Pediatric Critical Care

Elaine Reyes-Madamba, M.D.

Case #1

A 10 year old female from Muntinlupa came in to the ER for 3 days history of
bloody diarrhea and vomiting with associated fever and loss of appetite

On PE, (+) lethargic, BP 7-/30 HR 146 bpm RR 30 Temp 40 thready pulses, cold
clammy extremities

A problem well-defined is a problem half-solved

Shock

Definition:
Acute, complex state of circulatory dysfunction
Results in failure to deliver sufficient amounts of oxygen to meet tissue
metabolic demands
If prolonged, lead to multi-organ failure or death

Early diagnosis

Knowledge of underlying disease

Delivery of Oxygen
Dependent on

Cardiac output

Arterial oxygen content

Cardiac output HR x SV
Stages of Shock
1.
Compensated Shock
Vital organ function maintained by intrinsic regulatory mechanisms
2.
Uncompensated Shock
Cardiovascular systems ability to maintain perfusion in inadequate
3.
Irreversible Shock
Significant damage to key organs that death occurs despite therapeutic
response
Recognition and Assessment of Shock

Skin

Mucous membranes

Nailbeds

Pulse

Vital Signs

Sensorium

Respiration Urine

Blood pressure

CVP Metabolic acidosis

Hypoxemia
Types of Shock
1.
Hypovolemic
2.
Cardiogenic
3.
Distributive
4.
Septic
5.
Anaphylactic
Goals of Therapy

Optimize and maintain oxygen delivery

Normal O2 saturations, correct anemia, increase CO
Adequate renal output
Correct acidosis

Treatment of underlying process

Hypovolemic Shock

Acute loss of 25% or more needs immediate management

10-15% acute intravascular volume depletion is well tolerated

Etiologies of Hypovolemic Shock

Acute blood loss

External bleeding

Internal bleeding
GIT vessel injury
Intracranial
Fracture
Plasma loss

Burns

Capillary leak

Protein losing
Fluid and electrolyte loss

By: Rem Alfelor

Diarrhea
Diuretics
Endocrine

Cardiogenic Shock

Rhythm abnormalities

Cardiomyopathy/ Carditis
Hypoxic/ ischemic events
Infections
Metabolic
Connective tissue
Toxic reaction
Tachydysrrythmia
Other

Congenital heart

Trauma
Principles of Management

Airway

Breathing

Circulation
Isotonic solution: 20 ml/kg initial bolus
Endpoint: increase BP, tissue perfusion, urine output
Diagnostic Tools

Lab work-up

Complete Blood Count

Serum electrolytes

BUN, Creatinine

Arterial Blood Gas

Imaging

Chest X-ray

Echocardiography

Electrocardiography

CT-Scan
Therapy

Cardiogenic Shock
Decrease myocardial demand
Increase myocardial performance

Distributive Shock
Misdistribution of blood flow/ vasopressors
Anaphylaxis, spinal anesthesia, etc.
Reverse etiology, vigorous fluid management

Septic Shock
Sepsis with hypotension despite adequate fluid resuscitation along with
perfusion abnormalities/ interplay of various factors
Identify and control infection and rapid reversal of cardiovascular
dysfunction

Nutrition
Dengue Shock Syndrome

Symptoms
Fever for 2-7 days
Positive tourniquet test
Signs of bleeding
Thrombocytopenia
Prolonged BT, PTT evidence of circulatory failure

Caused by dengue virus 1-4

Pathophysiology
Capillary membrane leak leading to decreased intravascular volume
Normal BP Compensated Shock
Total body water may be normal

Principles of Therapy
Immediate assessment of cardio-respiratory system and degree of
electrolytes, acid-base and hemoconcentration
ABCs of resuscitation
In shock, isotonic solutions 0 20 ml/kg rapid infusion
FFP/ cryoprecipitate
Avoid large volumes of dextrose containing solutions
Burn Injuries

Skin can tolerate up to 42-44 C

45 C protein desaturation

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1st degree burn epithelium involved

Pain, redness
No scar
2nd degree burn
Superficial or deep partial thickness
Third degree burn Full thickness
Does not blister
Black, brown or leathery
Painless
4th degree burn extends to subjacent tissues
Disfigurement

Burn Injuries

Mild (<10%)

Moderate (10-30%)

Severe (>30%)

Hospitalization required if >10% burns or when face, hand, feet and genitalia
involved

Almost all burns in children occur at home during waking hours

Major causes of thermal burns

Hot liquids/ solids
Volatile flammable liquids

Scalding major cause of morbidity <3 years old

Zone of coagulation most intimately in contact with the heat source

Zone of Stasis concentric area of lesser tissue damage

Zone of hyperemia borders unaffected tissue; minimal injury and recovers 710 days
Therapy

ABCs

When in doubt intubate!

Rapid assessment of extent of injury

20 cc/kg isotonic solutions, if in shock

Insert NGT, Foley catheter

Estimate weight of patient, examine wound; tetanus toxoid given

Near-Drowning

Drowning death from suffocation by submersion in water

Near-Drowning survival even if temporary after asphyxia with no aspiration

Dry-Drowning. Drowning without aspiration Dying from asphyxia with no

aspiration

Secondary Drowning delayed onset of pulmonary insufficiency after neardrowning

Epidemiology
Peak incidence

Less than 5 years old

15-19 years old

Males more than females
Bathtub drowning for infants and children with seizure disorder

Pathophysiology
Functional Residual Capacity I the only source of gas exchange in the
submerged state
10-15% with laryngospasm leading to Dry Drowning and Asphyxia
Aspiration of 1-3 cc/kg leads to impairment of gas exchange

Management
Aggressive and Basic life support at the scene
Major determinant of survival is management o hypoxia and acidosis
Positive Pressure Ventilation with the highest possible oxygen
concentration
Isotonic fluids if in shock
Maintenance fluids with appropriate electrolyte contents if stable
Check for other injuries
Child abuse?
Need for hospitalization is determined by the severity of submersion and
clinical evaluation
Observe for 4-6 hours
Admission for abnormal ABG, hypoxemia, altered sensorium and distress
Definitions

Sepsis
Evidence of infection + systemic response elevated temperature,
tachycardia, increased respiration, leukocytosis or an impaired peripheral
leukocyte response and / or the presence of immature band forms in the
peripheral circulation

By: Rem Alfelor

Sepsis Syndrome
Sepsis with evidence of altered organ, perfusion and at least one of the
following: hypoxemia, elevated lactate concentration, oliguria, altered
mentation
Septic Shock
Refers to sepsis syndrome + hypotension despite adequate fluid
resuscitation

Signs and symptoms suggesting a systemic bacterial infection as the cause of sepsis
Primary

Fever
Chills
Hyperventilation *
Skin lesions
Change in mental status

Secondary
Hypotension
Bleeding
Leukopenia
Thrombocytopenia
Organ Failure:
Lung cyanosis, acidosis
Kidney oliguria, anuria, acidosis
Liver - jaundice
Heart congestive failure

Clinical Manifestations

Cutaneous manifestations can be seen with bacterial, viral, fugal or parasitic

processes
Skin lesions most commonly found in Ps. Aeruginosa bacteremia:
ECTHYMA GANGRENOSUM

Also in Aeromones hydrophia

Petechiae or purpura: Neisseria meningitidis
Hemorrhagic or bullous lesion after intake of raw meat

Generalized Erythroderma: Toxic Shock Syndrome from S. aureus or S.

pyogenes
Difficult to distinguish from cellulitis
May be useful to aspirate leading edge of the lesion
Etiology

Bacterial infections are the most common cause of septic shock

Gram-negative Septic Shock

Compress of total cases of sepsis, accounts for majority of

sepsis-related deaths
Gram-positive Septic Shock

Increasing incidence due to association with pneumonia, use of

intravascular devices

Fungal, viral pathogens can also cause septic shock but less common
Diagnosis

Laboratory test assist in the diagnosis

CBC with differential count, CRP, urinalysis, coagulation profiles, glucose,
BUN, creatinine, electrolytes, liver function tests, lactic acid level, ABG,
ECG, chest X-ray
Cultures: do not need to be positive (growths found in 30-50% of patients)
Elevation in the serum concentration of procalcitonin (PCT) is associated
with systemic infection novel biomarker of bacterial sepsis

Published evidence does not support PCT as a useful decision

support tool

Procalcitonin has a slightly better ability to exclude the diagnosis of

sepsis

Patients at increased risk of developing sepsis

Underlying disease: neutropenia, solid tumors, leukemia,
dysproteinemias, liver cirrhosis, diabetes, AIDS, serious chronic
conditions
Surgery or instrumentation: catheters
Prior drug therapy: Immunosuppressive drugs, broad-spectrum
antibiotics
Age
Miscellaneous conditions: childbirth, septic abortion, trauma and
widespread burns, intestinal ulceration
Adjunctive measures for treatment

Rationale:
Treatment can be complicated by a compromised immune system
resulting from an underlying disease or its treatment may be helpful to
enhance immune system activity

Dampening of immune response may also be beneficial to modulate

effect of inflammatory cytokines

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Since products are expensive, cost-effectiveness are an important

determinant of use

Anaphylaxis

Potentially fatal multisystem syndrome resulting from massive release of

inflammatory mediators from mast cells and basophils

Epidemiology
True incidence of anaphylaxis in unknown
Estimate of the risk of anaphylaxis per person in US is <1-3%
Occurs in all age groups but I more common in adults due to increased
time for exposure and sensitization

Patterns
1.
Acute explosives onset within seconds to minutes of exposure to
triggering event
2.
Biphasic followed by a reaction 3-8 hours after initial reaction (5-20% of
cases)
3.
Protracted lasts 3-21 days from onset of acute reaction

Fatal

The Allergy Cascade

Allergic Reactions

Etiologic and Pathophysiologic Classification of Anaphylaxis and Anaphylactoid

Reaction in Children

Anaphylaxis IgE mediated reaction

Drugs
Food
Insect bite
Latex
Some causes of exercise
Exercise-induced food-dependent exercise-induced
Food
Insect bite
Latex
Some causes of exercise
exerciseinduced
food-dependent exercise-induced

Clinical manifestations
The sign and symptom are highly variable and can range from mild
cutaneous symptoms to a fatal reaction
Reaction begins within seconds or minutes after exposure to the allergen
Initial fright or sense of impending doom

Criteria for Rapid Recognition

1.
Exposure to an allergen within 1 hour and systemic sign
2.
Urticaria or angioedema and 1 systemic sign

Systemic signs:
Hypotension
Bronchospasm or dyspnea
Laryngeal/pharyngeal edema, stridor or dysphonia

By: Rem Alfelor

Increased gastrointestinal tract motility

Occurs in <2% of patients with anaphylaxis

Most common etiology in children is food allergy
Anaphylaxis due to drug allergy increases with age
A history of asthma is a risk factor due to its greater reactivity to mediators
released

e.g. Histamine, Leukotrienes and Prostaglandins

Failure to administer Epinephrine of lack of Epinephrine seen in 90-100%
cases
Laboratory Findings
Immediate emergency treatment should never be delayed pending results
of laboratory studies
Elevated plasma histamine
Elevated serum tryptase longer half-life
Treatment
Epinephrine is the drug of choice
Potent catecholamine with both and adrenergic properties
Reverses all pathophysiologic features of anaphylaxis

: hypotension peripheral vasodilation, increased vasopermeability,

urticaria, angioedema

: positive inotropic and chronotropic effects, bronchodilation,

increases cAMP
Epinephrine 1:1000 0.01 ml/kg SC/IM 9ped) or 0.3 0.5 ml (adult) given q
20
Patient on blockers may be resistant to epinephrine so higher doses
may be required or glucagon given
Inspect sting or injected drug: infiltrate 0.1-0.2 ml locally to retard
absorption of the residual allergen
Tourniquet applied proximally if injection or sting is on an extremity
Therapeutic Principles
Immediate Therapy

Rapid ABCs of resuscitation

Epinephrine IV (1:100,000) = 0.01 mg/kg or continuous drip 0.1-0.2

g/kg/min

Separate IV line: no HCO3 infusion

Continuous monitoring of CVS status and O2

Rapid Hx of triggering event, current medications, Hx of asthma,

allergies and concomitant medical conditions
Subacute

H1 blocker Diphenhydramine 1-2 mg/kg, PO, IM, IV

Chlorpheniramine 10-20 mg IV/IM

Corticosteroids Hydrocortisone 4-0 mg/kg glucose or

methylprednisolone 102 mg/kg hr q 6 hrs

B2 agonist: nebulization q 20 mins continuously

Fluids los up to 50% intravascular volume may occur resulting in
profound hypotension not responsive to epinephrine
Antihistamines are not appropriate maintenance for the treatment of acute
anaphylaxis
Corticosteroids are used to prevent the biphasic responses and to control
bronchospasm
Bronchodilators are useful adjunct in tx group in those with asthma
Disposition
If still symptomatic admit for further treatment
If unstable V.S. laryngeal edema or refractory bronchospasm admit ICU
If the reactive with no biphasic response, discharge on 72 hours of
antihistamine, oral CS and inhaled 2 agonist
Discuss allergen trigger and evidence
Follow up with allergist
Complications
Permanent brain damage hypoxia
Myocardial infarction
Abortion (for pregnant woman)
Renal failure

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