The Three Phases ofRapid Cardiopulmonary Assessment 1. Physical examination 2. Classification of physiologic status 3. Initial management priorities 6
  7. 7. The ABCsNormal Vital Functions Are Maintained By To Provide Airway Ventilation Breathing Oxygenation Circulation Perfusion 7
  8. 8. Primary Abnormalities in Respiratory Failure Ventilation Airway AndBreathing OxygenationCirculation Perfusion 8
  9. 9. Classification of Respiratory Failure Potential respiratory failure Theraphy (eg, positioning, oxygen administration)Improvement Deterioration Potential Probable Resp. failure Resp. failure 9
  10. 10. Initial Assessment Pediatric Assessment Triangle : Circulation to Skin 10
  11. 11. Appearance (“Tickles” =TICLS)  Tonus  Interactiveness  Consolability  Look/Gaze  Speech/Cry 11
  12. 12. Potential respiratory failure 12
  13. 13. Work of Breathings  Abnormal airway sounds  Abnormal positioning  Retractions  Nasal flaring 13
  14. 14. The sniffing position The abnormal tripod position Retractions 14
  15. 15. Circulation to SkinCharacteristic of Circulation to Skin  Pallor (putih pucat)  Mottling (bercak2)  Cyanosis (kebiruan) 15
  16. 16. PAT: Potential Respiratory Failure Normal Increased Circulation to Skin Normal 16
  17. 17. PAT: Respiratory Failure Increased Abnormal or decreased Circulation to Skin Normal or abnormal 17
  18. 18. Rapid Cardiopulmonary AssessmentPhysical Examination - Airway 1. Clear 2. Maintainable 3. Unmaintanable without intubation 4. Obstructed 18
  19. 19. Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing 1. Rate 2. Effort / mechanics 3. Air entry 4. Skin color and temperature 19
  20. 20. Rapid Cardiopulmonary AssessmentPhysical Examination - Breathing Evaluation of rate, effort, and mechanics • Tidal Volume ( V T) • Minute ventilation (MV) • MV = VT X RR 20
  21. 21. Rapid Cardiopulmonary AssessmentPhysical Examination : Breathing 21
  22. 22. Primary Abnormalities in Shock Ventilation Airway AndBreathing OxygenationCirculation Perfusion 22
  23. 23. PAT: Shock Abnormal Normal Circulation to Skin Abnormal 23
  24. 24. Basic Relationships of Cardiovascular Parameters Preload Stroke Myocardial Volume contractility Cardiac Afterload Output Heart RateBloodPressure Systemic Vascular Resistance 24
  25. 25. Cardiac Output = Heart Rate X Stroke VolumeInadequate Compensation • Increased heart rate • Increased SVR • Posible increased SV 25
  26. 26. re s is te n s i v a s k u la r 140 100% kon trol 60 C u ra h ja n tu n g T e k a n a n d a ra h 20 25 50 75 % ta s e k e h ila n g a n d a ra h R e s p o n s h e m o d in a m ik te rh a d a p k e h ila n g a n d a ra h 29 26
  27. 27. Child in shock 27
  28. 28. Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation 1. Heart rate 2. Systematic perfusion • Peripheral pulses • Skin perfusion • Level of consciousness • Urine output 3. Blood pressure 28
  29. 29. Heart rates in Normal Children Age RangeNewborn – 3 Mos 85 – 200 bpm3 mos – 2 yrs 100 – 190 bpm2 – 10 yrs 60 – 140 bpm 29
  30. 30. Palpation of Central dan Distal Pulses 30
  31. 31. Rapid Cardiopulmonary AssessmentPhysical Examination - Circulation Skin perfusion • Extremity temperature • Capillary refill • Color • Pink • Mottled • Pale • Blue 31
  32. 32. Normal capillary refill is < 2 seconds in a warm environmentCapillary refill 32
  33. 33. Rapid Cardiopulmonary AssessmentPhysical Examination - CirculationLevel of consciousness •A = Awake •V = Responsive to voice •P = Responsive to pain •U = Unresponsive Child in shock with depressed mental status 33
  34. 34. Renal perfusion • Urine output (Normal: 1 to 2 mL/kg/hour) reflects • Glomerular filtration rate reflects • Renal blood flow reflects • Vital organ perfusion What information does blood pressure provide ? What is inadequate blood pressure ? 34
  35. 35. Rapid Cardiopulmonary Assessment Physical Examination - Circulation Age Fifth percentile mmHg Systolic BP0 – 1 Mo 60> 1 mo – 1 yr 70> 1 yr 70 + (2 x age in years) 35
  36. 36. Review of the Physical Findings in ShockEarly signs (compensated) • Increased heart rate • Poor systemic perfusionLate signs (decompensated) • Weak central pulses • Altered mental status • Decreased urine output • Hypotension 36
  37. 37. Child dying with anasarca , MOSFdespite resuscitation efforts 37
  38. 38. Definition of Cardiopulmonary Failure Deficits in • Ventilation • Oxygenation • Perfusion Resulting in • Agonal respiration • Bradycardia • Cardiopulmonary arrest 38
  39. 39. Rapid Cardiopulmonary Assessment Ventilation Airway AndBreathing OxygenationCirculation Perfusion 39
  40. 40. The Three Phases ofRapid Cardiopulmonary Assessment 1. Physical examination 2. Classification of physiologic status 3. Initial management priorities 40
  41. 41. Rapid Cardiopulmonary AssessmentClassification of Physiologic status • Stable • Respiratory failure • Potential • Probable • Shock • Compensated • Decompensated • Cardiopulmonary failure 41
  42. 42. The Three Phases ofRapid Cardiopulmonary Assessment 1. Physical examination 2. Classification of physiologic status 3. Initial management priorities 42
  43. 43. Rapid Cardiopulmonary Assessment -Priorities of Initial Management Stable • Begin further workup • Provide specific theraphy as indicated • Reassess frequently 43
  44. 44. Rapid Cardiopulmonary Assessment - Priorities of Initial ManagementPotential RF Probable RFKeep with caregiver Separate from caregiverPosition of comfort Control airwayOxygen as tolerated 100 % FiO2 Assist ventilationNothing by mouth Nothing by mouthMonitor pulse oximetry Monitor pulse oximetryConsider cardiac monitor Cardiac monitor Establish vascular- access 44
  45. 45. 45
  46. 46. Rapid Cardiopulmonary Assessment -Priorities of Initial Management Shock • Administer oxygen (FiO2 = 1.00) and ensure adequate airway and ventilation • Establish vascular access • Provide volume expansion • Monitor oxygenation, heart rate, and urine output • Consider vasoactive infusions 46
  47. 47. Rapid Cardiopulmonary Assessment -Priorities of Initial Management Cardiopulmonary failure • Oxygenate, ventilate, monitor • Reassess for • Respiratory failure • Shock • Obtain vascular access 47
  48. 48. Case No 1 A 3-week-old infant arrives at the emergency department. • CC : Vomiting and diarrhea • PE : Gasping respirations, bradycardia, cyanosis What is the physiologic status ? What are the initial interventions ? 48
  49. 49. Case No 1 - Cardiopulmonary failure Response to intubation and ventilation with FiO2 1.00 • HR : 180; BP 50 mm Hg systolic • Pink centrally; cyanotic peripherally • No peripheral pulses • No response to venipuncture What is the physiologic status ? What is the cause ? 49
  50. 50. Case No 1 - Response to Therapy • Vital sign improved • Perfusion still poor 50
  51. 51. What is the heart size ? 51
  52. 52. Case No 2 A 3-day-old infant has a history of irritability and one episode of vomiting PE : Gasping respirations, bradycardia, cyanosis What is the physiologic status ? What are the initial interventions ? 52
  53. 53. Case No 2 - Cardiopulmonary failure Response to oxygenation and ventilation with FiO2 1.00 • HR : 180; BP 40 mm Hg systolic • Pink centrally; cyanotic peripherally • No peripheral pulses • No response to venipuncture What is the physiologic status ? What is the next intervention ? 53
  54. 54. Chest X-ray after fluid bolus 54

×