Basic Guide to Suturing

A seriously ill child that requires critical interventions is fortunately enough a rare event (even in urban settings). Children unlike adults however can typically not compensate for as long and require active management (that feeling of going fine than falling off a cliff) which can be particularly challenging in a rural setting. Secondly, there are the issues involving; anatomical & physiological differences in children, weight-based fluid and mediation requirements, different equipment and potentially increased difficulty in performing procedures. All of this can up our fear levels and add to potentially ineffective management when it is required.

Below is an simplistic approach to the seriously ill child. It is very general, but designed to give you a fall back point when it gets stressful. For disease/illness specific approaches take at look at the Royal Children's Hospital Clinical Guidelines or consider doing an Advanced Paediatric Life Support course.

Neonatal resuscitation is a separate entity and will be covered at a later time.

This is part of the Rural Emergency Module series (designed in particular for ACRRM Trainees).

Approach

  1. Preparation
  2. Recognition and First Snapshot
  3. Primary Assessment & concurrent Resuscitative Management
  4. Secondary Assessment & ongoing Emergency Treatment
  5. Stabilisation and transfer to definitive care

Preparation

Given the relative rarity and the angst around treating an unwell child in Rural Environments, preparation is key in trying to achieve the best outcomes. Rural sites can prepare by ensuring processes and checklists are in place, appropriate paediatric equipment (e.g. Non-invasive high-flow oxygen), streamlined referral and telehealth options, education and regularly conducting in-house simulations.

The remainder of section will focus on how to prepare when you know a sick child is coming to your emergency department. For resuscitation preparation think P A E D S.

P eople
A rea
  • This is typically your resuscitation area in rural facilities, preferably one that has tele-health capacities.
E quipment
D rugs
S end for Help
  • External help (Paediatricians, Intensivists), Retrieval Services

Recognition & First Snapshot



Primary Assessment

The aim of the primary assessment in seriously ill children and infants is to identify the physiological abnormalities, and initiate the most appropriate management strategy to correct these abnormalities.

Airway and Breathing
Circulation
Disability
Exposure
Effort of breathing
Heart rate
Conscious level
Fever
Respiratory rate
and rhythm
Pulse volume
Posture
Rash
Stridor / wheeze
Capillary refill
Pupils
Bruising
Auscultation
Skin temperature
Skin colour

Airway

Children are respiratory creatures.
Assess Patency
Vocalisations

Airway anatomical challenges
  • 2 big: head, tongue
  • 2 small: narrow easily blocked nasal airways, narrow cricoid,
  • 2 short: airway (depth = 3 x ett), time to desaturation (less reserve)
  • 2 tall: epiglotis/floppy, think tall (prepare, pep talk, pee)

Should aim to: Resuscitate before you intubate (if maintaining oxygenation & ventilation)

Breathing

Respiratory Rate
Work of Breathing: Sounds & HOUNDS
Chest Auscultation
Pulse oximetry (check waveform as well)

Ciruclation

Heart Rate, Pulse Volume & Blood Pressure
  • Bradycardia and/or hypotension are OMINOUS, LATE SIGNS.
  • Stroke volume small and fixed in infants, CO more dependant on HR. SV has a greater role with age.
  • Comparing peripheral and central pulse volume may provide help with early detection.
PCPC (pallor, delayed cap refill, petechiae, cyanosis, mottling)
Think End organ perfusion: e.g. skin temperature, altered mental state, urine output.

Features Suggestive of Cardiac Failure
  • Cyanosis, not correcting with O2 therapy.
  • Tachycardia out of proportion to respiratory difficulty
  • Raised JVP
  • Gallop rhythm/murmur
  • Hepatomegaly
  • Absent femoral pulses

Cold shock = adrenaline (children typically)
Warm shock = noradrenaline

Disability

In Paediatric Emergencies AVPU provides a quick a succinct method to gauge level of consciousness.
  • A lert
  • V oice
  • P ain
  • U nresponsive

An age appropriate Paediatric-modified GCS could be calculated at a later date.

Posture
  • Most children with a serious illness are floppy
  • Stiff posturing suggests severe brain dysfunction

Pupils
Convulsions
BSL

Exposure

Swift head to toe observation of the child. Formal head-toe examination, should be part of your Secondary Assessment.

Temperature
  • Check for fever
  • Maintain Normothermia. Infants lose heat faster.
Rashes
Bruising

Fluid Status

Hydration Status
Moderate dehydration (4-6%)   
 Severe dehydration (>/= 7%)
  •  Delayed CRT
    (Central Capillary Refill Time) > 2 secs
  • Increased respiratory rate
  • Mild decreased tissue turgor
  • Very delayed CRT > 3 secs, mottled skin
  • Other signs of shock (tachycardia, irritable or reduced conscious level, hypotension)
  • Deep, acidotic breathing
  • Decreased tissue turgor
Inputs/Outputs
Think about what has gone into the child in terms of fluid (whether oral, IV or other) and what has and will be lost (e.g. diarrhoea, vomiting).

Secondary Assessment

See Approach to the Seriously Ill Child - part 2 (still to come).

Stabilisation and Transfer to Definitive Care

See Approach to the Seriously Ill Child - part 2 (still to come).

Advanced Life Support

Hopefully with early detection and management you avoid your patient having a Cardiac Arrest. But there is always a possible that they will or that's how they will arrive. Below is a flowchart summarizing the principles of Paediatric Advanced Life Support.

For more details see the Australian Resuscitation Council Guidelines at resus.org.au/guidelines.

Further Resources & References

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