Early Management of the Critically Ill Child

OVERVIEW

• most common cause is sepsis
• always think of congenital conditions though (heart disease or metabolic disorders)

DIFFERENTIAL DIAGNOSIS

SICC-FIT for the critically neonate:

• Sepsis
• Intracranial disorder (haemorrhage, tumour)
• Congenital heart disease
• Congenital adrenal hyperplasia/ adrenal crisis
• Feeding problems (e.g. formula errors)
• Intestinal emergencies (e.g. intussusception)
• Toxicological

In older children, remember KID as well:

• Kawasaki disease
• Injury
• Doesn’t thrive (failure to thrive)

PHYSIOLOGY

• they can turn into raisins quickly -> dehydrate (decreased ability to concentrate urine and increased insensible losses)
• blood volume = 80mL/kg
• shock = myocardial dysfunction (early use of inotropes)
• increased HR prior to decrease BP
• tachycardia: low output, fever, pain, seizures, drugs
• know the vitals that are worrying for each age group
• warning signs: persistently rising tachycardia, acidosis, lactate -> think cardiac anomaly

HISTORY

• IUGR and preterm babies -> significant implications long term
• FHx important
• < 6 on APGAR at birth
• onset of illness
• symptoms often non-specific (ie. babies often ‘off their food’)

EXAMINATION

• AVPU rather than GCS
• agitation
• hypothermia is a really bad sign
• RESP: RR and patter ?acidosis
• CVS: P, BP, CR, urine output

MANAGEMENT

Involve parents early

Calculate weight

• < 9: age x 2 + 8
• > 9: age x 3

Airway

• intubate if: arrested, obtunded, has respiratory failure, hypotension and need inotropes, severe metabolic acidosis (BE – 10) -> intubation decreases oxygen demand by 30%.
• preoxygenate
• 20mL/kg fluid preinduction
• ETT = age/4 + 4 (needs a small leak)
• intubate orally and then electively change for nasal ETT
• always insert a N/G to as gastric stasis very common and improves ventilation
• drugs: ketamine, fentanyl, atracurium, atropine, adrenaline
• CXR: tip of ETT should be between the clavicles c/o movement of tube with flexion and extension of neck

Ventilation

• CPAP
• BIPAP
• intubation: paralyse, IT 1 second, PEEP 5-10, PIP < 30cmH2O, rate < 30
• can use permissive hypercapnia (except in PHT and brain injury)
• early use of proning, HFOV and iNO

Circulation

• 2 IVC
• can use EJV or cannulation of umbilical vein (neonates)
• central access: femoral -> IJV -> SCV
• remember IO if required
• IVF: give and keep giving
• 30mL/kg – crystalloid
• > 30mL/kg – colloid (4% albumin) + inotropes
• > 40mL/kg – blood, platelets, FFP (give in 10mL/kg increments)
• maintenance: 4, 2, 1 – isotonic fluids
• feed early
• inotropes: dopamine, adrenaline, noradrenaline, milrinone
• Ca2+: great inotrope, good in sepsis (keep ionized > 1.0)

Disability/Drugs

• glucose (don’t worry about hyperglycaemia acutely)
• sedation: morphine, chloral hydrate
• careful with diazepam
• propofol infusion (good for procedures and wake ups)
• antibiotics: < 3 months – cefotaxime and amoxicillin, > 3 months – ceftriaxone + gentamicin
• hydrocortisone 2mg/kg: shock, pupura fulminans, adrenal insufficiency

Exposure

• aim for normothermia

CARDIAC

• incidence 1% (25% VSD, coarctation 6%)
• history: cyanosis, sweating, poor feeding -> sudden deterioration c/o duct dependence (shock, cyanosis, heart failure, arrhythmias).

Management:

A – ETT if shocked, acidosis, requires prostaglandins, transport
B – alkalanise, diuretics, PEEP, iNO, CXR
C – volume, cardioversion, inotropes, 4 limb BP’s, ECG
D – glucose, antibiotics (omit if > 4 days old and cultures negative), PGE1 opens duct – 30mcg/kg in 50mL of N/S = 10ng/kg/min

SEIZURES

• febrile convulsions (if > 1 hour or T > 40 C -> worry)

Management:

• resuscitate
• check BSL
• cool with tepid cloths
• cefotaxime, vancomycin, acyclovir (if focal)
• diazepam 0.3mg/kg or midazolam 0.2mg/kg
• phenytoin 20mg/kg
• phenobarbitone 25mg/kg
• thiopentone
• paraldehyde

ASTHMA

• salbutamol neb
• hydrocortisone IV
• salbutamol IV 5mg/kg
• aminophylline bolus -> infusion
• Mg2+
• CPAP
• intubate (rarely)

TRAUMA

• fall > 3m, MVA, drowning, poisoning
• can’t judge distances until 12 years old!
• have more serious c-spine injures (but rarer)
• SCIWORA
• sand-bags and tapes
• CT C1-2 and lateral
• abdominal trauma (mostly conservatively managed)

References and Links