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Today, we're going to concentrate on intensive care. So I try to highlight some differences between adults and Children will assume some basic level of competence is from here representing the pediatric Blast Injury partnership. And there's a lot of detail in the intensive care chapter. So I'm not going to go into lots and lots of details trying to keep it verity, very general critical care and critical illness of a vague terms. And we can think of critical illness as a state of ill health with organ dysfunction and a high chance of death if care is not provided. So when we think about critical care, we think about identifying monitoring and treating patients with critical illness throughout both the initial phase and that sustained support through their supporting their vital organ functions. And so when we think of when I think of critical care, I think it is a system of the care um that from Kam patient's when they first present with critical illness all the way through there on this, from the time of the first contact all the way through to the resolution. And so we have to think of critical care as it's wider concept of acute care that takes, takes into consideration, prehospital emergency care, trauma, surgical care, intensive care and ward care. Per purpose of this talk, we're going to concentrate just on uh intensive care. This component here, when we think of critical care and trauma, there are five main facets to providing intensive care in a pediatric trauma patient. The first is providing organ support as well as close monitoring interventions that aren't available on award we might be able to on in an intensive care, provide complex pain relief that might not be available on a normal ward as well as monitoring for signs of ongoing hemorrhage. And we can have that closely Asian with surgical teams in high risk. Pediatric patient's two other important facets of ICU care in pediatric wrong patient's are one that the patient's can be closely monitored for signs of infection and appropriately treated with antibiotics early. And finally, we can treat and recognize those abnormalities that we know are common in pediatric trauma, patient's and worsen their outcomes. So we can treat um and recognize early. So before we think about intensive care in itself, how do Children, different adults, I think it's just worth touching upon that and some of the challenges that are unique to Children in pediatric trauma. So there are many challenges as we all know in pediatric trauma, they conclude that the child obviously has different anatomy and different physiology with different exposure risk. And so a toddler may have different injuries to an adult hit by a car. For example, Children are clearly not a uniform demographic. So we have, you know, a one week old neonate up to a 16 year old child, obviously present different challenges and pain management can be often insufficient um in Children because it can be difficult to recognize and clearly, pediatric intensive care is costly. Pediatric injuries can have a longer term impact. Um and the child and they're obviously the human factors involved as well in intensive care. We keep, we try and keep things very simple. And so we assess the patient in a systematic way through airway breathing, circulation disability. We then go on to electric, consider their electrolytes and fluids, the gi tract, the hematological blood results and then any signs of infections and it means we look at the whole patient and hopefully don't miss anything. One of the standard teachings is that a child is not a small adult. We all, we all learn that as we go through medical. Um and whilst this can be the case, clearly, a two week old child has different anatomy and physiology to a 50 year old. They are still human, they are still, they are not an alien or a small crocodile in this case. So if you can treat an adult, you can treat a child. So uh as we intensive care is a massive subject, so I've tried to condense it down into an ABC approach and we're going to concentrate on those Children that are the most unwell and perhaps those that people are most uncomfortable looking after. So, in intensive care, we commonly have Children that are intubated. There are a guide as to what size of tube to use and where to secure it. And the reason to put uh trickle tube down is one to seal the trachea. So that pressure is unable to escape. And and the second reason why having a cuff tube is important is to make sure it seals the airway. So that material above the glottis doesn't enter the trachea. But in terms of housekeeping, when you're managing or caring for a child in intensive care that hasn't trick your tube. One of the most important thing is to ensure that the tube is well secured and this can be either with tapes or with ties or a special tube holder. Um It's important to ensure that the tube is in a good position on checks, chest X ray. But also to remember that the position of the tube can change as you move the patient's head. The teaching now is to use cuffed, track your tubes. And it's important that we regularly check the cuff pressure because we want to prevent damage to the trachea. It's important we suction when clinically indicated you should only suction for a shortest period of time. And we put the patient in 100% oxygen before we do so to prevent them desaturating. So, thinking about breathing issues in intensive care and one of the commonest issues that you'll have to deal with is a patient that's desaturating. And so as a monitor screen, like this is not uncommon. And in a pediatric trauma patient, the patient could be desaturating for any number of reasons. So it's important to have a systematic way to assess these patient's typically this could be bronchospasm, it could be secretions. Um it could be a pneumothorax or paul me hemorrhage. So chest X ray and ultrasound, if you have the ability is important to help you rule out urgent life threatening conditions like pneumothorax in this case. And so a pneumonic or a way of approaching a hypoxic patient in intensive care is D O P dope. So the end of trickle tube could be displaced or dislodged. Um it could be obstructed, there could be a pneumothorax or there could be issues with the equipment such as the ventilator. So, working on these um causes helps you determine what might be wrong with your desaturated patient. Why might we decide to ventilate a child with trauma? There, there are many reasons and the goals of ventilating a child are, there are four main goals and put simply it's to get oxygen in, get carbon dioxide out. We want to minimize any adverse effects. And lastly, we want to maximize patient comfort. So, in trauma, we may decide to ventilate a child of humanitarian reasons such as they might need lots of surgeries in a short paste, short period of time. They may have traumatic brain injury and a reduced level of consciousness. Um They may have severe hypoxia or work of increased work of breathing or cardio vascular compromise. And our goal is to try and reduce option consumption. There are lots of different ways to ventilate Children. We could use pressure control ventilation or BIPAP or S I N V. These, these are some standard settings that we would routinely use in Children and we tend to prefer pressure modes in Children. The advantages of that are that they tend to have a more stable mean airway pressure. The pressure modes tend to be better because they have a stable mean Al Viola pressure and they have a longer duration of uh recruitment of the Al Viola and we can protect against burrow trauma. We're very conscious in intensive care that we want to minimize harm. And we know from adults and Children studies that having these parameters limit lung injury as much as much as possible. And we commonly use peep because it helps recruit a Viola I and may result in just using lower oxygen. Commonly, patient's can get a ventilated, acquired pneumonia and we define a VAP or a ventilated acquired pneumonia as a pneumonia that a child gets after being on a ventilator for two days. And we, we try and recognize and treat this early because we know that if it's untreated, the patient's spend longer in intensive care and have worse outcomes. So, there are, there are five key elements to trying to prevent ventilator acquired pneumonia. We keep the bed, the head of the bed elevated. We do good oral mouth care. We keep a close eye on a cuff pressures and we ensure that we have good airway suction technique. So once we've treated that child, and we, we think they're getting better. How do we know when the time is right to take the tube out? One of the most important thing is resolution of the underlying reason why the child was intubated in the first place. So having checklists, um such as this are good because it helps us determine whether the patient is ready to be extubated. And commonly patient's will receive dexamethasone because of worries of airway swelling. So we're going to briefly touch upon cardiovascular issues. As we said, Children aren't say uniform demographic. And so one of the reasons intensive care is hard is because the observations are so different and differ so greatly. So one of the things we we want to treat uh and recognize in intensive care is the presence of shock, there are many different definitions of shock, but essentially, it's the failure of the body to uh deliver oxygen to the cells. And we know from experience and research that the faster we reversed the shock, the better outcome Children have. And in a trauma patient, a pediatric trauma patient, Shaq can be from any number of these causes. So it's important when we manage our patient's on ICU and we're doing a systematic assessment when we come to see, we consider these features. So in a patient that is shocked in a trauma patient that shocked the first thing you clearly think about is hemorrhage control. And so as intensive, it's the first thing we would do is ask the surgeons to attend as soon as possible. And in the meantime, we would manage their airway and breathing in order to optimize their oxygen or to reduce our auction consumption, but to maximize their auction delivery. So if our patient's were demonstrating features of shock, which we know may manifest by tachycardia, delayed capillary, refill, hypertension, poor urine output, metabolic acidosis or arise and lactate on the blood cast. So the first thing we might do is deliver a fluid bolus. And then in an ideal world in a trauma patient, a first fluid bolus would be with blood. And depending on what you have available, you would either give whole blood or if we didn't have whole blood, we would give pack cells in a ratio to plasma and two playlets in a 11 ratio. And it's always important to them reassess after you've made an intervention. So reassess those clinical parameters we touched upon. If there are persisting signs of shock, we may need to come onto ionotropic support. So things like adrenaline or nor adrenaline, we haven't got time to go into the transfusion policy or massive transfusion policy. We would give five mils per kilo of blood. And we're aiming to maintain a radial pulse. And as part of our policy, our transfusion policy, we would also give trans anaemic acid as well as calcium. Another common cause of hypertension or shock in intensive care is sepsis. And if we suspect sepsis, we should ideally take a blood culture and then administer broad spectrum antibiotics as quickly as we can. An antibiotic choices dependent and guided by local protocols and availability in septic shock. As you know, they may need a lot of fluid i inotropes to treat the hypovolemia, the myocardial depression and the inappropriate visa dilation. And every time we make an intervention, it's important to reassess. So when we think about using inotropes, we can commonly start them proliferate. We don't have to start them centrally. So if you're worried about the patient's start them through a political cannula first and you can think about then inserting a central line. Um later on, once a child has some stability, there are guidelines available on the web about the concentrations to use fluids, prescriptions or fluid requirements. In Children are intensive care are an important consideration when managing these patient's. There are lots of lots of features to consider when prescribing fluids and clearly the enteral route for fluids and nutrition is preferred when it's safe and clinically appropriate fluid requirements for Children vary greatly. So for a term neonate, we would prescribe up to 100 and 50 mils per kilo per day. Whereas a 40 50 kg teenager would have same as an adult. So two liters a day and we often prescribe fluid as, as a percentage of full maintenance. So we would prescribe fluids as a percentage of what they would normally have when. Well. So an an intensive care patient may have high uh anti diuretic hormone secretion because they're ventilated, they have let fewer insensible losses. So they don't need as much fluid as when they're well. So we would commonly prescribe two thirds or 70% maintenance, but it's important to reassess them based on their heart rate, urine output, cat refill. And the other things, other parameters we've mentioned there is a lot of evidence and discussion about which fluid to use. But clearly, this is based on what is available and what is feasible. What is important to remember is that we try and start fees as soon as possible because that's the safest way to rehydrate these patient's, we're going to talk a little bit about sedation in intensive care. Again, this depends on local availability. Um and cost in general, uh we propofol is not licensed for continuous sedation in Children in intensive care and this is due to the risk of profile infusion syndrome. But if you have a child that is cardiovascularly stable. And you think they're only going to be intubated and ventilated for 48 hours. It's reasonable to use it in general. Our first line agents are more from Midazolam. It's important as part of intravenous pharma logical agents. We think about non pharmacological interventions. So these are there are there are many ways to sedate Children. We have intravenous methods as seen here. It's important to start introducing enteral sedation and analgesia early. So we can reduce the IV agents. But not only are there, pharma logical interventions. There are non pharmacological interventions as well that we can use. And it's important when we are sedating a child that before we go up on their uh sedation, that we rule out other causes of pain or agitation such as, you know, a full bladder or the patient is hypoxic or um their sleep deprived. So we can use something called a sedation school. And these allow both the physicians and the nurses to determine how sedated they would like the child to be. And clearly, the sedation score depends on upon uh the underlying condition of the child and where they are in their disease process. So for a child that has just come in uh to intensive care, that's very sick, we'd probably want them very deeply sedated as compared to a child that were just about to extubate. We'd want them at sedation score one or two. And so we briefly spoke about non pharmacological interventions. And so we would consider things such as trying to encourage the patient to have normal sleep patterns, minimizing light and noise and making sure the family close by talking to the child and reassuring them. So, and finally, we're just going to briefly touch upon exposure issues and intensive care. So one of the one of the common things that we see in trauma, patient's um is something called the trauma tried, which is a combination of bagel opathy, acidosis and hypothermia. And also, and also we should really consider um you know, hypocalcemia as well. And all these three features together um make the outcome of the child worse. So our role within the intensive care is to ensure that we treat each one of these separately and together. But more importantly, we want to prevent them. So there are a few key dues and do not in intensive care when dealing with the patient and the patient's family. It's important, it's important to make contact and so introduce yourself by name and who you are and ask her child's name. Uh It's important to stay calm and help the parents to stay calm and trying to communicate with Children in ways they understand. And obviously, it's important to try and support the child's caregivers. We we try not to give false reassurances or promises to Children or their caregivers when dealing with Children that are dying. It's obviously a very difficult time for everybody. And it's important to keep what, what is best for the child in the forefront of everybody's mind. It's important to show compassion to the family as well as the staff and to have family involvement early and to know what they're wishes are going forward. So, intensive care is a massive subject. You've had a very, very quick uh whistlestop tour of basic contents of care and to summarize when we're doing, when we're looking after a patient in intensive care, a systematic approach from A B C D E F G H I is important. It means we um consider the whole of the patient and minimizes our chances of missing anything. And so today, we've briefly spoken about the importance of uh injured, kill g position and, and the importance of securing it appropriately. We've briefly touched upon how to approach a patient that is hypoxic on the ventilator using the dope assessment. And we've briefly talked about ventilator modes and how we might limit our patient's getting value, trauma and ventilator choir pneumonias. And we've briefly spoken about the criteria that we would look at when a patient is ready to be extubated. When we consider the cardiovascular issues in intensive care. The most important thing if a patient is shocked if a trauma patient is shocked is to rule out hemorrhage. And we know another common um ause of shock is sepsis. We've mentioned that there are lots of resources to help us with transfusion and fluids and feeding. And when we come on to assess disability, um uh in a patient, we have touched upon sedation and we've talked about the importance of trying to prevent the trauma triad, making sure we keep the patient warm, not acidotic and preventing regular opathy. And finally, and perhaps most importantly, um ensuring that we involve family um and the child as our in our care going forward.