Resuscitation: Care of the seriously unwell child

PIC Endorsed

Given the current low prevalence of COVID-19 in Australia (May 2020), particularly in children, resuscitation of children should be as per usual protocols. For children in whom COVID-19 is suspected or confirmed , see Resuscitation (COVID) . Individual State policies should be followed.

Key points

Commence immediate resuscitation if there are signs of hypoxia and/or shock to prevent progression to cardiorespiratory arrest
Effective resuscitation relies on an cohesive team with not only knowledge and skills, but good communication and teamwork
Consider early referral to specialised paediatric/retrieval service

Background

This CPG is for seriously unwell children, it does not cover trauma and seriously injured children, neonates or children in cardiorespiratory arrest

Assessment and Management

Call early for help within your hospital and to local paediatric retrieval service as necessary

Reactive resuscitation of seriously unwell children includes assessment and prompt management in parallel

Early allocation of roles can optimise resuscitation (if personnel available). Suggested roles:

Team leader
Airway nurse and doctor
Circulation nurse and doctor
Primary survey doctor
Scribe and timekeeper with a stopwatch
Staff member dedicated to family support

Approach to Assessment and Management

Assessment	Clinical Features	Management	Links
Airway
Patency Look, Listen feel Added noises	Chest wall recession Abdominal breathing Hoarse voice Drooling Stridor Stertor	Keep child calm (e.g. hands off approach, caregiver present, distraction techniques) Optimise head position to achieve patent airway Continue child’s adopted posture < 1y neutral position >1y sniffing position Consider suction Simple airway manoeuvre Head tilt Chin lift Jaw thrust Insert oropharyngeal airway Insert nasopharyngeal airway (contraindicated facial/base of skull fracture) Oxygen if hypoxic Consider PEEP in upper airway obstruction	Acute upper airway obstruction Croup Inhaled foreign body Emergency airway management Resuscitation: Hospital management of cardiopulmonary arrest Appendices: airway manoeuvre
Breathing
Chest rise and fall SpO2 Respiratory rate Effort of breathing Effect of breathing Accessory muscle use Efficacy of ventilation Effect on other organ systems (HR, conscious state)	Tachypnoea Desaturation Cyanosis (not when crying) Agitated Limited ability to talk Increased work of breathing Use of accessory muscles: intercostal, subcostal or suprasternal recession, abdominal breathing, nasal flare, head bob, tracheal tug, forward posture Respiratory noises (wheeze, grunting, crepitations) Reduced chest expansion Reduced air entry Secondary signs of inadequate oxygenation: tachy or bradycardia, colour change (pale or blue), cool peripheries, altered mental state	If the child is not breathing, commence artificial ventilation Consider elevating head of the bed Oxygen 15L/min non rebreather mask Non-invasive ventilation High flow nasal canulae CPAP BiPAP Do not use self-inflating bags in spontaneously ventilating patients, they are designed to deliver O₂ only if squeezed Emergency airway management T-piece/neopuff may be used to administer PEEP	Assessment and severity of respiratory conditions Asthma Bronchiolitis Pneumonia Resuscitation: Hospital management of cardiopulmonary arrest Continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV)
Circulation
Efficacy of circulation Heart rate Blood pressure Capillary Refill Time	Tachycardia, bradycardia Arrhythmia Narrow pulse pressure Hypotension (hypotension is a late and preterminal sign) *ensure correct cuff size Delayed capillary refill Flash capillary refill Poor peripheral perfusion Reduced pulse volume Secondary signs: tachypnoea (especially if no increased work of breathing) or bradypnoea; altered conscious state; colour change (pallor or cyanosis)	If there are no signs of circulation (no pulse, slow pulse <60 or you are not sure) commence external cardiac compressions Determine cardiac rhythm and treat accordingly 2 large bore intravenous cannulas Insert intraosseous cannula if unable to gain IV promptly Fluid resuscitation Fluid Bolus 10-20ml/kg Sodium chloride (NaCl) 0.9% (up to 40ml/kg) Consider sepsis Consider inotropes/vasopressor Correct electrolytes	Intravenous fluids Intraosseous Access Supraventricular Tachycardia Sepsis Antibiotic Febrile Neutropenia Febrile child guideline Blood product Resuscitation: Hospital management of cardiopulmonary arrest Hypokalaemia Hyperkalaemia
Disability
Altered conscious state AVPU/GCS	Irritable lethargic AVPU/modified GCS/GCS Pupil reflexes Focal motor deficit Seizure activity Toxin exposure	Blood gas (capillary, venous, arterial) Hypoglycaemia (also perform bedside ketone for hyperketonaemia) Hypo, hypernatraemia Hypocalcaemia Consider Brain injury Stroke Meningitis/Encephalitis Shunt complication Manage seizures	Hypoglycaemia Hyponatraemia Hypernatraemia Seizure Afebrile Seizure Febrile NAI Stroke Meningitis and encephalitis
Exposure
Assess child fully Temperature	Hypo/hyperthermia Rash, petechiae, purpura	Correct hypothermia Pain management	Acute pain management

Important considerations

Cardiac dysfunction & pericardial effusion (consider transthoracic echocardiogram)
Coagulopathy
Non accidental injury

Post resuscitation care

Refer to and obtain phone advice early from local specialised paediatric service
Review history and examine thoroughly
Reassess regularly to monitor progress
Maintain oxygenation and ventilation
Aim normal systolic blood pressure, urine output, glucose, electrolytes, temperature
Monitor for end organ damage
Consider analgesia and sedation
Counsel family regularly

Family members of patients undergoing resuscitation should be given the option to be present, ideally with an assigned support person.

Regardless of the outcome resuscitation is stressful and can be psychologically traumatic to team members providing care. Debriefing should be offered to all involved staff who wish to attend.

Consider Consultation with local paediatric team when:

Any child requiring resuscitation

Consider transfer when:

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, call Retrieval Services .

Additional Resources:

Neonatal Handbook

APLS algorithms
Acceptable Ranges for Physiological Variables
Emergency Drug and Fluid Calculator
Monash Hospital Paediatric Emergency Medication Book
Withholding or Withdrawal of Life-Sustaining Treatment
Basic Life Supporting Training
ID badge size Resuscitation Card

Resuscitation – Appendices

Parent information

Kids Health Info
Febrile seizures
Fever in children

Last Updated May 2020

Reference List

Australia APLS. Advanced Paediatric life Support Algorithms [Internet]. APLS. 2019 [cited 2019 Nov 18]. Available from: https://apls.org.au/page/algorithms.

Council AR. Paediatric Advanced Life Support Guidelines [Internet]. ARC. 2019 [cited 2019 Nov 18]. Available from: https://resus.org.au/guidelines

Craig S. THE PAEDIATRIC EMERGENCY MEDICATION BOOK [Internet]. Monash Children’s Hospital. 2019. Available from: https://monashchildrenshospital.org/for-health-professionals/resources/resuscitation/

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines