ADVANCED PAEDIATRIC LIFE SUPPORT - part 1 ppsx

LIFE SUPPORT The Practical Approach Third edition Advanced Life Support Group BMJ Books... ADVANCED PAEDIATRIC LIFE SUPPORTThe Practical Approach Third edition Advanced Life Support Grou

LIFE SUPPORT

The Practical Approach

Third edition Advanced Life Support Group

BMJ Books

ADVANCED PAEDIATRIC LIFE SUPPORT

The Practical Approach

Third edition

Advanced Life Support Group

Edited by Kevin Mackway-Jones Elizabeth Molyneux Barbara Phillips Susan Wieteska

© BMJ Books 1997, 2001 BMJ Books is an imprint of the BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR

www.bmjbooks.com All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means electronic, mechanical, photocopying, recording, and, or otherwise, without the prior written permission of the Advanced Life

Support Group.

First published in 1993 by the BMJ Publishing Group

Reprinted 1994 Reprinted 1995 Reprinted 1996 Second edition 1997 Reprinted 1998 Reprinted with revisions 1998 Reprinted 1999 Reprinted 2000 Third edition 2001

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 0-7279-1554-1

Typeset in Great Britain by FiSHBooks, London Printed and bound by Selwood Printing Ltd, Burgess Hill, West Sussex

Contact Details and Website Information xvi

PART IV: THE SERIOUSLY INJURED CHILD

Chapter 15 The structured approach to the seriously injured child 161

Chapter 19 The child with injuries to the extremities or the spine 191

WORKING GROUP

K Mackway-Jones Emergency Medicine, Manchester

E Molyneux Paediatric Emergency Medicine, Malawi

P Oakley Anaesthesia/Trauma, Stoke on Trent

B Phillips Paediatric Emergency Medicine, Liverpool and Manchester

K Williams Paediatric Emergency Nursing, Liverpool

S Young Paediatric Emergency Medicine, Melbourne

P Baines Paediatric Intensive Care, Liverpool

D Bickerstaff Paediatric Orthopaedics, Sheffield

P Brennan Paediatric Emergency Medicine, Sheffield

J Couriel Paediatric Respiratory Medicine, Liverpool

D Heaf Paediatric Respiratory Medicine, Liverpool

E Ladusans Paediatric Cardiology, Manchester

J Leggatte Paediatric Neurosurgery, Manchester

CONTRIBUTORS

S Levene Child Accident Prevention Trust, London

K Mackway-Jones Emergency Medicine, Manchester

T Martland Paediatric Neurologist, Manchester

E Molyneux Paediatric Emergency Medicine, Malawi

B Phillips Paediatric Emergency Medicine, Manchester and Liverpool

J Robson Paediatric Emergency Medicine, Liverpool

J Tibballs Paediatric Intensive Care, Melbourne

W Whitehouse Paediatric Neurologist, Birmingham

S Young Paediatric Emergency Medicine, Melbourne

CONTRIBUTORS

x

PREFACE TO THIRD EDITION

Since this book was first published in 1993, the Advanced Paediatric Life Support(APLS) concept and courses have gone a great way towards their aim of bringing simpleguidelines for the management of ill and injured children to front-line doctors andnurses

Over the years an increasing number of experts have contributed to the work and weextend our thanks both to them and also to our instructors who unceasingly providehelpful feedback The Advanced Paediatric Life Support Course is now well established

in several countries outside the United Kingdom These include Australia, NewZealand, the Netherlands, Portugal and South Africa APLS is also the recommendedpaediatric course for the European Resuscitation Council Furthermore, material fromAPLS is being successfully used in countries with under-resourced health care systemssuch as Bosnia-Herzegovina, Malawi and Uganda

A small “family” of courses have developed from APLS in response to differenttraining needs One is the Paediatric Life Support (PLS) course, a one-day locallydelivered course designed for doctors and nurses who have only subsidiaryresponsibility for seriously ill or injured children (see note, page xvi) Another is Pre-Hospital Paediatric Life Support (PHPLS), which has its own textbook and is for thepre-hospital provider

Readers will find significant changes in the third edition The chapters onresuscitation and the management of arrhythmias have been informed by the newInternational Guidelines, produced by an evidence-based process from thecollaboration of many international experts under the umbrella of the InternationalLiaison Committee on Resuscitation (ILCOR) The chapters on serious illness havebeen rewritten both to include new knowledge and practice and also to reflect theproblem-based approach used in teaching In addition there are some new chapters

In the past the editors have been criticised for the decision not to include in the textthe many references which support its assertions We have not changed this now – buthave harnessed the power of the World Wide Web to allow us (and you the reader, thecandidate and the instructor) to keep the evidence available and up to date Log on to

www.bestbets.org to see how far we have got and how you can help.

KMJEMBPSWManchester 2001

PREFACE TO THE FIRST EDITION

Advanced Paediatric Life Support: The Practical Approach was written to improve the

emergency care of children, and has been developed by a number of paediatricians,paediatric surgeons, emergency physicians, and anaesthetists from several UK centres

It is the core text for the APLS (UK) course, and will also be of value to medical andallied personnel unable to attend the course It is designed to include all the commonemergencies, and also covers a number of less common diagnoses that are amenable togood initial treatment The remit is the first hour of care, because it is during this timethat the subsequent course of the child is set

The book is divided into six parts Part I introduces the subject by discussing thecauses of childhood emergencies, the reasons why children need to be treated differently,and the ways in which a seriously ill child can be recognised quickly Part II deals withthe techniques of life support Both basic and advanced techniques are covered, and there

is a separate section on resuscitation of the newborn Part III deals with children whopresent with serious illness Shock is dealt with in detail, because recognition andtreatment can be particularly difficult Cardiac and respiratory emergencies, and comaand convulsions, are also discussed Part IV concentrates on the child who has beenseriously injured Injury is the most common cause of death in the 1–14 year age groupand the importance of this topic cannot be overemphasised Part V gives practicalguidance on performing the procedures mentioned elsewhere in the text Finally, Part VI(the Appendices) deals with other areas of importance

Emergencies in children generate a great deal of anxiety – in the child, the parents, and

in the medical and nursing staff who have to deal with them We hope that this book willshed some light on the subject of paediatric emergency care, and that it will raise thestandard of paediatric life support An understanding of the contents will allow doctors,nurses, and paramedics dealing with seriously ill and injured children to approach theircare with confidence

Kevin Mackway-JonesElizabeth MolyneuxBarbara PhillipsSusan Wieteska

(Editorial Board)

1993

A great many people have put a lot of hard work into the production of this book, andthe accompanying advanced life support course The editors would like to thank all thecontributors for their efforts and all the APLS instructors who took the time to sendtheir comments on the first and second editions to us

We are greatly indebted to Helen Carruthers MMAA and Mary Harrison MMAA forproducing the excellent line drawings that illustrate the text Thanks to the BritishPaediatric Neurology Group for the status epilecticus protocol and the Child’s GlasgowComa Scale

Finally, we would like to thank, in advance, those of you who will attend the AdvancedPaediatric Life Support course and other courses using this text; no doubt, you will havemuch constructive criticism to offer

CONTACT DETAILS AND WEBSITE INFORMATION

ALSG: www.aslg.org

Best bets: www.bestbets.org

For details on ALSG courses visit the website or contact:

Advanced Life Support Group

Second Floor, The Dock Office

Clinicians practising in tropical and under-resourced health care systems are advised to

read A Manual for International Child Health Care (0 7279 1476 6) published by BMJ

Books which gives details of additional relevant illnesses not included in this text

NOTE

Sections with the grey marginal tint are relevant for the Paediatric Life Support (PLS)Course

xvi

I I I

INTRODUCTION

I 1 I

Introduction

CAUSES OF DEATH IN CHILDHOOD

As can be seen from Table 1.1, the greatest mortality during childhood occurs in thefirst year of life with the highest death rate of all happening in the first month

Table 1.1 Number of deaths by age group

The rate for under ones is per 1 000 population and for over ones per 100 000 population England and Wales, 1991 and 1998 Office of National Statistics (ONS) Australia 1998

The causes of death vary with age as shown in Table 1.2 In the newborn period themost common causes are congenital abnormalities and factors associated withprematurity, such as respiratory immaturity, cerebral haemorrhage, and infection due toimmaturity of the immune response

From 1 month to 1 year of age the condition known as “cot death” is the mostcommon cause of death Some victims of this condition have previously unrecognisedrespiratory or metabolic disease, but some have no specific cause of death found atdetailed postmortem examination This latter group is described as suffering from thesudden infant death syndrome There has been a striking reduction in the incidence

of the sudden infant death syndrome over the last few years in the UK, Holland,Australia and New Zealand In England and Wales the decrease has been from 1597

in 1988 to 454 in 1994 and to 239 in 1998 The reduction has followed nationalcampaigns to inform parents of known risk factors such as the prone sleeping position

in the infant and parental smoking The next most common causes in this age groupare congenital abnormalities and infections (Table 1.2)

Number of deaths (rate) Age group 1991 (E&W) 1998 (E&W) 1998 (Australia) 0–28 days 3052 (4·4) 24189 (3·8) 842 (5·02) 4–52 weeks 2106 (3·0) 1207 (1·9) 410 1–4 years 993 (36) 722 (28) 347 5–14 years 1165 (19) 897 (13) 376 1–14 years 2158 (24) 1619 (17) 723 (19·7)

Table 1.2 Common causes of death by age group

England and Wales, 1998, ONS.

*Numbers in parentheses are the percentage.

After 1 year of age trauma is the most frequent cause of death, and remains so untilwell into adult life Deaths from trauma have been described as falling into three groups

In the first group there is overwhelming damage at the time of trauma, and the injurycaused is incompatible with life; children with such massive injuries will die withinminutes whatever is done Those in the second group die because of progressiverespiratory failure, circulatory insufficiency, or raised intracranial pressure secondary tothe effects of injury; death occurs within a few hours if no treatment is administered,but may be avoided if treatment is prompt and effective The final group consists of latedeaths due to raised intracranial pressure, infection or multiple organ failure.Appropriate management in the first few hours will decrease mortality in this groupalso The trimodal distribution of trauma deaths is illustrated in Figure 1.1

Figure 1.1 Trimodal distribution of deaths from trauma

Only a minority of childhood deaths, such as those due to unresponsive end-stageneoplastic disease, are expected and “managed” Most children with potentially fataldiseases such as complex congenital heart disease, inborn errors of metabolism, orcystic fibrosis are treated or “cured” by operation, diet, transplant or, soon, even genetherapy The approach to these children is to treat vigorously incidental illnesses (such

as respiratory infections) to which many are especially prone Therefore, some childrenpresenting to hospital with serious life-threatening acute illness also have an underlyingchronic disease

PATHWAYS LEADING TO CARDIORESPIRATORY ARREST

Cardiac arrest in infancy and childhood is rarely due to primary cardiac disease This

is different from the adult situation where the primary arrest is often cardiac, andcardiorespiratory function may remain near normal until the moment of arrest InINTRODUCTION

4

Number of deaths* at Cause 4–52 weeks 1–4 years 5–14 years

Congenital abnormality 285 (24) 102 (14) 66 (7) Infection 228 (19) 69 (10) 35 (4)

Minutes

by some poisons or during convulsions Raised intracranial pressure (ICP) due to headinjury or acute encephalopathy eventually leads to respiratory arrest, but severe neuronaldamage has already been sustained before the arrest occurs.

Whatever the cause, by the time of cardiac arrest the child has had a period ofrespiratory insufficiency which will have caused hypoxia and respiratory acidosis Thecombination of hypoxia and acidosis causes cell damage and death (particularly in moresensitive organs such as the brain, liver, and kidney), before myocardial damage issevere enough to cause cardiac arrest

Most other cardiac arrests are secondary to circulatory failure (shock) This will haveresulted often from fluid or blood loss, or from fluid maldistribution within thecirculatory system The former may be due to gastroenteritis, burns, or trauma whilstthe latter is often caused by sepsis or anaphylaxis As all organs are deprived of essentialnutrients and oxygen as shock progresses to cardiac arrest, circulatory failure, likerespiratory failure, causes tissue hypoxia and acidosis In fact, both pathways mayoccur in the same condition The pathways leading to cardiac arrest in children aresummarised in Figure 1.2

The worst outcome is in children who have had an out-of-hospital arrest and whoarrive apnoeic and pulseless These children have a poor chance of intact neurologicalsurvival There has often been a prolonged period of hypoxia and ischaemia before thestart of adequate cardiopulmonary resuscitation Earlier recognition of seriously illchildren and paediatric cardiopulmonary resuscitation training for the public couldimprove the outcome for these children

Septic shock Cardiac disease Anaphylaxis

RESPIRATORY DISTRESS

Foreign body Croup Asthma

RESPIRATORY DEPRESSION

Convulsions Raised ICP Poisoning

CIRCULATORY

FAILURE

RESPIRATORY FAILURE

CARDIAC ARREST

Figure 1.2. Pathways leading to cardiac arrest in childhood (with examples of underlying causes)

The most obvious reason for treating children differently is their size, and its variationwith age

Weight

The most rapid changes in size occur in the first year of life An average birth weight

of 3·5 kg has increased to 10·3 kg by the age of 1 year After that time weight increasesmore slowly until the pubertal growth spurt This is illustrated in the weight chart forboys shown in Figure 2.1

As most therapies are given as the dose per kilogram, it is important to get some idea of

a child’s weight as soon as possible In the emergency situation this is especially difficultbecause it is often impracticable to weigh the child.To overcome this problem a number ofmethods can be used to derive a weight estimate If the age is known the formula:

Weight (kg) = 2 (Age + 4)can be used if the child is aged between 1 and 10 years old In addition various charts(such as the Oakley chart) are available which allow an approximation of weight to bederived from the age Finally, the Broselow tape (which relates weight to height) can beused Whatever the method, it is essential that the carer is sufficiently familiar with it to

be able to use it quickly and accurately