Download Paediatric Emergencies in the Recovery Room

Paediatric Emergencies
in the Recovery Room
Michelle McNamara
Proposed Learning
Paediatric Emergencies
A.B.C.D.E
Airway
Breathing
Circulation
Disability (depressed consciousness,
unresponsiveness).
Exposure ( significant hypothermia,
bleeding, shock).
Paediatric Challenges
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Not ‘Small’ Adults
Are Someone's Child
Age groups – size, development
Opiate use intra-op/Post-op
Emergence delirium
Families
Fear of mistakes
Paediatric Considerations
Higher Anaesthetic Morbidity &
Mortality
 Higher Intra-operative Bradycardia
(Infants)
 Higher Respiratory Complications
(Recovery)
 Associated outcomes worse
 Complications occur in healthy
children of normal weight
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Paediatric Anaesthesia Report
Patient specific additions
 Defer verbal report if condition is unstable
or emergency intervention is warranted.
 Birth history (premature birth, or congenital
conditions).
 Developmental considerations (ensure
personal comfort items are present, toy,
blanket, religious items).
 Special needs (e.g. glasses, hearing
implants)
 Pre-operative behaviour, (calm or
anxious).
 Loose teeth (returned for tooth fairy).
Approach to Paediatric
Assessment
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ASSESS (General, Primary, Secondary,
Tertiary)
CATEGORIZE (Respiratory, Circulatory)
DECIDE (Course of Action)
ACT (Initiate Appropriate Treatment for
Clinical Condition & Severity
REASSESS The Above Process Is Ongoing
e.g. reassess after any intervention to ensure
effectiveness
Assessment
General
 Primary
 Secondary
 Tertiary
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SAMPLE
 Signs & Symptoms
 Allergies
 Medication
 Past Medical History
 Last Meal
 Events
Paediatric Definitions
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Premature Newborn – Birth before 37/40
Newborn – Birth to 72 hours
Neonate - Infant during first 28 days of life
Infant - 1st year of life (including neonate)
Toddler 1-3yrs
Preschooler 4-5yrs
School Age 6 – 12yrs
Adolescent > 13yrs
Airway
Approach to Paediatric
Assessment
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ASSESS (General, Primary, Secondary,
Tertiary)
CATEGORIZE (Respiratory, Circulatory)
DECIDE (Course of Action)
ACT (Initiate Appropriate Treatment for
Clinical Condition & Severity
REASSESS The Above Process Is Ongoing
e.g. reassess after any intervention to ensure
effectiveness
Anatomy and Physiology
Airway
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Large Tongue
Narrow Nostrils
Smaller Airway Opening
Short Neck
Neonates are obligatory nose breathers
More Susceptible to Laryngeal /
Bronchospasm
Easily Obstructed Airway
Post Intubation Oedema
Airway problems
Tracheal intubation (under 5 years)
 History of pre-term birth
 Reactive airway disease
 Airway surgery
 Excessive Secretions/Nasal
Congestion
 Parents who smoke.

Breathing
Approach to Paediatric
Assessment
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ASSESS (General, Primary, Secondary,
Tertiary)
CATEGORIZE (Respiratory, Circulatory)
DECIDE (Course of Action)
ACT (Initiate Appropriate Treatment for
Clinical Condition & Severity
REASSESS The Above Process Is Ongoing
e.g. reassess after any intervention to ensure
effectiveness
Normal Respiratory Rate by
Age
Age
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Breaths Per Minute
Infant
(< 1yr)
Toddler
(1 – 3yrs)
Preschooler (4 – 5yrs)
School Age (6 – 12yrs)
Adolesent (13 – 18 years)
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30 – 60
24 - 40
22 – 34
18 – 30
12 - 16
A respiratory Rate
consistently > than 60 bpm in
a child of any age is abnormal
Normal Spontaneous
Ventilation
Minimal work
 Quiet breathing
 Easy inspiration
 Passive expiration
 Rapid in the neonate
 Decreases in older infants & children
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Paediatric Considerations
(Respiratory)
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High metabolic rate
Oxygen demand is higher
Infant Oxygen Consumption is 6-8mls/kg
per minute (compared to 4mls/kg for
adults)
Hypoxaemia more rapid in infants &
children
A room air Sao2 < 94% in a normal child
indicates hypoxaemia.
Causes of Respiratory
Dysfunction Post Op
Residual effects of anesthetic agents
 Opiate Agents
 Sedative agents
 Excessive fluid volume
 Pain/ Anxiety
 Hypothermia/Hyperthermia
 Pre-existing Pulmonary Disease.
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Early
Respiratory Distress
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Increased Respiratory & Heart Rate;
Decreased Oxygen Saturation, Nasal Flaring
(Infants);
Chest Retractions, use of Accessory Muscles;
Poor chest rise
Poor air entry
Grunting
Croup
Stridor
Wheezing
Mottled Colour
LATE
Respiratory Distress
Bradypnoea
 No respiratory effort
 Apnoea
 Cyanosis
 Poor or absent distal air movement
 Coma
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Types of Respiratory Distress
 Upper
airway obstruction
 Lower airway obstruction
 Lung Tissue Disease
 Disordered control of breathing
Croup
 Inflammation
of the upper airway
 Post-intubation croup
 Presentation -'bark-like' cough
 Mild, Moderate, or Severe
Causes of Croup
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Intubation (Traumatic Prolonged or Repeated)
Tight fitting E.T.T.
Subglottic Injury
Coughing (with E.T.T in place)
Change of position (whilst Intubated)
Surgery >1 hour
Surgical trauma
May be accompanied by
 Stridor
 Respiratory Distress
Stridor
 Shrill
 Harsh
 loud
 Crowing
sounds
 Heard during inspiration,
expiration or both.
Management of Croup / Stridor
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Notify Anaesthetist
Nebulised cool mist
Steroid IV
Humidified oxygen
Keep N.P.O.
Nebulised Epinepherine
Keep Pt > 2hrs
Re-intubate (size smaller ETT than
calculated for the age of the child)
Laryngospasm
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Involuntary muscle contraction of the
laryngeal muscles causing the vocal cords
to close.
Dyspnoea
Crowing sound on Inspiration
Aphonia (no sound)
Rocking Motion of Chest
Use of Accessory Muscles.
Laryngospasm
Nursing Interventions
Notify Anaesthetist
 Administer 100% Humidified Oxygen
 Positive Pressure Ventilation by BVM
 Maintaining PEEP to Open Vocal
Chords.
 Prepare for Intubation
 Oropharyngral Suction as required
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Bag Mask ventilation
Signs & Symptoms
Lower airway obstruction
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Tachypnoea
Wheezing, (expiratory most common)
Increased respiratory effort
Retractions
Nasal flaring
Prolonged expiration (with expiration being
an active rather than a passive process).
Bronchospasm
Causes
Preexisting Airway Disease
 Asthma, Bronchiolitis
 Allergy/Anaphalaxis
 Aspiration
 Mucous plug
 Foreign Body
 Pulmonary Edema.
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Bronchospasm / Asthma
Treatment
Notify Anaesthetist
 Humidified Oxygen 100%
 Suction
 Bronchodilators / Ventolin
 Support ventilation
 Intubate if necessary
 Admission overnight
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Aspiration
Causes
 Residual
gastric volume (intra-op)
 Post op Nausea & Vomiting
 Inhalation of foreign body e.g.
tooth
 Inability to protect airway
Aspiration
Nursing Interventions
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Position head down & turned to the side to
promote drainage
Humidified Oxygen/Suction
Anti-emetic prophylaxis / rescue
Notify anaesthetist
Chest x-ray
I.V. Antibiotic
Prepare to re-intubate if necessary
Respiratory Management
Distress/Failure/Obstruction
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Notify Anesthetist
Reposition/Support the airway
Open airway
Clear the airway
Insert an O.P.A. Or N.P.A.
Assist ventilation
High concentration O2
Monitor SAO2 / HR
Nebulised Medication (Albuterol / Epinepherine)
Prepare for Endotreacheal Intubation
Circulation
Approach to Paediatric
Assessment
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ASSESS (General, Primary, Secondary,
Tertiary)
CATEGORIZE (Respiratory, Circulatory)
DECIDE (Course of Action)
ACT (Initiate Appropriate Treatment for
Clinical Condition & Severity
REASSESS The Above Process Is Ongoing
e.g. reassess after any intervention to ensure
effectiveness
Normal Heart Rate
Age
Newborn to 3months
3 months to 2 yrs
2yrs to 10yrs
> 10yrs
Awake Rate
85 –205
100 –190
60 – 140
60 - 100
Mean
140
130
80
75
Sleeping Rate
80 - 160
75 - 160
60 - 90
50 - 90
Normal Blood Pressure by Age
(mm Hg)
Age
Systolic
Diastolic
Neonate (1st day)
Neonate (4th day)
Infant ( 1 month)
Infant ( 3 months)
Infant ( 6 Months)
Infant ( 1year)
Child ( 2 years)
Child ( 7years)
Adolescent ( 15years)
60 – 75
67 84
73 – 94
78 – 103
82 – 105
68 – 104
70 – 106
79 – 115
93 – 131
30 – 45
35 – 53
36 – 56
44 – 65
46 -68
20 – 60
25 – 65
38 – 78
45 - 85
Cardiac Physiology
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Higher cardiac output
Higher baseline heart rate
Infants – cardiac output dependent on heart
rate DO NOT COMPENSATE for lower B/P
Bradycardia in an infant ominous sign (CPR
<60) May indicate hypoxaemia
B/P lower than adults and increase with age
H/R higher than adults and decrease with
age
Cardiac Arrest Assessment
Broselow PaediatricTape
H’s
 Hypoxia
 Hypovolaemia
 Hydrogen Ion
 Hyper/Hypokalaemia
 Hypoglycaemia
 Hypothermia
T’s
 Toxins
 Tamponade
 Tension
Pneumothorax
 Thrombosis
 Trauma
Circulation Assessment
Cardiovascular
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Vital signs
Central and Peripheral Pulses
Brain Perfusion (Mental Status)
Skin Perfusion (Capillary refill <3 seconds)
Renal Perfusion (Urine Output)
Infants & Young Children 1.5 – 2ml/kg/hr
Older Children & Adolescents 1ml/kg/hr
Bradycardia
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Assess & Support ABC
Hypoxemia
What is the BP?
How is perfusion?
Arrhythmias?
Adolescent athlete
Perform CPR if HR<60/min with poor
perfusion
Tachycardia
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Assess & Support ABC
Check Perfusion
Crying ?Pain
Temperature ?Malignant hyperthermia
Anxiety
Full bladder
Fluid overload
Medications (glycopyrrolate, atropine)
Sinus Tachycardia (Infants <220, Children<
180)
Cardiac Arrest
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Asystole
PEA
VF
Pulseless VT
Asystole & PEA most common initial arrest
rhythms in under 12yrs
Activate Emergency Response,
commence CPR per BCLS/PALS
guidelines
Disability
Approach to Paediatric
Assessment
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ASSESS (General, Primary, Secondary,
Tertiary)
CATEGORIZE (Respiratory, Circulatory)
DECIDE (Course of Action)
ACT (Initiate Appropriate Treatment for
Clinical Condition & Severity
REASSESS The Above Process Is Ongoing
e.g. reassess after any intervention to ensure
effectiveness
Depressed Consciousness
Post op
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Anesthetic, Opiates, Sedatives
Hypoglycemia / Hyperglycemia
Hypothermia / Hyperthermia
Sepsis
Seizure
Neurological Disease / Head Injury
Respiratory Depression
Emergence Delirium
Paediatric Response Scales
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Alert
Voice
Painful
Unresponsiveness
Modified Glasgow Coma Scale for Infants &
children GCS (3 -15)
Pupil Response to light PERRL (Pupils Equal
Round Reactive to Light)
Emergence Delirium
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Post-Anesthesia Agitation,
Emergence Agitation,
Post-Anesthetic excitement
Non-purposeful movement
Incidence 25-80%
Preschool children (< 6)
Lasts up to 45 minutes
Associated with Sevoflurane
Emergence Delirium treatment
R/o physiologic causes ( ABC / Pain/
Anxiety)
 Identify Emergence Delirium
 Include family at bedside promptly
 Protect from harm
 Calm environment
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Exposure
Approach to Paediatric
Assessment
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ASSESS (General, Primary, Secondary,
Tertiary)
CATEGORIZE (Respiratory, Circulatory)
DECIDE (Course of Action)
ACT (Initiate Appropriate Treatment for
Clinical Condition & Severity
REASSESS The Above Process Is Ongoing
e.g. reassess after any intervention to ensure
effectiveness
Normal Temperature
Age of child
Core Temp ( c)
0
< 6 months
7 months – 1yr
2 - 5 yrs
> 6 yrs
37.5
37.5 - 37.7
37.2 – 37.0
36.6 – 36.8
Paediatric Temperature
Concerns
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Larger body surface area/kg
Cold Theatre, IV fluids, Anaesthetic Gases
Surgery > 1 hour (Wound Exposure)
Hypothermia (Core Temperature < 36 )
Delayed awakening
Cardiac Irritability (Poor Perfusion)
Respiratory depression
High Temperature is a LATE sign of MH
, infant
Thermoregulation
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Shivering Increases metabolic rate &
discomfort
Infants cannot shiver – to increase heat they;
Metabolize brown fat
Move
Cry
Pethidine calms shivering (Lowers seizure
threshold)
Treat (Bair Hugger)
Hypothermic Interventions
 Warm
Recovery Room
 Warm blankets
 Hat, Socks, Swaddle, Hold Close
 Infant Incubator
 Forced Air Warmer (Bair Hugger)
 Radiant Heat Lamp/s
Shock
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In Shock, Tissue perfusion is Inadequate
Relative to Metabolic Needs
Hypovolaemic Shock
Distributive Shock
Cardiogenic Shock
Obstructive Shock
PALS Protocol
Compensated/Uncompensated Shock
Hypovolaemia
Fluid/Blood Volume Deficit
 Assess Imbalance
 Treat underlying Cause & Correct
Imbalance
Blood Loss
 Mild< 30%
 Moderate 30%-45%
 Severe >45%
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A.S.A. Minimum Fasting
Guidelines
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2 Hours For clear Liquids
4 Hours For Breast Milk
6 Hours For Infant Formula,
Non-Human Milk ,
Light Meal (Tea & Toast)
8 Hours For a Meal (Fried or Fatty Foods)
Fluid Requirement
Formula
Body Weight kg
Hourly Fluid Requirement
0 – 10 kg
4ml/kg/hr
10 - 20 kg
40ml + 2 ml/kg/hr
>20 kg
60ml + 1 ml/kg/hr
e.g. 6 kg = 24 ml/hr
e.g. 17 kg = 54 ml/hr
e.g. 24 kg = 64 ml/hr
Maintenance
Hypovolaemia Interventions
Fluid Resuscitation IV / IO access
 Bolus 20ml/kg of Isotonic Crystalloid
N/S CSL
 Reassess & Repeat
Transfusion
 RBC 10ml/kg
 Reassess & Repeat
Paediatric
Postoperative care
ABCDE System Support
 Pain Management
 Anxiety Management
 Psychosocial Considerations
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Thank you!
References
American Heart Association & American Academy
of Paediatrics (2005) Paediatric Advanced Life
Support Provider Manual. Illinois:Worldpoint
ECC,INC.
Aitkenhead, A., Smith, G. & Rowbotham, D.(2007)
Textbook of Anaesthesia. 5th edn.
London:Churchill Livingstone.
De Fazio-Quinn, D.M. (2003) ‘Perianaesthesia
nursing as a speciality’ in Drain, C.B. (ed) Peri
Anaesthesia Nursing, A Critical Care Approach.
Missouri: Elsevier,11:29.
References Contd.
Johnson, D. (2004) ‘Care of the pediatric Patient’ in
Drain, C.B. (ed) Peri Anaesthesia Nursing, A
Critical Care Approach. Missouri: Elsevier,
661:681.
Motoyama, E., Davis,P. & Smith, P. (1996)
Anesthesia for Infants and Children. 6th edn. St
Louis:Mosby.
Schick, L. & Windle, P. (2010) PeriAnesthesia
Nursing Core Curriculum:Preoperative, Phase 1
And Phase 11 PACU Nursing. Missouri:Saunders
References contd
Smith, B. & O’Brien, D. (2004) ‘Space Planning
and Basic Equipment Systems’, in Drain, C.B.
(ed) Peri Anaesthesia Nursing, A Critical Care
Approach. Missouri: Elsevier, 1:10.
Stoddart, P. & Lauder, G. (2004) Problems in
Anaesthesia Paediatric Anaesthesia.
London:Taylor & Francis.
Trigg, E. & Mohammed,T. (2007) Practices in
Childrens Nursing; Guidelines for Hospital
and Community. 2nd edn. London:Churchill
livingstone.