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)

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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