Rapid Cardiopulmonary Assessment Recognition of Respiratory Failure and Shock
Objectives
At the end of this session, participants will be able to: • Perform a rapid cardiopulmonary assessment • Recognize signs of distress or respiratory failure and shock
Rapid Cardiopulmonary Assessment
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Respiratory failure and shock Variables
Respiratory failure
Shock
Cardiopulmonary failure Cardiovascular arrest
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Survival after cardiovascular arrest in children 100%
50%
0%
Respiratory arrest
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Cardiovascular arrest
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Rapid Cardiovascular Assessment
1. General assessment: neurological evaluation, muscle tone (mental status, tone, responsiveness) 2. Clinical examination: airways, breathing and circulation (ABCs) 3. Classification of the physiological state
A rapid cardiovascular assessment must be performed in less than 30 seconds!
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General evaluations
• Skin colour • Mental state and type of response • Activity, movements and muscle tone • Age-appropriate response
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Airways
• Patent and functional • Supported • Non-functional without intubation
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Breathing
• Respiratory rate • Respiratory mechanics: difficulty-effort • Breath sounds/inspiratory effort/volume • Inspiratory stridor • Expiratory wheezing • Skin colour and O2 saturation
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Classification of the pathophysiological state
• Respiratory distress Increased respiratory work • Respiratory failure Inadequate ventilation and/or oxygenation
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Effects on systemic perfusion
Volume Lower volume Cardiac output
Heart rate
Myocardial contractility Peripheral resistances
Blood pressure Vascular resistances
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Hemodynamic response to shock
Vascular resistance
Percent of control
140 100 60 Cardiac output
20
Compensated shock Rapid Cardiopulmonary Assessment
Blood pressure
Decompensated shock 11
Decompensated shock: characterized by hypotension
Compensatory mechanisms to maintain adequate blood pressure and cardiac output
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Circulatory examination
Cardiovascular function: • Heart rate • Peripheral pulses and capillary reperfusion • Blood pressure Perfusion and function: • Central nervous system • Skin • Kidneys
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Circulation
• Neurological assessment • Quality of peripheral pulses, skin temperature, capillary reperfusion • Blood pressure • Monitoring of urine quantity
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Circulation
Response assessment: • A — Active and alert • V — Responsive to verbal stimulation • P — Responsive to painful stimulation • U — Unresponsive
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Heart rate in children
Infant 85
220
300
Normal Sinus Tachycardia SVT
60
Child
180
200
Normal Sinus Tachycardia SVT
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Circulation
Assessment of tissue perfusion: • Temperature of the extremities • Capillary reperfusion • Colour • Pink • Pale • Blue • Mottled
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Assessment of peripheral pulses
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Capillary reperfusion
Capillary reperfusion >10 seconds in a three-month-old baby with cardiogenic shock
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Circulation
Ideal blood pressure: Age
Accepted pressure (5th percentile)
0 – 1 month
60 mm Hg
>1 month – 1 year
70 mm Hg
1 – 10 years
70 mm Hg + (2 x age in years)
>10 years
90 mm Hg
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Circulation
Cardiovascular function: • Heart rate • Pulses and capillary reperfusion • Blood pressure Tissue function and oxygenation: • Central nervous system • Skin • Kidneys
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Circulation
Assessment of tissue function and oxygenation Kidneys Urine quantity: Normal: 1 - 2 mL/kg per hour
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Shock classification
Early signs of compensation: • Tachycardia • Peripheral hypoperfusion
Late signs of decompensation: • Weak pulses • Neurological alterations • Hypotension
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Septic shock • Cardiac output can be normal, increased or decreased. NOT SIGNIFICANT • Hypotension is a sign of decompensation even with preserved tissue perfusion. • Other early signs of septic shock decompensation are: • Fever or hypothermia • Tachycardia and tachypnoea • Leukocytosis, leukopenia or thrombocytopenia
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Trauma • Airway and ventilation problems are more common than those related to shock • Use ABC • Airways + immobilization of the cervical spine • Respiration + pneumothorax • Circulation + blood loss control • Identification of life-threatening injuries
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Poisoning • Airway obstructions, respiratory depression, circulatory problems. • ABC approach • Airways: keep patent • Respiration: prevent respiratory depression • Circulation: arrhythmias, hypotension, myocardial ischemia • Early detection of reversible complications • Administer antidotes
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Cardiopulmonary failure
Cardiopulmonary failure is characterized by signs of respiratory failure and shock: • Dyspnoea • Bradycardia • Cyanosis and hypoperfusion
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Cardiopulmonary failure
• Stable • Respiratory distress • Respiratory failure • Shock • Compensated • Decompensated • Cardiopulmonary failure
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Summary
• General assessment • ABCs assessment • Classification of the respiratory status • Respiratory distress • Respiratory failure • Compensated shock • Decompensated shock • Cardiopulmonary failure • Initial management: ABCs support
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Case
Three-week-old infant taken to the ER History of vomiting and diarrhoea Respiratory gasping, bradycardia, cyanosis, and tissue hypoperfusion
What’s his/her status? What immediate action should you implement?
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Continuation
Intubated and ventilated with 100% FiO2 Heart rate: 180 bpm Blood pressure: 50 mm Hg systolic Centrally pink and peripheral cyanosis No peripheral pulses No response to pain What’s his/her status now? What’s the priority now?
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Treatment
• Improving vital signs • Better tissue perfusion
What would you do now?
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