& KEGAWATAN PADA ANAK i Deaths in hospital often occur within 24 hours of admission = if very sick children aro > Identified soon after their arrival and > ‘treatment is started immediately could be prevented ‘Te Cone Eau toil Deaths 2006 found that 26% had avoidable factors associated with them, TRIAGE Check For emergency sign Children are the most vulnerable citizens in any society and the Greatest of our treasures Nelson Mandela: Nobel Prize ceremony, Oslo, Norway, 1993 Failure to Rescue Failure to rescue is defined as B inability to save patient's life by > Not recognizing deterioration > Failing to take action to reverse Absent present = —- Check for priority give signs or conditions EMERGENCY TREATMENT until stable. Child is not small adult Children have unique developmental characteristics » require assessment and a management techniques specific to the child's age. & change + Not SICK * SICK Stable potential unstable. UnStable Level 1 Resuscitative Level 2 Emergent ‘Level 3 Urgent ‘Level 4 Less urgent ‘Level 5 Non-urgent Systematic Approach To The Seriously Ill Or Injured ChildIdentify CATAGORIZE ILLNESS and SEVERITY RESPIRATORY Respiratory Distress Respiratory Failure CIRCULATORY Compensated Shock Decompensated Shock/ Hypotensive Shock stable Interverne GENERAL ASSESSMENT BRIMARY, ASSESSMENT Evaluate GENERAL ASSESSMENT PAT BRIMARY, ASSESSMENT ABCDE SECONDARY ASSESSMENT SAMPLE TERTIARY ASSESMENT LABORATORY _ TEST Not Life threatening Life threatening Continue with the + Start Life support systemic Approach interventions + Get help Evaluate mio. tran ween pprpite tons ggreat ine Identify problem Interverne ee Identify Type and Severity Of Potential Problems Respiratory * Upper airway obstruction + Respirator Distress lower airy obstuction + Respiratory Faire + puordered contrat of breathing Circulatory Hypovelemic shock Compensated shock arciogenc shock shock Hypotensive + Obert eck Shoot) Cardiopulmonary Failure Interverne Intervene with appropriate actions + Posi isthe child to maintain an open/patent airway + Activating the emergency response system + Starting CPR + Obtaining the code cart and monitor + Placing the child on cardiac monitor and pulse aximeter + Administeringo2 + Supoporting ventilation + Starting medication and fluids (eg. Nebulizer, V/10 fluid bolus) The Pediatric Assessment Triangle + The First quick"from the doorway” observation of the chile’s appearance, breathing and circulation + Help to identify the general type of physiologic problems » Appearance: the child’s mental status, muscle tone, and body position » Breathing : visible movement at the chest or abdomen and work of breathing; » Cireulation: the child's skin colarPEDIATRIC ASSESSMENT TRIANGLE EGITIGA PENILAIAN PEDIATR ‘The general observational assessment three ciel ouesions (i) severe ear ws or (2) Ura me most ty shyslcal (2) Wate gnc for restore Circulation Nilai Appearance * Moves spontaneously + Resists examination + Sits or stands (age appropriate) * Appears alert and engaged with clinigian tracts with people, environment aches for toys, objects (eB, penlight) * Stops crying withholding and comforting bycaregver » Tone > imeractiveness 7% Consclability «a diferential response to caregiver * Makes eye contact with clinician > loskime [pacha vsealy 5 + Was strong ey 7 Seeechlery |. Uses age-appropriate speech Evaluation of Work of breathing Normal Abnormal Regular 7 Nal flaring Breathing, * Retractions or use of no increase effort | accessory muscles Respiratory | sie expiration |+ increase, ore inadequate, or absent respiratory effort Lung and | Noabnormal_|+ Noisy Breathing (ex respiratory Wheezing, grunting, airway soundsaudible | stridor) sounds circulation Evaluate > Skin and Mucous Membranes Normal | Abnormal > Pallor + Motling + cyanosis: Appears > Skin color | APPR > Petechiae or ‘Obvious significant melt | wot ileeangSedng 7 normal within the skin ( eg. aon) Purpura, petechiae oe . “SEGITIGA PENILAIAN PEDIATRIK (PEDIATRIC ASSESSMENT TRIANGL SIRKULASI KULIT Nilai > Work of breathing > Abnormal | Atered speech, airway |, Seen sounds | grunting > Abnormal |" Hse bobbing, + node positioning |: Suzan Retr ott dinding dada, > Retractions |+ supractavcula + intercostal or substernal > Flaring |" Nass! Fling Relationship of the PAT Components to Physiological Categories a ee Respiratory Respiratory Dissres Failure aa Normal Normal Abnormal Work of breathing --Normal_—Abnormal Abnormal Circulation Normal Normal Normal/ tothe skin AbnormalRelationship of the PAT Components to Physiological Categories ape component fongennted Sgr Hypotensive as oie ‘Normal ‘Abnormal Wake ey Noemi ermal EET jonto Abnormal: skin Findings of the PAT used to Form a General Impression of the Respiratory Physiologic State Seneral _Appeerance Work of Creation to Impression Breathing the skin stable Nowmal Normal Normal Respiratory Normal Abnormal——‘Normal Distress Nasal fae Gating Stidor Wheeing fetratons Respatory abnormal abnormal Normal? Faire Sonormal Management Priorities by General Impression (PAT| (General ren feet + Spleen orn as rede attr em cramneeprerie ne) Respiratory distress ein the heat snsopenthe stv * laboratory androgens hates Management Priorities br General Impression (pary eo Corts sec) ‘Specific therapy based on posible etiologies caramels Relationship of the PAT Components to Physiological Categories Component CNS/ Cardiopulmonary ‘Metabolic Failure Dysfunction eee Abnormal Abnormal Work of breathing Normal Abnormal Circulation tothe Normal ‘Abnormal skin Findings of the PAT used to Form a General Impression of the circulatory Physiologic State ‘ssesmont Normal ‘Componsated_Decomponsatod Er eee a one Dee] Seat ete eel eee creer Sidr lowers = sya (eens) Hy roveatie Management Priorities by General Impression (PAT) Coy erred ae fo Ea ‘Shock : Becinhtreacatin ot ‘ Jeompensated —/” Srroiessrpesieauatanfor tour meets + rode onsen Sota accese rpm rencsetion + Spe therapy based posible ticles Serica bast teins, ‘ardowrionh m + Ubrtery ar reiogaphe evation as rates After completing the Triangle, if the child is determined not to need CPR ‘begin a more complete assessment ‘> pediatric primary survey. sw Xe, —_ é Abrief, hands-on EF decoesssesnentot > ee & tetragonal EF stabity DISABILITY+ In pediatrics, normal respiratory rate, heart rate, and blood pressure have age-specific norms > can be difficult to remember 4 Che's respratoryrte shouldbe <60 breaths/min for 3 sustained period; 2. Normal heart ratels roughly 2-3 times normal respiratory ratefor age: 3. Asimple glde for pediatric blod pressures that « + Look for movement ofthe chest oF abdomen + Listenfor aie movement and ‘as gurgling, snoring, grunting, or stridor + Feel for air movementat the child’s mouth or nose | Airway Is The patient able to speak or cry ? * If you can see movernent and hear normal breath sounds, the airway is patent (open) * Vocalization, speech, crying, or coughing indicates 2 patent airway, although partial obstruction may be present s Upper Airway Status and Description fa Pn Clear Away apen an unabsrcteaor era benting Imartane by simple measures (Se Henson) Intrverton fp ntbaton Airway * Gurgling sounds may mean that there are secretions or blood that must be suctioned, + Stridor or snoring may mean that the tongue, secretions, or a foreign body are partially blocking the airway Airway The Signs Sugest That The Upper Airway Is Obstructed Increased inspiratory effort with retraction > Abnormal inspiratory sounds > Episodes where no airway or breath you cannot hear or feel Breathing, Management as Respiratory Emergency Airway | Ifyou see > Increased inspiratoty effort with deep retraction > you cannot hear or feel breathing, the airway is completely obstructed — Management as Respiratory Emergency| Breathing eee, Evaluation of respiratory i » performance > Respiratory rate, regularity and patern > Respiratory effort > Chest expansion and air moverent > Lung and airway sounds 02 Saturation by pulse oximetry Breathing + Work of breathing PLook and listen for signs that indicate increased work of breathing “+ Retractions, * Stridor, a high or low-pitched + Nasal flaring + Wheezing, ‘Head bobbing + Grunting, + Gurgling, I Breathing * Rate ai Neonate Infant (1 mo~1 yr) 25-50 Toddler (1-3 yr} 24-40 Preschooler(3~6 yr) 22-38 Schoobage (6-12 0) 18-30 Adolescent (12-18 yr) 22-16 fri can show ates ofetween 33nd 80 eats! min depending tthe stot echo. + WHO: eeutet ot ooreaths/ inte preumona inant end yungchiren*= | Breathing * Depth and pattern ¥ Note shallow depth, which indicates decreased work of breathing. ¥ Watch for irregularities in the breathing pattern, including opneo, in which breathing pauses for atleast 15 seconds. Y Watch the chest wall for equal movement on both sides and equal time spent inhaling and exhaling Breathing | If The Child Is Able To Breathe Spontaneously ‘> EVALUATE *+ Work of breathing and breath sounds + Respiratory rate + Respiratory depth and pattern + Central color at the lips and tongue * Breath sounds on auscultation with a stethoscope + Signs of chest trauma, if present Breathing | Stridor and wheezing are signs of respiratory distress Grunting is also a sign of severe respiratory distress or respiratory failure. > Crackles are caused by fluid in the lungs and ‘may accompany pneumonia or asthma. > Gurgling may indicate secretions that require suctioning > Gasping this isa sign of severe hypoxia and ‘may be pre-terminal Breathing | + RATE by counting the numberof mes thechest or abdomen ses and falls 1 tnchidren pal, fear, o fever ean nctease the respirator ate; ¥ inmeonates, exposure tocol can inrease the ‘espirator ate and may cause espatory dstess. Y_—espirator rates that are very fast or very slow can ead tow blood oxygen eves Breathing + COLOR Y Check the color of the lips and tongue. ¥ Pink is normal. ¥ Apale color at the lips and tongue isa sign of respiratory distress or respiratory failure, ¥ A cyanotic colar indicates low blood oxygen, and is 2 sign of respiratory failure for respiratory arrest In childrenT Breathing + Auscultation ¥ compare breath sounds of the right and left lungs tosee if they are equal, ¥ Since children have small chests, you should place the stethoscope near the armpits rather than the nipples when listening for breath sounds. This minimizes the possiblity that sounds are being transmitted from one side ofthe child's chest to the other |< Circulation » / Evaluation of Perfusion performance Recognition of potential circulatory failure esrtrate and hth Pues (bth perp an cena) Breathing | + Respiratory Mechanics * Head Bobbing * Nasal Flaring = Retractions = Grunting + Stridor ‘+ Wheezing or Prolonged Exhalation Circulation + Evaluation of » Perfusion performance ‘+ Recognition of potential circulatory failure create eat a th Fuse bot prea ana cent) |<) Circulation + Evaluation of Perfusion performance » Peripheral puise > Capillary refill time Skin color and temperature Respiratory system > Mental status > Urine output © Circulation Pulse > Compare the peripheral pulse tothe central pulse. A peripheral pulse thats weak, iregulr, or difficult ‘topalpate may indicate poor | perfusion, + asign of shock beeing Cm Trecaenae (a 5 Prem) = Terenas + Mapestr one iad tet Plone topot rates © Circulation ‘Normal ood Pressure fr children 0 28 ay FT 20 2-1 me 270 int0y 70 + 2a3geiny >a0y >20Brachial pulse check in infant temperature and moisture * Estimate capillary refill Pressure for 5 seconds, capillary refill should occur within 2seconds Carotid pulse check in child yn TABLE 4 ORCULATORY ASSESSMENT F¥OINGS FoR PEDIATRIC SHOCK "essa __ Nama Cpe Deegan Matas Nom Fat Vetter ‘enaube Nama Nama Pendle Noma Weak ‘Sieve ee Nema mal pyc series ane ‘Sinierpwate Noma oat Giplayl Damm Ese a Namal HomeloanDisability Quick evaluation of » Neurologic function > Mental status/ conscious|evel > DISABILITY AVPU - GCS > PUPILS > POSTURE | Exposure Focus to physical Examination Lookfor + Bleeding ‘evidence of + Burn frauma + Unucualmarking suggest onacldenta trauma Look ofthe + Petechiae presence nd + Purpura Progression + rashes ssnytorme Temperature pn 08 Oh » eoare [The whole assessment should take less than a minute, SAMPLEHIstory + sions and symptomstdfcuy breathing 18 min after eating 2 cookie + alleries: Peanuts + Medicetions: None ~ Past medical history: presiously heathy + Lost meoshad only a cook since breakfast + Events: eifclty of breathing began within several min of eating cookie summary: the rapid clinical assessment of an infant or child Stowe Scary + batty + ene [The whole assessment should take less than a minute, ‘res Beatie onsereston oe cence beg soie hove teen ca raft unnganeon can Secondary Assessment Focused history + Signs and symptoms + Allergies + Medications + Past Medical History + Last Meal + Events Focused physical examination Ongoing Reassessment tertiary Assessment Diagnostic Tests + Assessment of respiratory and circulatory abnormalities ABG, electrolyte, Hb, Leucocyte, Blood sugar Pulse oximetry, Chest XRay, Capnography (ETCO2], exhaled COZ arterial lactate 2DEcho, ECG, rm PaO boven conf Adeaate BoodOz cortePediatric Early Warning Signs Causes of breathing dificult in children, according to mechanism Clinical presentations of the child with breathing difficulty Respiratory conditions can present with respiratory ‘symptoms or symptoms within other systems: Respiratory Non respiratory Teneo Nosy reathing (ior or wheeze) Fer easing Change in oleurorconscous etl