the child with circulatory probelms
DESCRIPTION
Presentation to ACT Ambulance ServiceTRANSCRIPT
Jamie Ranse: Critical Care Education Coordinator, Staff Development Unit, ACT Health.
THE CHILD WITH CIRCULATORY PROBLEMS
• Differences in children• Circulatory assessment
– General– Dehydration
• Management of circulatory alterations• DVD of circulatory assessment• Case study
overview
• Myocardium• Compensation• Body water• Surface area• Venous access
differences in children
• Less compliant • Has less contractile tissue• Significance:
– CO = HR x SV– Tachycardia– Other signs of shock rapid venous access
differences in children:myocardium
• Normotensive until 25% of their blood volume is lost– Circulating volume– Hypotension late / sudden sign of decompensation
differences in children:compensation
• 60% of body weight of an adolescent• 65% of the preschooler• 80% of the infant• Is distributed between two body compartments
– Intraceullular – Extracellular
differences in children:body water
• Intracellular fluid compartment• Extracellular fluid compartments
– Intravascular– Interstitial– Transcellular
• CSF• Synovial• Pleural
differences in children:body water
differences in children:body water
• Larger surface area / volume ratio• Significance:
– Greater risk of dehydration– Maintenance fluid requirements higher
differences in children:surface area
• Intraosseous cannulation threshold
differences in children:venous access
• Myocardium• Body water• Metabolic rate• Distribution of body fluids• Surface area• Venous access• Immature renal function• Rely on others to give them fluid
summary
• Observation• Palpation• (Percussion)• Auscultation
circulatory assessment:general
• Observe– Skin colour– Work of breathing– Mental status– Hydration status
• Palpation– Pulse characteristics– Capillary refill – Blood pressure
• Auscultation– Chest / heart
circulatory assessment:general
Broad categories• Hypovolaemic• Cardiogenic• Distributive• Obstructive
circulatory assessment:general
Hypovolaemia• Hypovolaemia most common cause of shock in
children• Gastroenteritis most common cause of
hypovolaemia in children
circulatory assessment:general
• Dehydration results from– Reduced intake– Increased fluid loss– Excessive renal loss– From skin and respiratory systems
circulatory assessment:hydration status
• Steiner et al 2003– Prolonged CR – Abnormal skin turgor– Abnormal breathing
• Useful clinical signs include– Cool pale peripheries
& prolonged CR– Decreased skin turgor– Deep breathing– Increased thirst
circulatory assessment:hydration status
circulatory assessment:hydration status – estimating deficit
Mild 3% Reduced urine output
Thirst
Dry mucous membranes
Mild tachycardia
Moderate 5% Dry mucous membranes
Tachycardia
Abnormal respiratory pattern
Lethargy
Reduced skin turgor
Sunken eyes
Severe 10% As above plus
Poor perfusion (mottled, slow CR, altered LOC)
Shock (poor perfusion, weak pulses, tachycardia)
Broad categories
management of circulatory alterations
management of circulatory alterations
• Calculation of fluid replacement– 10mls/kg isotonic solution
• Calculation of fluid maintenance– TKVO – 10mls/hr
• IV / IO
management of circulatory alterations
DVD of circulatory assessment
1010: Called to an infant with 3/7 history of diarrhoea
1015: On arrival 6/12 ♀ named Mary:A: clear and open
B: dyspnoeic
C: skin pale
D: awake and interactive
case study
1020: During your initial examination, you notice Mary’s condition deteriorate…
A: clear
B: ↑ effort, ↑ efficacy
C: sunken fontanel and eyes, poor peripheral circulation, dry mucous membranes, doughy skin, cyanosed
D: flaccid, no response to stimuli, fixed stare
case study
• What are Mary’s problems?• What else do we need to know to assist her?
case study
• Foetal problem – nil• Illnesses / injuries since birth – nil • Immunisation status – fully immunised for her age• Developmental status – normal for her age• Allergies – nil • Events leading up to your arrival
– 3/7 history of diarrhoea – No oral intake for previous 12/24– Unknown urine output
case study
• Observe– Skin colour– Work of breathing– Mental status
• Palpation– Pulse rate v heart rate– Capillary refill – Blood pressure
• Auscultation– Chest / heart
case study: your circulatory assessment
Jamie Ranse: Critical Care Education Coordinator, Staff Development Unit, ACT Health.
THE CHILD WITH CIRCULATORY PROBLEMS