APLS Notes

APLS notes AIRWAY OP Airway Can lead to gag or vomit if not completely unconscious Sizing size from centre of incisors to angle of mandible Too small --> ineffective Too large --> laryngospasm Either can cause mucosal trauma or worsen airway obstruction Insertion Use laryngoscope or tongue depressors to insert OR insert upside down and rotate NP airway Can perforate basal skull fractures Sizing Size from lateral edge of nostril to Tragus of ear Diameter to fit but not blanch the alar nasi Insertion Lubricate and push posteriorly ET airway Uncuffed tubes unless familiar with intubation Sizing Internal diameter (mm) = (age/4) + 4 (if cuffed + 3.5 not 4) Length for oral (cm) = (age/2) + 12 Length for nasal (cm) = (age/2) + 15 Neonates = 3 to 3.5 (smaller in prems) Insertion Prepare tubes one size above and below planned size Position the child (towel under neck if needed for better position) Pre-oxygenate for 30s Intubate Check position by bagging and auscultation Complications Oesophageal intubation Endobronchial intubation Severe hypoxia from prolonged attempts Chipping / loosening of teeth Exacerbation of c-spine injury LMA Limited use in children BREATHING Basic - mouth to mouth / mouth and nose / mask Breathing enhanced oxygen - bag and mask with O2 supply Pressure limiting valve set to approx 4.5kPa CARDIAC ARREST Safety Stimulate Shout Airway manoeuvres Look, listen and feel 5 rescue breaths Check for signs of life / pulse CPR 15:2 Assess rhythm - shockable (VF, pulseless VT) OR non shockable (PEA, Asystole) Reversible causes Hypoxia Hypovolaemia Hypothermia Hyper/hypokalaemia (and other metabolic disorder) Tension pneumothorax Tamponade Toxins Thromboembolism PEA - Tamponade, tension or hypovolaemia Asystole - Hypoxia or Hypovolaemia VF/Pulseless VT - Hypothermia, Hyperkalaemia, Toxins Asystole / PEA Adrenalin immediately and every 4 minutes (10mcg/kg) Reassess every 2 minutes VF / Pulseless VT Rare in children other than hypothermia, TCA overdose and cardiac disease SHOCK 4J/kg every 2 minutes Use paediatric paddles if under 10kg Adrenalin after 3rd shock then every alternate shock (10mcg/kg) Amiodarone after 3rd and 5th shock only (5mg/kg RAPID IV bolus) Lidocaine can be used if amiodarone is not available 1mg/kg Precordial thump IF witnessed monitored arrest AND defib not immediately to hand Magnesium if hypermagnesaemia or torsades du point (polymorphic VT) ACCESS FOR DRUGS IO access Rapid and effective if no IV access available Tibia: anterior surface, 2-3cm below tibial tuberosity Femoral: anterio-lateral, 3cm above lateral condyle Follow by 5ml flush Tracheal Tube Not ideal but can give adrenalin via if no other access Give 100mcg/kg adrenalin flushed with 1-2mls normal saline DRUGS Adrenalin 10mcg/kg IV fluids Only if Hypovolamic AND should not delay other drugs Bicarbonate ONLY if good ventilation established as causes increased CO2 to cells Consider if prolonged arrests and no effect from adrenalin OR if Hyperkalaemia or TCA overdose 1mmol/kg (1ml/kg of 8.4%) solution DON'T give via same line as calcium (causes precipitates) FLUSH WELL between bicarbonate and adrenalin as inactivate each other CAN'T give down ET tube Calcium ONLY to be used if hypocalcaemia, Hyperkalaemia, hypermagnesaemia or calcium channel blocker overdose Atropine Has NO ROLE in arrest situation ONLY used for excessive fatal tone causing bradycardia in perusing patient Amiodarone In VF/Pulseless VT after 3rd and 5th shocks only (5mg/kg) given by RAPID IV bolus Lidocaine Can be use if amiodarone is not available 1mg/kg Magnesium If hypermagnesaemia or torsades du point (polymorphic VT) OTHER CONSIDERATIONS Oxygen 100% during resus then aim for sats 94-98% Therapeutic hypothermia Core temp 32-34 degrees beneficial to neuro recovery Parents Staff member to support Team leader to explain to parents POST ARREST FOLLOW UP CXR Blood gases Hb and haematocrit Electrolytes LFTs and Coag screen - hepatic damage can manifest upto 24 hours later BM Urinalysis 12 lead ECG RECOGNITION OF THE SERIOUSLY ILL CHILD Breathing Effort of breathing - may be normal if neuromuscular disease or exhaustion Resp rate Accessory muscles Nasal flaring / grunting Positioning Efficacy Air entry and O2 sats >95% = normal 85-95% = low <85% = seriously low Circulation Heart rate Pulse volumes Blood pressure - cuff width should be more than 80% of upper arm length and bladder more than 40% of arm circumference Cap refill Urine output (<1ml/kg/hour children or <2ml/kg/hour in infants) Disability AVPU (assess pain by sternal pressure, supra orbital pressure or pulling frontal hair) Posturing - decorticate or decerebrate Pupils THE CHILD WITH BREATHING DIFFICULTIES Upper airway - croup, epiglottis, foreign body Lower airway - tracheitis, asthma, bronchiolotis Lungs - pneumonia, pulmonary oedema Pleura - rib fractures, empyema, pneumothorax Muscles - neuromuscular disorders Diaphragm - peritonitis, abdominal distension Increased respiratory drive - DKA, shock, poisoning, hyperventilation Decreased respiratory drive - coma, convulsions, raised ICP, poisons NB: no increase in effort is seen if exhaustion, reduced conscious level or neuromuscular disorder Stridor Viral croup Oxygen Adrenalin 1:1000 (5mls) nebuliser Intubate if required Dexamethasone / budesonide Bacterial croup Oxygen Intubate if required IV flucloxacillin and cefotaxime Epiglottis KEEP CALM Seek help, Intubate IV cefotaxime or ceftriaxone Foreign body Choking child procedure Direct laryngoscopy Surgical airway if required Wheeze Asthma Ventilate if: Exhaustion with rising CO2 Deterioration (progressive or sudden) Massive atelectasis Bronchiolotis More severe if: <6 weeks old Unable to feed Cardiac malformations Preterm infant (Esp if CLD) NO ROLE for steroids or bronchodilators CXR may help ONLY to exclude pneumothorax or cardiac problem Fever Pneumonia Absence of upper airway obstruction Breathing difficulties with significant fever Give oxygen, antibiotics, pleural drainage may be required Cardiac causes of breathing problems = heart failure Signs Cyanosis not correcting with oxygen Tachycardia out of proportion to resp difficulties Raised JVP Gallop rhythm Enlarged liver Absent femorals Causes L to R shunt e.g. VSD, PDA L heart obstruction e.g. Aortic stenosis Pump failure e.g. Myocarditis Dysrhythmias e.g SVT Treatment Oxygen and furosemide if in failure Prostin if duct dependent lesion THE CHILD IN SHOCK Compensated shock Mild agitation or confusion Skin pallor Increased HR Cold skin with slow CRT Reduced UO Uncompensated shock Falling BP Prolonged CRT Tachycardia Cold peripheries Acidotic breathing Depressed cerebral state Severely reduced / absent UO Cardiogenic E.g. Tamponade Trauma history, muffled heart sounds Treat with pericardiocentesis Dissociative E.g. Severe anaemia Extreme pallor, SOB, splenomegaly, dark urine, limb pains, heart failure Treat with transfusion on packed red cells and diuretics Distributive e.g. Septicaemia. Fever, lethargic, rash, myalgia, flushed or pale, drowsy, petechiae or purpura Treat with antibiotics e.g. Ceftriaxone or cefotaxime E.g. Anaphylaxis Swelling, itching, abdo pain, collapse, hives, cough, airway obstruction Treat with IM adrenalin, IV steroids and anti-histamine Hypovolaemia E.g. DKA Vomiting, polyuria, pale, ketones, fast breathing Treat with IV fluid replacement, insulin 10 mls/kg bolus of normal saline Aim to replace deficit within 48 hours with 0.45% saline Insulin infusion of 0.5-1.0 units/kg/hour AFTER the first hour Once glucose is <12-15mmol/l then add glucose to fluid E.g. Gastroenteritis Diarrhoea and vomiting, pale, dry mouth, irritable Treat with IV fluids and replace ongoing losses Obstructive THE SEPTIC CHILD Usually treat with cefotaxime or ceftriaxone UNLESS evidence of staph (then use flucloxacillin or vancomycin) THE CHILD WITH ABNORMAL RATE OR RHYTHM ABC If bradycardia and shock then CPR + fluid bolus Treat hypotension and shock aggressively with volume expansion Consider bolus of adrenalin 10mcg/kg followed by infusion (0.5-1.0mcg/kg/min) If from vagal stimulation then atropine 0.2mg/kg (max 2mg) If tachycardia then... Supraventricular --> DC shock / adenosine In infants usually 220-300 Vagal manoeuvres if no delay Diving reflex - iced water One sided carotid body massage Valsalva manoeuvre Synchronous shock 1J/kg then 2J/kg, consider amiodarone if no response OR IV adenosine 100mcg/kg, then 200, then 300 (2min intervals) Warn of sense of doom, short acting therefore short lived Rapid bolus and immediate flush into large vein Then consider 4-500mcg/kg OR DC shock OR Amiodarone OR other antiarrhythmic Ventricular --> DC shock One or 2 synchronous shocks at 1 then 2J/kg (sedate first if sufficiently stable) OR asynchronous shocks if other not available OR amiodarone 5mg/kg over 30 minutes (can cause low BP) OR Procainamide 15mg/kg over 30-60mins. (can cause low BP) IF due to TCA overdose then give bicarbonate 1-2mmol/kg and hyperventilate THE CHILD WITH DECREASED CONSCIOUS LEVEL Conscious level AVPU GCS Pupils Symmetrical? Responsive? Changes at back of eyes? Bleed, papilloedema etc Fixed dilated - barbiturate overdose, during and post seizure, hypothermia, anticholinergic drugs, severe hypoxia, Pinpoint reactive - narcotic ingestion, medullary lesion, metabolic disorders, organophosphate poisoning Unilateral dilated - 3rd nerve lesion, focal epilepsy, focal brain lesion Posture Decorticate - severe brain damage, motor response of 3 on GCS Decerebrate - more severe damage, motor response of 2 on GCS Progression can indicate ongoing bleeding or herniation Glucose If low (or reading not available) then 2mls/kg of 10% Raised ICP Support ventilation (pCO2 of 3.5-5.0) Maintain head up 20-30degrees Mannitol (250-300mg/kg = 1.25-2.5mls) 20% IV over 15 minutes then 2hrly as required OR use hypertonic saline 3% saline 3mls/kg Consider dexamethasone if space occupying lesion (0.5mg/kg 6hrly) Causes and clues Meningitis / encephalitis - fever, rash, 1-2 day history Long term mortality / morbidity inputs 30% Signs Older child - neck stiffness, photophobia, severe headache, confusion, joint pain, seizures, diarrhoea, Infant - poor feeding, buldging fontanelle, floppy, whimpering, neck retraction, pale and blotchy, fretful, jaundice, blank expression Either - purpurin rash, pyrexia, lethargy, drowsiness, vomiting, Treatment. Cefotaxime or ceftriaxone Dexamethasone reduces hearing loss in bacterial meningitis and should be started within 4 hrs of abx LP unless contraindications: impending herniation, prolonged or focal seizures, focal neurology, GCS of 13 or less, uncorrected clotting disorder Child abuse - other injuries, younger age, inconsistent history Trauma - other injuries + history Metabolic - large liver, low BM, vomiting, odd smells Diabetes - high BM, Acidotic, polyuria ABC Oxygen Cardiac monitor Bloods and urine including cultures Aim to rehydrate over 48 hours avoiding rapid changes in osmo and K+ Give 10ml/kg fluid blouses Start insulin AT END OF 1st hour (initially 0.5-1.0 units/kg/hr) Start KCl in fluid at end of 1st hour (40mmol/litre) Assess regularly to avoid cerebral oedema Hypertensive encephalopathy - headaches, fundal changes, high BP CVA - sudden onset, focal neuro, severe headache Poisoning - history, specific signs Charcoal will bind to many poisons Gastric lavage is rarely needed Naloxone for all opiates (beware methadone has a long half-life) THE CONVULSING CHILD Status epilepticus is: Continuous and generalised convulsions for more than 30 minutes Repeated convulsions without full recovery between seizures Prolonged convulsions cause neuronal damage BUT most fits stop within 5 minutes The longer the fit the harder it is to stop ABC and high flow oxygen Monitor BM Clinically confirm this is an epileptic seizure Consider posturing (raised ICP), dystonic reactions and pseudo epilepsy IF FITTING FOR 5 minutes IF IV access then give lorazepam 0.1mg/kg IV IF no IV access then give diazepam 0.5mg/kg PR OR buccal midazolam (buccal) 0.5mg/kg IF CONTINUING AFTER 10 minutes IF IV access give lorazepam 0.1mg/kg IV IF no IV access, give paraldehyde 0.4mls/kg PR (with same vol olive oil) IF CONTINUING AFTER 10 minutes Call for senior help Phenytoin 18mg/kg over 20 minutes OR Phenobarbitone 20mg/kg over 10 mins (if already on phenytoin) AND paraldehyde 0.4mls/kg (if not already given) AND call anaesthetist IF CONTINUING AFTER 20 minutes Rapid sequence induction with thiopentone 4mg/kg IV AND transfer to PICU Common causes of convulsions in children Fever (6m to 5y) Considered complex if over 15 minutes 8% of febrile convulsions are prolonged Cerebral hypoxia CNS infection Metabolic abnormalities (hypoglycaemia, hyponatraemia, hypocalcaemia, hyperammonaemia, hepatic encephalopathy) Epilepsy and anticonvulsant withdrawal Trauma Intoxication (tricyclics, alcohol, drugs of abuse) Systemic hypertension Complications of status epilepticus Pulmonary oedema Hyperthermia Cardiac Dysrhythmias Hypertension Cerebral oedema - nurse head up, ventilate to pCO2 3.5-4.5, consider mannitol Myoglobinuria DIC FLUID AND ELECTROLYTES Fluid requirements 100 mls/kg for the 1st 10kg 50 mls/kg for the next 10kg 20mls/kg for every kg after that Intravascular compartment = 80mls/kg Loss of 25% of this 20mls/kg will result in hypovolaemic shock It is possible to be: Dehydrated and not shocked (intravascular compartment intact) Over hydrated and shocked (e.g. Nephrotic syndrome) Shocked and not dehydrated Treatment of Dehydration is gradual replacement of fluids Shock is rapid replacement 20 mls / kg bolus (unless DKA) If not responding after 40mls/kg then PICU Normal electrolyte levels Sodium. Potassium. Chloride. Urea. Glucose. 136-145 3.5-4.5 96-106 2.5-6.4 3.9-5.8 Assessment of hydration Drop in weight - only useful for total body water. Often no recent weight available Depressed fontanelle - only if still patent and not if meningitis Sunken eyes - difficult to objectify Dry mouth - dry if mouth breather, wet if recent oral fluids Decreased skin turgor - unreliable if fat / malnourished / hypernataraemic dehydration Decreased urine output - can be inaccurate in DKA / renal conditions. Difficult to measure in nappy wearing children with wary diarrhoea Assessment of shock Tachycardia with poor peripheral pulses / prolonged CRT / cool peripheries Poor perfusion - altered mental state, poor UO, metabolic acidosis with compensatory increased RR Dehydrated and not shocked = 5% Shocked = 10% or more ACID BASE Normal values pH 7.36-7.44 pCO2. 4.7-6 kPa (35-45mmHg) BE. -2 to +2 mmol/l pO2. >10.6 on air (>80mmHg) Base excess??? Amount of base that would have to be removed (or neutralised) to return pH to normal = POSITIVE BASE EXCESS Base deficit = amount to be added = NEGATIVE BASE EXCESS TRIAGE 1. Immediate (0 mins). Airway compromise, apnoea, no pulse, shock, fitting, hypoglycaemia, unresponsive 2. Very urgent (10 mins). Increased work of breathing, abnormal pulse, major haemorrhage, V or P only, hot, purpura, severe pain, exhaustion 3. Urgent (60 mins). Significant asthma, minor haemorrhage, moderate pain, pleuritic pain 4. Standard (120 mins) 5. Non urgent (240 mins) STABILISATION AND TRANSFER Checklist before transfer Respiratory - ET tube, humidification, ventilator settings, CXR, blood gases CVS - status, hepatic size, ionotropes, ECG, CXR Neuro - GCS, Pupils, sedation, analgesia, paralysis, imaging, neuro-protection for ICP Gastro - nutrition, gastro protection, ileum and gastric decompression (NG or OG tube) Renal - urine output, fluid balance, urea and creatinine, need for renal support Hepatic - LFTs Biochemistry - electrolytes, blood sugar, calcium, magnesium Haematology - FBC, clotting studies Infection - temp, WCC, CRP, swabs, PCR, antibiotics Skin/joints - skin, mouth and eye care, rashes, passive movements Drugs - complete IV and enteral drugs list, drug levels Lines - access for monitoring, blood sampling and IV drugs, security of catheters and drains Parents - communication, support, concerns PAIN Morphine - bolus then tritrate with aliquots over 10 min intervals Intranasal diamorphine or fentanyl - rapid analgesia without need for IV access Nitrous oxide RECOGNITION OF THE SERIOUSLY INJURED CHILD C spine. If mechanism is consistent then assume c-spine injury until proven otherwise Protect with inline immobilisation, collar and blocks Protect IF: Unconscious after trauma Midline pain Focal neurology Sedative drugs Painful distracting injury Reduced mental state Circulation Excess fluid bolus can disrupt forming clots leading to further bleeds Bolus at 10mls/kg IF significant head injury then aim to maintain normal blood pressure to maintain cerebral perfusion ONCE total of 40mls/kg given then use blood CONTACT surgeons if not stable after 20 mls/kg of fluid Timings of blood availability O-Neg = immediate ABO-type specific = 10-15 mins Full cross match = 45-60 mins DISABILITY If neuro injury (GCS < 8 or unequal pupils) Oxygen Control ventilation to control CO2 Maintain BP to maintain cerebral perfusion pressure Head up tilt 20-30 degrees with in line stabilisation of neck (avoid compression of neck veins from tight collar) Mannitol or hypertonic saline of indicated to lower ICP Anaesthesia or sedation or analgesia to reduce cerebral metabolism Prompt treatment of seizures CHILD WITH A CHEST INJURY Elasticity of children’s ribs means they can have damage to deep structures without broken ribs Small resp reserve, high metabolic rate AND small functional residual capacity means can desaturated rapidly ET tube can easily displace due to short trachea Mask ventilation can cause gastric distension causing diaphragmatic splinting Overinflation of lungs can cause pneumothorax Tension pneumothorax Signs Surgical emphysema, can have distended neck veins with delayed cap refill and hypotension Ipsilateral reduced air entry and hyper-resonant to percussion, tracheal deviation Treatment High flow O2 Immediate needle thoracocentesis Then chest drain Massive haemothorax Signs Pleuritic pain, hypotension Ipsilateral decreased air entry and DULL percussion Tracheal deviation Treatment High flow O2 and IV access Large chest drain Open pneumothorax Signs Ipsilateral hyperresonance and decreased air entry Sucking wound Treatment High flow O2 Chest seal 3 sided dressing or 4 sided dressing with chest drain Surgical repair and definitive drain Flail chest Signs Abnormal chest movement, crepitus Treatment High flow O2, analgesia CPAP if available (splints fractures) Intubation and ventilate if decompensating Cardiac Tamponade Signs Hypotension Muffled heart sounds Distended upper neck veins Treatment High flow O2 IV access for volume Emergency needle pericardiocentesis Emergency thoracotomy THE CHILD WITH ABDOMINAL INJURY Differ from adults ... Less rib protection Thinner abdo wall More horizontal diaphragm causing liver and spleen to lie lower and more anterior Bladder more abdominal than pelvic (meaning exposed when full) Aids to assessment Gastric decompression Urinary catheter Abdo ultrasound for free fluid Rectal examination ONLY if essential and then by consultant who may operate Management is conservative where possible Haemorrhage is often self-limiting Chance to preserve the spleen Lower morbidity and mortality Surgery if... Worsening distension or peritonitis Evidence of ruptured diaphragm Eviscerated bowel Evidence of bowel perforation Circulatory instability not responding to fluids CHILD WITH TRAUMA TO THE HEAD Head injuries are more fatal than any other High energy transfer (RTC or fall from height) History of loss of conscious Altered conscious on assessment Neuro signs such as headache, vomiting, convulsions or limb weakness Penetrating head injury Aim is to stabilise and prevent secondary brain injury due to: Hypoxia Inadequate perfusion due to low BP or high ICP Excessive metabolic demand (fits) Hypoglycaemia ABC Disability with aim to assess and protect Constant reassessment (can change rapidly) CT scan as appropriate (NICE guidelines) CHILD WITH INJURY TO THE SPINE Management Firm surface BUT remove board to prevent pressure to skin Manual inline immobilisation Log roll Blocks and straps Assessment Inspection Palpation Neuro exam Plain XR CT scan CHILD WITH BURNS AND SCALDS Severity depends on temperature and duration of contact Most common cause of death after burn is smoke inhalation ABC Indicators of airway involvement: Exposure in a confined space Deposits around mouth or nose Carbon in sputum Aim for early intubation as oedema onsets quickly Burns to chest or abdo may restrict breathing Fluids = % burn x weight x 4 Give half over 1st 8 hours (from time of burn) And rest over next 16 hours Use Lund and Browder chart to calculate area Consider thickness of burn Remember analgesia Care of the burn Sterile towels or cling film Cold compress ONLY for 10 mins and only if <10% superficial or partial Avoid unnecessary examination Leave blisters in tact Ointments and creams only as part of definitive care Transfer to burns unit if 10% partial and full thickness 5% full thickness Special areas - face, hands, feet, perineum Circumferential burns Inhalation injury Chemical, radiation, or high voltage electrical burns Suspicion of NAI CHILD WITH DROWNING Pathophysiology Submersion Voluntary apnoea Causes acidosis and hypoxia Involuntary breath Water hits glottis causing laryngeal spasm = dry drowning OR secondary apnoea leads to gasping and aspiration = wet drowning Management Assume C-spine injury Handle with care. Rough handling can cause VF in hypothermic patients Intubate to prevent aspiration of stomach contents Gastric drainage Hypothermia Can be protective if less than 32 degrees VF can be refractory below 30 degrees (limit to 3 shocks) Warm to 30 degrees ASAP Dose interval doubled between 30 and 35 degrees for resus drugs Resus until at least 32 degrees body temp External warming sufficient if over 30 degrees Remove wet clothes Warm blankets or air system Heating blanket Radiant lamp Internal rewarming if less than 30 degrees Warm IV fluids Warm ventilator gases Gastric or bladder warm lavage Peritoneal lavage Endovascular warming Extra corporeal warming Investigations BM, gases, lactate, UE, COAG, blood and sputum cultures, CXR, C-spine X-ray, monitor K closely Prognostic factors Good Hypothermia before drowning Rapid CPR on leaving water Immersion time less than 10 mins Short time to first spontaneous respiratory effort Poor Persisting coma pH less than 7.1 despite therapy PaO2 less than 8kPa despite therapy