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Nwts study day 2021 11 08

title: NWTS Study Day tags: #FFICM notebook: 🌑-FFICM type: inprogress

category: paediatrics

NWTS.NHS.UK <- Regional Guideline Website

education nwts2020

A - E Assessment of the Sick Kid

Speaker: Dr Kathryn Wood

The big difficulty with a lot of this, is that reference ranges are all over the place.

tl;dr - Take some obs and do an SBAR

Do an SBAR style thing:

  • Inc neonatal history
  • Rest as normal SBAR
  • Inc fontanelle, AVPU

Do an A-E assessment. When discussing with others helps relay it in a meaningful way.

They recommend getting the NWTS referral form and structure your chat like that. So I should look at the scotstar stuff.

Is an A-E assessment any different? Well no it's the same structure, but yes cos theres diff ranges and kids compensate longer.

Airway

Anatomical Stuff

  • High anterior larynx
  • Short trachea
  • Big tongue
  • Tube can go down either bronchus more easily

What are we looking for?

  • Patent or not?
  • Optimal positioning? - Neutral or extended?
  • Is airway potentially difficult?
  • Dysmorphic features?
  • Tracheostomy/Long Term Ventilation
  • If so why?
  • Just for suction
  • LTV?
  • Do they have an upper airway or not?
  • Additional Sounds
  • Stridor + Stertor

Additional Sounds:

  • Stridor
  • Stertor - More Nasopharyngeal

  • Grunting

  • A child that is drowsy with evidence of respiratory distress is v v concerning. Are they getting a sleep or have they got reduced GCS

  • You want to know about if any history of laryngomalacia

  • They can get impressively sick with a mild infection

  • You want to know about rate of deterioration

  • A stertorous child - you can fall into trap of thinking they are a stridor that's not responding

  • Under 6 months are obligate nasal breathers so a stuffy snotty nose is an airway obstruction a bit!

  • Also an NG tube is obstructing half their airway

  • Use a cuffed airway tube whenever possible

  • Put in an NG whenever possible - Cos you will inflate stomach when bagging a baby.

Breathing

  • Smaller Airways
  • Weaker Diaphragm
  • Much more compliant chest - Thats why you see recession
  • Higher metabolic rate than adults

Effort

  • What is the degree of increase of work of breathing
  • Smaller the child the more compliant, the greater the recession seen
  • Sternocleidomastoid involvement = Head bobbing
  • Nasal Flaring, the babies are trying to increase diameter of airways
  • So an older child with visible recession is proper sick
  • Rate is much more important
  • They can have proper apnoeas when sick, like 20 seconds

  • No place for bronchodilators in 6 months and down, they dont have the receptors

  • RR (Apnoea)

  • Subcostal Recession
  • Intercostal Recession
  • Head Bobbing
  • Reduced GCS
  • Gasping, head flopped back
  • Bradycardia is a pre terminal event
  • Remember you tire when you are really sick, so your work of breathing may be fine
Apnoeas

What would be worrying about an apnoea?

  • If bradycardiac with it
  • If desaturation with it
  • How frequent are they?
  • 1 episode every two hours needs observation but is alright
  • Every five minutes is a big big deal
  • The pause needs to be >20s to count as an apnoea

BIPAP

  • Kids are often started on non-invasive with paeds, paeds are great at identifying who needs it, maybe need a bit of help with troubleshooting machines themselves (are they triggering are they ventilating etc)

Circulation

  • You cant really increase your stroke volume before age of two
  • You have a great cardiac index as a neonate (prob cos youve a tiny body surface area!)

Assessing circulation.

  • Differences include palpable liver way more important in kids than in adult
  • Feel it when first assessing them
  • It will move on fluid status
  • Fluid resus will push liver down the way!
  • Pushing down on liver is like a passive leg raise in an adult
  • It's a really good sign
  • Best place to feel a pulse in a baby is brachial or femoral
  • Most reliable is femoral
  • But also cardiac babies think about where pulses should b
  • C is much the same as adults
  • Obvs have diff ref ranges
  • Fluid overload in baby is seen more in periorbital area first.

Mean Pressure should estimate to gestational age in neonates (well, it's the 5% percentile. So it's acceptable but it is low.

If 39 weeks, MAP should be 39 and above.

Hypotension in a baby/smaller child is a preterminal event. They compensate until they die.

  • What's the usual most effective way of treating bradycardia in a child?

    • Oxygenation!
    • Most common cause of bradycardia is hypoxia
    • Give oxygen not atropine! Most of the time (sometimes you do need it)

  • When would you consider a duct dependent lesion in a child when:

  • Less than month old or
  • Poor femoral pulses or
  • Not responding to fluid boluses or
  • Presenting feature is hypoxia

If you give them oxygen and they don't get better, is this a right sided duct dependent lesion

Look at the screenshot of:

  • Blue Baby
  • Gray Baby
  • Pink Baby

Practical Points

  • Cap Refill is not sensitive or specific
  • Be cautious that theres an undiagnosed cardiac defect (especially if gets worse with fluid, or doesn't get better with O2)
  • Gestational age is a good way of estimating MAP

Disability

  • Use AVPU
  • Pupils
  • Modified GCS
  • Fontanelle

Resp Illnesses

Kate Parkins

Bronchiolitis

  • It's a diagnosis for those under 2
  • RSV is most common organism

Mortality Risk of ~1% in hospitalised. ~3.5% in higher risk (airway or congenital heart disease)

Risk Features

  • Smaller you get more likely your airways are to be obstructed
  • < 6 weeks
  • < 5 kgs
  • Premature
  • Trisomy 21
  • Cardiac / Lung Disease

Assessment

History
  • Find out about risk factors
  • Find out previous ventilation (re subglottic stenosis risk)
  • Find out if known organisms

Decision Making / Top tips

What to do and when. We aren't too certain based on evidence as to who should go onto what modality.

However, if they're smaller/younger (as in less than 6 weeks), prob more likely to start with NIV rather than HFNO2.

If they've got apnoeas, start NIV sooner. Also if they've an Hb less than 100, consider topping up.

Consider proning.

Put in an NG Tube!

NIV def reduces hospital stay, likelihood of invasive ventilation.

What about if they're older? Non invasive prob only useful up to about 6kgs. So try HFNO2. But toddlers often hate it. You need to start it warm. Start it super low flows (~2L/min before slowly working up to 2-3L/kg/min)

Asthma

Kate Parkins

Working up in this order.

  1. Nebulisers
  2. IV Magnesium (bolus)
  3. IV Aminophylline (infusion)
  4. IV Magnesium again (bolus +/- infusion)
  5. IV Salbutamol (bolus +/- infusion)
  6. Intubation

Don't pay too much attention to tachycardia as salbutamol will drive it.

Context is key. Ultimately it looks much the same as adults.

Does a cap gas work? Yes! It's good for pCO2 and for pH/H+

Pneumothorax

Same as in adults

Chest drains, also the same as adults (apart from smaller sizes)

Intubation

Again, basically same as adults

The only other thing is remember remember remember that a low/low normal BP is a preterminal thing.

Kids compensate until they die.

Risks of Intubation

  • Low Oxygen Reserve
  • Rapidly Desaturate
  • So you need great pre-oxygenation
  • Apnoeac Oxygenation - 2l/kg/min on HFNO2.
  • You want sats >94% before induction
  • Often difficult to clear CO2
  • Put the largest fitting cuffed ET Tube on first go
  • Clearing secretions and CO2
  • Bronchospasm - Slow RR
  • Bronchodilators
  • Avoid morphine/thiopentone/atracurium/sux (you don't want a histamine release in asthma)
  • Still struggling? Consider volatile agenst post
  • Remember hypoxia more important than hypercapnoea
  • Vent strategies are same as in adults
  • Hypovolaemia
  • They are normally dehydrated
  • Give IV
  • Consider 1:100000 adrenaline (use that rather than metaraminol)
  • They have delayed gastric emptying
  • Place an NG
  • Modified RSI
  • Fentanyl/Ketamine/Rocuronium
  • You can give induction agents through an IO
  • Don't delay stuff for sake of IV
  • Place ETT to level of T2 (between heads of clavicle)
  • Small movements in kids = big movement of tube

Tracheostomies

Same as adults apart from:

  • Paeds tracheostomies don't have an inner tube, you have to change the whole thing

Assessment of the Stridulous Child + Button Battery Ingestion

Dr Gemma Burdiss

  • The chat is be worried about haematemesis in kids (i mean, obviously)

  • Haematemesis in button battery ingestion has a high risk of progressing to cardiac arrest.

  • Assume it is an aortoenteric fistula until proven otherwise.

  • Ongoing damage can happen up to 28 days after button battery ingestion even if removed.

  • Oesophagous lodgement can occur at:

  • Thoracic Inlet - Upper oesophageal

  • Aortic Arch

  • Gastrooesophageal Sphincter

  • As this is where everything narrows

  • Can cause perforation within first 2 hours.
  • Serious internal burns and production of sodium hydroxide. Will cause liquefaction and necrosis of tissue.
  • Ultimately the button battery needs to come out ASAP. Time = Tissue.

  • Don't wait until fasted. Do it endoscopically. Look for evidence of injury on removal of battery.

  • You can do a CT Chest Angio to look for evidence of vascular involvement.

  • Basically button battery ingestion is fucking awful

  • Damage within two hours
  • Can cause problems up to a month after removal
  • Problems include catastrophic aortoenteric fistula and death

  • Plus long term tracheo/oesophageal fistulae

  • Multiple X Rays, AP and lateral chest, plus abdominal

  • Get major haemorrahge protocol activation if any bleeding (its aortoenteric fistula)
  • You need cardiothoracic involvement, general, ENT involvemnt
  • You need 2x wide bore IV/IO

  • It needs to be out within 2 hours of attending ED

  • Consider giving honey 10ml every 10mmins. Or sucralfate, 1G every 10 mins. Aim of these is to coat battery to reduce amount of damage.

  • Should it come out locally or not?
  • A button within oesophagus needs to come out ASAP
  • May need to come out locally if takes too long to get elsewhere.

  • If there's concerns about aortic/major vessel involvement - transfer to an ECMO setting.

  • Its kids under 5 most at risk, most likely to ingest and least able to speak through it.

  • X RAY early. Symptoms are subtle

Status Epilepticus in the DGH

Dr Ashlea Norton

An untreated episode of status has a 5% mortality risk

10% of kids first presentations with seizures is status epilepticus

Causes:

  • MCAD (Metabolic)
  • Hypoglycaemic
  • CVA (Ischaemic and haemorrhage)
  • VP Shunt Blocked
  • SOL
  • Meningitis/Encephalitis
  • Electrolyte Stuff
  • Hypertensive crises
  • Toxins
  • Inborn errors of metabolism
  • Febrile Convulsive Status Epilepticus / Febrile Convulsion (6 months to 5 years, in otherwise normal neurological child)
  • These febrile things have a way lower risk of permanent complications
  • But do have a higher risk of epilepsy later in life

  • Most commonly caused by a Viral URTI

  • SCN1A genetic Stuff

  • Pitfall here is you can't give phenytoin
  • This abnormality is a sodium channel thing
  • Phenytoin acts on sodium channels
  • Phenytoin makes seizures with this abnormality worse

Management

  • Main take away: use Keppra as first line antiepileptic (after benzos)
  • Benzo doses same as Mon11October0739PM_11
  • You need two doses of benzos on the guideline (inc anything had prehospital)
  • Don't give extra doses, you've already flooded the receptors, you're more likely to cause resp depression than you are to terminate seizures

AEDs

  • APLS suggests Keppra (40mg/kg) as first line over 5 - 10 mins, and then as second line RSI (or phenytoin if not ready for RSI)
  • What if theyre on keppra anyway? Still give same 40mg/kg
  • NWTS suggests Keppra as first line, then as second line RSI (skip phenytoin)

For Neonates:

  • Phenobarbitol 20mg/kg over 20mins
  • (+/- Paraldehyde 0.8mg/kg)
  • Remember paraldehyde is short acting and shouldn't get in the way of you doing other long acting stuff

RSI

  • Fentanyl, Ketamine, Rocuronium
  • 1micro/kg, 1mg/kg, 1mg/kg
  • At low doses ketamine may be proconvulsant, but is anticonvulsant at anaesthetic doses
  • Maintain sedation with propofol rather than morphine/midazolam

Extubation

  • Maybe do soon
  • Especially if intubation due to resp depression
  • and Normal obs
  • and everything seems alright
  • this is why they recommend propofol - cos might be able to extubate soon
  • Less likely if known refractory epilepsy

Investigation

CT?

  • Majority of patient does get imaging, especially if a new prolonged seizure, or signs of Inc ICP, or focal seizure

Neonates

  • Almost every neonate who is seizing has some (mostly intracranial) nasty pathology.
  • Neonates often dont have a mature enough brain for proper tonic clonic seizures
  • So instead they will have more subtle things

Time Critical Transfer and Decision Making

Mary-Ann Bentham

Life or limb saving treatment required that can't be provided at a local centre. Will not benefit from further resucitation.

Includes:

  • Injuries
  • Tracheooesphageal fistulae
  • Raised ICP
  • Button Batteries
  • Cardiac - Inc Duct Dependent Stuff
  • metabolic

Trauma Case - Polytrauma, Traumatic Head injury

Traumatic Head Injury with raised ICP, has same as adults targets.

Yeah just go for same as adults

Hypertonic Saline:

  • 3ml/kg 3% Hypertonic Saline over 30 mins

Remember though if a kid has a traumatic head injury they need a safeguarding referral.

Surgical Sieve in Neonates

  • Sepsis
  • Cardiac
  • Inborn errors of metabolic
  • Acute Surgical
  • Non-Accidental Injury

Duct Dependent Circulation

  • Don't push increased O2 as you might shut the duct
  • So target mid 80s
  • Will need a prostacyclin infusion to start
  • Will need cautious fluid boluses (5ml/kg)

Examples

Taken from this

Duct Dependent Systemic (blood cant get from the left side to the body)
  • Coarctation of Aorta
  • Critical Aortic stenosis
  • Hypoplastic left heart

Duct dependent pulmonary (blood cant get from the right side to the lungs)

  • Pulmonary atresia
  • Critical pulmonary stenosis
  • Tricuspid atresia
  • Tetralogy of fallot

Duct dependent both

  • TGA with restrictive circulation

Time Critical Cardiac Conditions

  • TGA with intact septum
  • Critical Aortic stenosis
  • Closing duct despite prostin with duct dependent circulation
  • Blocked BT shunt

Bowel Obstruction

Different pathologies causing it:

Neonates

  • Hirchsprung
  • Incarcerated hernia
  • Necrotising enterocolitis
  • Volvulus
  • Gut atresia/stenosis
  • Treachoesphageal fistula

Polytrauma

Polytrauma is polytrauma - not really different in adults

Metabolic Hyperammonaemia

  • Presents in times of stress
  • Send an ammonia in any kid presenting with reduced GCS

  • If ammonia greater than 200mmol/L start treatment

    • Sodium Phenylbutyrate
    • Sodium Benzoate
    • Arginine
    • Carnitine

  • Raised ammonia can cause neurological damage,

  • Caused by height of peak and duration of peak
  • If ammonia is > 400 and resistant to treatment then you NEED to start CVVHDF within 6 hrs
  • Treat with neuroprotective targets to help minimise damage to brain
  • Also STOP feeding them. Give them 10% glucose
  • This will stop catabolism

Transfers in general

  • Use a transfer checklist

Managing The Paediatric Patient in the Adult ICU

Kate Parkins

There's a surge expected on paediatric and adult intensive care units, with fear that kids are going to be overwhelmed.

The last two winters in paediatrics have been a lot less than adults, cos of societal lockdown, negligible RSV cases. However now society is reopening, and it's paeds turn to have a shit time. There's a cohort of kids who haven't been exposed to anything.

This will be a mix of:

  • RSV
  • LRTI
  • Croup
  • PIMS-TS
  • Sepsis

So one of the problems is that PHE think that adult ICUs will take paeds overflow. However, adults are likely to be full too.

Paediatric patients in adult ICU, aims of national guidance would be that a paediatric consultant would have 12 hourly reviews. There needs to be a member of team trained on paeds resus. Plus 24hr access for parents (within covid restrictions).

Previous examples:

  • Alcohol/drug intoxication
  • Trauma
  • Paracetamol overdose

Use a humidified circuit.

Ventilator Settings: - Same as adults - With a higher setting for allowed TVs

  • Can you use propofol?
  • Yes - For 24-48hrs
  • If looks like won't extubate by then, change to midaz (to reduce risk of Propofol Related Infusion Syndrome)