The Acutely Ill Child: A Ready Reckoner Mukti Sharma, BM John, Vishal Sondhi
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SECTION 1
1Supporting a Sick Child
  • ♦ ‘Pediatric Advanced Life Support’ Assessment
  • ♦ Hypovolemic Shock
  • ♦ Cardiogenic Shock
  • ♦ Septic Shock
  • ♦ Anaphylactic Shock
  • ♦ Obstructive Shock
  • ♦ Hyponatremia
  • ♦ Hypernatremia
  • ♦ Hypokalemia
  • ♦ Hyperkalemia
  • ♦ Hypocalcemia
  • ♦ Approach to Arterial Blood Gas Analysis
  • ♦ Sedation and Analgesia in Children
  • ♦ Nutrition in a Critically Ill Child2

‘Pediatric Advanced Life Support’ AssessmentCHAPTER 1

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Follow a rapid systematic approach for management of a seriously ill/injured child. It is described in following steps:
  1. Initial impression: It is the first quick visual and auditory observation of the child's consciousness, breathing, and color (CBC).
    1. Consciousness: Level of consciousness may be characterized as unresponsive, irritable, or alert.
    2. Breathing: Check for increased work of breathing, use of accessory muscles, absent/decreased respiratory effort, abnormal breath sounds or abnormal breathing pattern.
    3. Color: Look for abnormal skin color—Pallor, cyanosis, mottling suggesting poor perfusion, poor oxygenation or both.
  2. Based on the initial assessment, determine if the child's problem is life-threatening or not
    • If life-threatening problem, immediately begin appropriate interventions.
    • If not life-threatening, continue with the systematic approach.
      1. If the child is unresponsive and not breathing/only gasping, shout for help/activate emergency response. Check to see if there is a pulse.
        • If no pulse: Start CPR, follow pediatric cardiac arrest algorithm.
        • If pulse present, provide rescue breathing.
        • If, despite adequate oxygenation and ventilation, the heart rate < 60/min with signs of poor perfusion, provide chest compressions and ventilations. Proceed according to pediatric cardiac arrest algorithm.
        • If heart rate > 60/min, begin the evaluate—identify—intervene sequence.
      2. If child is breathing adequately, proceed with the evaluate—identify—intervene sequence.
  3. Evaluate—identify—intervene sequence: Evaluate the child by primary assessment, secondary assessment and diagnostic tools. After evaluation, identify the problem by type and severity and then, intervene with appropriate actions.
    1. Evaluation: It includes primary assessment, secondary assessment and diagnostic tools. These are as described below:
      1. Primary assessment: Follow ABCDE approach as described below:
        1. 4Airway—Check for airway patency, which is done by:
          • Look for movement of chest or abdomen
          • Listen for breath sounds
          • Feel the movement of air at the nose/mouth.
          Based on above evaluation, classify airway as:
          1. Clear: Airway is open and unobstructed
          2. Maintainable: Can be maintained by simple measures (e.g. head tilt chin lift)
          3. Not maintainable: Cannot be maintained without advanced interventions (e.g. intubation).
          Simple measures:
          • Comfortable positioning
          • Use head tilt chin lift to open airway (in case of cervical spine injury, open the airway using a jaw thrust without neck extension)
          • Suction the nose/oropharynx
          • Foreign body airway obstruction relief measures:
            • < 1 year: back slaps and chest thrusts
            • > 1year: abdominal thrusts
          Advanced measures:
          • Endotracheal intubation
          • Foreign body removal with laryngoscopy
          • CPAP
          • Cricothyrotomy.
        2. Breathing
          Assessment of breathing includes evaluation of:
          1. Respiratory rate: Count the number of times chest rises in 30 sec and multiply it by 2 to determine the respiratory rate and assess as tachypnea/bradypnea/apnea
          2. Respiratory effort: Signs of increased respiratory effort include nasal flaring/retractions/open mouth breathing, head bobbing/see-saw respiration
          3. Tidal volume: Check for
            • Magnitude of chest wall excursion
            • Auscultate for distal air movement
          4. Airway and lung sounds: Stridor/grunting/wheezing/gurgling/crackles
          5. Pulse oximetry: Oxygen saturation > 94% indicates adequate oxygenation.
        3. Circulation
          Assessment of circulation includes evaluation of:
          1. Cardiovascular function:
            • Skin color
            • Heart rate
            • Heart rhythm
            • Blood pressure
            • Pulses (central and peripheral)
            • Capillary refill time.
          2. 5End organ function:
            • Brain perfusion (mental status)
            • Skin perfusion
            • Renal perfusion (urine output).
        4. Disability
          Disability assessment includes quick evaluation of cerebral cortex and brainstem evaluation which includes:
          1. AVPU pediatric response scale: System for rating child's level of consciousness and response to stimuli:
            A : Alert
            V : Voice
            P : Pain
            U : Unresponsive
          2. Glasgow coma scale
          3. Pupillary response to light.
          The causes of decreased level of consciousness in children include:
          • Poor cerebral perfusion
          • Meningitis, encephalitis
          • Hypoglycemia
          • Hypoxemia, hypercarbia
          • Traumatic brain injury
          • Drugs.
        5. Exposure
          1. Undress the child to facilitate a focussed physical examination. Check for hypothermia, bleeding, petechiae/purpura, abdominal distension.
          2. Secondary assessment: It is done after the primary assessment and stabilization of the child. It includes focused history and detailed physical examination.
            • Focused history: Use the SAMPLE mnemonic to identify important aspects of child's history and presenting complaints.
              S : Signs and symptoms
              A : Allergies
              M : Medications
              P : Past medical history
              L : Last meal
              E : Events
            • Detailed physical examination: Perform a thorough head to toe physical examination.
          3. Diagnostic tests: These consist of ancillary studies to detect and identify the presence and severity of respiratory and circulatory abnormalities.
            1. Assessment of respiratory abnormalities:
              • Arterial blood gas
              • Venous blood gas
              • Hemoglobin concentration
              • 6Pulse oximetry
              • Chest X-ray
              • Exhaled CO2 monitoring
              • Capnography
              • Peak expiratory flow rate.
            2. Assessment of circulatory abnormalities:
              • Arterial blood gas
              • Venous blood gas
              • Central venous oxygen saturation
              • Total serum CO2
              • Arterial lactate
              • Hemoglobin concentration
              • Invasive arterial pressure monitoring
              • Chest X-ray
              • Central venous pressure monitoring
              • Echocardiography.
  4. Identify the type and severity of child's problem as follows:
    1. Respiratory
      Type
      Severity
      Upper airway obstruction
      Respiratory distress
      Lower airway obstruction
      Respiratory failure
      Lung tissue disease
      Disordered control of breathing
    2. Circulatory
      Type
      Severity
      Hypovolemic shock
      Compensated shock
      Distributive shock
      Hypotensive shock
      Cardiogenic shock
      Obstructive shock
    3. Cardiopulmonary failure
    4. Cardiac arrest
  5. Intervene: On basis of identification of child's problem, intervention steps include:
    • Positioning the child to maintain patent airway
    • Activate emergency response
    • Start CPR
    • Place the child on monitors (cardiac, pulse oximeter)
    • Oxygen
    • Ventilation
    • Medications and fluids.
  6. The sequence of evaluate—identify—intervene continues until the child is stable.
    7
    PALS Systematic Approach Algorithm
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