Assessment to sick child in emergency department of pediatrics

1. Assessment to a sick child
Presenter:
Dr Subodh Kumar Shah
1st year Resident
Pediatric
Moderator:
Dr Sandip Kumar Singh
MD pediatrics
Fellowship in Pediatric critical care
Assistant professor

2. Objectives :
 To understand the structured approach to the recognition of the
seriously ill child .
 To learn a rapid clinical assessment sequence{ Pediatric assessment
triangle } to identify serious illness in a child .
 Know the ED management of Common Pediatric Emergencies.

3. Physiological differences between children
and adults
Airway In children <8 years of age the head is proportionately larger and the neck
shorter
The trachea in infants is also more malleable, and with the large tongue can
result in airway obstruction if the head is overextended
Infants <6 months are obligate nasal breathers
The epiglottis is horseshoe shaped
Breathing Small diameters throughout the respiratory system increase the risk of
obstruction
Infants have ribs that lie more horizontally and they rely on the diaphragm for
breathing
Increased metabolic rate and oxygen consumption contribute to higher
respiratory rates

4. Circulation Small stroke volume but a relatively higher cardiac output facilitated by
higher heart rates
Stroke volume increases with age as heart rate falls, but until the age of
2 years the ability of the pediatric patient to increase stroke volume is
limited
Systemic vascular resistance is lower
The circulating volume to body weight ratio of children is higher than
adults at 80–100 mL/kg but the total circulating volume is low
Others The surface area is high, and this results in rapid heat loss
Glycogen stores in the liver are limited and hypoglycemia can be present
in any pediatric patient that has been too ill to feed or with high
metabolic demands

5. Systematic Approach to a sick child :
In order to recognize the sick baby or child a structured
assessment is required.
• The initial Impression (appearance, work of breathing, circulation to skin)
• Primary survey including ABCDE
• Secondary survey( focused history and physical exam)
• Diagnostic tests

6. YES NO
Initial impression
[Appearance ,work of breathing ,circulation]
Does the child need Resuscitation [CPR] ?
Evaluate
• Primary assessment
• Secondary assessment
• Diagnostic
identify
intervene

8. Pediatric Assessment Triangle:
The pediatric assessment triangle (PAT) is a rapid assessment that relies on three observations to
quickly identify a child with respiratory or circulatory compromise, or both, who requires immediate
supportive care

9. Appearance:
Appearance reflects the adequacy of oxygenation,
ventilation, brain perfusion and CNS function.
Characteristics of a child's appearance: TICLS
 Tone: what is the infant’s muscle tone?
normal - vigorous movement and normal muscle tone.
seriously ill – limp or abnormal muscle tone
 Interactiveness: Is the child playful and interactive?
 Consolability: consoled or distracted by a parent or caregiver?
 Look/Gaze: unfocused or stare look- abnormal mental status
 Speech/cry:
weak cry?
hoarsed or muffled voice suggest upper airway obstruction

10. • A child who is alert, easily consolable when crying,
has good muscle tone, and responds to a
caregiver is unlikely to be critically ill.
• On the other hand, the clinician should be very concerned about an
infant who is limp, not interactive, listless, and has a weak cry.

11. Work of Breathing :
RR: abnormal rate, Abnormal airway sounds:
Work of breathing reflects child’s physiological
compensatory response to cardiopulmonary stress.
Characteristics of (work of breathing):
• RR: abnormal rate
• Abnormal airway sounds: stridor, wheezing or grunting
• Abnormal positioning: head bobbing, sniffing or tripoding
• Retractions: use of accessory muscles intercostals, subcostal and
supraclavicular
• Flaring: nasal flaring

12. Circulation to the skin:
Circulation to skin reflects the overall status of circulation to vital
organs(heart, brain, kidneys).
• Characteristics of circulation to skin:
• Pallor: white skin coloration from lack of peripheral blood flow.
• Cyanosis: bluish discoloration of skin and mucous membranes.
• Mottling: patchy skin discoloration due to vascular instability or cold.

14. Review of initial impression
• Assess on Entry by rapid visual and auditory assessment(PAT),Only few
seconds.{30sec}
• Appearance.
• Work of breathing.
• Circulation to skin.
• Overall Purpose of PAT ( to decide whether sick or not sick)

16. What is next ?
• Primary survey
• Secondary survey
• Diagnostic

17. Primary survey:
• A rapid hands-on ABCDE approach to evaluate respiratory, cardiac,
and neurologic function of a sick child regardless of complaint.
Components of primary survey:
• Airway
• Breathing
• Circulation
• Disability or neurological status
• Exposure

18. A : Airway Assessment:
The goal is to assess:
 if the airway is patent or if there are signs of obstruction (eg. stridor,
dyspnea, hoarse voice).
 Is the airway noisy (eg. snoring, stridor, wheeze, grunting or hoarse
speech)?
 Determine if the airway is patent, and able to be maintained with
positioning and suction, or not.
 If cervical spine injury is suspected, manually stabilise the head and
neck in a neutral, inline position (jaw thrust without head tilt
maneuver to open the airway).

22. B: Breathing and ventilation:
The goal in assessing breathing and ventilation is to determine
whether there is adequate gas exchange.
 Will the child lie flat? Are they in the tripod or ‘sniffing’ position?
 Are accessory muscles being used (head bobbing in infants)? Or is there minimal
movement of the chest wall?
 Is there sternal, supraclavicular, substernal, or intercostal recession present?
 Is nasal flaring present?
 Is the respiratory rate fast, slow, or normal?
 Is cyanosis present?
 Is air movement audible on auscultation?
 What is the oxygen saturation (Sp02)?

25. C: Circulation:
The goals are to assess adequate cardiovascular function and tissue
perfusion, ensure effective circulating volume, and in trauma, control
of bleeding.
• Is skin color normal, or is it pale or mottled?
• Is there an increased respiratory rate without
increased work of breathing?
• Is it cool peripherally but warm centrally?
• Is the pulse rate fast, slow, or normal?
• Is the pulse volume weak or strong?
• Is the capillary refill time (CRT) normal or prolonged?

27. D: Disability (mental status)
• Assess the patient by looking at appearance as part of PAT and at level
of consciousness with the AVPU
(Alert, response to Verbal stimuli, response to Pain, Unresponsive)
scale.

28. • The Pediatric Glasgow Coma Scale is a second option
• Evaluate the brainstem by checking the responses in each pupil to a
direct beam of light. A normal pupil will constrict after a light
stimulus.
• Evaluate the motor activity by looking for symmetrical movement of
the extremities, seizures, posturing or flaccidity.

29. • Is the child mobile? Or is there limited movement with poor muscle tone?
• If the child is crying or speaking, is this strong or weak?
• If crying, can the child be consoled?
• Does the child fix their gaze on the carer(s), or does he/she have a
‘glazed’ appearance?
• Is the child’s behavior normal for their developmental age?
• Is the child fitting, stiff or floppy

31. E: Exposure
• Proper exposure of the child is necessary for completing the initial physical
assessment.
• The PAT requires removal of part of the child’ clothing to allow careful
observation.
• Be careful to avoid rapid heat loss, especially in infants and children in a
cold environment.
• Is there fever?
• Is there a non blanching rash present?
• What is the blood glucose level?

32. Secondary survey:
It is important to perform an additional assessment with a focused history
and physical examination in stable patients.
Generally, the initial assessment is aimed at detecting immediate life
threatening problems that can compromise basic life functions, as in the
primary survey.
The secondary survey is intended to detect less immediate threats to life and
has several specific objectives:
• obtaining a complete history, including mechanism of injury or
circumstances of the illness. The SAMPLE mnemonic

33. • The SAMPLE mnemonic:

34. • performing a detailed physical examination
• establishing a clinical diagnosis
• performing laboratory investigations and imaging.

35. DIAGNOSTIC TESTS :
• Appropriate Laboratory investigations/Radiology:

36. MANAGEMENT PRIORITIES
Depend on the physiological status
• Stable
• Respiratory distress/failure
• Circulatory failure‐Compensated/Hypotensive
• Cardiopulmonary failure/arrest
• STABLE CARDIOPULMONARY STATUS
Begin further work up
Provide specific therapy as indicated
Reassess frequently

38. Case scenario:
• A 3 month old male infant who was admitted to the hospital
yesterday with bronchiolitis.
• The infant has a 3 day history of nasal congestion and low grade
temperature. The patient’s mother brought him to the hospital for
difficulty breathing and not feeding adequately for the last 24 hrs
• Over the last 12 hrs. the infant has been coughing more, his work of
breathing has increased and he has copious amounts of airway
secretions, he has not been responding to nebulization.

39. Initial impression of the patient:
• Appearance: irritable with mild lethargy
• Breathing : tachypnea and significant work of breathing
• Color : pink

40. Primary assessment of patient:
• Airway :
Airway patent, copious secretions. But the infant has significant
wheezing and crackles with severe retractions
Breathing :
Respiratory rate is 73 and the breathing is shallow and labored.O2
saturation is 86% on 4l/min by nasal cannula. Decreased air movement
on auscultation.

41. • Circulation :
Heart rate is 190 capillary refill less than 2 secs 1 wet diaper today. IV
placed on admission and IV maintenance fluid infusion
• Disability:
Patient moves all extremities, irritable mild lethargy
• Exposure :
Skin warm and pink

42. Vital signs:
• 99.9 degree F
• HR 190
• RR 73
• O2 sat 86%
• Bp 85/52
• Chest x ray – no lung infiltrates, hyperinflation

43. • Based on the assessment, the most likely cause of this respiratory
distress is Lower airway obstruction
• Bronchiolitis is a disorder of the lower airway , as the x-ray showed
Hyperinflation and the child has wheezing a low grade temp and 3
days history of runny nose.
• Both hyperinflation, wheezing and decreased air movement are fairly
indicative of the lower airway obstruction.
• No infiltrates are visible on the x-ray which decreases the likelihood of
lung tissue disease ( pneumonia ) being involved.

44. REFERENCE:
• American Heart Association (AHA) guidelines for Cardiopulmonary
resuscitation (CPR) and Emergency cardiovascular care (ECC) of
pediatric and neonatal patients: Pediatric advance life support.
Pediatrics. 2006;117:e1005-28.
• Nelson textbook of pediatrics 21 Edition: chapter 81 ( Pediatric
emergencies and resuscitation)
• Ghai Essential Pediatrics 9th edition: chapter 28 {pediatric critical care}