9. 15 month old male with fever
• NVD at term, BW 2.7kg
• Previously fit and well
• No meds, NKDA
• Immunisations UTD
• Family all coryzal
10. Country Hospital
• At triage
– Alert and playful
– Temp 39, Hr 160, Rr 40
– Good central perfusion
– Mottled peripherally
11. 4hrs later Seen by RMO
• Given panadol with resolution of fever, HR
never < 170 since triage
• Bloods sent
• Urine NAD
12. 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
13.
14. 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
15. Rapid deterioration
– AVPU
– Increasing respiratory distress
– HR >200, Only femoral pulse palpable
– IO sited
– Aggressive filling
– DA started
22. • 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
shock
Arch Dis Child 2009
23. Early Resuscitation of Children with
Moderate to severe TBI
Pediatrics 2009
• 299 kids with mod-severe TBI
• 39% became hypotensive
– Of these only 48% were treated
• 44% became hypoxic
– Of these 92% were treated
52. Is lactate really the ‘Holy Grail’ of
sepsis biomarkers?
No, but sepsis often masquerades
as respiratory disease in kids
I
n
53. 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…
Declaration.
I am not the other Francis Lockie, Sydney Based Health prof.
If you came to see her, you are in the wrong talk!
She, disappointingly is google hits 1-20
So get in there early, establish your web presence, don’t make the same mistake I have
998 miles
GC map.com
I am lucky enough to live and work in Adelaide, capital of South Australia
Overlapmaps.com
To put in a UK perspective
1 million sq kn
1.6 million people largely based in Adelaide
Roughly the size of Texas
When we look at the population density map, we can see Australia virtually disappears into a thin slither in the SE corner of the world map, compared to the bloated areas of the SC, china and even the UK
Population density
Makes my life interesting as I am luck enough to have a split roles in PEM and Paeds / neonatal retrieval
With the retrieval work MedSTAR travels as far afield as Darwin and Alice Springs, to Melbourne for our cardiac babies. Of course we serve regional SA and metro Adelaide too.
We are the only Children’s Hospital in the sate so of course all cases of critical illness and trauma comes through our department.
My role has put me in a good position to notice recurring themes
Yes, we live in a post imms era, with air bags, pool fences and child proof screw tops kids
There is still the burdon of critical illness – it’s rarity makes the challenge greater if anything
It’s great that that cardiac anaesthetist can tube kids with one arm tied behind his back, but he or she isn’t in the community hospital at midnight
Doesn’t matter if we’re sitting in our ivory towers or we’re in the outback
In fact in the outback I’ve met some of the most talented doctors in rural areas going above and beyond
Didn’t mean to put the solutions on the horizon..but that’s sometimes where it feels like they are.
However by keeping things simple and doing the basics well – we can change the trajectory for our sick kids
Lives with me and affects the way I practice medicine on a daily basis
How good are we at implementing ACCM guidelines. C/W ACCM guideline NOT timeline! Replicated in other setting including surviving sepsis campaign audit’s.
Sub-optimal treatment related to FAILURE to RECOGNISE SHOCK
Unsupervised juniors / lack of paediatric consultant supervision
Failure to start inotrope
This study from UTAH worried me a lot
OBJECTIVES: Traumatic brain injury is a leading cause of death and
disability in children. Guidelines have been established to prevent secondary UTAH
brain injury caused by hypotension or hypoxia. The purpose of
this study was to identify the prevalence, monitoring, and treatment of
hypotension and hypoxia during “early” (prehospital and emergency
department) care and to evaluate their relationship to vital status and
neurologic outcomes at hospital discharge.
METHODS: This was a retrospective study of 299 children with moderate-
to-severe traumatic brain injury presenting to a level 1 pediatric
trauma center. We recorded vital signs and medical provider response
to hypotension and/or hypoxia during all portions of early care.
RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded
during some portion of “early care.” Documented hypotension
occurred in 118 children (39%). An attempt to treat documented hypotension
was made in 48% (57 of 118 children). After adjusting for
severity of illness, children who did not receive an attempt to treat
hypotension had an increased odds of death of 3.4 and were 3.7 times
more likely to suffer disability compared with treated hypotensive children.
Documented hypoxia occurred in 131 children (44%). An attempt
to treat hypoxia was made in 92% (121 of 131 children). Untreated
hypoxia was not significantly associated with death or disability, except
in the setting of hypotension.
CONCLUSIONS: Hypotension and hypoxia are common events in pediatric
traumatic brain injury. Approximately one third of children are
not properly monitored in the early phases of their management. Attempts
to treat hypotension and hypoxia significantly improved outcomes
And look at the effect on mortality!
Adjusted OR for death and GOS
Growing body of evidence that secondary insults occur frequently and exert a powerful, adverse influence on outcomes from severe TBI.
Enemies are hypoxaemia and hypotension
Trauma Coma Data Bank: hypoxaemia occurred in 22.4% of severe TBI patients: asociated with significantly increased morbidity and mortality.
HEMS series 55% of patients were hypoxic prior to intubation. 46% normal BP.
In non-hypoxic pts mort 14.3% and 4.8% disability. If SaO2 < 60% mort rate 50% with 100% severely disabled.
Hypoxaemia <90% in an inhospital study of 124 TBI patients independent RF for mortality
HYPOTENSION. Single pre-hospital obseration of hypotension SBP < 90 was amoung 5 most powerful predictors of outcome. Incr morbidity and doubled mortality
Induction of anaesthesia is risky:
Recurring themes in the Sim Lab
75 Simulations
12.4 doctors / nurses per session
194 incidents of subobtimal care
Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus
This is not just in paeds
THIS IS THE CFIT OF THE MEDICAL WORLD
ED staff
Anaethetics
Theatre staff
Standardised scenarios
Causes of error
75 Simulations
12.4 doctors / nurses per session
194 incidents of subobtimal care
Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus
This is not just in paeds
This is the (hopefully present)
Examples of scenarios
Knowledge
Clinical skills
Leadership
Communication
Resourse utlisation
Anticipation and planning
Situational awareness
At medstar we run joint scenarios.
We as paediatric specialists can learn lots from the trauma and CCM delivery outside theatre / Particularly in the vital areas of clinical decision making, CRM, leadership and teamwork
Hopefully our holistic view and what we consider good communication skills are useful to the adult teams
Training with the SOT paramedics has been a revelation to me not something I would do anywhere else in the world.
Changed the way we run in the kids hospital where it’s often difficult to generate the momentum to make things happen quickly
MCDonalds – I probably shouldn’t be promoting this as a paediatrician!
One thing they are famous for – in addition to childhood obsesity is the consistency of their product!
In fact, the strength of a nation’s currency is often judged aginst the price of a big mac!
I know that if I travel to London and order a Big Mac – I will get:
I just won’t be allowed to donate blood again!
If I jump on the Eurostar and order Un Big Mac, I will get Ummm hopefully: albeit with a bit of surly attitude thrown in.
Consistent approach to out of theatre anaesthesia to be applied to all patients from 90 years to newborn and all in between
Indispensible for certain situations
Generates a degree of muscle memory and automaticity that is vital when it all goes wrong.
Creat Space: look how this adult team has created space.
The scene is secure: they can get to work
Everyone knows there place, literally where to stand and their role.
We use this in PED and it has been revolutionary
Patient assessment
Often predictable
Every moment spent on patient position is time well spent!
Dump bag: everything laid out and ready.
Amazing the effect on the room when a piece of kit is not available: what was a calm environment becomes visible tense: everything changes
This is a key CRM moment: everything is calm, everyone is focussed
Leadership
Build confidence in the team that is both Immediate and latent
I authorise the c-spine controller to relax their death grip of the head to flex the neck and allow me to visualise the larynx
These techniques of preparation are often amazingly eye opening for our trainees rotating through. They take them with them for the rest of their careers and always feedback that this was the most powerful message of their MedSTAR rotation.
Our nursing staff love it too and feel empowered to trouble shoot and guide less experienced medical staff
The most effective Graded assertivess I have encounterred was on retrieval in the middle of the night when I was being particularly physicianly when a baby patently needed a chest drain. Beard stroking was not getting the job done.
I was fresh off the boat from England and shocked to be told to just “fucking do it Fran”
Amazing to see that CRM is still not featuring highly in Medical education
Time
Checks
Briefs
Leadership
Build confidence
Immediate
Latent
Keep the momentum going: not pause to high five each other and nip out for coffee
Amazingly hard to derail this process
We did a sim recently where I was trying to be an incompetent team leader.
The nurses feel so empowered in their CRM skills: worst doctor nurse, wost doctor, worst patient, worst day
And still be safe.
10 different induction agents,
20 different LMA including one you’ve never seen before
Limited AP expansion, limited lateral expansion. Ventilation depends on the diaphragm: fatigues easily, lacks Type 1 muscle fibres. Any restriction of diaphragm movement results in resp difficulties
Ie stomach inflation due to forced inflation
Lung compliance 5ml/cm H2O, 1/12 adult value, chest compliance 260ml/cm H2O (5x aduly value. High risk of barotrauma
Small lung vol rel to body size Small FRC: high RR to maintain the FRC
Under GA anaesthesia FRC declines by 10-25% in health adults and 35-45% in 6-18yo.
Stress: ratio of MV to FRC is doubled, FRC is diminished and desat occurs
PEEP important in kids <3, essential in infants <9m. Mean pee to respore FRC to normal:
Infants < 6 months 6, children 6-12
Higher O2 consumption 6-7ml/kg, adults 3-4 ml / kg
Rapid desatiration
Smaller FRC
Greater VO2 per unit weight than adults
Critical hypoxia rapid after apnoea
Consider 1 month old
no pre-oxygenation = 90% sats in 15 seconds
Pre –oxygenation for 1 min = 90% sats in 90 seconds
Patterns of Injury
Size and shape
Smaller body mass - greater force per unit body area
Less protective tissues and close proximity of organs
Frequently multiple organs injured
Skeleton
Pliable skeleton often deforms without fracture allowing significant injury to underlying organs
Presence of rib fractures suggests massive force and high risk multiple organ injury
Psychological
Developmental stages
Language skills – difficult to communicate symptoms; may deny symptoms
Fear – alters normal vital signs making them difficult to interpret
Parents – help and hindrance
Long term effects
Growth and development
Psychological – child and family
Size
Proportions
Breathing
Circulation
Stress
Sugar
Family
Scared
Lonely
What can we do to overcome this rapid desaturation after apnoea?
Apnoeic oxygenation and PEEP
Mapleson F, Jackson-Rees modification to the Ayer’s T-piece.
Compact Inexpensive No valves Minimal dead space Minimal resistance to breathing Economical for controlled ventilation
Disadvantages
The bag may get twisted and impede breathing High gas flow requirement
Uses
Children under 20 kg weight
Mapleson F, Jackson-Rees modification to the Ayer’s T-piece. Cildren under 20KgCompact Inexpensive No valves Minimal dead space Minimal resistance to breathing Economical for controlled ventilation
Disadvantages
The bag may get twisted and impede breathing High gas flow requirement
Uses
Children under 20 kg weight
ABSTRACT
Background: A crossover study was performed in
healthy volunteers to compare the efficacy of a selfinflating
bag with the Mapleson C breathing system for
pre-oxygenation.
Method: 20 subjects breathed 100% oxygen for 3 min
using each device, with a 30 min washout period. The
end tidal oxygen concentration and subjective ease of
breathing were compared.
Results: There was a statistically significant difference in
performance between the two devices, with the
Mapleson C providing higher end expiratory oxygen
concentrations at 3 min. The mean (SD) end expiratory
oxygen concentration was 74.2 (3.8)% for the selfinflating
bag (95% CI 72.4% to 75.9%) and 86.2 (3.7)% for
the Mapleson C system (95% CI 84.5 to 88.0);
p,0.0001. The 95% CI of the difference between the
mean values for end expiratory oxygen concentration at
3 min was 10.0% to 14.2%. There was also a statistically
significant difference in the subjective ease of breathing,
favouring the Mapleson C system.
Conclusion: The Mapleson C breathing system is more
effective and subjectively easier to breathe through than a
self-inflating bag when used for pre-oxygenation.
However, these benefits must be weighed against the
increased level of skill required and possible complications
when using a Mapleson C breathing system.
Pre-oxygenation is an established prerequisite to
rapid sequence induction of anaesthesia and
tracheal intubation.1 It is undertaken to maximise
the oxygen fraction of the functional residual
capacity by displacing nitrogen with oxygen. This
delays the onset of oxygen desaturation of arterial
blood after induction of apnoea. Good pre-oxygenation
is essential in the emergency department
before rapid sequence induction of anaesthesia,
because intubation is often undertaken in patients
with significant acute morbidity who are therefore
prone to early and rapid desaturation.2 3 Preoxygenation
must therefore be optimal in this
environment4 and emphasised during training.5
Adequate pre-oxygenation is indicated by achieving
an end expiratory oxygen concentration of
.90%.6 7
Pre-oxygenation in the emergency department is
often achieved using a self-inflating bag with a
valve-mask assembly and a reservoir bag with highflow
supplemental oxygen. In some centres a
Mapleson C breathing system is used for this
purpose (fig 1). The Mapleson C system can also be
used for oxygenation during sedation.8
Self-inflating bags are universally available in UK
emergency departments because they are easy to
use and will function without an oxygen supply.
They are appropriate for use during assisted
ventilation, but during spontaneous breathing they
may increase the resistance to breathing.9
Furthermore, a self-inflating bag may deliver a
lower inspired oxygen concentration than an
anaesthetic breathing system.10
We aimed to determine whether a self-inflating
bag with reservoir and supplemental oxygen
supply provides the same degree of pre-oxygenation
as a Mapleson C anaesthetic breathing system
when both are used correctly. We also compared
the subjective ease of breathing for patients preoxygenated
using these devices.
METHODS
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
Solutions:
Recognise the physiology.
Not rely on concensus based dogma about fixed physiological limits across many ages
Solutions:
Recognise the physiology.
Not rely on concensus based dogma about fixed physiological limits across many ages
We Say the physiology never lies: except sometimes it does!
Don’t intubate Jonny because he’s scared and misses his mum