The ABC of high dependency
Emergency and high-dependency care is about providing the right care and support in a timely manner. Practising paediatrics under these condi-tions means that you will need to anticipate what could happen next, which can be very difficult. Therefore, we shall start with an emphasis on patient safety—the ABC—the assessment of Airway, Breathing, and Circulation. Then, we shall cover most of what is needed next for acute care—knowledge, assessments, and treatments.
Use fractional inspired oxygen (FiO2) 100%; use the optimum method for patient size and monitor.
· Neonates, infants: head-box oxygen with in situ FiO2 monitor.
· Infants, toddlers: nasal cannulae (NC). The ideal estimate of FiO2 from tidal volume (7mL/kg) and NC flow rate is shown in the following example.
Consider a 6kg infant on 0.25L/min NC oxygen (tidal volume = 42mL; NC flow = 250mL/min, 4mL/s; inspiratory time = 1s).
FiO2 value is: 4mL × 1.0 = 4mL oxygen, plus 38mL × 0.21 = 8mL oxygen.
FiO2 = (4 + 8)/42 = 0.29.
· Toddler, pre-school: NC, face mask.
· School-age child: non-rebreathing mask.
· Support airway when needed with jaw lift: suction nasopharynx and mouth as needed. Provide oral or nasopharyngeal airway.
· Maintain patient in upright position: do not force a distressed patient to lie down. Minimize discomfort.
· Identify the level of respiratory involvement: treat specific problems appropriately (e.g. bronchodilators).
· Assist work of breathing with non-invasive support: this can be achieved with nasopharyngeal continuous +ve airway pressure, or –ve pressure ventilation.
· Intubation and mechanical ventilation.
· Start pulse oximetry and cardiac monitoring.
· Provide IV fluids: when the circulation is good it is advisable to limit fluid intake to an amount ranging from restricted to just below maintenance.