Episode 24: Paediatric Resuscitation
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Christina Harry
31/10/18
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Guest Bios
Christina Harry
Christina is Australian and completed her undergraduate medical degree there before travelling to the UK. She completed her paediatric intensive care training in Glasgow and now works as a Paediatric Intensive Care Consultant at the Royal Hospital for Children. Christina has a keen interest in trauma and is the Joint Paediatric Clinical Lead for Trauma at Royal Hospital for Children. Christina is also very passionate about retrieval medicine and enjoys her work with the ScotSTAR Paediatric Retrieval Service and is the ScotSTAR Paediatric Clinical Lead.
Show Notes
Eoghan and Christina discuss paediatric resuscitation and some considerations to remember in the heat of battle. A.P.L.S. is a mnemonic prompting the team to consider certain important things that can really make a difference.
Take Home Points
A
“Ask about the heart rate”
a sensitive marker of their physiology
infants have a small stroke volume so the main mechanism to increase their cardiac output is by raising their heart rate
however it is not specific (rises with pain, stress, pyrexia etc)
Advice: if you have a child who is calm, apyrexic and behaving appropriately, but has a high heart rate, be cautious
It is also a good measure of how your therapy is going
Low heart rate is also concerning if no immediate explanation (such as certain drugs/sedation etc) – go back to ABCDE
Single numbers are important but the trends probably have more value
P
“Possibly Sepsis”
think to your self – ‘why isn’t this sepsis?’
it can have an insidious presentation and can be easy to miss – particularly in very mall children
if intervened quickly the child can do much better
If you have a sick child and cannot exclude sepsis as a possible cause then give antibitotics
Make sure to get appropriate culture samples sent
“Prostin”
A neonate who presents very unwell – think Sepsis, Metabolic and Cardiac
Probably treat as for sepsis in the first instance (fluids, antibiotics, oxygen)
If you are treating and the child isn’t improving or looking like you would expect then consider cardiac/metabolic
Clues may be:
Abnormalities on cardiac exam (e.g. absent femoral pulses)
Saturations not improving with oxygen
When dealing with a sick neonate best to phone early for appropriate help
Probably better to discuss with expert before starting prostin
Isn’t a benign drug (can cause apnoea)
Help with prescribing and making up the drug
FLUIDS: in a shocked neonate – the most likely cause is sepsis (unless child has a specific history suggestive of cardiac cause)
Best to give volume
If child not improving or getting worse then consider cardiac and be more cautious
L
“Learn to love your lactate”
Never ignore a high lactate in a child
The overall number is important but so is the trend
Lactate levels can take some time to rise so a normal level doesn’t exclude serious illness
Capillary samples can haemolyse and artificially elevate the lactate – so if high level and child looks well, it may be prudent to retest
S
“Syringe in the volume”
Typically delivered in 20ml/kg boluses
If reach 60ml/kg and persistent cardiovascular instability then requires specialist help
Caution taken in certain cases – give 10ml/kg aliquots
KNOWN cardiac disease (risk of pulmonary oedema)
DKA (risk of cerebral oedema when illness severe or if really young)
Stop at 30ml/kg even if they still look rubbish (probably because they are acidotic)
Trauma – ideally blood products if blood lost
After these maximum amounts have been reached – further instability may require vasopressors/inotropes
If requiring intubation – support the circulation prior to intubation (vasopressors etc) – as they are at high risk of cardiovascular collapse with an anaesthetic agent
CAREER ADVICE
Be kind to yourself
we often blame ourselves when things don’t go well but there are often many reasons why the situation occurred.