5.2 Resuscitation
The term ‘collapse’ is used here to describe a state in which a child’s neurological and/or cardiorespiratory function is acutely and severely impaired.
Diagnosis
Collapse may occur because of: a primary neurological process; loss or reduction of oxygen supply to the brain; or a metabolic disturbance or toxins affecting brain function. Collapse may be the result of many different disease processes, some examples of which are shown in Table 5.2.1. A more thorough differential diagnosis and approach to assessment of the collapsed child is presented in Chapter 5.1.
Table 5.2.1 Some causes of collapse in children
| Category | Diagnosis |
|---|---|
| Primary neurological process | MeningitisHead injuryEncephalitisSeizures |
| Failure of oxygen supply to brain | Acute asphyxia (e.g. drowning, birth asphyxia)Respiratory causes (e.g. severe asthma, croup)Cardiac causes (e.g. arrhythmias, myocarditis)Hypovolaemia (e.g. dehydration, haemorrhage)SepsisAnaphylaxis |
| Metabolic disturbance or toxins | HypoglycaemiaHyponatraemiaDrug or other toxic ingestionEnvenomationBacterial toxins |
David, a 21/2-year-old boy, was found collapsed in the bedroom while visiting his grandmother’s house. He was taken immediately to a local hospital where he was noted to be floppy and poorly responsive to voice or physical stimulation. He had an adequate airway, his breathing was a little shallow and slow, and he was slightly dusky in colour. His limbs were pink and felt warm, and he had strong pulses.
David was placed on his side and oxygen was administered by facemask; his colour improved immediately. He was afebrile, with normal blood glucose on bedside testing, and no other physical abnormalities were found.
A careful history showed that he had been very well all day. He had been playing unobserved in his grandmother’s house for about an hour before he was found. His grandmother kept some sedative drugs (nitrazepam) in the bedside cabinet, and a telephone call back to the house revealed that the tablet bottle was lying open on the bedroom floor.
David continued to receive oxygen and close observation, and his clinical condition improved steadily over the next 12 hours. He was discharged home well the following day.
Sometimes the cause of collapse is immediately obvious, as in head injury or drowning, but sometimes it may be a diagnostic problem initially (e.g. sepsis or drug ingestion). In this latter setting, resuscitation usually has to take priority over obtaining a complete history, examination and investigation. With sufficient personnel available, diagnostic and resuscitative procedures may progress in parallel. One important investigation to consider early when the cause of collapse is unknown is a blood glucose estimation.
Resuscitation
If you find yourself responsible for the immediate care of a collapsed child, you should be familiar with at least the procedures used in basic life support. The general principles may be the same as those used in the resuscitation of adults, but specific techniques are required in children.
The primary aim is to restore an adequate supply of oxygenated blood to the brain – to prevent secondary brain damage. The resuscitation procedures required will vary, depending on the degree of physiological impairment, from simple ones, such as application of an oxygen facemask or administration of a bolus of intravenous fluid, through basic cardiopulmonary resuscitation (CPR) to advanced life support measures including endotracheal intubation, mechanical ventilation and the use of vasoactive drugs.
Resuscitation techniques for newborn infants are discussed in detail in Chapter 11.1.
Life support
The environment is important: make sure you are in a safe situation – you will be of no value to the collapsed child if you, the rescuer, become a second victim (e.g. at a road accident scene). Get someone to summon sufficient extra help.
Quickly evaluate the degree of collapse:
Then move quickly to the ABC. The term ABC is a useful reminder of not only the manoeuvres required (Airway, Breathing, Circulation) but also of the correct sequence in which to apply them. Assessment of the airway and breathing should be performed quickly, with emphasis on rapid progression to the circulation.
In obviously more advanced states of collapse, do not waste time on assessment but commence CPR immediately.
Jodie, a 6-year-old girl, was a rear seat passenger when her family’s car was involved in an accident while travelling at around 60 km/h. She was not wearing a seat belt.
On arrival at hospital, she was awake but agitated with multiple superficial abrasions to her face, trunk and limbs. Within 20 minutes her state of consciousness deteriorated, she developed increasing tachycardia and her blood pressure had fallen.
Jodie was intubated to protect her airway; during the procedure careful attention was paid to prevent excessive movement of her cervical spine. The doctor had already inserted a large-bore cannula into a vein in her antecubital fossa, and through this she was given 40 mL/kg saline. She was re-examined for possible sites of hidden bleeding, including the abdomen and limbs (especially fractured femur). Her abdomen was noted to be distended and she underwent computed tomography (CT), which showed small lacerations of the liver and spleen. CT of her brain, performed at the same time, was normal. Jodie was managed with supportive care, including mechanical ventilation and blood transfusion. Surgical exploration of the abdomen to control bleeding was considered but not performed, as she stabilized with medical treatment. She was discharged from the intensive care unit 4 days later.
Airway
If conscious, the child will usually adopt the best posture to maintain his or her own airway: don’t force the child to lie down.
In an unconscious child, assess the adequacy of the airway by observing the degree of chest movement and by listening and feeling for breath at the mouth (place your ear close to the child’s mouth).
An unconscious child with a patent airway should be placed on the side: this improves the size of the airway (gravity pulls the jaw and tongue forward), allows saliva and other secretions to drain from the mouth, and reduces the risk of aspiration of gastric contents should they be regurgitated. Moving the child in this way may be harmful if there is a possibility of cervical spine injury (e.g. following road trauma); in this case, work to obtain an optimal airway in the existing position without excessive rotation, flexion or extension of the neck.
If the airway is completely or partially obstructed, it may be further improved by extending the neck to the neutral, or slightly extended, position, and supporting the jaw in a forward position; this is easiest done with the child on their back (Fig. 5.2.1). This may be done by placing your fingers behind the angle of the mandible and applying gentle forward pressure. If secretions, gastric contents or food may be obstructing the airway, suck them out, preferably with a wide-bore rigid sucker.
Fig. 5.2.1 Optimal head and neck position for airway protection in an infant. Do not overextend the neck. This head and neck position may be used with the child on its side or lying on its back.
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