Managing a child with cardiac instabilityManaging a child with cardiac instability
ผศ.นพ.สรวุฒิ พงศโรจนเผานพ.ชัยสิทธิ์ แสงทวีสิน
นพ.สรศักดิ์ โลหจินดารัตน
รูปที่ 1 Pathway to pediatric cardiac arrest
Precipitating ConditionsRespritatory Circulatory Sudden Cardiac
(Arrhythmia)
RespiratoryDistress
Shock
RespiratoryFailure
Cardiopulmonary Failure
Cardiac Arrest
Outcome of Respiratory Outcome of Respiratory vsvs Cardiopulmonary Cardiopulmonary Arrest in ChildrenArrest in Children
0
10
20
30
40
50
60
70
80
90
Respiratory Cardiopulmonary
Percentage of RecoverPercentage of Recover
Case PresentationCase Presentationเด็กหญิงไทย อายุ 2 ป 2 เดือน ภูมิลําเนา บางคอแหลม กทม.
ประวัติจากบิดามารดา เชื่อถือได
CC. Progressive dyspnea for 1 week
How to approach the seriously ill patient as How to approach the seriously ill patient as
this girl ?this girl ?
รูปที่รูปที่ 22 Approach the seriously ill patient by the method of: Approach the seriously ill patient by the method of:
AssessAssess--CategorizeCategorize--DecideDecide--Act Act
Assess
Categorize
Decide
Act
ตารางที่ 1 ขั้นตอนในการประเมินอาการ ( Assess ) ผูปวยเด็กภาวะวิกฤต
Clinical Assessment Brief Description
General assessment
(Pediatric assessment
Triangle: PAT)
A rapid visual and auditory assessment of the child’s overall
appearance, work of breathing, and circulation completed
within the first seconds of patient encounter
Primary assessment A rapid, hands-on ABCDE approach to evaluate
cardiopulmonary and neurologic function; this step
includes assessment of vital signs and pulse oximetry
Secondary assessment A focused medical history using the SAMPLE mnemonic
and a thorough head-to-toe physical exam
Tertiary assessment Laboratory, radiographic, and other advanced tests that help to
establish the child’s physiologic condition and diagnosis
ตารางที่ 3 The general assessment using the pediatric assessment triangle (PAT)
PAT General Assessment
Appearance Muscle tone, interaction, consolability, look/gaze, or
speech/cry
Work of Breathing Increased work of breathing (eg, nasal flaring, retractions),
decreased or absent respiratory effort, or abnormal sounds
(eg, wheezing, grunting, stridor)
Circulation Abnormal skin color (eg, pallor or motting) or bleeding
Primary assessmentPrimary assessment
-- AAirwayirway
-- BBreathingreathing
-- CCirculationirculation
-- DDisability: isability: neurologicneurologic statusstatus
-- EExposure: PExposure: PE
-- handshands--on evaluation on evaluation
-- assess cardiopulmonary & assess cardiopulmonary & neurologicneurologic functionfunction
-- include : VS, SpOinclude : VS, SpO22
ตารางที่ 5 Normal Respiratory Rates by Age3
Age Breaths per Minutes
Infant (<1 year) 30 to 6060
Toddler (1 to 3 years) 24 to 40
Preschooler (4 to 5 years) 22 to 34
School age (6 to 12 years) 18 to 30
Adolescent (13 to 18 years) 12 to 16
CirculationCirculationIncludes evaluation of1) Cardiovascular function
- skin color & temp- HR- rhythm- BP- pulses (peripheral & central)- capillary refill time
2) End-organ function- brain perfusion (mental status)- skin perfusion- renal perfusion (urine output)
ตารางที่ 7 Normal Heart Rates (per Minute) by Age
Age Awake Rate Mean Sleeping Rate
Newborn to 3 months 85 to 205 140 80 to 160
3 months to 2 years 100 to 190 130 75 to 160
2 years to 10 years 60 to 140 80 60 to 90
>10 years 60 to 100 75 50 to 90
Modified from: Hazinski3 and Gillete6
Basic Relationships of Cardiovascular Basic Relationships of Cardiovascular ParameterParameter
PreloadPreload
MyocardialMyocardialcontractilitycontractility
AfterloadAfterload
Stroke volumeStroke volume
Heart rateHeart rate
Cardiac outputCardiac output
Systemic vascular resistanceSystemic vascular resistance
BloodBloodpressurepressure
Cardiac outputCardiac output
Systemic vascular resistanceSystemic vascular resistance
ตารางที่ 9 Definition of Hypotension by Systolic Blood Pressure and Age
Age Systolic Blood Pressure (mm Hg)
Term neonates
(0 to 28 days)
< 60
Infants
(1 to 12 month)
<70
Children
1 to 10 years
5th BP percentile
<70+ (age in years x 2)
Children
>10 years
<90
Capillary RefillCapillary Refill
• Normal capillary refill < 2 seconds in a warm environment
MottledMottled
ตารางที่ 10 Normal urine output in well-hydrated infants, young children,
older children, and adolescents
Age Normal Urine Output
Infants and young
children
1.5 to 2 mL/kg per hour
Older children and
adolescents
1 mL/kg per hour
ตารางที่ 13 The SAMPLE mnemonic for secondary assessment to identify important
aspects of the child’s history and presenting compliant by focus on history and PE.
Signs and Symptoms Signs and symptoms at onset of illness, such as
Breathing difficulty (eg, cough, rapid breathing, increased
respiratory effort, breathlessness, abnormal breathing pattern,
chest pain on deep inhalation)
Altered level of consciousness
Agitation, anxiety
Fever
Decreased oral intake
Diarrhea, vomiting
Bleeding
Fatigue
Time course of symptoms
Allergies Medications, foods, latex, etc
Medications Medications
Last dose and time of recent medications
Past medical history Health history (eg, premature birth)
Significant underlying medical problems (eg, asthma,
congenital heart disease, seizures, head injury, brain
tumor, diabetes, hydrocephalus, neuromuscular disease)
Past surgeries
Immunization status
Last meal Time and nature of last liquid or food (including breast
or bottle feeding in infants)
Events Events leading to current illness or injury (eg, onset
sudden or gradual, type of injury)
Hazards at scene
Treatment during interval from onset of disease or injury
until your evaluation
Estimated time of arrival (if out-of-hospital onset)
ตารางที่ 13 The SAMPLE mnemonic for secondary assessment to identify important
aspects of the child’s history and presenting compliant by focus on history and PE.
Case PresentationCase Presentationเด็กหญิงไทย อายุ 2 ป 2 เดือน ภูมิลําเนา บางคอแหลม กทม.
ประวัติจากบิดามารดา เชื่อถือไดCC. Progressive dyspnea for 1 weekPI. 2 weeks PTA ไขสูง ไอมาก หอบไปโรงพยาบาลใกล
บาน แพทยตรวจเลือด X-ray บอกวา ปอดบวม พนยา ฉีดยาให ไดยามา 4 ชนิด และนัดไปฉีดยาทุกวัน
1 week PTA ไขหายไป ไอลดลง แตสังเกตวาเด็กเหนื่อยเพิ่มขึ้น กินนมนอยลง พาไปโรงพยาบาลเดิมอีกครั้ง แพทยบอกวาเปน หลอดลมอักเสบ เพิ่มยาใหอีก 1 ชนิด เหนื่อยไมลดลง จึงพามาโรงพยาบาลนี้
Case Presentation (2)Case Presentation (2)
PH. บุตรคนเดียว คลอดรพ.ใกลบาน แรกเกิด 3300 กรัม แข็งแรงดีมาตลอด
กินทุกอยางไมเลือก ขาว 3 มื้อ นมครั้งละ 4 ออนซวันละ 2 ครั้ง พัฒนาการสมวัย
ทั้งบิดา มารดาอายุ 24 ป แข็งแรงดี อยูกัน 3 ครอบครัว 8 คนในบาน
Case Presentation (3)Case Presentation (3)
PE. Alert, active, dyspneaT 37.0°C, RR 52/min, BP 90/66 mmHg, HR
150/minNot pale, no jaundice, no conjunctival
injectionPharynx and tonsils – not injected
Case Presentation (4)Case Presentation (4)
Chest – equal chest movement, subcostalretraction, rhonchi both lungs
Heart – hyperactive precordium,no murmurAbdomen – liver 6 cm below right costal
marginExtremities – no edemaNeuro – normal muscle power, reflex 2+ allSkin – no rash
Positive finding from AssessmentPositive finding from Assessment
•• General assessment : irritableGeneral assessment : irritable
dyspneadyspnea, , subcostalsubcostal retractionretraction
no central cyanosisno central cyanosis
•• Primary assessment : increased RR (>40/min)Primary assessment : increased RR (>40/min)
subcostalsubcostal retractionretraction
increased HR ( >140/min)increased HR ( >140/min)
poor peripheral pulsepoor peripheral pulse
cap refill < 2 sec.cap refill < 2 sec.
•• Secondary assessment:Secondary assessment:
SS&S: Heart; hyperactive &S: Heart; hyperactive precordiumprecordium
Lung; Lung; rhonchirhonchi, , subcostalsubcostal retractionretraction
AbdAbd; liver 6 cm>RCM; liver 6 cm>RCM
AA: no: no
MM: antibiotic and bronchodilator : antibiotic and bronchodilator
PP: no: no
LL: 3 hrs: 3 hrs
EE: Rx as pneumonia for 2 wks: Rx as pneumonia for 2 wks
with antibiotic and bronchodilator with antibiotic and bronchodilator
Positive finding from AssessmentPositive finding from Assessment
Tertiary assessment of circulatory abnormalitiesTertiary assessment of circulatory abnormalities
Lab studies- ABG- central venous oxygen saturation (Svo2) - total serum CO2
- arterial lactateNonlab studies
- ABP monitor- CVP monitor- CXR- ECG- Echocardiography