1. Dr. Lilia Dewiyanti, SpA, MSiMed.

2. Many etiologies
Respiratory failure Shock
Cardiopulmonary failure
Cardiopulmonary arrest
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3. Outcome of respiratory vs Cardiopulmonary Arrest in
Children
100% 75 – 90 %
Survival rate
75%
7 – 11 %
Respiratory arrest Cardiopulmonary arrest
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4. Core Knowledge and Skills
1. Recognize respiratory distress and
potensial respiratory failure
2. Recognize shock
3. Describes priorities for
management of
respiratory distress, failure, and
shock
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5. Is this child in respiratory failure
or shock ?
Is this child in respiratory
failure or shock?
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6. The Three Phases of
Rapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
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7. The ABCs
Normal Vital Functions Are Maintained
By To Provide
Airway Ventilation
Breathing Oxygenation
Circulation Perfusion
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8. Primary Abnormalities in Respiratory Failure
Ventilation
Airway
And
Breathing
Oxygenation
Circulation
Perfusion
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9. Classification of Respiratory Failure
Potential respiratory failure
Theraphy
(eg, positioning, oxygen administration)
Improvement Deterioration
Potential Probable
Resp. failure Resp. failure
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10. Initial Assessment
Pediatric Assessment Triangle :
Circulation to Skin
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11. Appearance (“Tickles” =TICLS)
 Tonus
 Interactiveness
 Consolability
 Look/Gaze
 Speech/Cry
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12. Potential respiratory failure
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13. Work of Breathings
 Abnormal airway sounds
 Abnormal positioning
 Retractions
 Nasal flaring
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14. The sniffing position
The abnormal tripod position
Retractions
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15. Circulation to Skin
Characteristic of Circulation to Skin
 Pallor (putih pucat)
 Mottling (bercak2)
 Cyanosis (kebiruan)
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16. PAT: Potential Respiratory Failure
Normal Increased
Circulation to Skin
Normal
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17. PAT: Respiratory Failure
Increased
Abnormal or
decreased
Circulation to Skin
Normal or abnormal
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18. Rapid Cardiopulmonary Assessment
Physical Examination - Airway
1. Clear
2. Maintainable
3. Unmaintanable without intubation
4. Obstructed
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19. Rapid Cardiopulmonary Assessment
Physical Examination - Breathing
1. Rate
2. Effort / mechanics
3. Air entry
4. Skin color and temperature
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20. Rapid Cardiopulmonary Assessment
Physical Examination - Breathing
Evaluation of rate, effort, and mechanics
• Tidal Volume ( V T)
• Minute ventilation (MV)
• MV = VT X RR
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21. Rapid Cardiopulmonary Assessment
Physical Examination : Breathing
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22. Primary Abnormalities in Shock
Ventilation
Airway
And
Breathing
Oxygenation
Circulation
Perfusion
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23. PAT: Shock
Abnormal Normal
Circulation to Skin
Abnormal
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24. Basic Relationships of Cardiovascular Parameters
Preload
Stroke Myocardial
Volume contractility
Cardiac Afterload
Output
Heart
Rate
Blood
Pressure
Systemic
Vascular
Resistance
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25. Cardiac Output = Heart Rate X Stroke Volume
Inadequate Compensation
• Increased heart rate
• Increased SVR
• Posible increased SV
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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
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27. Child in shock
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28. Rapid Cardiopulmonary Assessment
Physical Examination - Circulation
1. Heart rate
2. Systematic perfusion
• Peripheral pulses
• Skin perfusion
• Level of consciousness
• Urine output
3. Blood pressure
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29. Heart rates in Normal Children
Age Range
Newborn – 3 Mos 85 – 200 bpm
3 mos – 2 yrs 100 – 190 bpm
2 – 10 yrs 60 – 140 bpm
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30. Palpation of Central dan Distal Pulses
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31. Rapid Cardiopulmonary Assessment
Physical Examination - Circulation
Skin perfusion
• Extremity temperature
• Capillary refill
• Color
• Pink
• Mottled
• Pale
• Blue
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32. Normal capillary refill is < 2
seconds in a warm
environment
Capillary refill
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33. Rapid Cardiopulmonary Assessment
Physical Examination - Circulation
Level of consciousness
•A = Awake
•V = Responsive to voice
•P = Responsive to pain
•U = Unresponsive
Child in shock with depressed mental status
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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 ?
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35. Rapid Cardiopulmonary Assessment
Physical Examination - Circulation
Age Fifth percentile mmHg
Systolic BP
0 – 1 Mo 60
> 1 mo – 1 yr 70
> 1 yr 70 + (2 x age in years)
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36. Review of the Physical Findings in Shock
Early signs (compensated)
• Increased heart rate
• Poor systemic perfusion
Late signs (decompensated)
• Weak central pulses
• Altered mental status
• Decreased urine output
• Hypotension
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37. Child dying with anasarca , MOSF
despite resuscitation efforts
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38. Definition of Cardiopulmonary Failure
Deficits in
• Ventilation
• Oxygenation
• Perfusion
Resulting in
• Agonal respiration
• Bradycardia
• Cardiopulmonary arrest
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39. Rapid Cardiopulmonary Assessment
Ventilation
Airway
And
Breathing
Oxygenation
Circulation
Perfusion
39

40. The Three Phases of
Rapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
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41. Rapid Cardiopulmonary Assessment
Classification of Physiologic status
• Stable
• Respiratory failure
• Potential
• Probable
• Shock
• Compensated
• Decompensated
• Cardiopulmonary failure
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42. The Three Phases of
Rapid Cardiopulmonary Assessment
1. Physical examination
2. Classification of physiologic status
3. Initial management priorities
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43. Rapid Cardiopulmonary Assessment -
Priorities of Initial Management
Stable
• Begin further workup
• Provide specific theraphy as indicated
• Reassess frequently
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44. Rapid Cardiopulmonary Assessment -
Priorities of Initial Management
Potential RF Probable RF
Keep with caregiver Separate from caregiver
Position of comfort Control airway
Oxygen as tolerated 100 % FiO2
Assist ventilation
Nothing by mouth Nothing by mouth
Monitor pulse oximetry Monitor pulse oximetry
Consider cardiac monitor Cardiac monitor
Establish vascular- access
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45. 45

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
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47. Rapid Cardiopulmonary Assessment -
Priorities of Initial Management
Cardiopulmonary failure
• Oxygenate, ventilate, monitor
• Reassess for
• Respiratory failure
• Shock
• Obtain vascular access
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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 ?
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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 ?
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50. Case No 1 - Response to Therapy
• Vital sign improved
• Perfusion still poor
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51. What is the heart size ?
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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 ?
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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 ?
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54. Chest X-ray after fluid bolus
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