big trouble, little people: paeds retrieval by lockie
DESCRIPTION
Little Adults? Fran Lockie examines our approach to critically ill children and the importance of sticking with our tried and tested formulae.TRANSCRIPT
BIG problems, little people: lessons learned from paediatric retrieval
Dr Fran [email protected]
Sydney Based Health practitionerPassion for female weight loss‘www.hotfatchicks.com’
Sydney Based Health practitionerPassion for female weight loss‘www.hotfatchicks.com’
Recurring Themes….Recurring Themes…..
CaseIssues
Solutions
15 month old male with fever
• NVD at term, BW 2.7kg• Previously fit and well• No meds, NKDA• Immunisations UTD• Family all coryzal
Country Hospital
• At triage – Alert and playful– Temp 39, Hr 160, Rr 40– Good central perfusion– Mottled peripherally
4hrs later Seen by RMO
• Given panadol with resolution of fever, HR never < 170 since triage
• Bloods sent• Urine NAD
4 hrs after that…
• Given panadol with resolution of fever, HR never < 170 since triage
• Bloods• Urine NAD
• 2 small vomits in waiting room, then a small area of petechiae
Advice: O2, 20ml/kg Fluid bolus, Antibiotics, peripheral inotropes
VBG pH 7.15, BE -10, B/C 10, lact 5, CO2 25, BSL 6
22:00
• A BVM with high flow O2• B RR 60, marked increased resp effort• C peripheral CRT: absent, central >5 secs
• Multiple attempts at iv access unsuccessful• D alert, talking to mum
Rapid deterioration
– AVPU– Increasing respiratory distress– HR >200, Only femoral pulse palpable
– IO sited – Aggressive filling– DA started
Ketamine, sux, adrenaline bolus
Courtesy: Stefan Mazur
PEA Arrest• Filling, filling, filling• Dopamine started at 20mcg/kg/min• Filling, filling, filling
– 4% albumin– Blood products (packed cells, plts, FFP, cryo)
• Noradrenaline, Adrenaline, infusions commenced
• Stat dose hydrocortisone
6hrs later….still PEA / ROSC• Maximal inotropic / pressor support• multiple dextrose, Ca, Mg boluses• Total fluids 180ml/kg• Sustained bradycardia, worsening acidosis• Massive pulmonary haemorrhage
Recurring Themes….
• Oxygen delivery• Vascular access• Fluid, antibiotic administration
Recurring Themes….
• Oxygen delivery• Vascular access• Fluid, antibiotic administration
• Teamwork, leadership and communication• Recognition of paediatric critical illness
Recurring Themes…..At audit
• Audit of 17 PICU’s • 107 patients with septic shock • 8% received care c/w ACCM guideline
– 21% not given >60ml/kg despite ongoing shock– 15% not given dopa/ dobu despite fluid refractory
shock– 23% not given catechol for dopa/ dobu refractory
shock– 30% not given steroid despite catechol resistant
shockArch Dis Child 2009
Pediatrics 2009
Early Resuscitation of Children with Moderate to severe TBI
• 299 kids with mod-severe TBI• 39% became hypotensive
– Of these only 48% were treated
• 44% became hypoxic– Of these 92% were treated
Resuscitation 2014
Resuscitation 2014
Train together daily!
• One Base• Adult teams
– ED– Intensivists– Anaesthetists
• Paediatric and neonatal teams
• Special operations paramedics
McDonalds approach to ‘out of theatre’ anaesthesia
Courtesy: Stefan Mazur
PREPARATION PHASE
Courtesy: Matt Hooper
PREPARATION PHASE
ELM
PREPARATION PHASE
PREPARATION PHASE
PREPARATION PHASE
PREPARATION PHASE
PREPARATION PHASE
INTUBATION PHASE
POST - INTUBATION PHASE
Patients intubated by MedSTAR:
Date LocationWt(kg) Indication Ket Sux Prop Roc Fent View
ETT size
ETT depth ETCO2 ILS Adjuncts Cricoid Comment Seniority
02/01/14 Yorketown Hospital 100 Cardiac 40 200 I 8 24 Calorimetric No None No Adrenaline Infusion +
Fluid 1000mLED Registrar
>100
08/01/14 Stansbury 70 Head Injury – threatened airway
100 200 I 8 23 Calorimetric Yes Bougie No Anaesthesia Reg> 100
12/1/14 Whyalla 45 Gastrointestinal 25 100 II 7 22 No None Yes N. Saline 200mL Para > 100
14/1/14 Moonta 120 Combative / Agitated
200 200 II 8 24 Waveform Yes Bougie No Fluid 500mL Anaesthesia Reg >100
16/01/14 Balaklava 80 Neurological 100 100 50 I 7 22 Waveform No Bougie Yes Fluid 1000mL Anaesthesia Reg > 100
17/01/14 115
Head Injury – threatened
Airway; Chest trauma
150 200 IV 8 23 Yes Bougie No Anaesthesia Reg >100
17/01/14 Mt. Compass Head injury- threatened
100 100 I 8 24 Waveform Yes Bougie No Anaesthesia Reg > 100
18/01/14 Pt. Broughton 100 Neurological 50 150 10mL / hr III 8 24 Calorimetric No Bougie No Pancuronium + N.
Saline 1000mLICU Reg
> 100
18/01/14Head Injury –
Threatened airway
I 7 23 Calorimetric Yes Bougie Yes In car – difficult access; no induction meds.
Para 10-100
19/01/14 Victor 65 Respiratory 50 100 40 III 7 23 Yes No Nil / Bougie No
2 attempts – nurse then MD, unexpected
Gr IIINurse <10 ;
Consultant > 100
28/01/14 Berri Combative / Agitated
100 100 30None then
IIWaveform Yes Nil /
Bougie Yes 2 Attempts – same MD; desat <92%
Anaesthesia Reg > 100
smaller FRCGreater VO2 than adults
How can we overcome rapid desaturation after apnoea?
Ann Emerg Med. 2012
Ann Emerg Med. 2012
BMJ 2007
• Mapleson circuit– Significantly easier to
breath through – More effective
Ann Emerg Med. 2012
Kids have smaller FRCGreater VO2 than adultsRapid desaturation (with stress and apnoea)
10 days, pCO2 100, pH 7.00
• He’s Tired Doctor:• Diaphragmatic exhaustion• Lacks type 1 muscle fibres
• Decompress the stomach– Often results in dramatic
improvement!
• Know your vent: wt limits– Generally TV 4-6 ml/kg
• 95 patients• Mean age 5.5• 95% success• 10 seconds or less• Pain score 2.3
Pediatr Ermerg Care 2008
• 95 patients• Mean age 5.5• 95% success• 10 seconds or less• Pain score 2.3
• Fluids, ABx, DA
Pediatr Emerg Care 2008
Lancet 2011; 377: 1011–18
• Listen to the physiology!• Don’t rely on consensus based dogma with
fixed physiological limits a cross many ages
Lancet 2011; 377: 1011–18
Is lactate really the ‘Holy Grail’ of sepsis biomarkers?
Intensive Care Med 1997
Is lactate really the ‘Holy Grail’ of sepsis biomarkers?
Intensive Care Med 1997
No, but sepsis often masquerades as respiratory disease in kids
Sugar and temperature
• Large SA: body wt (2-2.5 x BW)• Thin skin and subcut fat (less insulation)• No shivering• Immature thermoregulatory center
• Sugar ALWAYS goes down in critical illness…
Just before Christmas..
Just before Christmas..
Lessons learned…
• Collaborate / cross-pollinate
• Drills, teamwork• Evaluate practice• Attention to detail, keep
it simple
Thanks to:A/Prof Stefan MazurA/Prof Matt Hooper