Urgencias Pediátricas Ricardo L. Sánchez, M.D., M.P.H. Jefe de Urgencias, Saint Francis Hospital Profesor Asistente, Traumatología y Urgencias Universidad de Connecticut HONDURAS- Mayo 24, 2002

Tres amplios temas: Evaluacion cardiorespiratoria rápida Intervenciones de urgencia Conceptos y datos sobre Fiebre

Evaluación Cardiorespiratoria Rápida 3/23/2017 Evaluación Cardiorespiratoria Rápida Reconocimiento de la falla respiratoria y del shock © 2001 American Heart Association y amigos Slide 1: Rapid Cardiopulmonary Assessment: Recognition of Respiratory Failure and Shock Assessment and management of the seriously ill or injured child begins with rapid cardiopulmonary assessment. This assessment is designed to quickly identify potential or actual respiratory failure and shock. Rapid cardiopulmonary assessment is the foundation of pediatric advanced life support because once respiratory failure or shock is identified, the provider can plan appropriate intervention to improve patient outcome. 1

Progresión por falla respiratoria y shock 3/23/2017 Progresión por falla respiratoria y shock Patología primaria Falla Respiratoria Shock Optional Slide 3: Progression of Respiratory Failure and Shock to Cardiopulmonary Failure and Arrest In infants and children a variety of conditions (such as airway obstruction, trauma, toxic ingestion, or sepsis) may ultimately cause cardiopulmonary failure and cardiopulmonary arrest. These conditions typically produce either respiratory failure, shock, or a combination of the two and can lead to cardiopulmonary failure if not promptly and adequately treated. Falla cardiorespiratoria Paro cardiorespiratorio

Sobrevivencia al paro Tasa de Sobrevivencia 100% 50% 0% Paro 3/23/2017 Sobrevivencia al paro 100% Tasa de Sobrevivencia 50% Optional Slide 4: Survival Following Respiratory Arrest vs Cardiopulmonary Arrest in Children Respiratory and cardiac arrest are both life-threatening events requiring resuscitation. But good outcome of resuscitation (survival to hospital discharge) is more likely following respiratory arrest than cardiopulmonary/cardiac arrest. Respiratory arrest often precedes cardiac arrest in infants and children. If respiratory arrest is recognized early and treated appropriately, cardiac arrest can be prevented and the likelihood of recovery increased. 0% Paro Respiratorio Paro Cardio-respiratorio

Evaluación Cardiorespiratoria Rápida 3/23/2017 Evaluación Cardiorespiratoria Rápida 1. Apariencia general (estado mental, tono muscular y grado de respuesta 2. Exámen de vias aéreas, respiración y circulación (ABCs) 3. Clasificación del estado fisiológico Slide 5: Elements of Rapid Cardiopulmonary Assessment Rapid cardiopulmonary assessment begins with an evaluation of the child’s general appearance, including mental status, muscle tone and position, and response to any stimulation (such as your approach, parents, voice, or painful procedures). The physical examination component of rapid cardiopulmonary assessment focuses on airway, breathing, and circulation to identify respiratory distress, respiratory failure, or shock. Classification of physiologic status occurs after assessment when you determine the severity of the patient’s respiratory or cardiovascular dysfunction. This physical examination and classification should be accomplished in less than 30 seconds. 30 segundos!

Evaluación de la apariencia general 3/23/2017 Evaluación de la apariencia general Color (malo ó bueno) Estado mental, grado de respuesta (de acuerdo a la edad) Actividad, movimiento y tono muscular Slide 6: Evaluation of General Appearance From the moment of the initial encounter with the infant or child the PALS provider should begin to form an opinion about the degree of distress the child demonstrates: is this an emergency or can the child wait for a more detailed assessment? Evaluation of general appearance can become instinctive and takes into account the child’s General color Apparent mental status and responsiveness Activity, movement, and muscle tone Watch for age-appropriate behaviors (eg, resistance to separation from the primary caretaker and “stranger anxiety” in the toddler). Remember: a decreased response to painful stimulus is abnormal in a child of any age.

Vías respiratorias: Aire 3/23/2017 Vías respiratorias: Aire Libre de obstrucción Estable Inestable: intubación immediata Slide 7: Physical Examination of the Airway The participant should evaluate the child’s airway and determine if intervention is required. The following terms can be helpful in determining the need for airway support: Clear means that no airway assistance or protection is necessary. Maintainable means that noninvasive assistance is necessary to ensure airway patency (head position, suctioning, bag-mask ventilation), but invasive intervention is not required. Not maintainable means that invasive intervention is necessary to maintain airway patency (eg, tracheal intubation, needle cricothy-rotomy, relief of foreign-body obstruction).

El aire solo sirve si llega más allá de los Bronquiolos 3/23/2017 El aire solo sirve si llega más allá de los Bronquiolos Tasa respiratoria Esfuerzo y mecánica respiratoria Sonidos respiratorios, flujo expiratorio máximo Estridor Silbido Color y oximetría de pulso Slide 8: Physical Examination of Breathing To assess the effectiveness of breathing you should evaluate the following: Rate: Should be appropriate for the child’s clinical condition. Tachypnea is a nonspecific sign of distress. A respiratory rate of more than 60 breaths per minute, however, is abnormal in all age groups. A slow or irregular respiratory rate in an acutely ill or injured infant or child is ominous because it often indicates that respiratory arrest is imminent. Effort: Relates to the work of breathing and breathing mechanics. Air entry/tidal volume: Determined by observation of chest expansion and auscultation over central and peripheral lung fields. Inspiratory stridor suggests croup or the presence of a foreign body. Wheezing or a prolonged expiratory phase suggests asthma or bronchiolitis. Skin color: Pink skin and mucous membranes suggest good oxygena-tion; cyanosis suggests hypoxemia. Pulse oximetry can quantify oxygen saturation.

Circulación Función Cardiovascular: Función y perfusión de órganos 3/23/2017 Circulación Función Cardiovascular: Pulso Flujo Capilar y pulsos periféricos Tensión arterial Función y perfusión de órganos Cerebro Piel Riñón (1-2 mL/Kg-hora) Slide 13: Physical Examination of the Circulation Cardiovascular assessment begins with an evaluation of the child’s responsiveness—if the child is unresponsive, urgent intervention is required. Then you begin direct assessment of the cardiovascular system, including evaluation of heart rate, quality of proximal and distal pulses, and blood pressure. Indirect assessment of the cardiovascular system is discussed later and includes evaluation of signs of end-organ function to evaluate end-organ perfusion. End-organ function includes function of the brain, skin, and kidneys. You will evaluate indirect signs of brain and skin perfusion during the cardiovascular assessment. A compromise in end-organ function may indicate that cardiac output and end-organ perfusion are inadequate.

Variación del pulso con la edad 3/23/2017 Variación del pulso con la edad Bebé 85 220 300 Normal Taquicardia SVT Niño Slide 16: Typical Ranges of Heart Rates in Children The heart rate in infants and children normally varies with age and activity. The “normal” range of heart rate decreases as the child ages. Heart rate must be evaluated in the context of the patient’s clinical condition. Heart rate increases with fever, anxiety, pain, or shock. A healthy, screaming 6-year-old child may have a heart rate of 130 bpm. The same heart rate of 130 bpm in a quiet 6-year-old child may be evidence of shock. Increased heart rate (tachycardia) may be a nonspecific sign of cardiorespiratory distress. Heart rate ranges for normal sinus rhythm, sinus tachycardia, and supraventricular tachycardia (SVT) overlap, as depicted in the slide. The diagnosis of SVT should always be considered when the heart rate is more than 220 bpm in an infant and more than 180 bpm in a child. 60 180 200 Normal Taquicardia SVT

Circulación Perfusión de la piel: Temperatura al tacto Flujo capilar 3/23/2017 Circulación Perfusión de la piel: Temperatura al tacto Flujo capilar Color Slide 17: Physical Examination of the Circulation—Evaluation of Skin Perfusion Indirect assessment: Evaluation of skin perfusion may provide important information about cardiac output. Skin perfusion may be compromised early in some forms of shock (eg, hypovolemic and cardiogenic shock) that result in redistribution of blood flow away from the skin and toward vital organs (brain, heart). Pulses: Peripheral pulses may be diminished if stroke volume is decreased or peripheral vasoconstriction is present. Temperature: Cool extremities suggest inadequate cardiac output or cold ambient temperature. Capillary refill: Normal capillary refill time should be less than 2 seconds if the ambient temperature is warm. Color can change with changes in perfusion/oxygen delivery: Pink color of mucous membranes indicates normal perfusion. Pale color may indicate ischemia, anemia, or cold environment. Blue color (cyanosis) indicates hypoxemia or inadequate perfusion with pooling of blood flow or increased oxygen extraction in the skin. Mottled color may be caused by a combination of the above. With distributive shock (eg, septic shock) skin perfusion may be normal or adequate.

Circulación: pulsos periféricos 3/23/2017 Circulación: pulsos periféricos Slide 18: Palpation of Central and Distal Pulses Evaluation of pulses and distal perfusion is part of the direct cardiovascular assessment. Palpation of central and peripheral pulses provides important information for the cardiovascular examination: Palpation of pulses can be used to evaluate heart rate and some indirect evidence of stroke volume and systemic vascular resistance. Pulse quality reflects the adequacy of peripheral perfusion. Weak or absent pulses may indicate poor stroke volume, increased systemic vascular resistance, or both. Loss of perfusion in hands and feet often precedes hypotension and critical loss of vital organ perfusion in shock. Hypotension often develops before loss of central pulses.

Circulación: Flujo capilar 3/23/2017 Circulación: Flujo capilar Flujo capilar prolongado (10 segundos) en un bebé de tres meses en shock cardiogénico Slide 19: Evaluation of Capillary Refill These 2 photos of the foot demonstrate a capillary refill time of 10 seconds in a 3-month-old infant in cardiogenic shock with a systolic blood pressure of 90 mm Hg 1 hour before death. To evaluate capillary refill, elevate the extremity above the level of the heart to ensure that arterial (not venous) perfusion is being evaluated. Note: Capillary refill can also be prolonged in cold ambient tempera- tures or hypothermia.

Circulación Tensión arterial mínima Edad (5o percentil) 3/23/2017 Circulación Tensión arterial mínima Edad (5o percentil) 0 - 1 mes 60 mm Hg 1 mes-1 año 70 mm Hg 1-10 años 70 mm Hg + (2 ´ age in years) >10 años 90 mm Hg Slide 20: Physical Examination of the Circulation—Estimate of Minimum Systolic Blood Pressure Ranges in Infants and Children Lower-limit (5th percentile) systolic pressures are estimated in children 1 to 10 years of age, using the following formula: 70 mm Hg + (2 x age in years) = 5th percentile systolic BP Note that children older than 10 years should have a systolic blood pressure of at least 90 mm Hg. Blood pressures lower than the recommended ranges are usually inadequate. Remember: A child may demonstrate signs of shock despite a “normal” blood pressure (this is compensated shock). The presence of a blood pressure lower than the minimum systolic blood pressure range for the child’s age indicates hypotension and the presence of decompensated shock.

Clasificación del estado fisiológico 3/23/2017 Clasificación del estado fisiológico Esfuerzo respiratorio: Trabajo aumentado Falla respiratoria: Oxigenación y ventilacion inadecuadas Slide 9: Rapid Cardiopulmonary Assessment: Classification of Physiologic Status Rapid cardiopulmonary assessment allows classification of the patient’s respiratory status. Respiratory distress is characterized by increased effort/increased work of breathing. Respiratory failure indicates the presence of inadequate pulmonary gas exchange, resulting in inadequate oxygenation or ventilation. Note that respiratory failure may be present with or without respiratory distress. A video shown later in this course includes images of infants and children in respiratory distress and respiratory failure.

Clasificación del estado fisiológico: Shock 3/23/2017 Clasificación del estado fisiológico: Shock Signos tempranos (Shock “Compensado”) Elevación del pulso Disminución de la perfusión periférica Signos avanzados (Shock “descompensado”: disminución de la perfusión a órganos vitales) Disminución de la calidad del pulso Cambio de estado mental Hypotensión Slide 23: Classification of Physiologic Status—Shock Once you have examined the child’s circulatory function, you should be able to determine if the child is in shock and to further classify the shock as compensated or decompensated. A major goal of the PALS Provider Course is to ensure that participants are able to recognize and manage compensated shock to prevent the development of decompensated shock and cardiac arrest. Early signs of compensated shock include tachycardia (a nonspecific sign) and evidence of poor systemic perfusion (reviewed in slide 21) Hypotension is a critical sign of decompensation that is typically accompanied by weak central pulses and altered mental status.

Shock séptico, caso especial 3/23/2017 Shock séptico, caso especial Flujo cardiáco variable Perfusión periférica persistente Slide 24: Septic Shock Is Unique —Signs of Septic Shock Differ From Hypovolemic and Cardiogenic Shock In septic shock the patient’s calculated cardiac output may be normal, increased, or decreased. In hypovolemic and cardiogenic shock, cardiac output is redistributed (diverted away from the skin, intestines, and kidneys) to maintain flow to the brain and heart. In septic shock blood flow is maldistributed so that some tissue beds (typically including the skin) receive excellent blood flow whereas others receive inadequate blood flow. Hypotension may be present despite skin perfusion that appears to be good. Early signs of septic shock include fever or hypothermia plus tachy-cardia and tachypnea. The number of white blood cells may be increased (leukocytosis) or severely decreased (leukopenia), and the number of immature (band) forms of white blood cells is increased.

Clasificación del estado fisiológico 3/23/2017 Clasificación del estado fisiológico Estable Falla respiratoria Shock (“compensado” y “descompensado”) Falla cardiorespiratoria Paro respiratorio Paro cardio-respiratorio Slide 28: Classification of Cardiopulmonary Physiologic Status The ABC-focused physical examination during rapid cardiopulmonary assessment enables rapid classification of cardiopulmonary physiologic status, which guides initial management.

Circulación Perfusión de la piel: Temperatura al tacto Flujo capilar Color

Pediatric Advanced Life Support Science Update © 2001 American Heart Association y amigos 1

Proceso de Revisión de Guías 500 expertos representando 30 países Más de 25,000 manuscritos revisados Recomendaciones revisadas por sub-comités y por la junta editorial de Circulation Guías endosadas por seis comités internacionales

La diferencia entre llamar “primero” y llamar “rápido” “Rápido”es apropriado para lamayoría de los bebés porque los problemas respiratorios son más comunes “Primero” es apropriado a cualquier edad si hay un colapso súbito (posible arritmia) “Rápido” es apropriado para los de más de 8 años si se anticipan problemas respiratorios”

Verificación del pulso Más de 24 segundos se pierden buscando el pulso Hay un 35% de error en el pulso reportado Más efectivo buscar “señales” de circulación

Defribiladores automáticos para mayores de 8 años FV/TV más comunes que lo que se pensaba La defibrilación temprana es recomendable Los defibriladores automáticos (AED) funcionan apropriadamente para los mayores de 8 años ó de más de 25 Kg.

Compresion-Respiración Recién nacido: 3:1 = 120 eventos/min ( 30 respiraciones/min) Bebés y niños: 5:1 para paro respiratorio >8 años: 15:2 para paro cardíaco

Técnica de dos pulgares

Máscara-Bomba Presión sobre el Cricoide ayuda a reducir el aire gástrico Cricoid cartilage Occluded esophagus Cervical vertebrae

PALS : Cambios Intubación pre-hospitalaria Confirmación secundaria de intubación Máscara laríngea (LMA) aceptable Acceso Intraóseo a mayores de 6 años Epinefrina de alta dosis “des-enfatizada”

PALS: Cambios Algoritmos de arritmias: Maniobras vagales para SVT Amiodarone Magnesium Modification of PALS approaches may be needed for special resuscitation situations Postresuscitation interventions updated

Intubación pre-hospitalaria Exito en solo 57% Cada intento hace perder 2-3 minutos Errores fatales: 8% Gausche. JAMA. 2000;283:783.

Intubación ó uso de bomba-máscara Igual en cuanto a sobrevivencia en general Intubación: 110/416 (26%) Bomba-máscara: 123/404 (30%) Más sobreviveientes con bomba que con intubación en el caso de paro respiratorio Intubación: 33/54 (61% survival) Bomba-máscara: 46/54 (85% survival) Gausche. JAMA. 2000;283:783.

Colorimetric Exhaled CO2 Detector Purple: No exhaled CO2 detected Yellow: Exhaled CO2 detected

Confirmación secundaria de intubación: CO2 Requiere ritmo de perfusión Intubación bronquial Se recomiendan 6 ventilaciones antes de medir

Máscara Laríngea en PALS Extensa experiencia en el quirófano Requiere ausencia de reflejo….

Aplicación de la máscara laríngea

Amiodarone Acceptable en paro y en taquiarritmias ventriculares. Benzyl alcohol (preservativo) sale del tubo plástico en las infusiones lentas. Síndrome de ahogo.

Farmacología en paro cardíaco Adrenalina: 0.01 mg/kg (traqueal: 0.1 mg/kg) Vasopressin: Justificada en adultos Sin datos para pediatría

Maniobras para estimular el Vago en TSV En pacientes estables solamente ó Mientras se prepara cardioversión

Drug Therapy: Amiodarone Inhibición de receptores a- and b- Larga vida media Prolonga QT mediante bloqueo de salida de K Inhibe los canales de Na ® disminuye la velocidad de conducción y prolonga el QRS Puede ser útil en arritmias ventriculares y supraventyriculares Y en FV y TV sin pulso resistentes a choque

Magnesio Torsades de pointes VT o hipomagnesemia 25 to 50 mg/kg IV/IO (maximum : 2 g) Asthma cuando los agonistas b- fallan 25 to 50 mg/kg slow infusión sobre 20 minutos (maximum : 2 g) Considerar la posibilidad de hipotensión y bradicardia

Intoxicaciones Antidepresivos Tricíclicos Bicarbonato Sobredosis con bloqueador de canal de calcio IV calcio (IIb) Rehidratación (5 to 10 mL/kg) Opioides Ventilación para normalizar CO2 (IIb) Seguida por Naloxone (IIa) !!!

Intoxicaciones b-Bloqueadores Infusión de Adrenalina Cocaine Benzodiazepinas Posible síndrome coronario agudo (ACS) Considere a-bloqueadores (IIb) Evite b-bloqueadores (III)

Cinco hipos: causas reversibles del paro Hipoximia Hipovolemia Hipotermia Hipo/Hiperkalemia Hipoglicemia

Cuatro Ts: Paro potencialmente reversible Tamponada Tensión (Neumotorax) Tóxicos Tromboembolismo pulmonar

Atención de parto Ventilación efectiva Masaje cardiáco externo si el pulso es menor que 60/min a pesar de 100% oxígeno Si se observa meconium: Succión de faringe al presentar la cabeza Si la respiración no es satisfactoria, si el pulso es menor de 100 ó si el tono es flácido, succionar la tráquea

3/23/2017 Fiebre en la Urgencia Pediátrica 1

Fiebre ó temperatura elevada? Interleukin-1, -6 y factor de necrosis liberados por los macrófagos y monocitos Variación diurna hasta de 2 grados centígrados Temperatura “normal”= 37o +/- Xo C Incierta temperatura timpánica

Beneficios de la fiebre Leukocitos funciona mejor entre 38o y 40o Aumento de producción de superóxidos Aumento en interferón Inhibición de replicación de algunos viruses Resolución temprana de síntomas en rubeola y varicela

Control de la fiebre Baños y otras medidas Acetaminofeno: Bloqueo de prostagladinas hipotalámicas (15 mg/kg q4 hr) Ibuprofeno: hipotálamo + anti-inflamatotrio (10 mg/kg q6 hr)

Objetivos del Diagnóstico urgente Meningitis Bacterimia Oculta Infección Bacterial con potencial de deterioro

Meningitis Incidencia decreciente gracias a vacuna Limitaciones del exámen: punción lumbar para los menores de 3 meses con temperatura por encima de 38 23% se presentan sin fiebre 20-30% con Otitis media Escala de Observacion de Yale (llanto, reacción a los padres, variabilidad del estado, color, hidratación, respuesta a la estimulación social)

Infección del Tracto Urinario Progresión a urosepsis Anomalidades anatómicas (reflujo y riesgo renal) Sensibilidad limitada del análisis sin cultivo ( 75-85%) Exámen microscópico (Gram, 94-99%)

Neumonía Baja probabilidad sin síntomas respiratorios Neonatos: Streptococo B, Stafilococo Primer mes: Clamidia (tos sin fiebre) Tres y más meses: 86% adenoviruses, parainfluenza, influenza A y micoplasma. Streptococo, H. influenza, Bordetella Pertussis y Stafilococo Aureus.

Bacteremia Oculta Cultivo de sangre positivo en el paciente febril de apariencia normal 3-6% en el grupo de 3 a 36 meses Progresión a meningitis en 25%, baja a 1% con antibioticos parenterales Progresion a meningitis de 6% a 1% con antibioticos parenterales en casos de neumonía.

La escala de Rochester Padres responsables Nacido a término De apariencia “no-tóxica” De buena salud, sin antibioticos simultáneos Cuenta de glóbulos blancos: 5-15 mil, (< 1,500 formas inmaturas) Menos de 5 glóbulos blancos en materia fecal Radiografía normal del torax Urinálisis normal Fluído cerebroespinal normal