Practical Approach to Pediatric Intensive Care Praveen Khilnani
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Section One
1Basic Practical Issues2

Managing Any Pediatric Emergency: A Practical ApproachCHAPTER 1

Praveen Khilnani
In outpatient practice pediatric specialist as well as general practitioner comes across common pediatric illnesses frequently. It is important to recognize potentially life threatening conditions as well as conditions requiring immediate intervention and transfer to a higher level medical facility.
Besides accidental trauma, poisoning, insect bites, allergic reactions, common medical problems that bring the child to medical attention are fever, cough, respiratory distress, cyanosis, ear ache, poor feeding, vomiting, diarrhea, irritability, lethargy, convulsions and unresponsiveness.
Common conditions that require immediate attention are—respiratory distress, shock, lethargy and coma.
Since our main goal as a medical practitioner is to prevent unnecessary mortality and morbidity by prompt and early recognition of potential problems leading to respiratory or cardiorespiratory arrest, it is important to pay attention to following during history and physical examination DONE SIMULTANEOUSLY.
  • Listen carefully to the mother.
  • Do not ignore, it will not get better if something is not done.
Important general features signifying potentially serious problem include:
  • Constantly crying child (unconsolable)
  • Sick looking child refusing to feed
  • Lethargic child
  • Comatose child
  • Child with respiratory distress (tachypnea, irregular respirations, nasal flaring, suprasternal, intercostal and subcostal retractions, grunting, head bobbing, stridor, wheezing, sweating, tired looking, gasping)
  • Child in shock (is suggested by clinical findings of cool extremities, poor peripheral pulses, poor urination by history, lethargy, tachycardia, blood pressure normal or low).
 
CLINICAL ASSESSMENT
Perform rapid cardiopulmonary assessment.
Quick head to tow examination (TIME IS OF ESSENCE!) assessing:
Airway Noisy, nose block, congested, audible wheeze or stridor whether accessory muscles working.
Common conditions related to problems with upper airway include croup (laryngo tracheo bronchitis), bacterial tracheitis, peritonsillar or retropharyngeal abscess, rarely epiglottitis.
Breathing Respiratory rate, tachypnea, grunting, accessory muscle use, nasal flaring, intercostal and subcostal retractions, cyanosis, crepitations, rales and wheezes. Common conditions causing respiratory distress include pneumonia and asthma, other conditions to be kept in mind include chest trauma causing a flail segment, hydropneumothorax, foreign body aspiration, near drowning, aspiration of gastric contents, pulmonary edema, pleural effusion, and empyema. SpO2 should be checked by pulse oximetry.
Circulation Heart rate, pulse, blood pressure, capillary refill time.
Common conditions involving circulatory impairment include: hypovolemic shock, septic shock, 4cardiogenic shock, anaphylactic shock and neurogenic shock.
Central nervous system Lethargy, coma, GCS (Glas-gow Coma Scale), neck stiffness, convulsions.
Common conditions involving CNS include meni-ngitis, encephalitis, metabolic encephalopathies and poisonings.
Note: Clinical assessment needs to be rapid and simultaneous with intervention for stabilization.
 
STABILIZATION
Things required at all practice locations (hospital or private practice): Oxygen, bag mask (ambu), intubating equipment, intraosseous needle, iv canula, iv fluids. Additionally: Suction, pulse oximeter and nebulizer.
  • Once the critically ill child is recognized requiring intervention.
  • Do not waste time in detailed investigations and diagnosis.
  • Do the following regardless of diagnosis. Give oxygen.
 
If Respiratoy Distress
  1. Ensure airway, i.e. open by head tilt, jaw thrust or chin lift maneuvers, if not open then intubate endotracheally and give bag ventilation. If can not intubate do bag and mask ventilation.
    If known foreign body obstruction then back blows, chest thrusts and Heimlich maneuver.
  2. Nebulize as required (adrenaline or beta two stimulant) if pulse oximeter available, monitor oxygen saturation.
 
If Shock
  1. Establish intravenous/intraosseous access. Do not waste more than 90 seconds on trying for intravenous access or wasting time with central line. Establish Intraosseous access.
  2. PUSH fluid bolus—20 cc/kg isotonic fluid (normal saline or ringer lactate).
  3. If known hypovolemia/suspected sepsis, or Dengue: 3–4 fluid boluses 40 to 80 ml/kg fluid push may be required.
 
After Each Intervention Reassess
Airway, breathing and circulation (capillary refill, color, heart rate pulse blood pressure, mental status, urine output).
 
Other Supportive Therapy
  1. Anticonvulsants—If convulsions diazepam iv/rectal/midazolam iv (caution–respiratory depression respiratory arrest). Phenytoin/Phenobarbitone intravenously.
  2. Antipyretics/sponge if high fever.
  3. Analgesics, if pain—Nonsteroidal anti-inflammatory agents narcotics as necessary.
  4. Antiemetics, if vomiting.
  5. Antiallergics—If allergic reaction/anaphylaxis (subcutaneous adrenaline antihistaminics, steroids).
After initial stabilization and ensuring airway breathing and circulation under reasonable control with established iv access, transfer/transport to a higher level facility needs to be arranged based on following indications for admission to pediatric intensive care unit.
 
Common Indications for the PICU Admission
  1. All unstable patients.
  2. Respiratory distress with or without mechanical ventilation (multiple causes).
  3. All patients with shock (due to multiple causes with the exception of uncomplicated hypovolemia due to gastrointestinal losses).
  4. All lethargic and comatose patients including:
    • Diabetic ketoacidosis
    • Hepatic failure
    • Concussion head injury
    • Major multi trauma
    • Convulsions
    • Poisonings.
  5. Any patient with active bleeding.
  6. Acute renal failure.
  7. Near drowning.
  8. All patients after successful resuscitation.
  9. Postoperatively after complex major surgery.5
 
SUMMARY
 
Stabilizing the Pediatric Patient (Flow chart 1.1)
  1. Goals in the care of the critically ill child:
    1. Initial stabilization—Buys time until the child can get to the PICU.
    2. Safe and expedient transfer to a PICU.
    3. Definitive care—Fine tuning of diagnosis and therapy in the PICU.
  2. Operating principles of stabilization:
    1. Focus the assessment and therapy on the crucial problems which are the life-and organ-threatening problems.
    2. The primary life-threatening problem in ALL emergencies is oxygen deficiency.
    3. Provide specific disease directed therapy.
  3. First goal of therapy Rapidly restore and maintain oxygen delivery to the cells and tissues. A.airway B. Breathing C. Circulation.
  4. Oxygen delivery to the tissues:
    1. Respiratory system—Need to consider both the PO2 (partial pressure of oxygen) and SpO2 (oxygen saturation).
    2. Cardiovascular system—Need to consider cardiac output.
    3. Hematologic system—Need to consider hemo-globin concentration and function.
  5. Brain injury When significant brain injury exists, oxygen delivery to the brain may become dependent on the maintenance of an adequate cerebral perfusion pressure (Mean arterial pressure minus intracranial pressure).
  6. Four requirements of oxygen delivery:
    1. SpO2
    2. Cardiac output
    3. Hemoglobin concentration and function
    4. Cerebral perfusion pressure.
  7. Oxygen delivery This is defined as the oxygen content in the blood times the cardiac output.
  8. Pathological states of decreased oxygen delivery:
    1. Hypoxemia—Support increased cardiac output and increase hemoglobin levels.
    2. Severe anemia—Increase FiO2 levels, support increased cardiac output and increase hemoglobin levels cautiously.
    3. Diminished cardiac output (shock)—Provide volume support before inotropes, increase FiO2 and increase hemoglobin levels.
  9. Oxygen delivery and utilization:
    1. Supply > need—ideal situation
    2. Supply < need—tissue hypoxia
      • Decrease the oxygen need by temperature control and measures that reduce body work such as mechanical ventilation, neuromuscular paralysis and sedation.
  10. Typical cases
    1. Septic shock:
      • Volume—20 ml/kg IV push to start with and keep going until the patient starts to improve or the liver edge is palpable.
      • Inotropes—After volume expansion if not enough to compensate.
    2. Seizures—Be sure to check your ABC's before starting antiepileptic drugs.
 
TAKE HOME MESSAGE
  • Solve immediate problem. Do not waste time in establishing precise diagnosis.
  • Recognize critical illness, stabilize. Arrange transfer to a PICU. Ensure continued stabilization measure until care is handed over.6
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Flow chart 1.1: Managing the sick child