4. I- Recognition of Potential
Respiratory Failure
1. Effort of breathing.
2. Efficacy of breathing.
3. Effects of respiratory
inadequacy on other
organs.
5. 1- Effort of breathing
A- Respiratory rate
At rest, tachypnea indicates → difficulty in breathing or metabolic
acidosis.
A slow respiratory rate indicates → fatigue, cerebral depression,
pre-terminal
B- Recession
Intercostal, subcostal or sternal recession > shows ↑ effort of
breathing.
- If the child becomes exhausted, recession decreases.
E- Flaring of the alae nasi
D- Accessory muscle use
The sternomastoid muscle may be used as an accessory respiratory
muscle when the effort of breathing is increased leading to head
bobbing up and down with each breath& see – saw respiration
C- Inspiratory or expiratory noises
- Stridor - Wheeze – Grunting
F- Gasping
This is a sign of severe hypoxia and may be pre-terminal
Exceptions
There may be absent or decreased evidence of
increased effort of breathing in 3 circumstances:
1) Exhaustion. Exhaustion is a pre-terminal sign.
2) Children with CNS depression.
3) Children who have neuromuscular disease (such
as spinal muscular atrophy or muscular dystrophy)
may present in respiratory failure without increased
effort of breathing.
6. 2- Efficacy of breathing
A- Chest expansion
B- Auscultation. A silent chest is a pre-terminal
sign.
C- Pulse oximetry can be used to measure the
arterial oxygen saturation (SaOz2). Normal 97-
100%.
TV=
7ml/kg
Oxygenatio
n
7. 3- Effects of respiratory
inadequacy on other organs
A) Heart rate
- Early, hypoxia produces tachycardia.
- Severe or prolonged hypoxia leads to bradycardia.
- Bradycardia is a pre-terminal sign.
B) Skin color
Pallor: Hypoxia (via catecholamine release) produces
vasoconstriction & skin pallor.
Cyanosis: is a late and pre-terminal sign of hypoxia
C) Mental status
- The hypoxic or hypercapnic child will be agitated and/or
drowsy. Gradually drowsiness increases and eventually
consciousness is lost.
8. II) Recognition of Potential
Circulatory Failure
1.Cardiovascular status
2.Effects of circulatory
inadequacy on other
organs .
10. 1.Cardiovascular status
A) Heart rate
Sinus tachycardia is a common response to e.g. anxiety, fever or pain but
is also seen in hypoxia, hypercapnia or hypovolemia (non-specifc but
early sign). If the increase in
heart rate fails to maintain adequate tissue oxygenation, hypoxia and
acidosis result in bradycardia, which indicates that cardiorespiratory
arrest is imminent.
B) Pulse volume
Compare peripheral & central pulses. Absent peripheral pulses & weak
central pulses are serious signs of advanced shock.
C) phrephral perfustion
Apply cutaneous pressure on the center of the sternum or on a digit for 5
seconds. A slow refill time (> 2-3 seconds) indicates poor skin perfusion.
CRT is useful in the warm child and in presence of other signs of shock.
D) Blood pressure
- Hypotension is a late and pre-terminal sign of circulatory failure. Once a
child's blood pressure has fallen cardiac arrest is imminent.
SVR ass by :
CRT Skin tempreture Diatolic blood pressure
11. 2.Effects of circulatory inadequacy
on other organs
A) Respiratory system
Tachypnea without recession is caused by the metabolic acidosis
resulting from circulatory failure.
B) Skin
Mottled, cold, pale skin peripherally indicates poor perfusion.
C) Mental status
Agitation and then drowsiness leading to unconsciousness are
characteristic of circulatory failure. These signs are caused by
poor cerebral perfusion
D) Urinary output
A urine output of less than 1 ml/kg/hour in children indicates
inadequate renal perfusion during shock. A history of oliguria or
anuria should be sought.
12. There is a clear overlap
between circulatory failure &
respiratory
The following signs are more in favor of a
circulatory condition:
1) Cyanosis despite supplied O2
2) Marked tachycardia out of proportion to
respiratory distress
3) Quiet tachypnea (tachypnea without
recessions)
4) Raised jugular venous pressure
5) Gallop rhythm/ murmur
6) Enlarged liver (beware of posted liver)
7) Absent/ weak femoral pulses.
13. III) Recognition of Potential
Central Neurological Failure
1.Neurological function
2. Respiratory effects of
central neurological failure
3. Circulatory effects of
central neurological failure
Neurological assessment should only be performed after airway
(A), breathing (B) and circulation (C) have been assessed and
treated.
14. 1. Neurological function
A) Conscious level
AVPU score
Glasgow Coma Score (GCS)
. If GCS is < 8, airway management should be considered
B) Posture
- Hypotonia in a previously well is a sign of serious illness
- Stiff posturing: is a sign of serious brain dysfunction
Decorticate (flexed arms, extended legs)
Decerebrate (extended arms, extended legs)
- Overextension of the neck may occur in upper airway
obstruction
- Opisthotonus occurs with meningeal irritation.
C) Pupils
- Unequal pupils is a medical emergency
- Dilated fixed pupils are not always due to brain death
15. 2. Respiratory effects of central
neurological failure
The presence of any abnormal respiratory pattern in a patient
with coma suggests mid- or hind-brain dysfunction.
An Example is:
16.
17. 3.Circulatory effects of central
neurological failure
Cushing’s triad of:
1- widened pulse pressure (increasing
systolic, decreasing diastolic),
2- bradycardia,
3- irregular respirations
This is a late and pre-terminal sign
CPP (cerebral perfusion pressure ) = MAP
- ICP
24. VENTILLATION
SUPPORT
ETT = OPTIMAL
CONTROL
Generally, tracheal intubation should be considered in
situations where it is felt that BMV is not efective, the airway
is insecure or a period of prolonged ventilatory support is
expected. Common indications are:
• Severe anatomical or functional upper airway obstruction.
• Need for protection of the airway from aspiration of gastric
contents (e.g. during CPR and after severe drowning).
• Need for high pressures to maintain adequate oxygenation.
• Need to precisely control CO2levels, e.g. intracranial
hypertension.
• Mechanical ventilation is expected to be prolonged.
• Need for bronchial or tracheal suctioning.
• Instability or high probability of one of the above occurring
before or during transport, in particular during air transport.
Uncuffed
up to 8 Y
cuffed
25 cmh2o
1- lung compliance is
poor
2- airway resistance is
high
3-if there is a large air
leak from the glottis
When to give sedation ?
Intubation of a child in
cardiorespiratory arrest does not
require sedation or analgesia, but
all other emergency situations do
Time ?
30 sec (RSI)
26. ASSESMENT DIAGNOSIS MANGMENT
HR
PULSE VOLUME
BLOOD
PRESSURE
P,PERFUSION
PRELOAD
HR + 4P
COMPANSATED
- Tachycaedia
- Vasoconstriction
(poor preph.perfusion)
- Normal
bl.pressure
DECOMPANSATED
- Bradycardia
- Hypotention
- Diminshed central
pulse
- Agitation
- Decrease uop
- -DCL
- tachypnea
COMPANSATED
- Maintane clear
airway
- Oxygen supply
- Vascular acess
- Start fluid resustation
DECOMPANSATED
- As above
- Ttt the cause
- -use vasoactive
druge or inotropes
acc to case
27. Emergency vascular
access
peripheral intravenous
[IV]
intraosseous route [IO]
Common sites for peripheral intravenous access
in children are
the back of the hand
dorsum of the feet
antecubital fossa.
The use of scalp veins during resuscitation is
not advisable due to the risk of extravasation
and potential tissue
necrosis.
28. Fluid in ressustation
Isotonic
Crystalloids
Colloids Blood
products
preferred as frst line
resuscitation fuids
because
• they are generally
safe
• readily available
• efcient in increasing
circulating volume
• inexpensive
Examples
• Normal saline (0.9 %)
• Ringer’s lactate
• Hartmann’s solution
• Plasmalyte….
Human albumin
solutions (5 or 4.5 %)
They are an
acceptable choice as
an adjuvant volume
expander in septic
shock but
contraindicated
in patients with
traumatic brain injury
Hypertonic
albumin (20 %)
indicated in
critically ill
children with
hypoalbuminemia
or oliguria
Any child with
presumed
haemorrhagic
shock after trauma
who has not
responded to 20-
40 ml/kg of
crystalloid needs
blood products as
soon as possible
noncross-matched
Group O
Rhesus-negative blood
and/or Group AB Fresh
Frozen Plasma
Do not give red blood cells together with
glucose or calcium containing fluids in the
same line as haemolysis occurs.
31. • Full exposure
• Maintain dignity
• Prevent hypothermia
• Ask for AMPLE history
• Further investigation
• Advanced help & consultation
• Continue reassessment
• Despositiese
32. Case scenario
You are called to the pediatric emergency
department to assess a 3 month old infant
who was brought in by ambulance.
According to the paramedics, the baby's
parents found her limp and unresponsive in her
crib.
On initial assessment in the resuscitation
room, the baby is pale and limp with shallow
breathing. Her AVPU score is 'P' for responsive
to pain only. Her heart rate is fast at 180
beats/minute but her blood pressure is low at
70/30. She feels cold to touch
33. You begin opening the airway and give oxygen
by face mask at 15L/min. After a few minutes her
respiratory effort improves slightly but she
remains barely responsive.
You listen to her chest and hear wheezes
bilaterally. Her oxygen saturation on the monitor
is 85% despite oxygen1
Given her signs of shock and compromised
respiratory status, you decide to secure her
airway.
34. She desaturates further during intubation
attempts. You are able to pass a 3.0 cuffed ETT and
her saturations recover to 95% on ventilation.
Her heart rate reduces to 150 but pressure remains
low.
You start a fluid bolus of 10ml/kg normal saline
through her right intraosseous line. Bloods drawn at
the same time show a severe metabolic acidosis and
mild hypoglycemia. You give a bolus of 2ml/kg
10% dextrose and continue her on maintenance
fluids and inotropic support. Her pressures and
perfusion improve slowly with treatment.
35. A provisional diagnosis of sepsis is made and
broad spectrum antibiotics are started after
cultures are taken.
You organize transfer to PICU for ongoing support
and investigations to identify the source of
infection. Her parents are updated on her condition
which remains critical but stabilized for transfer
