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72 Intensive Care

In evaluating a child with severe infection, the priority remains to Thoracic injury may be potentially life-threatening, requiring
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ensure adequate airway, breathing, and circulation. If severe shock prompt recognition and treatment. The adequacy of ventilation
is present in the setting of infection, it is important to aim to reverse should be assessed clinically by looking at respiratory rate, pattern,
the shock with aggressive fluid resuscitation and inotropic support, if and symmetry of chest movement and breath sounds on auscultation.
required, with the ultimate goal of achieving age-appropriate heart rates, Adequate oxygenation can be confirmed if the patient appears pink or
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normal blood pressure, and capillary refill time. As in the treatment of more definitively with pulse oximetry. Once the airway is definitely
hypovolaemia, boluses of crystalloid or colloid totalling up to 200 ml/ secure, if ventilation and oxygenation continue to be inadequate,
kg may be required, and inotropic support should be considered early lung injury should be suspected. Pulmonary contusion may result in
in patients unresponsive to two or three boluses of 20 ml/kg. Specific respiratory distress and may be confirmed radiologically, although
infections may dictate variations in management after initial stability is it may be difficult to distinguish from acute aspiration or atelectasis.
established. The site of infection as well as likely pathogens will guide The presence of unilaterally decreased breath sounds, hypoxia, and
the choice of antimicrobial therapy. cardiovascular compromise should raise the suspicion of pneumothorax
Postoperative Care or haemothorax. These conditions should be treated urgently by needle
or drain thoracocentesis. Mediastinal injuries with the potential for
Following major elective or emergency surgery, the child probably
large vessel or major airway trauma are surgical emergencies and
will be haemodynamically unstable and therefore require support for
require prompt imaging and surgical intervention.
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one or more organ systems. Other factors that influence this instability
Children are capable of losing up to 40% of their intravascular
include the age, underlying nutritional status, and premorbid health
volume while maintaining a relatively normal blood pressure. The signs
of the patient; the length of the operation; intraoperative cardiovas-
and symptoms of early shock due to blood loss may be subtle; it is
cular status; and fluid losses. Intensive care may be required from
therefore important to begin fluid resuscitation early, before a seriously
the immediate postoperative period, but delayed deterioration must
injured child becomes haemodynamically unstable. Direct pressure
always be anticipated in high-risk cases and these patients should be
should be applied to any visible external bleeding site in an attempt to
monitored accordingly.
stop the bleeding. Secure intravenous access should be sought; common
In caring for high-risk patients, the degree of support will be dictated
veins used include antecubital, saphenous, and femoral. In the absence
by the specific set of clinical circumstances as well as the local resources.
of obvious lower limb fracture, an intraosseous (IO) needle into the
Attention must be paid to ensure that adequate oxygen is delivered to the
anterior tibia is a reliable and potentially life-saving form of intravenous
recovering patient. This involves also ensuring adequate ventilation and
(IV) access. Initial fluid resuscitation should consist of two 10-ml/kg
circulation and appropriate monitoring of the vital signs of the patient.
boluses of isotonic crystalloid solution, which may be followed by a
Fluid balance is important in the perioperative period, and careful
further two 10-ml/kg boluses of fluid. If signs of shock with evidence
attention to and monitoring of intake and output are required. Many
of ongoing blood loss persist, consider the use of either O-negative or
abdominal surgical procedures result in patients requiring a prolonged
type-specific packed red blood cells for further fluid boluses.
period of nutritional support; if available, total parenteral nutrition
Once the child is physiologically stable, perform a complete
should be considered in patients who are unable to adequately meet
systemic examination. This would normally include various
their nutritional demands enterally. Other challenges include the need
radiological investigations of the cervical spine, chest, and pelvis, and,
for total immobility following complex reconstructive surgery, such as
if intrabdominal injury is suspected, ultrasound or CT. The specific
repair of an oesophageal atresia. These patients will require intubation
investigations are guided by the clinical scenario and availability of
and ventilation over several days in order to maintain adequate sedation,
specialised imaging. Many intrathoracic and intraabdominal injuries
analgesia, and muscle relaxation. Finally, it is important that each
may be managed conservatively; however, some surgical intervention
child be regularly and adequately assessed for pain and distress so that
may be required. Bowel injury may present in a delayed fashion,
appropriate analgesia and/or sedation may be administered.
requiring surgery some time after the initial injury. Detailed surgical
Trauma management of specific injuries is beyond the scope of this chapter, and
Traumatic injuries are a cause of significant childhood morbidity and is addressed in relevant chapters of this book.
mortality worldwide. Children are particularly vulnerable to traumatic Challenges of Paediatric Critical Care
brain as well as major organ injury due to their relatively immature and The biggest challenges for health care providers in the developing
elastic skeleton and their inability to withstand large blunt forces. 65–67 It world include improving primary care and public health efforts, such
is paramount that the initial resuscitation and stabilisation of a critically as immunisation and sanitation, as well as ensuring universal access to
injured child be both methodical and thorough in order to recognise and health care. 71
institute appropriate therapy in a timely manner. In children who die The provision of critical care and the limited means available to run
immediately or soon after an injury, the predominant causes of death a dedicated critical care environment suitable for children from infancy
are airway compromise resulting in hypoxia, hypovolaemic shock, and to adolescence present an ethical dilemma when multiple health care
injury to the brain and cervical spine. Children are extremely vulner- demands coexist. In an attempt to address such dilemmas, certain units
able to cerebral hypoxia; it is therefore understandable that airway have developed intensive care admission criteria that would not exist
management and attention to respiratory function are the most critically in the developed world. Examples of these criteria include refusing
important aspects of resuscitation and ongoing management of the seri- admission to an augmented or critical care environment in patients
ously injured child. Attention to these areas of care enable optimal known to be infected with human immunodeficiency virus (HIV) as
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oxygenation and ventilation and minimise secondary injury to the brain well as refusing admission to a critical care environment in patients
and other vital organs. The cervical spine should be immobilised by who present acutely to a health care centre and would require transfer
using either manual in-line stabilisation or on a firm surface with the to the regional paediatric intensive care unit (PICU). This is particularly
neck placed in a hard collar of the appropriate size, with lateral support evident in sub-Saharan Africa, where there is a huge burden on health
using firm blocks and straps. These cervical spine precautions should as a result of the HIV epidemic. 61–62
remain until such injuries have been excluded clinically, radiologically, Approximately two million children worldwide have HIV; of
or both. With attention to the cervical spine, the airway may be secured these, 90% live in sub-Saharan Africa. Although the rate of annual
by simple airway manoeuvres, or require more specialised equipment HIV-related deaths in children is gradually decreasing, approximately
or intervention in the form of oral endotracheal intubation. 68