Pediatric Critical Care division Dept of Child Health
RSUP Mohammad Husin Hospital Palembang Copyright 2007 Seattle/King County EMS 2 Copyright 2007 Seattle/King County EMS
Bayi dalam keadaan terbaring, tonus otot lemah. Bila disentuh dan didekati gelisah, suara tangisnya lemah. Tidak ada suara nafas abnormal, tidak ada retraksi dan nafas cuping hidung Tampak pucat dan mottled. Seorang ibu membawa anaknya usia 6 bulan ke IRD RSMH, keluhan muntah > 10 kali sejak 1 hari sebelumnya 3 Copyright 2007 Seattle/King County EMS Laju nafas 30 kali /min, HR 180 kali / min, dan TD 50 mm Hg / palp. Gerakan aliran udara normal, pada auskultasi suara nafas jelas, bersih. Kulit terasa dingin, capillary refiil Time 4 detik. Denyut nadi brakialis lemah. Abdomen meteorismus
4 Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS What are the key signs of illness in this infant?
Copyright 2007 Seattle/King County EMS The first stage of which is quick screening (triage) to identify
those who need emergency treatment those who are at special risk and should be given priority Or.... those who are non-urgent cases 9 Copyright 2007 Seattle/King County EMS Not SICK SICK
12 Copyright 2007 Seattle/King County EMS PEMERIKSAAN SULIT DILAKUKAN KOMINIKASI SULIT CENDRUNG KETAKUTAN PENILAIAN KEGAWATAN SULIT DILAKUKAN Copyright 2007 Seattle/King County EMS You must recognize the SICK child within the first minute of contact. Much of the information you need to make a decision can be obtained without touching the patient. Copyright 2007 Seattle/King County EMS dilema Harus mampu meengenal anak dalam keadaan sakit pada menit pertama kontak informasi harus dapat diperoleh agar dapat membuat keputusan Tanpa menyentuh pasien 15 Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Penilaian Umum (General assessment ) Penilaian awal ( Initial assessment ) Bantuan Hidup Dasar Penilaian Keparahan penyakit Penilaian sekunder (ananmnesa, pemeriksaan fisik lengkap, pulse oksimetri, prosedur2 Intervensi lanjutan Penilaian Ulang Transport / Rujuk Dokumentasi
17 Copyright 2007 Seattle/King County EMS MENENTUKAN ANAK SAKIT GAWAT PAT MELIHAT KEADAAN ANAK GENERAL ASSESSMENT
PENILAIAN ABCDE INITIAL ASSESSMENT 18 Copyright 2007 Seattle/King County EMS 19 Tiga elemen guna menentukan sakit atau tidak sakit. Gawat atau tidak Copyright 2007 Seattle/King County EMS Pediatric Assessment Triangle There are three elements that you need to assess in a pediatric patient in order to determine SICK or NOT SICK: Appearance Work of breathing Circulation to the skin These three clinical indicators reflect the overall status of a childs cardiovascular, respiratory and neurologic systems. Copyright 2007 Seattle/King County EMS Normal Appearance Increased Work of Breathing MEANS RESPIRATORY DISTRESS Normal Circulation Copyright 2007 Seattle/King County EMS MEANS RESPIRATORY FAILURE Normal circulation Copyright 2007 Seattle/King County EMS Poor Circulation to Skin
MEANS SHOCK Copyright 2007 Seattle/King County EMS Normal
MEANS CNS or Metabolic Normal
Copyright 2007 Seattle/King County EMS Poor Circulation to Skin
MEANS OBSERVE Copyright 2007 Seattle/King County EMS After completing the Triangle, begin a more complete pediatric primary survey. AIRWAY BREATHING CIRCULATION DISABILITY Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS 29 circulation Skin Signs Feel for temperature and moisture.
Estimate capillary refill. Copyright 2007 Seattle/King County EMS FREKUENSI JANTUNG TEKANAN SISTOLIK MINIMAL 70 + { 2 x umur (tahun) } USIA FREKUENSI < 3 bulan 85 - 200 3 bln 2 thn 100 - 190 3 10 tahun 60 -140 Copyright 2007 Seattle/King County EMS Normal Bood Pressure for children Age Systolic BP 0 28 day FT > 60 1 12 mo > 70 1 10 y 70 + 2 x age in y > 10 y > 90 35 Pulse In infants, feel over the brachial or femoral area. In older children, use the carotid artery.
Count for at least 1 minute. Note strength of the pulse. Copyright 2007 Seattle/King County EMS STATUS NEUROLOGIK Copyright 2007 Seattle/King County EMS A ALERT V RESPONS TO VOICE P RESPONS TO PAIN U UN RESPONSIVE A V P U CARA CEPAT MENILAI KESADARAN Copyright 2007 Seattle/King County EMS TINDAKAN LANJUT MENERUSKAN RESUSITASI PEMERIKSAAN /PEMANTAUAN LEBIH LANJUT MERUJUK Copyright 2007 Seattle/King County EMS Respiratory Emergencies Respiratory distress is a state where a child is able to maintain adequate oxygenation of the blood, but only by increasing his or her work of breathing.
Respiratory failure occurs when a child cannot compensate for inadequate oxygenation and the circulatory and respiratory systems begin to collapse.
Copyright 2007 Seattle/King County EMS Airway Obstruction Croup A viral infection of the airway below the level of the vocal cords Epiglottitis Infection of the soft tissue in the area above the vocal cords Foreign body airway obstructions Copyright 2007 Seattle/King County EMS Seizures Seizures may be caused by: Infection Head trauma Epilepsy Electrolyte imbalance Hypoglycemia Toxic ingestion or exposure Birth injury
Copyright 2007 Seattle/King County EMS Trauma Use appearance, work of breathing and circulation to the skin in your assessment.
Mechanism of injury may also play a factor when deciding whether the child is SICK or NOT SICK. Copyright 2007 Seattle/King County EMS Drowning The most important factors in drowning are the duration and severity of hypoxia.
Restoring the ABCs is vital.
Hypothermia can occur in cold water settings. Copyright 2007 Seattle/King County EMS Burns Check for possible involvement of the airway.
Make a quick estimate of the burned body surface area.
Take care to avoid further contamination of burn injuries by wearing gloves and carefully dressing the wounds. Copyright 2007 Seattle/King County EMS 47 Copyright 2007 Seattle/King County EMS For the purpose of resuscitation, children are divided -somewhat arbitrarily- into 3 age groups:
Infants: under one year of age Small children: 1 to 8 years of age Older children/adults: 9 years and over Basic Life Support Slide 49 S A F E approach Copyright 2007 Seattle/King County EMS Shout for help Aprroach with care Free from danger Evaluate ABC Copyright 2007 Seattle/King County EMS Basic Life Support Check for DANGER, stop and look Check RESPONSE, verbal and tactile but do not shake and shout If conscious, assess carefully, patient may still need urgent medical review
Continue to assess and manage Airway Breathing Circulation
Slide 52 D R A B C Slide 53 Basic Life Support Flowchart Check for DANGER Check for RESPONSE CONSCIOUS Make comfortable Observe ABC UNCONSCIOUS Alert assistance Clear airway Apply head tilt and jaw support Check for breathing NOT BREATHING 2 rescue breaths Check for pulse Look for signs of life BREATHING Lateral position Observe ABC INADEQUATE PULSE No signs of life Commence CPR Copyright 2007 Seattle/King County EMS Is The patient able to speak or cry ?
Copyright 2007 Seattle/King County EMS Airway Assessment Copyright 2007 Seattle/King County EMS Slide 56 Observe for secretions and clear (suction) Do not attempt a blind finger sweep Open the airway chin lift / jaw thrust neutral position in infants sniffing position in children
Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Slide 61 Airway Opening Manoeuvres Chin lift/head tilt Infants Neutral head position with chin lift Smaller children Sniffing position with chin lift Copyright 2007 Seattle/King County EMS Slide 62 Airway Opening Manoeuvres Chin lift/head tilt
Older children/adults Backward head tilt with pistol grip Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Slide 65 Airway Opening Manoeuvres Jaw thrust Jaw thrust Use when concerned re cervical spine injury May also facilitate bag and mask ventilation Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Slide 67 Foreign Body Mild airway obstruction Effective Cough Assess Severity Severe airway obstruction Ineffective Cough Unconscious Call for help Commence CPR Conscious Call for help Give up to 5 back blows If not effective Give up to 5 chest thrusts Encourage coughing Continue to check victim until recovery or deterioration Call for help Copyright 2007 Seattle/King County EMS Slide 68 Foreign Body If there is an effective cough (mild obstruction): Encourage coughing Continue to check victim until recovery or deterioration Call for help Do not attempt any manoeuvres to remove unless this is very easily done
Copyright 2007 Seattle/King County EMS Slide 69 Foreign Body If there is an ineffective cough (severe obstruction): Unconscious call for help, commence CPR Conscious call for help give up to 5 back blows firm blows between the shoulder blades using the heel of the hand Copyright 2007 Seattle/King County EMS Slide 70 Back blows infant
Back blows small child Copyright 2007 Seattle/King County EMS Slide 71 Chest thrusts infant Chest thrusts small child Hand position is lower half of the sternum Copyright 2007 Seattle/King County EMS Slide 72 Foreign Body If 5 back blows unsuccessful:
Chest thrusts identify same compression point as for CPR give up to 5 chest thrusts similar to compressions but sharper and delivered at a slower rate check to see if each thrust has relieved the airway obstruction
Infant place in a head down supine position across rescuers thigh
Child/ older child / adult may be placed in sitting or standing position Note: this is not the same as a Heimlich manouvere this manouvere is on the chest Copyright 2007 Seattle/King County EMS Airway Adjuncts Copyright 2007 Seattle/King County EMS Slide 74 Oropharyngeal Airways
Use: to keep the airway open in an unconscious patient and to facilitate bag and mask ventilation Use with caution
If airway is able to be maintained with head positioning and jaw support dont use an oropharyngeal airway
Copyright 2007 Seattle/King County EMS Slide 75 Oropharyngeal Airways
Use: to keep the airway open in an unconscious patient and to facilitate bag and mask ventilation Use of oropharyngeal airways:
size is imperative measure from centre of teeth/mouth to angle of the jaw layed across the face In the infant and small child insert the concave side over the tongue under direct vision. This avoids damage to the palate
Copyright 2007 Seattle/King County EMS Slide 76 Oropharyngeal Airways
Potential problems: Trauma Obstruction Illicit a gag reflex causing aspiration Laryngospasm Vagal response Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Nasopharyngeal Airway Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Evaluation of Respiratory Performance Copyright 2007 Seattle/King County EMS Slide 86 Look, Listen & Feel 10 seconds Copyright 2007 Seattle/King County EMS Breathing assessment Respiratory Rate and Regularity Level of Consciousness Color of the Skin and Mucous Membranes Respiratory Mechanics
Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS The Need for Oxygen 0 1 minute: cardiac irritability 0 4 minutes: brain damage not likely 4 6 minutes: brain damage possible 6 10 minutes: brain damage very likely > 10 minutes: irreversible brain damage
Initial assesment of the sick child Breathing No efective breathin g Airway Maintain able Un maintain able Bag mask ventil ation NIPP V Intub ation s oxyge n Airway adjunc t Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Simple mask Copyright 2007 Seattle/King County EMS partial rebreathing mask low flow nasal cannula. simple oxygen mask. high flow:
nonrebreathing masks. Venturi masks. oxygen hoods oxygen tents. Copyright 2007 Seattle/King County EMS aspirationfsh.swf Copyright 2007 Seattle/King County EMS Slide 99 Breathing If breathing is absent or inadequate: Give 2 rescue breaths allowing about 1 second per inspiration Sufficient breath to achieve gentle rise and fall of chest, this means puffs for an infant breaths for a child full breaths for an older child/adult Copyright 2007 Seattle/King County EMS Slide 100 Bag and Mask Correct mask size: cover mouth and nose only Holding the mask: C-grip C Slide 101 Bag and Mask a few technicalities... Mask size Bridge of nose to cleft of chin and sufficiently wide to cover mouth If too big you may get an air leak and also potential damage especially with pressure applied to the eyes Self inflating bag Connect to oxygen 10L/Min Once reservoir bag full, delivering 95-100% oxygen Pressure release valve prevents too high pressure Self-inflating, so can be used to deliver room air Slide 102 Self Inflating Bag Sizes
Child (500ml) 2.5 25kg
Preterm Infant (240ml) <2.5kg Adult (1600ml) >25kg Copyright 2007 Seattle/King County EMS Slide 103 Checking Self Inflating Bags Check that the self inflating bag compresses and reinflates quickly and air is felt from patient outlet Check the one way valve opens when self inflating bag is compressed Occlude patient outlet with hand and compress bag, listen for the pressure release value to release Take off oxygen reservoir bag and place over the patient outlet. Inflate the reservoir bag checking for holes Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Bag mask ventilation
Copyright 2007 Seattle/King County EMS Bag to Mask Ventilation Slide 107 Cricoid pressure: Place two fingers on the level of the cricoid cartilage and apply pressure (gently!) Closes the oesophagus and straightens trachea Dont release pressure until instructed or if the patient actively vomits Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Monitor the Effectiveness of Ventilation Monitor the Effectiveness of Ventilation Visible chest rise with each breath. Oxygen saturation. Heart rate. Blood pressure. Distal air entry. Patient response. Copyright 2000 American Heart Association Circulation 2000;102:253I--290I- Bag-mask ventilation for child victim Contraindicated if gag-reflex is intact
Higher success rate
Does NOT protect from aspiration
Difficult to maintain during transport Copyright 2007 Seattle/King County EMS Slide 119 Basic Life Support Airway
Breathing
Circulation Color of skin and capillary refill Strength of peripheral and central pulses Skin temperature Obtain vascular access (set IV lines) Initiate volume replacement Perform chest compressions Defibrillate or provide synchronized cardioversion Initiate drug therapy Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS PULSE Check Take no more than 10 seconds Cardiac output in infancy and childhood largely depends on heart rate. No scientific data has identified an absolute heart rate at which chest compressions should be initiated; the recommendation to provide cardiac compression for a heart rate <60 bpm with signs of poor perfusion Copyright 2007 Seattle/King County EMS Slide 126 Pulse Check the smallprint Do not check for longer than 10 seconds If the patient shows no sign of life and a pulse cannot be palpated in 10 seconds presume it to be absent!
Brachial is recommended in the infant as carotid pulse is difficult to find and extension of the neck may compromise the airway Carotid pulse locate thyroid cartilage and feel to side, dont feel too high due to the risk of inadvertently massaging the carotid sinus, inducing bradycardia and hypotension
Locating and palpating carotid artery pulse ( > 1 year) Locating and palpating brachial pulse ( < 1 year) 127 Copyright 2007 Seattle/King County EMS Slide 128 Look for signs of life
No signs of life = unconscious unresponsive not moving not breathing normally No signs of life commence external cardiac compressions
Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Slide 131 Circulation Assess for pulse and signs of life
If no pulse, inadequate pulse or no signs of life
commence ECC CPR of the pediatric patient 132 PIJAT JANTUNG LUAR Copyright 2007 Seattle/King County EMS If no pulse palpated, begin chest compression 134 Copyright 2007 Seattle/King County EMS Slide 135
Patient should be on a hard surface eg. cardiac board Rhythmic action, equal time for compression and relaxation Aim for a rate of 100 compressions per minute Copyright 2007 Seattle/King County EMS Slide 136 CPR Ratio CIRCULATION Hand Position Depth of Compression INFANT 1/3 depth of chest OLDER CHILD
30 compressions: 2 breaths 5 cycles / 2 min
SMALL CHILD Lower half of sternum Ratio and Rate 1 rescuer The ratio describes the number of compressions in relation to breaths, the rate is the number of compressions/breaths given per minute. Ratio and Rate 2 rescuers 15: 2 5 cycles/min 30: 2 5 cycles/2 min Copyright 2007 Seattle/King County EMS Slide 137 CPR Infant Infant Locate the lower half of the sternum Two fingers one operator CPR Two thumbs / two fingers if two operators Ratio Lone health care provider/ lay rescuer 30 compressions : 2 breaths (5 cycles per 2 minute) Two health care providers 15 compressions : 2 breaths (5 cycles per 1 minute) Aim for a rate of 100 compressions per minute Copyright 2007 Seattle/King County EMS Slide 138 CPR Infant Finger/Thumb position: lower 1/2 of the sternum
Compression depth: 1/3 of the depth of the chest Copyright 2007 Seattle/King County EMS Slide 139 CPR Ratio CIRCULATION Hand Position Depth of Compression INFANT 1/3 depth of chest OLDER CHILD
30 compressions: 2 breaths 5 cycles / 2 min
SMALL CHILD Lower half of sternum Ratio and Rate 1 rescuer Ratio and Rate 2 rescuers 15: 2 5 cycles/min 30: 2 5 cycles/2 min Copyright 2007 Seattle/King County EMS Slide 140 CPR Small Child Child: Up to 8 years Use the heel of one hand Locate lower half of sternum Ratio Lone health care provider/ lay rescuer 30 compressions : 2 breaths (5 cycles per 2 minute) Two health care providers 15 compressions : 2 breaths (5 cycles per 1 minute) Aim for a rate of 100 compressions per minute
Copyright 2007 Seattle/King County EMS Slide 141 CPR Ratio CIRCULATION Hand Position Depth of Compression INFANT 1/3 depth of chest OLDER CHILD
30 compressions: 2 breaths 5 cycles / 2 min
SMALL CHILD Lower half of sternum Ratio and Rate 1 rescuer Ratio and Rate 2 rescuers 15: 2 5 cycles/min 30: 2 5 cycles/2 min Copyright 2007 Seattle/King County EMS Slide 142 CPR Older Child/Adult Older child/adult i.e.>9years Use two hands Locate lower half of sternum Ratio: Lone health care provider/ lay rescuer or two health care providers 30 compressions : 2 breaths (5 cycles per 2 minute) Aim for a rate of 100 compressions per minute Pressure is exerted through the heel of the hand, with arm/s straight, using body weight as the compression force Copyright 2007 Seattle/King County EMS Slide 143 CPR (Small and older child) Compression depth: 1/3 of chest CPR older child/ adult 1/3 CPR small child Copyright 2007 Seattle/King County EMS Slide 144 CPR ARC recommend minimum interruptions of ECC and CPR should not be interrupted to check for signs of life Ineffective CPR: too gentle too slow incorrect hand position too many interruptions Copyright 2007 Seattle/King County EMS Locating finger position for chest compressions in infant (< 1 year) Imagine a line drawn between the nipples Place 2 fingers on sternum 1 fingers width below line. Depress - 1 in. At least 100 per min 1 breath to every 5 compressions 145 Copyright 2007 Seattle/King County EMS Locating hand position for chest compressions in child (> 1 year) Use 2-3 fingers to locate lower margin of rib cage. Follow rib margin to base of sternum (xiphoid process) Over 8 yr Place other hand on top of hand on sternum Depress 1 - 2 in 80-100 per min 2 breaths to every 15 compressions 146 Copyright 2007 Seattle/King County EMS 1 ~ 8 yr Use heel of one hand Depress 1 1 in 100 per min One-rescuer 1 breath to every 5 compressions Two-rescuer 2 breaths to every 15 compressions 147 Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2000 American Heart Association Circulation 2000;102:253I--290I- Brachial pulse check in infant Copyright 2007 Seattle/King County EMS Copyright 2000 American Heart Association Circulation 2000;102:253I--290I- Carotid pulse check in child Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Circulation 2000;102:253I--290I- One-hand chest compression technique in child Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS After each compression allow the chest to recoil fully because complete chest reexpansion improves blood flow into the heart Copyright 2007 Seattle/King County EMS Copyright 2007 Seattle/King County EMS Slide 159 Can you identify 10 Things wrong with this resus? Copyright 2007 Seattle/King County EMS Slide 160 1. Incorrect size bag & mask
Copyright 2007 Seattle/King County EMS Slide 161 1. Incorrect size bag & mask 2. Incorrect mask & bag technique
Copyright 2007 Seattle/King County EMS Slide 162 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board Copyright 2007 Seattle/King County EMS Slide 163 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way Copyright 2007 Seattle/King County EMS Slide 164 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way 5. Monitor not on or connected Copyright 2007 Seattle/King County EMS Slide 165 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way 5. Monitor not on or connected 6. Incorrect pad placement
Copyright 2007 Seattle/King County EMS Slide 166 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way 5. Monitor not on or connected 6. Incorrect pad placement 7. Incorrect hand placement
Copyright 2007 Seattle/King County EMS Slide 167 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way 5. Monitor not on or connected 6. Incorrect pad placement 7. Incorrect hand placement 8. No scribe
Copyright 2007 Seattle/King County EMS Slide 168 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way 5. Monitor not on or connected 6. Incorrect pad placement 7. Incorrect hand placement 8. No scribe 9. No drugs prepared
? Copyright 2007 Seattle/King County EMS Slide 169 1. Incorrect size bag & mask 2. Incorrect mask & bag technique 3. No cardiac board 4. Chair in way 5. Monitor not on or connected 6. Incorrect pad placement 7. Incorrect hand placement 8. No scribe 9. No drugs prepared 10.No oxygen tubing Copyright 2007 Seattle/King County EMS