Official guidelines available as PDFs from the Resus Council. Training is offered by the Advanced Life Support Group. My abbreviated APLS Guidelines are here.
IntraOsseous- bretylium is the only contraindicated drug! Feel calf for extravasation. Aspiration not always possible, doesn't mean you're in the wrong place. Warn labs if marrow samples sent (it blocks up their machines).
Changes to Paediatric Resuscitation guidelines (Resuscitation Council UK 2005):
2005 changes to AHA resuscitation guidelines:
The PIM is a predictive score, the second version (PIM2) has been validated in 20,787 children from ICUs in Australia, New Zealand, and the United Kingdom. Includes ten variables that are measured at entry into the PICU:
The discrimination value of the PIM-2 is 0.90. Similar, if not better, than the PRISM III score. PIM scores avoid problems of early treatment bias because it includes only data at entry into the PICU. General scales like PRISM and PIM scores may not be applicable to children with a specific disease, eg cancer, purpura fulminans but actually PRISM2 seems to work better than any of the 25+ scores developed for meningococcus!
Pediatric Logistic Organ Dysfunction (PELOD) score - 12 variables across 6 organ systems. Not a predictive score so much as a descriptive score although multiorgan dysfunction is associated with mortality.
Despite the resuscitation tools and drugs available, research suggests that time-to-treatment also has a significant impact on patient outcome. Identifying which patients may need intervention is perhaps not too difficult - there are almost always deteriorating basic observations eg respiratory rate, heart rate, blood pressure and sats; additionally, subjective factors eg work of breathing, nurse concern have also been associated with cardiac arrest. Furthermore, many of the pre-arrest clinical conditions have been deemed preventable eg arrests were more likely to occur in non–ICU settings; in inpatient units without adequate clinical expertise; under the care of trainees; handover times.
Having clear activation criteria for the medical emergency team is important. There may also be a role for a Rover Team that is made aware of patients at risk for deterioration - such a proactive approach helps by creating a shared mental model of clinical status and possible complications.
Such interventions have significantly reduced arrests, deaths and post-arrest ICU stays Clinical Pediatric Emergency Medicine Volume 7, Issue 4 , December 2006, Pages 241-247
Contraindications to nasal intubation - basal skull fracture,coagulopathy, cleft palate, age over 10 yrs
For nonfasted, GI obstruction - but not if scary airway (gaseous?)
Get help, oxygenate, is intubation really necessary eg laryngeal mask?, change equip!/approach, cricoid.
Fail through nose- trim suction catheter, use as guide wire.
Fail at cords- rotate to avoid tip getting wedged in vallecula.
Induction takes longer if low cardiac output.
Monitor cardiac output by:
Pulmonary hypertension (clinically low sats, low BP, tachycardia, hepatomegaly; seen in previously high pulmonary flow eg VSD, Truncus):
Heart rate:
Extracorporeal Membrane Oxygenation. Minimum 1.2kg, 32/40 corrected age. Not more than 7/7 high pressure ventilation. Unresponsive to conventional ie Oxygen Index >40 or pCO2>90mmHg.
OI = Paw (mean airway pressure)/PaO2 X FiO2 x 100, all in mmHg
Reversal of shock before the transport team arrived at the patient's bedside was associated with 96% survival and >9-fold increased odds of survival. Each additional hour of persistent shock was associated with >2-fold increased odds of mortality. When resuscitation practice was in agreement with ACCM-PALS guideline, a lower mortality was observed (8% vs 38%). Pediatrics. 2003 Oct;112(4):793-9 Han YY
Similarly, early aggressive fluid resuscitation in septic shock improves survival (see Sepsis below). Children who receive larger volumes of intravenous isotonic fluid in the initial hour after presentation in septic shock have lower mortality, esp those who receive >40 mL/kg. Furthermore, when groups receiving smaller versus larger volumes of intravenous fluids are compared, there is no increase in acute respiratory distress syndrome or noncardiogenic pulmonary edema. The London experience with meningococcal sepsis is of improved survival when increased fluid resuscitation was instituted as part of early resuscitation therapy.
Crystalloid vs Colloid - 2001 meta-analysis showed no difference. But will need more crystalloid to achieve same end point (larger volume of distribution). SAFE study in adults confirmed, slight benefit in sepsis for albumin.
Intubation may required to secure airway. Since young infants have such low functional residual capacity ventilation should be considered early.
Give fluid boluses up to 60 ml/kg. Correct hypoglycaemia and hypocalcaemia.
Thyroid replacement beneficial in post-bypass patients but not yet studied in sepsis. Consider in trisomy 21 and pituitary disease.
Consider thyroid replacement.
For peripheral infusion, make up dopamine as 3x wt =mg in 50ml 5% dex, 10ml/hr = 10mcg/kg/min
Dopamine action requires stores, often reduced in young infants. Some people like to use Dobutamine & noradrenaline because synergistic.
If fluid refractory, begin dopamine and establish arterial line.
If dopamine refractory then titrate epinephrine for cold shock (suggesting myocardial depression), norepinephrine for warm shock (ie vasodilatation).
There is evidence that adrenal insufficiency common in sepsis but poor evidence that steroid therapy is of any benefit (see below). High dose is definitely of no value in sepsis. Physiological dose would be hydrocortisone 1-2 mg/kg 6 hrly.
If catecholamine refractory, give hydrocortisone if at risk of adrenal insufficiency (pituitary disease, steroid dependent, purpura fulminans [adrenal haemorrhage=Waterhouse Friedrichsen syndrome]); consider insufficiency if random cortisol <500nmol/L) or rise <250nmol/l after ACTH).
Milrinone is type 3 phosphodiesterase inhibitor, inotrope, vasodilator, faster ventricular relaxation. No increase in myocardial O2 consumption. In neonates less inotrope effect. SE hypotension. Long half life (6 hours) so loading is pharmacokinetically appropriate - but danger of overshoot hypotension.
If cold shock with normal blood pressure, add vasodilator (nitroprusside) or type 3 phosphodiesterase inhibitor (milrinone - use amrinone if renal impairment) with volume.
If other shock - titrate volume and inotropes, aim for normal MAP-CVP difference for age and CI>3.3 and <6 l/min/m2 (if pulm catheter). Consider ECMO.
Vasopressin acts on V1 receptor on vascular smooth muscle. Enhances catecholamine sensitivity, vasoconstrictor without heart effects (but differential depending on dose eg GI tract, kidneys, brain). No large trials, no dose regimens...
Consider Vasopressin - (0.01-0.04u/min in adults) does not use alpha receptor so may be useful in norepinephrine refractory shock.
In neonates, consider prostaglandin (dinoprostone=PgE2) for duct dependent lesion, start with dopamine and dobutamine, add epinephrine if resistant. Consider NO and ECMO.
A neuroblastoma should be considered in newborn infants presenting with a shock-like condition together with systemic hypertension.
Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med2002; 30 :1365 -1378
Reduces afterload because negative intrathoracic pressure during normal respiration detracts from systolic peak! So good for cardiac output. Equally, paralysis may reduce tissue oxygen consumption.
Monitor CVP (myocardial dysfunction more common in kids): 8-12cm H2O, more if ventilated or increased intrabdominal pressure. Acidosis, lactate, pulse pressure, venous pO2/sats, PiCCO (new device for measuring cardiac output, suitable for 10+ kg). Arterial-venous oxygen content difference is a better marker than venous sats if cyanotic heart disease or severe pulmonary disease.
Little evidence for benefit of PA catheter (=mixed venous sats). Doppler technique in adults.
Alpha receptors constrict blood vessels, but also found in heart (contractility mostly). Beta receptors on the other hand relax blood vessels, relax bronchial smooth muscle (beta-2), increase heart rate and force (beta-1). But there are many subtypes, and most inotropes have combined effects. Lots of controversy! Different actions at low/high dose, in sepsis vs non-sepsis, different amounts of tolerance... Coronary perfusion is also important: occurs during diastole (perfusion pressure = mean arterial pressure - central venous pressure), so impaired if excessive tachycardia, and related to wall stress (ie degree of relaxation). So excess volume beyond Starling curve will impair.
Four septic states have been defined in critically ill patients:
Rivers (Detroit) did RCT of early (ie first 6 hours in ER) goal-directed therapy in adults (n=263, no immunosuppressed).
Mortality was reduced from 46% to 30% (58%). Overall, same amounts of fluid, blood and inotropes used, but earlier in intervention group. Benefit potentially even greater for patients with normal BP but other markers of SIRS with lactate >4. N Engl J Med, Volume 345(19).November 8, 2001.1368-1377.
Delphi systematic review became Surviving Sepsis Campaign. Funded heavily by Lilly, manufacturers of rhAPC, does not include latest concerns about that drug.
Critical Care Medicine. 32:858, 2004.
Systematic review of steroids in sepsis (adults) found no benefit regardless of dose or duration (possibly even harm at high doses). Possibly benefit if actually adrenal insufficient. However, with long courses of low doses, mortality at 28 days was reduced! (BMJ329:480) Adrenal insufficiency in sepsis defined as random cortisol less than 496nmol/l or Syncathen test giving rise less than 248. Variable dose recommendations for steroids, because RCTs in Dengue gave conflicting results for high doses.
Anti TNF-[alpha] receptor proteins showed reduced mortality in one study of adults with sepsis but increased mortality at highest doses in another. Recombinant interleukin-1 receptor antagonists demonstrated no benefit. But many of these cytokines are found to be at their highest levels at the time of admission and are presumably most active before symptoms appear.
Controlled studies of hemofiltration have shown no benefit. A small randomized trial of plasmapheresis in adults with septic shock showed a reduction in some inflammatory markers and less organ failure but no effect on survival. Can these techniques hope to remove cytokines in the tissues? Plasma or whole blood exchange can be of some benefit by replenishing immunomodulating compounds and anticoagulants.
Recombinant human activated protein C (rhAPC, or drotrecogin alfa) is the only adjuvant therapy licensed for adult patients with sepsis. Protein C has anticoagulant, fibrinolytic and anti-inflammatory properties, tends to drop in sepsis. A large RCT in adults with sepsis (PROWESS) showed a reduction in all cause mortality at 28 days (25% vs 31%, P = 0.003). Earlier administration increases effectiveness of rhAPC. The most important adverse event associated with rhAPC is a low but increased risk of serious bleeding including intracranial hemorrhage. Several uncontrolled case series suggest protein C therapy may be effective in reducing sequelae and mortality caused by meningococcemia among children when given within 12-18 hours after hospitalization. RESOLVE (paed study) failed to show any benefit except possibly in those with the worst coagulation defects. It also confirmed haemorrhage as side effect although almost exclusively in babies under 60 days of age. The first patient in a unit to receive it always seems to do badly... (first patient effect) Lancet, Volume 369, March 2007, 836-843 See note on Surviving Sepsis campaign above.
Anti BPI - FDA refused license despite benefit vs amputation/functional outcome. European license application ongoing. Needs to be used early, at presentation which makes it tricky.
Procalcitonin - more specific than CRP.
GM-CSF: better outcome in septic neonates with neutrophils <1.5 when given for 7 days.
Intravenous immunoglobulin - small trials only. INIS trial disappeared without a trace...
t-PA (tissue plasminogen activity) retrospectively had a 8% risk of ICH (with 47% mortality) so will never get to RCT.
See
Note the potential for deactivation of ceftriaxone if administered within 48 h of calcium-containing solutions, including parenteral nutrition (calcium chelation). Hence Cefotaxime should be used as the first line antibiotic in meningococcal sepsis due to the high incidence of calcium replacement requirement in severe disease. However, ceftriaxone may still be considered as first line therapy in children with clinical meningitis, and for continuation of sepsis therapy after the acute phase when calcium infusions are no longer required.
Study of clinical presentation (n=448) suggests that classic rash, meningisim, impaired consciousness late compared to other features of sepsis: leg pains (eg refusal to walk), cold hands/feet, abnormal skin colour (seen in 72%, median time 8 hours, usually before hospital admission). Thirst also a feature in older children. Most children had non specific symptoms for 4-6 hours, critically ill within 24 hours. Hence recognising sepsis features more important than specific meningococcal features. If unwell for longer than 24 hours, unlikely to be meningococcal septicaemia, on the other hand if there is concern about non-specific findings alone with a short history, review should be done within 6 hours rather than next day. The Lancet 2006; 367:397-403
Referring hospital may be best placed to do transfer esp head injury. Scoop & run never proven for kids. First contact should provide advice even if no beds. Remember paramedics esp air paramedics. Team not strictly there for HDU patients.
Enteral feeding while shock persists is controversial.
Glucose control - NEJM adult ICU (all conditions) benefits in mortality & morbidity! Relevant to PICU?
Renal failure - Theophylline maintains diuresis. ? timing of replacement ie maintenance or rescue.
ECM0
Transfusion levels - moving down? 7g/dl in adults (after early goal-directed therapy).
Selective digestive decontamination? May reduce ventilator associated pneumonia.
Empirical antibiotic cycling to discourage resistance.
Novoseven is factor VIIa initiates coagulation esp X.
Anticoagulants - some studies suggest that heparin reduces the severity of distal necrosis in meningococcal sepsis, but no effect on survival has been demonstrated in animal models or small clinical trials. One review of recombinant tissue plasminogen activator (rTPA) for meningococcal sepsis in children described improved distal perfusion that may minimize amputations, but 5 (8%) of 62 patients developed significant intracranial hemorrhages. Serine proteases are important in activation of complement and fibrinolytic systems, serine protease inhibitors (serpins, including antithrombin III and C1-inhibitor) are theoretically promising but few data. Fresh frozen plasma, containing both serpins and anticoagulant factors, has been suggested as an adjuvant therapy, providing both fluid resuscitation and immunomodulation.
Good adult evidence for hypothermia post arrest. Negative evidence for near drowned kids...
ARDS definition (consensus 1994) - acute, bilat infiltrates, wedge pressure differentiates acute lung injury. Fibrosis occurs within 2/52. Meduri (JAMA 1998) RCT of methylpred in unresolving ARDS (adults) - zero mortality in Rx group cf 5 of 8! 2mg/kg/d starting dose. Stopped early (too early?).
VAP = nosocomial pneumonia in ventilated patients that develops at least 48 hr after initiation of mechanical ventilation. Main bugs isolated are:
Associated with extra 3.7 days of mechanical ventilation after adjusting for other factors (retrospective study of pediatric cardiothoracic surgery patients). Mortality and cost?
Diagnosis: clinical criteria from National Nosocomial Infection Surveillance System (NNIS).
The sensitivity and specificity of any of these clinical or radiographic findings alone is poor compared with histopathology.
Pathogenesis: aspiration, inhalation of aerosols containing bacteria, hematogenous spread and bacterial translocation from the GI tract. Risk factors include immunosuppressants, immunodeficiency, neuromuscular blockade, neuromuscular disorder, and reintubation.
Multiple preventive interventions assessed in adults, few in kids.
Draft guidelines for prevention proposed by the Hospital Infection Prevention Committee (2002) include:
Routine ET aspirates seem to predict antibiotic sensitivities in ventilator associated pneumonia (as diagnosed on BAL).
Oral antiseptics reduce rate of ventilator assoc pneumonia in adults. No impact on mortality or length of stay. Less risk of selecting out resistant organisms cf use of antibiotics. But needs to be part of package including semirecumbent positioning, care of circuit, closed suction systems.
Paracetamol - unless risk factors, under 150ml/kg don't need bloods. So a whole bottle of weak (120mg/5ml) can be taken by a 4yr old (12kg)?
Drink drive limit is 80 mg/dl alcohol in blood (different limits for urine/breath).
Manchester triage system for A&E: ascribes a time by which ideally a patient should be seen and where they should wait (resus vs elsewhere). Patient is allocated to 1 of 52 pathways (6 paediatric); subsequent questions delineate risk. Good inter-rater agreement. But requires experienced triage clinician. Not much evidence about how well it works; could be combined with early warning scores, although these are aimed at in-patients.
See also Head injury.
Blast injury to the abdominal viscera is uncommon, affecting around 1% of casualties with primary blast injuries. However:
Shock in trauma should be treated to achieve adequate perfusion, not normal BP (although debated) - ?exacerbate blood loss, exacerbate shock lung.
The fluid regime for burns is based on the percentage of body surface area burned. Only areas of partial or full thickness burns are counted. First treat shock if it is present and look for its causes.
For maintenance fluids the standard formula (Parkland formula) is:
The effects of smoke inhalation may be delayed by 12-36 hours. There is no doubt that patients exposed to smoke who have respiratory symptoms or signs, abnormal blood gases (including lactate and carboxyhaemoglobin), or abnormal chest films, should be admitted for treatment and observation. Patients with a significant smoke exposure, and who are asymptomatic, consider observation at home with advice.
Symptoms of mild carbon monoxide poisoning include weakness, headache, nausea and dizziness. Features of severe carbon monoxide poisoning include:
Cyanide poisoning can be difficult to diagnose. Symptoms and signs of cyanide poisoning include:
There may be a metabolic acidosis, with an elevated lactate. A high plasma lactate (greater than 10 mmol/L) in the absence of severe burns or hypotension is suggestive of smoke inhalation.
Invasive aspergillosis has been described in immunocompetent child after near-drowning.
See Neuro.
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