IAP Speciality Series on Pediatric Intensive Care Praveen Khilnani, Krishan Chugh, Soonu Udani, Deepak Ugra
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Recognition and Stabilization of Critically Ill Child1

Anand Shandilya,
Surpreet Nagi
 
INTRODUCTION
A “critically ill child” is a child who is in a clinical state, which may result in respiratory or cardiac arrest or severe neurological complications, if not recognized and treated promptly. Many diseases can lead to this “critically ill state”. Whether a child presents with a primary cardiovascular, respiratory, neurological, infectious or metabolic disorder, the goal should be early recognition of respiratory and circulatory insufficiency.
An experienced clinician finds it easy to recognize a critically ill child. It is essential for the clinician to assess and classify the degree of sickness. It is also important to identify a child with physiological derangement in its early stages when signs are subtle. The “golden hour” concept applies to all children with illnesses presenting as emergency. Early recognition of a “critically ill child” requires a systematic and rapid clinical assessment, with background knowledge of age appropriate physical signs and level of development. The process of examining a child is known as Rapid Cardiopulmonary Assessment. It should take the clinician about 30 seconds to complete this assessment with practice.
Selected conditions that require a rapid cardiopulmonary assessment:
2
A very simple and quick way of assessment of overall illness and injury severity is by the mnemonic ABC:
  1. Appearance of the child/Airway
  2. Breathing
  3. Circulatory status.
 
APPEARANCE OF THE CHILD
Appearance basically denotes the neurological status. It is determined by the oxygen and blood supply to the brain, which is dependent on the cardiopulmonary status and the structural integrity of the brain. The parameters assessed in appearance are alertness, distractibility or consolability, response to stimuli, eye contact, speech or cry, motor activity and color of the skin. In addition, seizures, abnormal posture, muscle tone and pupillary reaction are noted.
  1. Alertness: Normal children exhibit awareness and interest in surroundings. It is important to determine if the child is confused, irritable, lethargic or totally unaware of the environment. Changes in level of consciousness can also be rapidly assessed by using the mnemonic - AVPU.
    • Awake
    • Responsive to Voice
    • Responsive to Pain
    • Unresponsive.
  2. Distractibility or consolability by parent is a normal phenomenon in infants and young children. Children who are not distracted or consoled by the caregiver should be carefully assessed.
  3. Eye contact with parents or physician is noted normally after 2 months of age. Failure to do so is an early sign of cortical hypoperfusion and brain dysfunction.
  4. Speech/cry: It should be noted whether the cry is normal, whimpering, moaning or high pitched.
  5. Motor activity: A note should be made of the movement of the trunk and limbs. An assessment should be made of the muscle tone. A child who is limp and hypotonic is compromised.
  6. Color of the skin reflects skin perfusion and indirectly – the respiratory and circulatory status. The skin of the palm and fingers may be pink (normal), pale, cyanosed, mottled or ashen grey depending on the degree of compromise.
  7. Posturing: Intermittent flexor (decorticate) or extensor (decerebrate) posturing occur with prolonged cerebral hypoperfusion.
  8. Pupil size: Pupils may be small but reactive in cerebral hypoperfusion. Unequal pupils are a medical emergency; may indicate raised intracranial pressure or an intracranial bleed.
 
Airway
One needs to assess whether the airway is open and clear or maintainable with adjuncts like oropharyngeal or nasopharyngeal airways, suction, positioning or requires tracheal intubation to be maintained.
 
Breathing
 
Respiratory Rate
Tachypnea is an early sign of respiratory distress. Tachypnea without increased work of breathing (quiet tachypnea) is seen in shock, heart disease and acidosis (a response of the body to wash out 3carbon dioxide and usually denotes acidosis). A slow or irregular respiratory rate in an acutely ill child is ominous.
Normal newborn
Normal 1 year
Normal 18 years
< 40 – 60
24
18
> 60 always abnormal
 
Work of Breathing
Increased work of breathing (IWB) indicates respiratory distress or respiratory failure. IWB is assessed by nasal flaring, grunting, intercostal, subcostal and suprasternal retractions. Head bobbing and see saw respirations (severe chest retraction with abdominal distension) are more advanced signs of respiratory distress and respiratory failure. As long as the patient can maintain oxygenation and ventilation with this increased work of breathing he is said to compensate and is in Respiratory distress. Once a state is reached where the status quo of oxygenation and ventilation is not maintained, the child is said to be in Respiratory Failure. These are clinical distinctions.
 
Air Entry
Effective tidal volume is assessed by chest expansion and auscultation of breath sounds. Stridor indicates upper (extra thoracic) airway obstruction and may be because of the tongue, laryngomalacia, vocal cord paralysis, hemangioma, tumor, cysts, infection, edema, or aspiration of a foreign body. Wheezing indicates intrathoracic obstruction due to conditions such as bronchiolitis, asthma, pulmonary edema, or an intrathoracic foreign body.
 
Skin Color and Temperature
This will be discussed with circulatory status.
 
Circulatory Status
Circulation is assessed to find out if the cardiac output meets the tissue demands. Shock is defined as circulatory dysfunction in which there is inadequate delivery of oxygen and substrates to meet the metabolic demands of tissues. Circulatory status is assessed by heart rate and blood pressure directly. Heart rate changes alone may be too early a sign of derangement and are often nonspecific. By the time hypotension develops it may be very late and the shock is classified as decompensated shock. Hence we evaluate the organs perfused to assess for effective circulation. These are skin, peripheral pulses, brain, and kidneys.
 
Heart Rate
Tachycardia is a common response to a variety of stresses including shock. Hence its presence mandates further evaluation. Bradycardia in a critically ill child is ominous.
Newborn - 3 months
3 mos. - 2 years
2 - 10 years
> 10 years
Normal:
140
130
80
75
4
 
Pulse
Comparison of central (femoral, carotid and brachial) and peripheral (radial, dorsalis pedis and posterior tibial) pulses should be done. The presence, strength and volume of the pulses need to be assessed. One must be aware that a bounding pulse does not necessarily denote good perfusion. The loss of central pulse is a premorbid sign and is to be treated as cardiac arrest.
 
Skin Perfusion
  1. Temperature: When the ambient temperature is warm, the extremities should be warm. The peripheries start cooling when the cardiac output falls. Assessment of the temperature of the trunk and the extremities should be done simultaneously as cooling occurs from the periphery to the center.
  2. Color: Color of the skin reflects skin perfusion and indirectly respiratory and circulatory status. Skin of palm and fingers may be pink (normal), pale, cyanosed, mottled or ashen grey depending on the degree of compromise.
  3. Capillary refill time (CRT): This is checked by applying pressure on the skin or nail so as to cause blanching and assessing the time taken for the color to come back to normal. The normal CRT is less than 2 seconds. Delayed CRT is a feature of early shock. The exceptions are a rising temperature and cool ambient temperature. The extremity being tested should be raised above the level of the heart to make sure that only venous refill is not being tested.
 
Organ Perfusion
  1. Brain: Brain perfusion can be assessed by features already described in appearance, i.e. changes in level of consciousness, pupil size, muscle tone and posturing.
  2. Renal: Urine output may not be useful in initial assessment in a critically ill child, but is useful in monitoring the child and in evaluation of renal perfusion. At least 1 ml/kg/hour of urine output is normal.
  3. Blood pressure: Shock can be present with normal, increased or decreased blood pressure. In early compensated shock, BP is normal. In late or decompensated shock there is hypotension. Progression to irreversible/refractory shock or multiple organ failure or death rapidly follows.
 
Pulse Oximetry
Oxygen saturation assessment is an important adjunct to identify oxygenation state in an acutely ill child. This is also called the fifth vital sign.
Based on the appearance, breathing and circulatory status, the physiologic status of a critically ill child is classified as:
  1. Stable
  2. Respiratory distress5
  3. Respiratory failure
  4. Compensated shock
  5. Decompensated shock
  6. Cardiorespiratory failure is characterized by agonal respirations, bradycardia and cyanosis.
Based on this physiologic status the severity of the compromise is classified and the child is managed further accordingly.
Patients must be re-evaluated after every intervention. For example; if a fluid bolus has been given then assess the child for any improvement as indicated by improved capillary refill, stronger pulses, improved urine output and a lower heart rate.
 
Stabilization
Depending on the physiologic status of the child, the following stabilization measures can be undertaken.
 
Airway
It should be assessed whether the airway is maintainable or unmaintainable. If the airway is unmaintainable, nasopharyngeal or oropharyngeal airway or intubation is required. The patency of the airway is to be assessed and excessive secretions should be cleared. Airway should be opened by the appropriate maneuver.
 
Breathing
Hundred percent oxygen should be provided to any critically ill child irrespective of the physiologic status.
If the child has Respiratory Distress the child is kept with the caregiver, is allowed to maintain a position of comfort, and oxygen is provided in a non-threatening manner. Turbulent airflow leads to increased airway resistance; hence the child should be kept calm.
If the child has Respiratory Failure, the approach is more aggressive. In case of inadequate chest expansion or respiratory arrest, bag and mask ventilation should be given with 100 % oxygen. Tracheal intubation may be required.
Tracheostomy or cricothyrotomy may be required in cases of complete upper airway obstruction caused by diphtheria, severe orofacial injuries or laryngeal fractures.
 
Circulation
Once airway and breathing have been stabilized, vascular access is to be secured. Intraosseous route may be used in case of collapsed veins. No child should die due to a lack of vascular access. Any drug can be infused using this route provided it is followed by a flush of fluid to get the drug in the central circulation. Fluid resuscitation should be given. The child needs to be monitored after administration of each fluid bolus. The rate of administration and the number of boluses depend on the type of shock. Blood products should be administered only when specifically indicated for replacement o f blood loss or for replacement of components. When the circulation does not improve with fluid boluses alone, inotropes are used.
The goal of therapy is to improve the perfusion and correct the hypotension.
Arrhythmias if present need to be corrected.6
 
CNS Support
Seizures should be controlled by anticonvulsants. Raised intracranial pressure is to be corrected by appropriate measures.
 
SUMMARY
A Rapid Cardiopulmonary Assessment helps a clinician to classify the degree of compromise of the physiologic status. Based on the degree of compromise the patient is managed appropriately. During stabilization the priority is to address the Airway first followed by Breathing and Circulation.
BIBLIOGRAPHY
  1. Cummins RO, Hazinski MF. The most important changes in the international EED and CPR Guidelines 2000. Circulation 2000; 102: I371–76.
  1. Eisenberg MS, Mengert TJ Cardiac resuscitation. N Engl J Med 2001; 344: 1304–13.
  1. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 9: Pediatric basic life support. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102: 1253–90.
  1. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular Care: Part 10: Pediatric advanced life support. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102: 1291–342.
  1. Kochanek MK, et al. Cerebral resuscitation after traumatic brain injury and cardiopulmonary arrest in infants and children in the new millennium. Pediatr Clin North Am 2001; 48: 661–81.
  1. Mathers LH, et al. Anatomical considerations in obtaining venous access. Clin Anat 1992; 5: 89–106.