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RelaxChildren are just little adults
themesthe critically ill and injured childtaking actionnot APLSnot PEM in general
Disclosures
PICUKids EDTrauma centreTrauma centreTrauma centre
...but where are the kids?
Transfers were:SickerNeeded more ICU careHad a longer stayMore ventilationMore inotropes
Half of unplanned transfers from St.ElsewhereThey were sicker/youngerbutDied more often (8% vs 6%)Risk adjusted mortality ...
Selection bias?
Maybe...., but
Anecdotally.....Errors of Omission and delayWait for helpFailure to interveneCliff drop of kids pathologyBenjamin Ellis CC...
6 year old1/7 hxT 37.9 CRR 35Pulse 170BP 100/52
OxygenFluidsAntibiotics
Multiple cannulationattemptsED docsPaediatricians
5 hours laterCirculatory collapseDies in PICU
why?
Why are we scared of kids?Where are we scared?1. Unfamiliarity2. High stakes3. Because people tell us weshould be!
Children are not little adults!!!!
World Health Organisation http://www.who.int/ceh/capacity/Children_are_not_little_adults.pdf
‘Children are not little adults’
Is this still ABC?
transferrable skills
Neonates
aliens&prehumans
•Scary Aliens•Weird stuff often precipitatedby infection•Treat what you can whilstworking out the hard stuff!
Is it reallythat different?
but really?
EmergencyEmergencyMedicineMedicinePICUPICUPaediatricsPaediatricsAnaestheticsAnaesthetics
The resuscitiationist
Transferrable skills• Adult practice• to• Paeds practice
Kids are more difficult than adults.Co-morbidity?Anatomical variation?Range of conditions?
ToP TiPs• Airway issues• Lots of normal• RSI• Rescue
be prepared
Pressure control more popularPressure control more popularTidal volume reasonable (5-8 ml/kg)Tidal volume reasonable (5-8 ...
• Circulation• Fluids• Trauma resus• Access
• 1• 2• IO
• 1• 2• IO• Consider external jugular
• Fluids• APLS 20ml/Kg in sepsis• APLS 10ml/Kg in trauma
Fluid requirements• Sepsis -• Adequate volume important within 1-2 hours• Reduced mortality• less persistent hypovolaemia•...
In severe sepsislikely requirement for volume is200-360ml/Kg in first 24 hours
FEAST trialHigher mortality in kids with large fluid boluses
Question?Is 20ml/Kg too muchDose/response may be better in 5ml/Kg aliquots
Fluid choice?• Little evidence• Saline causes hyperchloraemic acidosis• Colloids (albumin) after 40-60ml/Kg• Plasmalyte co...
octaplas - prior reduced plasmaTrauma
Tranexamic acid15mg/Kg over 1 hour2mg/Kg/Hr for 8 hours
53 patients in 15 monthsNo improvement in mortalityFeasibility proven
Therapeutic end points• Titrate to effect• Normal pulses with no difference central/peripheral• Warm extremities• Return o...
Today...•Fire up the simulator• Kids & Adults in the past• Kids & Adults in the future
you are the resuscitationist
resuscitation aims to restore physiologyresuscitation skills are learned in adult medicinemost if not all skills are trans...
kids are little adults
ThanksNWTSRalph MacKinnonKate ParkinsRachel JennerKatherine Potier
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
Kids are just little adults. SMACC Paediatric Resuscitation
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Kids are just little adults. SMACC Paediatric Resuscitation

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Simon Carley takes the stance that Kids are just little adults - a talk given at SMACC 2013.

Published in: Health & Medicine, Technology
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Kids are just little adults. SMACC Paediatric Resuscitation

  1. 1. RelaxChildren are just little adults
  2. 2. themesthe critically ill and injured childtaking actionnot APLSnot PEM in general
  3. 3. Disclosures
  4. 4. PICUKids EDTrauma centreTrauma centreTrauma centre
  5. 5. ...but where are the kids?
  6. 6. Transfers were:SickerNeeded more ICU careHad a longer stayMore ventilationMore inotropes
  7. 7. Half of unplanned transfers from St.ElsewhereThey were sicker/youngerbutDied more often (8% vs 6%)Risk adjusted mortality 0.65 (0.53-0.80)
  8. 8. Selection bias?
  9. 9. Maybe...., but
  10. 10. Anecdotally.....Errors of Omission and delayWait for helpFailure to interveneCliff drop of kids pathologyBenjamin Ellis CCLhttp://www.flickr.com/photos/jamin2/3191895921/
  11. 11. 6 year old1/7 hxT 37.9 CRR 35Pulse 170BP 100/52
  12. 12. OxygenFluidsAntibiotics
  13. 13. Multiple cannulationattemptsED docsPaediatricians
  14. 14. 5 hours laterCirculatory collapseDies in PICU
  15. 15. why?
  16. 16. Why are we scared of kids?Where are we scared?1. Unfamiliarity2. High stakes3. Because people tell us weshould be!
  17. 17. Children are not little adults!!!!
  18. 18. World Health Organisation http://www.who.int/ceh/capacity/Children_are_not_little_adults.pdf
  19. 19. ‘Children are not little adults’
  20. 20. Is this still ABC?
  21. 21. transferrable skills
  22. 22. Neonates
  23. 23. aliens&prehumans
  24. 24. •Scary Aliens•Weird stuff often precipitatedby infection•Treat what you can whilstworking out the hard stuff!
  25. 25. Is it reallythat different?
  26. 26. but really?
  27. 27. EmergencyEmergencyMedicineMedicinePICUPICUPaediatricsPaediatricsAnaestheticsAnaesthetics
  28. 28. The resuscitiationist
  29. 29. Transferrable skills• Adult practice• to• Paeds practice
  30. 30. Kids are more difficult than adults.Co-morbidity?Anatomical variation?Range of conditions?
  31. 31. ToP TiPs• Airway issues• Lots of normal• RSI• Rescue
  32. 32. be prepared
  33. 33. Pressure control more popularPressure control more popularTidal volume reasonable (5-8 ml/kg)Tidal volume reasonable (5-8 ml/kg)or maybe better to look at chest wall excursion with pressure controlor maybe better to look at chest wall excursion with pressure controlAim for lower FiOAim for lower FiO22 albeit with higher PEEPalbeit with higher PEEP4-6 to start4-6 to start6-8 if bad lung disease6-8 if bad lung disease8-10 if wet lungs8-10 if wet lungsSpO2 = 88-96%SpO2 = 88-96%Chest tubesChest tubes
  34. 34. • Circulation• Fluids• Trauma resus• Access
  35. 35. • 1• 2• IO
  36. 36. • 1• 2• IO• Consider external jugular
  37. 37. • Fluids• APLS 20ml/Kg in sepsis• APLS 10ml/Kg in trauma
  38. 38. Fluid requirements• Sepsis -• Adequate volume important within 1-2 hours• Reduced mortality• less persistent hypovolaemia• no increase in ARDS• each additional hour of shock doubles odds of death.• reduced PICU stayRole of early fluid resuscitation in pediatric shock. Carcillo JA, Davis AL, Zaritsky A. JAMA 1991;266: 1242-1245.Early reversal of Pediatric - Neonatal septic shock by Community Physicians is associated with improved outcome. HanYY, Carcillo JA, Dragotta M et al. Peds 2003;112: 793-799.
  39. 39. In severe sepsislikely requirement for volume is200-360ml/Kg in first 24 hours
  40. 40. FEAST trialHigher mortality in kids with large fluid boluses
  41. 41. Question?Is 20ml/Kg too muchDose/response may be better in 5ml/Kg aliquots
  42. 42. Fluid choice?• Little evidence• Saline causes hyperchloraemic acidosis• Colloids (albumin) after 40-60ml/Kg• Plasmalyte coming into practice
  43. 43. octaplas - prior reduced plasmaTrauma
  44. 44. Tranexamic acid15mg/Kg over 1 hour2mg/Kg/Hr for 8 hours
  45. 45. 53 patients in 15 monthsNo improvement in mortalityFeasibility proven
  46. 46. Therapeutic end points• Titrate to effect• Normal pulses with no difference central/peripheral• Warm extremities• Return of Urine output (>0.5-1ml/Kg/Hr), HR, Cap refill,LOC• SVC or mixed venous gas• Normalising base deficit and lactate
  47. 47. Today...•Fire up the simulator• Kids & Adults in the past• Kids & Adults in the future
  48. 48. you are the resuscitationist
  49. 49. resuscitation aims to restore physiologyresuscitation skills are learned in adult medicinemost if not all skills are transferrable
  50. 50. kids are little adults
  51. 51. ThanksNWTSRalph MacKinnonKate ParkinsRachel JennerKatherine Potier

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