C is for Circulation (part 1 of 2)

12 August, 2010 by: colinparker

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Shock, dehydration, fluid management… How do we assess and manage the circulation in a paediatric emergency?
Learn about the clinical assessment of the Circulation in this PEMcast.


Click on the play button below to listen to this podcast, or subscribe using the iTunes button on the left…

Overview of Circulation (part 1) PEMcast

(CP) Introduction, disclaimer & welcome (gastro to be explored in separate episode)

Assessing circulation:

(KB) Elements: HR, CFT, pulses, BP, skin perfusion, mental status, urine output, general appearance (etc)
(SF) Shock: signs
(MB) Decreased BP late sign (why?)
(CP) ‘warm shock’ rare in kids
(KB) CFT caveats
(SF) Cutis marmorata can be normal or abnormal
(CP) Shock: causes (CHOD = cardiogenic, hypovolaemic, obstructive, distributive)
(KB) Shock: treatment: seek & treat cause; N/Saline boluses 20mL/kg; inotropes after 3rd bolus?
(SF) What inotrope? Adrenaline usually, Noradrenaline good for vasodilation in sepsis?

Dehydration – clinical signs & their evidence base:

See Steiner 2004 and Gorelick scale 1997
(CP) Fluid compartments & shifts (radio-labelled albumin experiments)
(KB) Various ‘scales’, unvalidated, no good evidence base
(MB) Local (PMH) study – inter-observer correlation
(SF) Steiner 2004: More features = more likely to be dry
Most predictive = CFT, respiratory pattern, skin turgor
Normal urine output reassuring, decreased urine output (by parental report) not predictive of dehydration
(All) Can we predict % dehydration clinically?
(KB) WHO recommendations now = none/some/severe

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One Response to “C is for Circulation (part 1 of 2)”
  1. Colin says:

    The ranges of normal heart rate produced by APLS and PALS are apparently misleading, according to this recent article in the Lancet:

    Fleming S, Thompson M, Stevens R, Heneghan C, Pl├╝ddemann A, Maconochie I,
    Tarassenko L, Mant D. Normal ranges of heart rate and respiratory rate in
    children from birth to 18 years of age: a systematic review of observational
    studies. Lancet. 2011 Mar 14. [Epub ahead of print] PubMed PMID: 21411136.


    These researchers from Oxford, UK and Oregon, USA have analysed data from 69 original studies, to produce a new evidence-based set of centile charts for normal respiratory rate and normal heart rate ranges according to age.

    Be sure to get the webappendix supplement; page 13 of the document contains a table of cutoff values for various centiles, by age range.

    I wonder whether this will result in a change to the established cutoffs used by international bodies such as APLS, and how long this will take?


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