pediatric critical care

1. Circulation

2. What are the physical examinations
which
reflect circulation status?

3. Objectives
• Evaluate the circulatory problems in children.
• Learn to perform Secondary Assessment by history and physical
examination
• Learn to make diagnostic assessments for circulatory problems

4. Physiology
• Blood pressure (BP) = cardiac output (CO) x Systemic vascular resistance
(SVR)
oCO= heart rate (HR) x Stroke Volume (SV)
o Stroke volume is dependent on: (1) Preload (2) Contractility and (3) Afterload.
• Oxygen delivery (DO2):
• Oxygen is delivered to tissues to maintain normal aerobic metabolism
• Oxygen delivery to tissues is determined by cardiac output x content of
oxygen in the arterial blood.
Oxygen delivery (DO2)
= Cardiac Output x Arterial Oxygen Content (CaO2)
= CO x (Hb x SaO2 x 1.34) + (PaO2 x 0.003)

5. Pediatric assessment triangle
• Appearance
• Work of breathing
• Circulation to Skin

6. Evaluation  Re-evaluation
• After each evaluation:
Identify the problem
Intervene with appropriate treatment
• Re-evaluate

7. Evaluation of Circulation problems
• Primary assessment through various parameters:
1. Heart rate & rhythm
2. Pulse
3. CRT
4. Skin color and temperature
5. Blood pressure
6. Urine output
7. Level of consciousness

8. Primary assessment through various parameters
• Heart rate & rhythm
1. Difference in various age groups
2. ECG/ monitor
• Pulse
1. Central pulse: Femoral, brachial (infants), carotid (older children)
2. Peripheral pulse: Radial, Dorsalis pedis, Posterior tibia
• CRT
1. Normal CRT =2 seconds
2. Prolonged CRT and Flash CRT

9. Primary assessment through various parameters
• Skin color and temperature
1. Color: skin, mucus membrane, nail beds, palms and soles
2. Temperature: central and peripheral temperature
• Blood pressure
1. Appropriate size cuff
2. Age wise BP
• Urine output
1. Reflects renal perfusion and fluid responsiveness
• Level of consciousness
1. Reflects brain perfusion
2. AVPU

10. Evaluation ..continue
• Secondary assessment:
• SAMPLE history
• Detailed physical
examination
S Signs & Symptoms
A Allergies
M Medications
P Pertinent Past History
L Last Intake And Output
E Events Leading Up To
Injury/Illness

11. Evaluation ..continue
Diagnostic assessment of circulatory problems (laboratory & Imaging)
• Laboratory assessment
o Blood gas analysis: metabolic acidosis
o Lactate: lactate acidosis
• Imaging assessment
o Electrocardiogram: arrhythmias
o Echocardiogram: poor contractility, features of myocarditis
• Ongoing clinical assessment
o Invasive arterial pressure monitoring: trends of BP

12. Ongoing assessment (PAT/ABCDE)

13. Any questions?

14. Summary
What are the physical examinations which
reflect circulation status?

15. Thank you!