Kids are just little adults. SMACC Paediatric Resuscitation
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Simon Carley takes the stance that Kids are just little adults - a talk given at SMACC 2013.
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Kids are just little adults. SMACC Paediatric Resuscitation
- 1. Relax Children are just little adults
- 2. themes the critically ill and injured child taking action not APLS not PEM in general
- 3. Disclosures
- 4. PICU Kids ED Trauma centre Trauma centre Trauma centre
- 5. ...but where are the kids?
- 7. Transfers were: Sicker Needed more ICU care Had a longer stay More ventilation More inotropes
- 9. Half of unplanned transfers from St.Elsewhere They were sicker/younger but Died more often (8% vs 6%) Risk adjusted mortality 0.65 (0.53-0.80)
- 10. Selection bias?
- 11. Maybe...., but
- 12. Anecdotally..... Errors of Omission and delay Wait for help Failure to intervene Cliff drop of kids pathology Benjamin Ellis CCL http://www.flickr.com/photos/jamin2/3191895921/
- 14. 6 year old 1/7 hx T 37.9 C RR 35 Pulse 170 BP 100/52
- 18. 5 hours later Circulatory collapse Dies in PICU
- 19. why?
- 20. Why are we scared of kids? Where are we scared? 1. Unfamiliarity 2. High stakes 3. Because people tell us we should be!
- 21. Children are not little adults!!!!
- 22. World Health Organisation http://www.who.int/ceh/capacity/Children_are_not_little_adults.pdf
- 23. ‘Children are not little adults’
- 26. Is this still ABC?
- 30. Neonates
- 32. •Scary Aliens •Weird stuff often precipitated by infection •Treat what you can whilst working out the hard stuff!
- 33. Is it really that different?
- 34. but really?
- 37. Transferrable skills • Adult practice • to • Paeds practice
- 38. Kids are more difficult than adults. Co-morbidity? Anatomical variation? Range of conditions?
- 39. ToP TiPs • Airway issues • Lots of normal • RSI • Rescue
- 40. be prepared
- 42. Pressure control more popularPressure control more popular Tidal volume reasonable (5-8 ml/kg)Tidal volume reasonable (5-8 ml/kg) or maybe better to look at chest wall excursion with pressure controlor maybe better to look at chest wall excursion with pressure control Aim for lower FiOAim for lower FiO22 albeit with higher PEEPalbeit with higher PEEP 4-6 to start4-6 to start 6-8 if bad lung disease6-8 if bad lung disease 8-10 if wet lungs8-10 if wet lungs SpO2 = 88-96%SpO2 = 88-96% Chest tubesChest tubes
- 43. • Circulation • Fluids • Trauma resus • Access
- 44. • 1 • 2 • IO
- 45. • 1 • 2 • IO • Consider external jugular
- 46. • Fluids • APLS 20ml/Kg in sepsis • APLS 10ml/Kg in trauma
- 47. Fluid requirements • Sepsis - • Adequate volume important within 1-2 hours • Reduced mortality • less persistent hypovolaemia • no increase in ARDS • each additional hour of shock doubles odds of death. • reduced PICU stay Role of early fluid resuscitation in pediatric shock. Carcillo JA, Davis AL, Zaritsky A. JAMA 1991;266: 1242-1245. Early reversal of Pediatric - Neonatal septic shock by Community Physicians is associated with improved outcome. Han YY, Carcillo JA, Dragotta M et al. Peds 2003;112: 793-799.
- 48. In severe sepsis likely requirement for volume is 200-360ml/Kg in first 24 hours
- 50. FEAST trial Higher mortality in kids with large fluid boluses
- 51. Question? Is 20ml/Kg too much Dose/response may be better in 5ml/Kg aliquots
- 52. Fluid choice? • Little evidence • Saline causes hyperchloraemic acidosis • Colloids (albumin) after 40-60ml/Kg • Plasmalyte coming into practice
- 53. octaplas - prior reduced plasma Trauma
- 54. Tranexamic acid 15mg/Kg over 1 hour 2mg/Kg/Hr for 8 hours
- 56. 53 patients in 15 months No improvement in mortality Feasibility proven
- 57. Therapeutic end points • Titrate to effect • Normal pulses with no difference central/peripheral • Warm extremities • Return of Urine output (>0.5-1ml/Kg/Hr), HR, Cap refill, LOC • SVC or mixed venous gas • Normalising base deficit and lactate
- 58. Today... •Fire up the simulator • Kids & Adults in the past • Kids & Adults in the future
- 59. you are the resuscitationist
- 60. resuscitation aims to restore physiology resuscitation skills are learned in adult medicine most if not all skills are transferrable
- 61. kids are little adults
- 62. Thanks NWTS Ralph MacKinnon Kate Parkins Rachel Jenner Katherine Potier
Notas del editor
- One thought is around drug doses - for most drugs it is not as exact a science as paediatric formularies would have you believe - ie if child about 20% / half the size of an adult draw up an adult dose give about 20% / half but round up. They don't (or at least didn't when I worked in OZ both times) have the equivalent of BNF / BNFC you had to use a MIMS book and the childrens hospitals produced their own formularies (presume there are apps now but might be worth checking) As I mentioned before teenagers probably better from a physiological perspective being looked after by adult nurses / docs who recognise the abnormal HR. Paediatric major trauma so rare in UK / Oz that only way to be a specialist in managing paed major trauma is to manage adult major trauma and kids with non trauma emergencies. Neonates - scary even for PEM specialists - if you don't know what is going on treat the treatable stuff (infection / dehydration / jaundice / hypoglycaemia) as not going to do any harm while trying to diagnose rarer stuff like metabolic/cardiac (and even in metabolic babies acute episode often precipitated by infection). Worth mentioning that APLS 20ml/kg fluid boluses may be over generous (I go 5ml/kg if they don't look too bad 10ml/kg if they look awful) can always keep giving. FEAST study has introduced debate / doubt about massive fluid volumes in resus for kids. Drawing fluid boluses up in 20ml not 50ml syringes much easier to push in babies. Will let you know if any more gems occur to me. Rachel Really good Simon. It all makes total sense what you've pulled together. I think it's worth re iterating that in kids you see probably a higher proportion of 'well' patients compared to adults. Most of the time I feel in adults you expect to find something, whereas in kids you don't. So when you've seen tons of well kids, the really sick ones pop out at you. If not its so engrained in your head to run through a head-toe examination that you'll pick stuff up if its there. Does that make sense? The other scarey bit with kids for many is all the syndromes and other weird stuff that can change, and get in the way of just seeing the patient in front of you. More common sense needed in kids sometimes. Adult practice gives you way more exposure to practical skills so when you get to do them on kids it's not so scarey apart from their size. They are my thoughts so far. In kids all this week so may be enlightened some more! K
- Easy when you are here new hospital all specialities on site dedicated ped all medical and surgical on site does this give me credibility or not?
- NOt so easy when you are here EMS get scared parents transport directly secondary transfers in more common most likely to see a non-specialist PEM physician Frequency of critically ill kids distributed in geography and in time
- Cliff of physiology
- The case. Let’s give you an example of what can and does happen as we see the effect of
- The case.
- The case.
- The case.
- The case.
- The case.
- Good people Good knowledge Good process but no action. Not an isolated event Still takes place.
- Where are we scared? 1. Unfamiliarity 2. High stakes 3. Unhelpful paediatricians
- What’s our starting point and why are we talking about this?
- Even the World Health Organisation thinks they are not little adults
- Because we all know that.........
- But this is SMACC2013 & it’s different
- Is the approach still going to be the same for the resuscitation of sick and injured kids? So what worries you here?
- Is it really just a size issue OR
- Perhaps we need to clarify a few things first. First there is a continuum of ages from birth through to adulthood. That’s fine and the differences change at a gradual rate, and change in different ways. Psychologically children extend to an age well in to teens, but physiologically we are pretty much adults from
- So what is that we are really that interested in?
- Still have lots of similarities A, B, C, Change of mindset. Look for similarities not look for difference. Where is the expertise in the management of the sick and injured child Have worked in lots of different setting where you either get people thinking someone else is the expert or in settings where they think they are the only people with the expertise. In reality it is a mixed picture.
- But in the acute and severe setting what we are looking for is the ability to deal with a group of undifferentiated, sick/injured kids for whom the picture is uncertain, where teams are required and where good overall management is needed. In a situation that is stressful for all. So if there was ever a time for the resuscitationist, then this is it & that perhaps more than anything else is what defines expertise in our specialities.
- But maybe they are in many ways, but a lot of the differences in EM management are about when children are fairly well. That’s not why we are here. So why does this matter to us?
- RSI Ket and Sux - follow up with Midaz and Morphine as propofol not used in children (though many people do) Airways are usually OK in normal kids. Other than that same process for getting out of trouble. Video laryngoscopes - no-one I know using them. Not usually needed. Same rescue process Last place for needle cric - know your kit. force required to open the mouth teeth tumour arthritis jaw opening HOW WILL YOUR APPROACH BE DIFFERENT? Take FB as an example as that is perhaps one of the scarier aspects
- What happens when it goes wrong? What would be your strategy for failure be? Need appropiate kit - but..... DL - LMA - Surgical appropriate speciality
- http://www.das.uk.com/content/paediatric-difficult-airway-guidelines
- 6ml/Kg is just fine. Set the vent as you would an adult or squeeze the bag. Use ETCO2 to guide Chest tubes a great example of a very rare event in children where the expertise will lie within the EM adult community.
- 6ml/Kg is just fine. Set the vent as you would an adult or squeeze the bag. Use ETCO2 to guide
- Top area for failure and preventable death, delay in therapy, chicken bombs etc. What are our rules for cannulation? What are our rules for IO? Who administers these rules - the nurses are good with this.
- Data on trauma resuscitation models predominantly from young adults. therefore probably applicable to kids as well. TXA used in paed cardiac surgery
- End points for resuscitation