RECOGNITION OF A SICK CHILD

Children are not simply "Miniature Adults

 Bones are much more likely to bend than break.

 Tongues take up a larger percetage of their oral cavities.

 Airways are sufficiently narrow that even slight inflammation can cause
distress.

 Blood volume-which is significantly smaller than that of adults-is another

differentiator.

EARLY RECOGNITON OF CRITICAL ILLNESS AND PROMPT TREATMENT

CAN SAVE LIVES
The initial assessment will answer the question

Sick or not sick?

Early recognition and management of potential respiratory, circulatory, or central

neurological failure will reduce mortality and secondary morbidity

SICK CHILD
Critical illness or sickness is a clinical state that may result in respiratory or cardiac
arrest or severe neurological complication if not treated properly.
CARDIOPULMONARY ASSESSMENT
 Initial impression(Hands free): Appearance

Breathing,

Circulation

 Primary assessment: ABCDE assessment

 Secondary assessment Focused history,

thorough physical examination

 Diagnostic tests: Lab tests,

radiology etc.
 0 1 2 3
CARDIOVASCULA Pink or capillary refill Pale or Gray or Gray or
1-2 second capillary capillary capillary
R refill 3 refill 4 refill > 5
second seconds seconds

Tachycardia Tachycardia
of 20 above of 30 above
normal rate. normal rate
bradycardia

RESPIRATORY Within establish >10 above >20 above <30 above

baseline. established established established
baseline. baseline baseline
No retraction room
air Mild Moderate Severe
retractions retraction retractions
up to up to 4l/min grunting up
2l/min or or 40% to 5l/min or
 30% 50%

BEHAVIOR Playing/appropriate Lethargic or

or sleeping confused

Reduced
response to
voice or pain

PEDIATRIC EARLY WARNING SCORE

 General examination is the most important part of physical examination
begins the moment the clinician sees the patient.

 Young children are unable to verbalize their complaints-so evaluation by a

health care provider depends upon general and specific features.

PEDIATRIC EARLY WARNING SCORE

 Many of early signs of distress are subtle-early recognition can
increase the likelihood that timely intervention will be successful and more
serious disease progression will be prevented.

 A PEWS score >= 3 should prompt an escalation in care, such as

information senior staff, increasing the frequency of vital sign checks and
clinical assessments, and/or transfer to an ICU.
APPREANCE

 Unresponsive
 Irritable

 Consolable

 Non consolable

 Alert

APPEARANCE

UNRESPONSIVE
Circulation to skin
 Bad sign

 Pallor

 Mottling

 Cyanosis

 Petechiae

 Purpura
(In children with dark skin tones look at the lips, tongue, palms or soles)
Rapid cardiopulmonary assessment
(Time is of essence!)

Quick head to toe examination is essential

"Treat as you go"

Airway

 Use look, listen, feel

 Any adventitious breath sounds including hoarseness, cough, stridor,

snoring, or gurgling sounds.

 Status

 Clear

 Maintained by simple measures

 Needs advance measures (Call for experts)

Breathing
1.Respiratory rate

2.Respiratory effort

3.Chest wall expansion

4.Lung and airway sounds

5.Pulse oximetry

Breathing

RESPIRATORY RATE
 Tachypnea is the first sign of respiratory distress

 Bradypnea is more ominous than tachypnea

 RR above 60 or below 10 at any age group: Significant

Breathing
RESPIRATORY EFFORT

 Nasal flaring

 Retractions

 Sea-saw breathing, head bobbing

 Retractions with stridor: Upper airway obstruction

 Retractions with wheeze: Lower airway obstruction

 Grunting: Lung tissue disease

BREATHING
Chest wall expansion
 Chest wall expansion and air movement

 Look for symmetrical chest rise

 Auscultate to listen air entry in distal areas of lungs

Breathing
Lung and airway sounds

 Stridor

 Grunting

 Gurgling

 Wheeze

 Crackles

Breathing
PULSE OXIMETRY

 Oxygen saturation (sPO2)>946 in room air: Adequate oxygenation.

 SPO290% while on 100% oxygen Additional interventions

required.

RESPIRATORY INSUFFICIENCY:
CATEGORISATION BY SEVERITY
DISTRESS FAILURE
Tachypnea Marked

Tachypnea/bandypnea Apnea
Tachycardia Bradycardia
Increased work of breathing Increased or decreased work of
breathing
Abnormal airways sound Cynosis
Altered sensorium

Cardiovascular assessment
 Heart Rate (ECG rhythm)

 Central and peripheral pulses

 CRT (capillary refill time)

 Core to peripheral temperature difference

 Urine output

 Blood pressure
(Normal blood pressure and a strong central pulses maintained in compensated shock.)
 CARDIOVASCULAR ASSESSMENT

BLOOD PRESSURE

HYPOTENSION
AGE SYTSOLIC(mmHg)
Term Neonates(0-28 days) <60

Infants(1-12 months) <70

Children 1-10 years 70+(age*2)

Children >10 years <90

Cardiovascular assessment

Urine Output
 Indirect indicator of cardiac output

 Indicates kidney perfusion

 Helps to monitor response to treatment

Cardiovascular assessment
CIRCULATORY INSUFFICENC CATEGORIZATION BY SEVERITY

COMPENSATED HYPOTENSIVE
Tachycardia BP below 5th centile
Cool pale skin Change in mental status
Delayed CRT
Weak peripheral pulses
Narrow pulse pressure
Oliguria

Disability
  Quick evaluation of cerebral cortex & brainstem

 Evaluate during Primary as well as Secondary Assessment to monitor

changes in neurologic status:

 AVPU

 GCS

 Pupillary response to light

(Continued spinal Immobilization with trauma patients)

AVPU Pediatric Response Scale

Alert Child is awake , active and response

Voice Child responds only to voice

Painful Child responds only to painful stimulus, such

as pinching the nall

Unresponsive Child does not respond to any stimulus.

Causes if deceased consciousness:

 Poor cerebral perfusion

 Traumatic brain injury

 Encephalitis, meningitis

 Hypoglycemia

 Drugs

 Hypoxemia
  Hypercarbia

EXPOSURE
Undress as appropriate

Avoid exposure to cold environment

Look for deformities/bruises/bleeds/fever or hypothermia

PRIMARY ASSESSMENT CLASSIFICATION OF SEVERITY

Respiratory insuffidency: Respiratory distress/failure

Circulatory failure-compensated or hypotensive

PRIMARY ASSESSMENT CLASSIFICATION OF TYPE

IDENTIFY
Type Severity
Upper airway obstruction Respiratory distress

Lower airway obstruction

Lung parenchymal disease

Disorder control of breathing

Hypovolemic Compensated shock

Distributive Hypotensive shock

 Cradiogenic

Obstructive

SECONDARY ASSESSMENT
Focused history

Focused physical examination

SECONDARY ASSESSMENT FOCUSED HISTORY, EXAMINATION

 Symptoms

 Allergies

 Medications

 Past history

 Last meal

 Events leading to the present problem

DIAGNOSTIC TESTS
Appropriate Laboratory investigations/Radiology

MANAGEMENT PRIORITIES
Depend on the physiological status
  Stable

 Respiratory distress/failure

 Circulatory failure-Compensated/Hypotensive

 Cardiopulmonary failure/arrest

PRIORITIES OF INITIAL MANAGEMENT

RESPIRATORY DISTRESS RESPIRATORY FAILURE

Keep with the caregiver Control airway
Position of comfort 100% fio2
Oxygen as tolerated Assist ventilation
Nothing by mouth Nothing by mouth
Monitor pulse oximetry Monitor pulse oximetry
Consider cardiac motor Consider cardiac monitor
Establish vascular access

PRIORITIES OF INITIAL MANAGEMENT

 Shock

 Administer 100% oxygen and ensure adequate airway and ventilation

 Establish vascular access

 Provide volume expansion

 Monitor oxygenation, heart rate, and urine output

  Consider vasoactive infusions

Initial Stabilisation

Things recommended at all practice locations (hospital or private practice

clinic:

 Oxygen source and mask

 Bag mask valve device (Ambu)

 Intubating equipment

 Intra-osseous needle

 IV cannula, IV fluids, Emergency drugs

 Suction

 Pulse oximeter

 Nebulizer

Do the following regardless of diagnosis

  Start oxygen

 If Respiratory distress

 Ensure airway

 open by head tilt chin lit

 Jaw thrust

 If not maintainable intubate.

 If cannot intubate ventilate with bag and mask

 If not able to maintain with bag and mask the use LMA

TAKE HOME MESSAGE

Rapid cardiopulmonary assessment & appropriate initial treatment improves
survival in critically ill children.