Pediatrik Gawat

Darurat
Case
• Anak perempuan usia 3 bulan dengan riwayat
prematuritas, dibawa ke IGD dengan demam,
batuk, pilek sejak 1 minggu. Pada saat datang, nadi
182/menit, RR 72/menit, Sat O2 87%, suhu 38,7 C.
anak tampak sesak, tampak retraksi, sianosis, dan
terdengar merintih
Pediatric Assessment Triangle
Airway and Respiratory System
• Nasal flaring, tachypnea, grunting, retractions 
sign of increased of work of breathing
• Bradypnea  impending respiratory arrest
• Positions of comfort (eg, tripod position)
Airway and Respiratory System
• Tachypnea • Bradypnea
• Hypothermia
• Fever
• Central nervous system injury
• Pain and anxiety • Drug induced depression
• Hypovolemia • Neuromuscular disease
• Severe shock
• Respiratory disease
• Metabolic disorder
• Metabolic acidosis
• Heart failure
• Normal respiratory rates in
• Adverse drug effect children
• Hyperviscosity syndrome • Newborn – 1 year: 30-60/min
• 1-3 years: 25-40/min
• 3-12 years: 20-30/min
• >12 years 12-20/min
Airway
• Ensure a patent airway
• Nasal pathway is the primary route for normal
breathing in neonates and young infants
• Total airway resistance and potential for
compromised breathing are greater in infants with
nasal congestion, increased secretions, or a
nasogastric tube
Airway
• Anatomical predisposition
• Large occiput
• Relatively large tongue
• Floppy epiglottis
• Anteriorly placed larynx

• Decreased hypopharyngeal tone

• Cause:
• Congenital
• Infectious (viral croup, bacterial tracheitis, epiglottitis)
• Foreign body
Airway
• Obstruction above thoracic inlet  stridor
• Obstruction intrathoracic  wheezing
• Children with stridor or wheezing, unresponsive
with appropriate bronchodilator and steroid
therapy  foreign body
 Breathing
• Respiratory distress  • Infant and toddlers
respiratory failure • Pneumonia
• Increased work of breathing muscle • Bronchiolitis
fatique
• Asthma
• Foreign body
• Premature neonates • Upper airway obstruction
related to infection
• Apnea of prematurity
• Respiratory distress syndrome
• Bacterial pneumonia
• Sepsis
• Meconium aspiration
• Congenital
Airway and Respiratory System
• Monitoring
• Physical assessment
• ABG
• Hypoventilation
• Hyperventilation
• Metabolic acidosis
• Metabolic alkalosis
• Pulse oximetry
• Maneuver to open and maintain airway
• Aligning the oral, pharyngeal, tracheal axis  sniffing
position
• Jaw thrust and chin lift maneuver
• Oropharyngeal and nasopharyngeal airway
• Bag-mask ventilation
• Tracheal intubation
Tracheal intubation
• Indication:
• Respiratory failure
• PaO2 <60 mmHg with FiO2 >0,6
• PaCO2 >55 mmHg
• Excessice work of breathing
• Upper airway obstruction
• Hemodynamic instability
• Loss or inadequancy of airway protective reflexes
• Neuromuscular weakness
• Therapeutic purposes
• Severe metabolic acidosis
• Intracranial hypertension
• Need deep sedation
Tracheal intubation
• 

• Laryngoscopes:
• Curved (macintosh)
• Straight (miller)
Ketamin
Dose: 1 mg/kg IV bolus
Onset: 1-2 min
Duration 10-30 min
Benefit: rapid onset, airway protective reflexes remain intact, no hypotension or bradycardia
Cautions: increased airway secreations and laryngospasm (blunted with atropine, elevates
intracranial and ocular pressure
Rapid Sequence Intubation
• RSI is employed when
• There is increased concern about aspiration
• All evidence indicates a normal airway, no difficult
intubation

• RSI include, preoxygenation before procedure,

giving rapidly acting sedative, analhesic, and
paralytic drugs simultaneously
Tracheal intubation
• Complication
• Abdominal distention by bag-mask ventilation
• Activation of vagus nerve
• Barotrauma
• Decreased cardiac output

• Troubleshoot: DOPE assessment

• Dislodgement of the tube
• Obstruction of the tube
• Pneumothorax
• Equipment failure
 Circulation
•• Cardiac
  output in children is dependent on
patient’s heart rate

• Tachycardia is one of the earliest signs of shock

• Severe tachycardia  decreased diastolic filling
time  rapid fall in stroke volume

• Bradycardia will result in decreased cardiac

output and oxygen delivery
• Sign of hypoxemia or acidosis

• Hypotension (1-10years)
Shock
• A state of circulatory dysfunction that fails to provide sufficient oxygen
and nutrient to meet the metabolic needs of vital organ and peripheral
tissues.

• Hypovolemic shock
• Fluid losses: GI tract disorder, renal dysfunction
• Blood loss
• Capillary leak: burns, NEC, intussusception

• Distributive shock
• Neurogenic shock
• Anaphylaxis
• Drug toxicity
• Adrenal insuffuciency
Shock
• Cardiogenic shock
• Congenital heart lesions
• Myocardial dysfunction: ischemic heart disease (Kawasaki disease)
• Dysrhytmia: SVT

• Septic shock
• Obstructive shock
• Cardiac tamponade
• Tensioin pneumothorax
• Pulmonary embolism
Shock
• Hypothermia or hyperthermia
• Altered mental status
• Peripheral vasodilation (warm shock) or
vasoconstriction with CRT >2” (cold shock)
• HR <70 or >150 bpm (children), or <90 or>160 bpm
(infant)
Shock
Shock
• Goal of therapy
• In Emergency Room: Restoring normal mental status,
threshold HRs, peripheral perfusion (CRT <3”), palpable
distal pulses, normal blood pressure for age, decreased UO
<1 ml/kg/hour
• In PICU: restore and maintain normal perfusion pressure
(MAP-CVP), ScvO2>70%, CI>3.3, <6.0 L/min/m2
 O2 consumption Exercise
Stress
Hemodynamic Factors Trauma
Sepsis
other
BP DO2 acute illnesses

SVR Cardiac Output Arterial Oxygen Content

Frequency Stroke Volume Hb x 1.34 x SaO2 + 0.003 x PaO2

Preload Afterload

PRC O2
Contractility
Tranfusion MAP

Fluid Vasoactive pH
Drugs pCO2
Temperature
Inotropic Drugs
W. C. Shoemaker, M. Bee. Pathophysiology, monitoring, and therapy of shock with organ failure. Appl Cardiopulm Pathophysiol.
2010;14: 5-15.
VO2-DO2-cardiac output
• Inspired oxygen from the environment moves across the alveolar-capillary
membrane into the blood and is then transported to the peripheral tissues. There,
it is removed from the blood and used to fuel aerobic cellular metabolism. This
process can be conceptualized as three steps: oxygenation, oxygen delivery, and
oxygen consumption
• Oxygen delivery (DO2) is the rate at which oxygen is transported from the lungs to
the microcirculation, oxygen consumption (VO2) is the rate at which oxygen is
removed from the blood for use by the tissues, and oxygen extraction is the
proportion of arterial oxygen that is removed from the blood as it passes through
the microcirculation.
• VO2 normally remains constant over a wide range of DO2 because changes in
DO2 are balanced by reciprocal changes in oxygen extraction. VO2 will decrease
only if DO2 declines to such a degree that it cannot be balanced by increasing
oxygen extraction.
• VO2 increases when metabolic demand increases (eg, exercise, pregnancy). This is
disproportionately accomplished by increasing the oxygen extraction, with
DO2 contributing little
Early Goal Directed Therapy
• Airway and breathing
• Lung compliance and work of breathing may change precipitously
• Intubate and ventilate if work of breathing increase, hypoventilation, impaired
mental status
• Intubate and mechanical ventilation can reverse shock
• Premed: ketamine + atropine

• Fluid resuscitation
• Rapid fluid bolus of 20 ml/kg crystalloids, while observign signs of fluid
overload
• Development increased work of breathing, rales, gallop, hepatomegaly
• Children commonly need 40-60 ml/kg in the first hour
• Correcting hypoglycemia or hypocalcemia
Early Goal Directed Therapy
Early Goal Directed Therapy
• Target of fluid • Stop fluid resuscitation
resuscitation • Increase work of
• Alert breathing
• Normal arterial pulse • Rales
quality
• Acute liver enlargement
• Normal heart rate
• Increasing jugular venous
• CRT <2” pressure
• Warm extremities
• Chest X-ray 
• Normal blood and pulse congestive sign
pressure
• Other test
• Urine output >1 ml/kg/hour
Crystalloid vs. Colloid
C R YS TA LLO ID C OL LOI D

• More affordable in • Provide more benefit in

emergency settings ARDS

• Low risk of toxicity • Increased plasma

colloidal osmotic
pressure without
worsening P(A-a)O2
gradient or pulmonary
shunt
• Increased cardiac index
Early Goal Directed Therapy

• USG
• USCOM
USG
• Preload status:
• IVC collapsibility
• IVC/Ao ratio

• Contractility
• LV function
• RV function

• Lung
• A or B Line
• Pleural effusion
 USCOM
Parameter Indikator
Preload SV. SVV. FTc
Inotropy Vpk, SV, FT, SMII
Afterload SVR, BP mean, MD,
PKR
Cardiac Output CO, CLSV, HR
Oxygen CO, SpO2, DO2
Delivery
PE:KE ratio PKR
Stroke volume variation

• Percentage change between maximal and

minimal stroke volumes

Flow time corrected

• Time needed for heart to eject a stroke

volume (can be used for preload or
inotropy assessment)
Minute distance

• How far the red blood cells travel in one minute

Peak velocity

• Peak velocity for ventricular ejection

PE:KE ratio – PKR

• Ratio between potential energy (blood pressure) and

kinetic energy (blood flow)
 D Na K kkal mOsm
D5 50 - - 200 278
D10 100 - - 400 556
NS - 154 - - 308
NaCl 3% - 513 - - 1026
D5 ½ NS 50 77 - 200 428
D5 ¼ NS 50 38.5 - 200 353
RL - 130 4 - 273
Kaen 1B 37.5 38.5 - 150 285
N5 100 30.8 - 400 -
Kaen 3A 27 60 10 108 290
Kaen 3B 27 50 20 108 290
Early Goal Directed Therapy
• Hemodynamic support
• Dopamine as first line vasopressor for fluid refractory shock
• Dose 1-20 mcg/kg/min
• Fluid refractory/dopamine resistant shock  central epinephrine 0.05-
0.3 mcg/kg/min (cold shock) or norepinephrine 0.05-1 mcg/kg/min
(warm shock)

• Hydrocortisone therapy
• Child at risk of adrenal insufficiency or adrenal pituitary axis failure and
remains in shock despite epinephrine or norepinephrine infusion
• Inotropes: contractility of heart muscle
• Vasoconstrictors: enhance systemic vascular
resistance (afterload ↑)
• Vasodilators: reducing systemic vascular resistance
(afterload ↓)
• Myocardial contractility ↑  cardiac output ↑
• Beta adrenoreceptors
• B1>b2
• Increase cardiac output
• Decrease peripheral resistance 
vasodilation certain vascular beds
• Beta 1 receptors: epinephrine =
norepinephrine
• Beta 2 receptors : epinephrine >
norepinephrine

• Alpha adrenoreceptors
• Regulates vascular smooth muscle tone
• Increase arterial resistance
• On heart  positive inotropic

• Dopaminoreceptors
• Vasodilation of renal, splachnic, coronary,
etc
Thank you