DESCRIPTION

Emergent treatment of pediatric patients with imminent or ongoing respiratory or circulatory failure

ETIOLOGY

• Respiratory failure
• Early shock (compensated)
• Late shock (uncompensated)
• Cardiopulmonary arrest
• Respiratory and/or circulatory failure leads to tissue hypoxia, acidosis, and cell death.
• Multisystem organ failure subsequently develops.

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

• History from caregivers/parents of onset, progression, inciting, contributing, or predisposing trauma/exposure/conditions, associated findings, past medical history, family history, medications, ingestions
• History of preceding events from pre-hospital personnel
• Respiratory failure:
  • Tachypnea
  • Slow, irregular breathing pattern prearrest
  • Decreased or absent breath sounds; inadequate ventilation
  • Retractions, accessory muscle use, expiratory grunting, nasal flaring
  • Mottled skin, cyanosis
  • Altered level of consciousness: Irritability, agitation, lethargy, weak or absent cry, decreased response to pain
  • Weak or absent cough or gag reflex
  • Most common presenting condition
• Early shock (compensated):
  • Vital signs initially compensated
  • Orthostatic changes or isolated tachycardia
  • Slightly delayed cap refill (> 2 sec)
  • Warm, dry skin in early septic shock
• Late shock (uncompensated):
  • Tachycardia, tachypnea, prearrest bradycardia
  • Hypotension, weak peripheral pulses
  • Mottled, pale, cool extremities with markedly decreased capillary refill
  • Poor muscle tone
  • Decreased urine output progressing to anuria
  • Decreased LOC, seizures, coma
  • Fever or hypothermia in septic shock
• Cardiopulmonary arrest:
  • Final common pathway of progressive deterioration of respiratory and circulatory function

Physical Exam

• Airway assessment:
  • Look, listen, feel for air movement, breath sounds, and chest movement. Observe for stridor or signs of obstruction.
• Breathing assessment:
  • Respiratory rate: Tachypnea or slow/irregular pattern (more ominous)
  • Respiratory effort: Note grunting, nasal flaring, head bobbing, retractions, stridor.
  • Pulse oximetry reflects hemoglobin oxygen saturation, not necessarily oxygen delivery.
  • Auscultation: Assess for wheezing, rales, diminished breath sounds.
• Circulatory assessment:
  • Pulse: Tachycardia or bradycardia (more ominous); orthostatic changes noted easily.
  • BP: Typical SBP in children is 90 mm Hg plus twice the age (yrs). Hypotension is a late finding; widened pulse pressure in early septic shock.
  • Peripheral pulse presence and strength (correlates better than BP)
  • Capillary refill: Delayed > 2 sec with poor perfusion
  • Skin: Mottled, pale, or cyanotic
• Mental status assessment:
  • Decreased responsiveness, irritability, confusion, agitation, poor muscle tone, sluggish pupillary response, posturing.
• Complete set of vital signs including rectal temperature, oximetry, and orthostatics when appropriate

ESSENTIAL WORKUP

• ABCDE evaluation:
  • Airway: Assess ability to speak/cry; assess for air movement. Assess for stridor or trauma.
  • Breathing: Observe for nasal flaring, grunting, head bobbing, retractions, tracheal deviation, chest injury or pneumothorax; auscultate, apply oxygen.
  • Circulation: Evaluate for pulses, capillary refill, mottling, cyanosis.
  • Disability: Determine mental status with alert/verbal/painful/unresponsive (AVPU) scale or Glasgow Coma Scale. Assess for neurologic deficits; check stat glucose.
  • Exposure/environment: Fully expose for skeletal survey. Prevent hypothermia.

DIAGNOSIS TESTS & INTERPRETATION

Lab

• Workup directed by history, assessment of (ABCs), and differential diagnosis
• Arterial blood gas with oximetry to assess oxygenation, ventilation, acid–base status
• Glucose, electrolytes
• Other metabolic/toxicology tests as indicated
• Sepsis evaluation including lumbar puncture, urine and blood cultures as indicated

Imaging

• CXR to evaluate pulmonary or cardiac sources
• Lateral decubitus, inspiratory/expiratory film, or laryngoscopy/bronchoscopy if foreign body (FB) suspected
• ECG
• Echocardiogram
• Cervical spine, other trauma films as indicated
• CT brain for trauma or abnormal neuro exam
• US as indicated

DIFFERENTIAL DIAGNOSIS

• Respiratory:
  • Upper airway obstruction: Croup, epiglottitis, peritonsillar or retropharyngeal abscess, FB, tracheitis, congenital abnormalities
  • Lower airway obstruction: Asthma, pneumonia, bronchiolitis, FB, cystic fibrosis
  • Thoracic trauma, near drowning
• Hypovolemia: Trauma/hemorrhage, diarrhea/vomiting, burns
• Cardiovascular: Congenital/acquired heart disease, myocarditis, pericarditis, CHF, dysrhythmias
• Infectious: Sepsis, meningitis, gastroenteritis, peritonitis, pyelonephritis
• CNS: Status epilepticus, epidural/subdural hematoma
• Metabolic: DKA, hypoglycemia, hypernatremia, hypo/hyperkalemia, acidosis
• Toxicologic: CO poisoning, cardiotoxic agents
• Near sudden infant death syndrome/apparent life-threatening event
• Consider child abuse when history is inconsistent with the illness or pattern of injury.

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Stabilize ABCs; monitor.
• Avoid prolonged on-scene times
• Gather pertinent history from family/bystanders
• Recognize respiratory or circulatory failure; intervene early.
• Recognize impending arrest; support ABCs
• Automated external defibrillator for ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in children ≥1 yr.
• Early ED notification to allow preparation

INITIAL STABILIZATION/THERAPY

• Early recognition and stabilization of shock
• Glucose, IV, oxygen, cardiac monitoring
• Diagnose and treat immediate life-threats
• Employ Broselow Pediatric Emergency Tape for appropriate drug doses and equipment.

ED TREATMENT/PROCEDURES

• Airway:
  • Secure 1st in every resuscitation.
  • Employ head tilt/chin lift or modified jaw thrust (if trauma suspected).
  • Clear secretions and blood with suction.
  • Temporary stabilization with oral or nasal airway, bag-valve mask assistance
  • Intubation as necessary using appropriate tube size ([16 + age in years]/4) or size similar to patient's little finger or nares
• Rapid-sequence intubation:
  • Preoxygenate
  • Pretreatment: Atropine to prevent bradycardia, lidocaine if head injury
  • Induction agents: Midazolam, thiopental, etomidate (avoid in septic shock), ketamine
  • Paralytics: Rocuronium, vecuronium, pancuronium, succinylcholine
  • Position of endotracheal tube (ETT) at lips (cm) = 3 times diameter of tube (mm)
  • Postintubation: Confirm placement with continuous end-tidal CO₂ monitoring
• Breathing:
  • Oxygenate with supplemental O₂, nonrebreather mask; assist ventilation with bag-valve mask or control ventilation if intubation performed.
  • Treat conditions that limit ability to oxygenate/ventilate: Pneumothorax, hemothorax, cardiac tamponade, circumferential burns.
• Circulation:
  • Obtain IV, intraosseous (IO), or central access
  • Resuscitate with 0.9% NS or LR bolus at 20 mL/kg; repeat if necessary
  • Control obvious bleeding sources: Apply direct pressure; elevate.
  • Consider transfusion of packed RBCs after crystalloid replacement in trauma.
  • Use pressors early; peripheral use OK
  • Dopamine preferred 1st line; if refractory, norepinephrine (warm shock) or epinephrine (cold shock)
• Cardiopulmonary resuscitation:
  • Provide blood flow to vital organs while restoring spontaneous circulation
  • Infant < 1 yr: Check brachial/femoral pulse
  • Child 1–8 yr: Check carotid pulse
• Cardiac dysrhythmias:
  • Often due to respiratory/metabolic process
  • Treat dysrhythmias per PALS algorithms.
  • Unstable tachydysrhythmias may require adenosine, amiodarone, procainamide, cardioversion, or defibrillation.
  • Unstable bradydysrhythmias may require atropine, epinephrine, or pacing.
  • Pulseless rhythms: VF, pulseless VT, pulseless electrical activity, asystole may require defibrillation, epinephrine, amiodarone, lidocaine.

MEDICATION

• 1st or loading dose unless otherwise noted
• All IV doses may be given IO if necessary
• LEAN (lidocaine, epinephrine, atropine, naloxone) may be given by endotracheal route
• Epinephrine: Multiple uses:
  • Pulseless arrest/symptomatic bradycardia: 0.01 mg/kg 1:10,000 IV q3–5min (max. 1 mg) or 0.1 mg/kg 1:1,000 ETT q3–5min
  • Asthma: 0.01 mg/kg 1:1,000 SC q15min
  • Anaphylaxis: 0.01 mg/kg 1:1,000 IM in thigh q15min (max. 0.3 mg); if hypotensive, 0.01 mg/kg 1:10,000 IV q3–5min (max. 1 mg)
  • Shock/hypotension: 0.1–1 mcg/kg/min IV
  • Toxins/overdose: 0.01 mg/kg 1:10,000 IV; may repeat to max. 0.1 mg/kg 1:1,000 IV.
• Rapid-sequence intubation
  • Pretreatment:
    • Atropine: 0.02 mg/kg IV (min. 0.1 mg)
    • Lidocaine: 1–2 mg/kg IV
  • Induction:
    • Etomidate: 0.3 mg/kg IV
    • Ketamine: 1–1.5 mg/kg IV; 4–5 mg/kg IM
    • Midazolam: 0.1–0.2 mg/kg IV
    • Thiopental: 3–5 mg/kg IV
  • Paralytics:
    • Succinylcholine: 1–2 mg/kg IV
    • Rocuronium: 0.6–1.2 mg/kg IV
    • Vecuronium: 0.1–0.2 mg/kg IV
    • Pancuronium: 0.1 mg/kg IV
• Antiarrhythmic agents:
  • Adenosine: 0.1 mg/kg (max. 6 mg) IV rapid push; 2nd dose 0.2 mg/kg (max. 12 mg).
  • Amiodarone: 5 mg/kg IV, max. dose 300 mg. Give as bolus for pulseless VF/VT, load over 20–60 min for SVT/VT.
  • Lidocaine: For VF or pulseless VT: 1 mg/kg IV bolus, 20–50 ug/kg/min IV infusion
  • Magnesium sulfate: 25–50 mg/kg (max. 2 g) for pulseless VT with torsades de pointes
  • Procainamide: 15 mg/kg IV over 30–60 min
• Inotropes and pressors:
  • Dobutamine: 2–20 ug/kg/min IV
  • Dopamine: 2–20 ug/kg/min IV
  • Inamrinone: Load 0.75–1 mg/kg IV over 5 min; maintenance 5–10 mcg/kg/min
  • Milrinone: Load 50 ug/kg IV over 10–60 min; maintenance 0.25–0.75 ug/kg/min
  • Norepinephrine: 0.1–2 ug/kg/min IV
• Other agents:
  • Albuterol: For asthma or anaphylaxis, multidose inhaler 4–8 puffs q20min or nebulizer 2.5 mg/dose (5 mg/dose if > 20 kg) q20min; severe symptoms: 0.5 mg/kg/h by nebulizer (max. 20 mg/h)
  • Alprostadil: 0.05–0.1 ug/kg/min IV for ductal-dependent congenital heart disease
  • Calcium chloride: 20 mg/kg slow IV push in hypocalcemia, hyperkalemia, Ca channel blocker overdose
  • Dexamethasone: 0.6 mg/kg IV (max. 16 mg) for severe croup or asthma
  • Dextrose: 0.5–1 g/kg IV. D₂₅W 2–4 mL/kg or D₁₀W 5–10 mL/kg.
  • Diphenhydramine: 1–2 mg/kg IV q4–6 hr
  • Ipratropium: 250–500 mcg q20min ×3
  • Naloxone: 0.1 mg/kg IV q2min (max. 2 mg)
  • Sodium bicarbonate: 1 mEq/kg IV
  • Terbutaline: 10 mcg/kg SC q10–15min or 0.1–10 mg/kg/min IV for status asthmaticus
• Cardioversion: 0.5–1 J/kg, increase to 2 J/kg
• Defibrillation: 2 J/kg, increase to 4 J/kg

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• All patients with impending or ongoing respiratory or cardiovascular compromise
• Survivors of cardiopulmonary arrest require continuous monitoring for decompensation postresuscitation in an ICU setting.
• Consider transfer to pediatric critical care center.

Discharge Criteria

Patients with mild dehydration who respond to fluid resuscitation without signs of hemodynamic instability may be considered for discharge.

Discharge Criteria

• Consultation as appropriate depending on specific etiology
• Involve authorities if abuse is suspected.

FOLLOW-UP RECOMMENDATIONS

• Educate patients, parents, and caregivers regarding household products and toxins
• Educate patients about self-administration of epinephrine in anaphylaxis (if age appropriate).

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Empiric treatment is often necessary.
• Be vigilant for signs of early sepsis in children.
• Consider abuse if history contradicts exam
• Early recognition and stabilization

ICD9

• 427.5 Cardiac arrest
• 518.81 Acute respiratory failure
• 785.50 Shock, unspecified

ICD10

• I46.9 Cardiac arrest, cause unspecified
• J96.00 Acute respiratory failure, unsp w hypoxia or hypercapnia
• R57.9 Shock, unspecified

[Outline]

• ICD9
• ICD10

• Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatrics and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666–688.
• Fuchs S. Cardiopulmonary resuscitation and pediatric advanced life support update for the emergency physician. Pediatr Emerg Care. 2008;24(8):561–565.
• International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Pediatric basic and advanced life support. Pediatrics. 2006;117(5):e955–e977.
• Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S876–S908.
• Ralston M, Hazinski MF, Zaritsky AL, et al. Pediatric Advanced Life Support. Dallas, TX: American Heart Association; 2006.

Brian Clyne

Seth Gemme