Pediatric Critical Care Division,

Child Health Department Sanglah

Hospital, Faculty of Medicine University
of Udayana

Introduction
Children's bodies respond to
significant injury and shock
differently than adults.
These differences may be subtle
and difficult to recognize.
providers
providers must
must recognize
recognize these
these
differences
differences in
in order
order to
to provide
provide the
the best
best
possible
possible care
care for
for an
an ill
ill or
or injured
injured child.
child.

childs anatomy differs in four

significant ways from an adults. They
are:
Smaller airways
Less blood volume
Bigger heads
Vulnerable internal organs

smaller
smaller airway
airway

Large tongue in
relation to a small
oropharynx
Diameter of the
trachea is smaller
Trachea is not rigid and
will collapse easily
Back of the head is
rounder and requires
careful positioning to
keep airway open

smaller
smaller airway
airway
less
less blood
blood
volume
volume

Relatively smaller
blood volume
Approximately 70 cc of
blood for every 1kg (2
lbs) of body weight
A 20 lb child has about
700cc of bloodabout
the volume of a
medium sized soda
cup

smaller
smaller airway
airway
less
less blood
blood
volume
volume
bigger
bigger heads
heads

Head size is
proportionally larger
Prominent occiput and
a relatively straight
cervical spine
Neck and associated
support structures
arent well developed
Infants and small
children are prone to
falling because they
are top heavy

smaller
smaller airway
airway
less
less blood
blood
volume
volume
bigger
bigger heads
heads
internal
internal organs
organs

Internal organs are not

well protected
Soft bones and
cartilage and lack of
fat in the rib cage
make internal organs
susceptible to
significant internal
injuries
Injury can occur with
very little mechanism
or obvious signs

Infant:

1 to 12 months

Active extremity movement

Tracks object with eyes
Obstruction of the nose may cause
respiratory distress
Separation anxiety later in this
period
Provide sensory comfort such as a
warm stethoscope
Explain procedures in very simple

Toddler:

1 to 3 years

Approach slowly & limit physical

contact
Most have stranger anxiety
Sit down or squat next to and use a
quiet voice
Not good at describing or localizing
pain
Use play and distraction objects
Have caregiver hold

Preschool

Age: 3 to 5 years

Explain procedures in simple terms

Use games or distractions
Set limits on behaviors
Praise good behavior
Offer a stuffed animal or toy to hold
Do not allow to handle equipment

School

Age: 6 to 12 years

Speak directly to the child

Be careful not to offer too much
information
Explain procedures immediately before
carrying them out
Dont negotiate unless the child really
has a choice
Keep conversation with child to a
minimum

Adolescent:

12 to 15 years

Explain what you are doing and why

Show respect
Get history from patient if possible
Respect independence; address
directly
Allow parents to be involved in
examination if patient wishes
Consider asking questions about sexual
activity, drug/alcohol use privately

CNS
Respiratory
Cardiovascular
Gastrointestinal
Endocrine
Etc

ing
at h
Br e

ea
ra

of

Ap
p

rk
Wo

nc
e

The PAT

Circulation to Skin

Respiratory distress

Shock

N
Primary CNS
dysfunction/
metabolic abnormality

Cardiopulmonary
failure

Airway
Breathing
Circulation
Disability
Exposure

A state in which there is inadequate

tissue perfusion to meet metabolic
demands
It is not LOW BLOOD PRESSURE !!!
It is HYPOPERFUSION..

COMPENSATED
blood flow is normal or increased and may be
maldistributed; vital organ function is maintained
UNCOMPENSATED
microvascular perfusion is compromised;
significant reductions in effective circulating
volume
IRREVERSIBLE
inadequate perfusion of vital organs; irreparable
damage; death cannot be prevented

Hypovolemic or
Hemorrhagic
Cardiogenic
Obstructive
Distributive

Neurological: fluctuating mental status,

sunken fontanel
Cardio-pulmonary: tachypnea, tachycardia
Skin and extremities: cool, pallor, mottling,
cyanosis, poor cap refill, weak pulses
Renal: scant, concentrated urine

Always begin with ABCs

Airway: must be patent, adequately
oxygenated and ventilated
Breathing: always provide suplemental
oxygen
Circulation: vascular access, volume
expansion

Mainstay of therapy is fluid

Fluid challenge
Fluid loading
Fluid replacement
Fluid maintenance

Isotonic crystalloid is always a good choice

20 to 50 cc/kg rapidly if cardiac function
is normal
Degree of dehydration often
underestimated
Reassess perfusion, urine output, vital
signs

Treat underlying cause

Correct acidosis
Inotropic and vasoactive drugs: select to
optimized desire effect

 The impaired ability of the

respiratory system to maintain
adequate oxygen and carbon
dioxide homeostasis

 Two main categories:

Ventilation

Oxygenation

Removal of waste CO2

Transfer of O2 from air in blood

 Acute hypoxemic (Type I):

pneumoni
Ventilatory (Type II): asthma

 Specific treatment vary according to

the underlying cause
Corrected hypoxemia
Reduced load on the respiratory
muscle
Optimized ventilatory pump capacity

 Administration of supplemental
oxygen
Acute hypoxaemic or mixed respiratory
failure
Simple mask, nasal cannulae, Venturi mask,
mask with rebreathing bag, oxygen tents
Physiological effects of oxygen therapy
Oxygen toxicity

Control of secretion
Hydration

 Control of secretion

Mucolytic agents
Chest physiotherapy
Tracheal intubation and tracheostomy
Respiratory stimulants

Control of infection
Treatment of airways obstruction
-stimulants, ipratropium bromide,
steroids

 Control of lung water

Optimizing ventilatory pump
capacity
Malnutrition, catabolism, immobility,
metabolic disturbance

Mechanical ventilatory support

Seizure : transient, involuntary alteration of

consciousness, behavior, motor activity,
sensation, and/or autonomic function
caused by an excessive rate and
hypersynchrony of discharges from a group
of cerebral neurons

Convulsion : seizure with prominent

alterations of motor activity

 Ensure airway patency

Jaw thrust, suctioning of the

oropharynx, use of adjunctive

airways
BREATHING
(oral or nasopharyngeal)
Considered intubation : hypoxia,
CIRCULATION
hypoventilation, GCS < 8
Supplemental oxygen provided and
respiration assisted as needed

 Established intravena access or

intraosseous
Hypotension or dehydration
isotonoic fluid resuscitation
BREATHING
Hypoglycemia dextrose
intravenously
CIRCULATION
Electrolyte abnormalities replaced
appropirately

Prehospital

Hospital/ED

ABC

Diazepam 5-10 mg per rectal, max 2x, interval 5 mnt

0-10 min

Diazepam 0.25-0.5 mg/kg iv/io, max dose 20 mg,

rate 5mg/min

10-20 min

OR
Midazolam 0,2 mg/kg iv bolus
OR
Lorazepam 0,5-1 mg/kg iv, rate < 2mg/min

ICU/ED

Phenytoin 15-20 mg/kg iv, max 30 mg/kg,

rate 20 min/50 ml NS

20-30 min

Phenobarbitone 20 mg/kg iv, max 1000 mg,

rate >5-10 min (100mg/min)

30-60 min

Additional 5-10 mg/kg iv

Additional 5-10 mg/kg iv

ICU/ED

Midazolam 0.2-0.5 mg/kg iv bolus,

followed by infusion 0.05-4 ,cg/kg/min

Refracter

Pentotal 10-15 mg/kg iv then

2-5 mg/kg q 5 min to stop seizure,
followed by infusion 1-3 mg/kg/hr
Tiopental 5 mg/kg iv then
1-2 mg/kg q 5 min to stop seizure,
followed by infusion 3-5 mg/kg/hr

Propofol 2-5 mg/kg iv, followed by

Infusion 25-65 mcg/kg/min

Statler KD. Status epilepticus. 2007

Komisi Resusitasi Pediatrik. Konvulsi. 2006