Basics
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.
Diagnosis
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 90mm 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.
Treatment
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 patients 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
Follow-Up
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).
Pearls and Pitfalls
- Empiric treatment is often necessary.
- Be vigilant for signs of early sepsis in children.
- Consider abuse if history contradicts exam
- Early recognition and stabilization
Additional Reading
- 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.
Codes
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
SNOMED
- 409622000 Respiratory failure (disorder)
- 439569004 Resuscitation (procedure)
- 410430005 Cardiorespiratory arrest (disorder)
- 27942005 shock (disorder)