Pediatric Emergency Medicine Course (PEMC) Indumathy Santhanam
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1Recognition of Critical Illness2

Recognition of Early Signs of Critical Illness in the Out Patient Department1

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Figure 1.1: Long queues waiting at the OPD of a medical college affiliated, public children's hospital in Southern India
Early recognition of critical illness, is perhaps the most important link in the chain of survival. Delayed recognition, late referral and failure to provide effective prehospital resuscitation were some of the reasons for children reaching our hospital with respiratory failure and shock.1
This is highlighted by the fact that children who presented late to the emergency service with respiratory failure and shock had increased risk of mortality.1 More recently features of pulmonary edema, myocardial dysfunction and non-convulsive status epilepticus2 were also associated with increased risk of hospital mortality.
This chapter discusses, how to pick up early signs of serious illness in a large volume PED (Figure 1.1) and avoid the consequences of prolonged hypoxia and shock on the heart, lung and brain.
 
ASSESSMENT OF APPEARANCE BASED ON THE AVPU SCALE
An acute fall in mental status is one of the earliest symptoms of hypoxia and shock. The severity of altered level of consciousness (ALOC) or ‘appearance’ may be evaluated rapidly using the alert, voice responsive, pain responsive, unresponsive (AVPU) scale.3
  • Incessant cry, a seemingly innocuous symptom emerged as the most ominous of all the presenting symptoms in a cohort of shocked children.5
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  • ‘Drowsiness’ in the background of fever, diarrhea or breathlessness may be missed by the physician, since a drowsy child could briefly wake up and appear alert, while he is being assessed.
  • Unresponsiveness can be considered as ‘sleeping’ by parents and not brought to the attention of the ED personnel in a busy OPD.
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Figure 1.2: This figure shows a healthcare worker scanning children as they wait in queue
All too often, the physician seated in a busy OPD, can miss early fall in mental status.
It is worthwhile to remember that a mother knows her child best.
If she reports that her child is ‘not as usual’ then it is best to triage her child as hypoxic or shocked even if her child appears to be alert.
 
Alert (A)
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Figure 1.3: This infant was brought by his mother for diarrhea and fever. Since he was alert and playing he was triaged as normal and referred to the oral rehydration therapy (ORT) cell.
Alertness is evaluated based on age appropriate interaction of a child with his parents and environment (Figure 1.3).
 
Responsive to Voice (V)
Recognition of drop in mental status to ‘responsive to voice’ is a challenge in all age groups.
Most infants will initiate crying when put down and will stop crying immediately when picked up and held.
Crying has frequently been thought of as attachment behavior caused by an infant's need to cling to its caregiver. If an infant with ‘minor symptoms’, continues to cry despite being carried and cuddled, evaluate and treat fever, pain, dehydration, wet nappy, etc. If crying does not resolve, categorize as responsive to voice and perform the rapid cardiopulmonary cerebral assessment.
 
Responsive to Painful Stimulus (P)
Acute onset of posturing or failure to respond to the mother is alarming. Such children must be rushed directly into the ED. Sudden flexor or extensor stiffening associated with an upward gaze or hypotonia in a neurologically normal child may be secondary to respiratory failure and shock due to sepsis, hypovolemia, near fatal asthma, etc.
Refer Protocol 1.1: PEMC approach: Recognition of relative bradypnea and relative bradycardia; Protocol 1.2: PEMC approach: Recognition of severity of illness on arrival to the ED, and also Figures 1.4 to 1.7.
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Figure 1.4: A 3-year-old asthmatic girl was brought to the OPD with history of increasing breathlessness and incessant cry since early morning. She was triaged as having a near fatal attack of asthma, since she was sleepy with features of respiratory failure. Note her tone and posture as she lies floppily on her mother's lap.
A weak cry and loss of eye contact in infants more than 2 months of age are early ominous signs of cerebral hypoperfusion. In older children lethargy, inability to sit, stand or walk, agitation, fighting the oxygen mask and confusion alternating with drowsiness herald brain hypoperfusion.
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Figure 1.5: A 11-month baby was brought to the OPD for acute onset of respiratory distress and fever. Since the morning he had been crying incessantly and was not recognizing his mother. Enroute to the hospital he developed posturing. This baby presented with airway instability, RR > 80/min, grunt, abdominal respiration, tachycardia, muffled heart sounds, de-compensated shock and increased liver span. Note the vacant upward gaze of the infant. His saturation was < 92%.
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Figure 1.6: This infant also presented with odd squirming, wriggling movements of the limbs, which vary from the classical tonic-clonic components of status epilepticus. Features of severe cardiopulmonary failure help differentiate convulsive status epilepticus from posturing secondary to hypoxia and shock.
Febrile infants who present with squirming movements and upward gaze are often inappropriately referred or treated as atypical febrile fits.
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Figure 1.7: Hypoxia, shock and myocardial function improved following fluids, inotropes and elective intubation. Administration of anticonvulsants would have aggravated cardiorespiratory failure precipitating cardiac arrest.
  1. Confirm history to find out whether the child is having a tonic-clonic movement or posturing.
  2. Ask targeted questions to find out whether the child had fall in mental status such as lethargy or incessant crying prior to the onset of abnormal movements.
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  3. Perform the rapid cardiopulmonary cerebral assessment.
  4. Correct hypoxia and shock. Reassess; a clearer picture may emerge to guide therapy.
A neurologically normal child developing difficulty in sitting or standing without support or being carried into the hospital, is indicative of critical illness (Figures 1.7 to 1.10).
Children who are normal will not voluntarily lie un-attended (when parents leave their line of vision). Hence, older children with fever, vomiting, etc. who lie quietly (do not protest) in their parents absence should also be subjected to a more detailed assessment (Figure 1.8).
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Figure 1.8: A 6-year-old girl, with fever and first episode of acute respiratory distress was carried into the OPD. Since she was unable to maintain her usual tone and posture, she was triaged into the PED. She presented with impending respiratory failure and shock. At 40 mL/kg, she developed grunt, abdominal respiration, SaO2 of 90% and hepatomegaly, but shock persisted.
Thirst for water is another ominous symptom in older children presenting with respiratory distress and shock. Failure to recognize this ‘red flag’ symptom and aggressively resuscitate has often resulted in cardiac arrest!
Acute onset of altered behavior, incoherent speech, agitation or fighting the mask in older children with additional history of fever, trauma, diarrhea, etc. may also suggest a serious drop in mental status.
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Figure 1.9: Fluids were interrupted, inotrope initiated and intubation was performed using ketamine, atropine and suxamethonium. Crepitations resolved, saturations improved to 100% and the hepatomegaly resolved. Further fluid boluses were continued till therapeutic goals of shock were achieved. Thirst for water is another ominous symptom in older children presenting with respiratory distress and shock. Failure to recognize this ‘red flag’ symptom and aggressively resuscitate has often resulted in cardiac arrest!
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Figure 1.10: Note the alert, smiling child in comparison with herself in Figure 1.8. Early recognition of ALOC secondary to hypoxia and shock and early goal-directed management were responsible for her neurologically intact survival.
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Figure 1.11: This picture shows a 7-year-old child with shock fighting the oxygen mask. It is an ominous sign indicative of severe hypoxia especially in older children, who are aware that an oxygen mask is not a noxious intervention. Fighting the mask, however is normal in infants and toddlers if the other parts of the pediatric assessment triangle are normal.
 
Unresponsiveness (U)
Unresponsiveness, whilst not difficult to triage, is often a diagnostic challenge to novice pediatricians manning the ED.
  • Sudden unresponsiveness in the absence of precipitating events in a previously normal child or a child with seizure disorder is suggestive of non-convulsive status epilepticus (NCSE).
  • Failure to regain baseline consciousness after a brief generalized tonic-clonic seizure is also suggestive of NCSE.
  • Occasionally, acute posturing and abnormal eye movements (oculogyric crisis) occur due to an over dose of phenothiazine group of drugs. Negative ‘triage questions’ and normal ABCs in an alert child are diagnostic of acute phenothiazine toxicity.
  • History of fever, breathlessness (due to varied etiologies), acute watery diarrhea, etc. followed by progressive LOC and posturing is suggestive of very severe hypoxia and shock.
 
Breathlessness
Breathlessness is the commonest symptom for which an acutely ill child is brought to the PED (Figure 1.12).
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Figure 1.12: This figure shows why children presenting with severe shock may also have respiratory distress.
Bronchiolitis, pneumonia and asthma are well known etiologies of acute respiratory distress. However, a significant number of shocked children who present to the ED, have breathlessness due to pulmonary edema2 (Figure 1.11).
Severe insults such as sepsis, anaphylaxis, status epilepticus, scorpion sting, submersion injury, perinatal depression can directly affect the heart, systemic and pulmonary vasculature.
  • Vasodilation and capillary leak leads to loss of fluids. Loss exceeding 25% of effective circulating volume, results in shock.
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  • Capillary leak also occurs in the pulmonary capillaries. Increased pulmonary vascular permeability leads to pulmonary edema, also known as acute lung injury (ALI).
  • Severe insults (hypoxia, prolonged shock, venom, etc.) can lead to acute myocardial dysfunction. The resultant hydrostatic pulmonary edema can present as respiratory distress.
 
ASSESSMENT OF AIRWAY
Crying or vocalization indicates that the airway is patent. Harsh inspiratory sounds suggests stridor secondary to structural airway obstruction. ‘Snoring’ in an unresponsive child indicates that the airway is obstructed by secretions or falling back of tongue. Unresponsive children presenting with stridor must be evaluated on the resuscitation trolley.7
The patency of the airway is maintained by the normal tone of the palatopharyngeal muscles and tongue. Loss of tone of these muscles in unresponsive victims result in airway obstruction.
  • Neurogenic or functional stridor should be recognized early. The airway is positioned using the head tilt- chin lift maneuver.
  • If trauma is suspected in the unresponsive child, jaw thrust maneuver must be employed to open the airway.
  • Crying children or children with suspected ‘structural’ airway compromise should be evaluated in their parent's lap.
 
ASSESSMENT OF BREATHING
Oxygen must be administered simultaneously as the assessment is being performed.
  • Use a flow-inflating ventilation device (refer Chapter 5), if respiratory distress is identified (with the exception of asthma).
  • Use non-rebreathing mask, if effortless tachypnea is noted.
  • Simultaneously, place the hand on the chest and count respiratory rate for 6 seconds and multiply by 10.
  • Check the vital signs chart for age-related ranges.
  • Note whether respiratory rates for age are increased, decreased or normal.
Vital signs for each age group must be displayed in the ED. Refer protocol 1.1.
Respiratory effort offers information, as to whether the child has respiratory distress or respiratory failure.
  • Auscultate infra-axillary regions on both sides.
  • Listen for air entry, wheeze and crepitations.
  • Evaluate color by comparing the palm of the physician with that of the child's sole (Figure 1.13).
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  • Pallor, dusky hue, ashen, mottling is documented as abnormal.
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Figure 1.13: It is not uncommon for the color to be noted as normal in shocked children. The difference may be apparent only when comparing with the ‘normal’ color of the physician.
 
ASSESSMENT OF CIRCULATION
 
Heart Rate
Assess heart rate for 6 seconds and multiply by 10. Simultaneously, check the vital signs chart to determine whether tachycardic, bradycardic or normal for age (Figure 1.14).
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Figure 1.14: Assessment of heart rate. Note that the physician is holding the airway as he evaluates the heart rate.
  • Tachycardia is the earliest compensatory response to decreased stroke volume or hypoxemia.
  • Young infants and neonates, however, may respond with paradoxical bradycardia.3
  • Normalization of heart rate is one of the most reliable signs of shock resolution.8
  • However, tachycardia may persist when atropine is used for intubating children in shock.5
  • Other causes of persistent tachycardia are fever, anxiety, pain and systemic inflammatory response syndrome (SIRS).3,9
  • In addition, tachycardia may be the only sign of ongoing seizure activity in a paralyzed and sedated child with shock.
  • Heart rates greater than 220 beats/minute in infants and 180 beats/minute in children warrant urgent evaluation and treatment.3 An electrocardiography (ECG) may be necessary, because the pulse oximeter may be unreliable in identifying supraventricular tachycardia.
  • Other causes of relative bradycardia in children presenting with shock are raised intracranial pressure,10,11 hypothermia, hypokalemia (often noted in diarrheal dehydration and severe malnutrition complicating septic shock), dengue shock syndrome12 and drugs such as digoxin and beta blockers.
 
Perfusion
 
Comparison of Pulses
Central pulse (femoral) is felt by placing the index finger of one hand snugly into the inguinal region. It is compared with the dorsalis pedis, which is felt by simultaneously placing three fingers perpendicularly on the dorsum of the foot.
  • Weak or absent distal pulses is caused by peripheral vasoconstriction, while absent distal pulses suggest decompensated shock.
  • Loss of central pulses is a premorbid sign requiring very rapid intervention.7
  • Bounding central and distal pulses in association with tachypnea, tachycardia and altered mental status suggest the presence of a hyperdynamic circulation with low systemic vascular resistance.
  • Vasodilatory shock is identified when diastolic pressure is lower than 50% of systolic blood pressure.15
  • If dorsalis is not felt, do not report as ‘normal’ peripheral pulse based on the posterior tibial (Figure 1.15).
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Figure 1.15: Comparison of central and peripheral pulses is shown in this picture. Since interpretation of this sign is not easy, it needs experience to feel and compare the femoral and dorsalis pedis in infants. Occasionally, difficult to feel central pulses with palpable dorsalis pedis in a neonate presenting with cardiogenic shock harbingers coarctation of aorta with a patent ductus arteriosus.
Reassuring one's self that the child is not shocked based on the presence of the posterior tibial pulse in the absence of the dorsalis pedis has often resulted in failing to pick up hypotensive shock. [Caution: The dorsalis pedis artery may be absent in 12% of normal individuals (Sarrafian's anatomy of the foot and ankle by Armen S Kelikian)].
Table 1.1   Comparison of femorals and dorsalis pedis
Femorals
Dorsalis pedis
Pulse pressure
Inference
+++1
+++1
+++1
++3
+++4
+5
30–40 mm Hg
> 40 mm Hg
< 40 mm Hg
Normal
Bounding (vasodilation)
Shock
++2
06
Not recordable
Hypotension
1: Easy to feel femorals.
2: Difficult to feel femorals.
3: Easy to feel dorsalis pedis.
4: Dorsalis pedis as well felt as femoral pulse.
5: Dorsalis pedis just felt.
6: Dorsalis pedis not felt.
 
Core-peripheral Temperature Gap
Assess core-peripheral temperature gap by comparing simultaneously, the temperature of the trunk with that of peripheries using the dorsal surface of both hands (gloves need not be removed to evaluate this variable) (Figure 1.16).
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Figure 1.16: Note that the dorsal surface of one hand is placed over the trunk of the infant, while the dorsal surface of the other hand slides over the thigh, leg and foot to compare the difference in temperature between the center and peripheries. If warm or cool throughout, it could signal warm or cold shock in children when other parts of the PAT are abnormal.
  • When cardiac output falls, cooling of the skin begins peripherally in the fingers and toes and extends proximally towards the trunk. A core/toe temperature difference of more than 2°C is a sign of poor perfusion.
 
Capillary Refill Time (CRT)
It is well known that poor peripheral perfusion may result from cool environmental temperatures in very young infants3 and hence, in very young age groups, this sign may have limited utility for both the recognition of shock and monitoring response to therapy. Other therapeutic goals such as normalization of mental status, respiratory rates and heart rates for age may be more reliable when evaluating for shock resolution in this age group. Conversely, early alterations in extremity perfusion are more reliable in older children, where the baseline mental status may appear to be relatively well preserved despite circulatory compromise.
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Figures 1.17A and B: The capillary refill time (CRT) is assessed by lifting the extremity slightly above the level of the heart and applying enough pressure to blanch the skin. Normal time taken for refilling of the blanched area is 2 seconds or less. A prolonged CRT may be seen in shock, rising fever and cold ambient temperature. It is also influenced by lighting and age.3
 
Blood Pressure
Blood pressure (Table 1.2) may be preserved in early shock due to the compensatory increase in systemic vascular resistance (SVR). In young children, increase in vasomotor tone results in BP that is in the higher range for age. Under these circumstances, as therapeutic goals of shock are achieved, blood pressures may decrease to the normal range for age.
In vasodilatory shock states, low SVR results in widening of pulse pressure. This is characterized by a diastolic BP that is less than or equal to half of the systolic BP. In these children, pulse pressure narrows with resolution of shock. Wide pulse pressures may also be noted in children with neurogenic and anaphylactic shock, as well as chronic anemia and congenital heart diseases with shunt lesions. Accurate blood pressure measurement requires the use of an appropriate sized cuff covering at least 75%–80% of the upper arm. Normal blood pressure readings should be displayed in the ED. Age-associated blood pressure cuffs should be used to record this vital sign (Figure 1.18).
Table 1.2   Hypotension based on Emergency Cardiovascular Care Guidelines 2000 is characterized by the following limits of systolic blood pressure (SBP)
Age
SBP
Term newborn (0–28 days)
< 60 mm Hg
For infant < 12 months
< 70 mm Hg
1–10 years
< 70 + (2 × age)
> 10 years
< 90 mm Hg
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Figure 1.18: Different sizes of BP cuffs used in children. Use of inappropriate large cuffs in small children will result in the recording low BP and vice versa.
Systolic blood pressure: Interpretation of systolic blood pressure in children with shock:
  • High in shock (normal response).
  • Normal range (relative hypotension).
  • Hypotension (can progress to imminent arrest in minutes).
Diastolic blood pressure13: As mentioned earlier, diastolic pressures less than 50% of systolic pressure harbinger vasodilatory shock when associated with altered mental status, abnormal respiratory rates, work of breathing, tachycardia, warm, pink peripheries, bounding pulses and rapid CRT.
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  • Mean arterial pressure (MAP) is calculated as the sum of the diastolic pressure and one-third pulse pressure. A value less than 65 mm Hg is considered as hypotension.
  • Conventionally, documentation of systolic pressure is given importance. Early warm shock could be missed, if diastolic pressure and MAP are not noted.
 
Liver Span
Measure liver span during the assessment of circulation. It is helpful in assessing and monitoring the severity of myocardial dysfunction.5
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Figures 1.19A and B: A. Marking lower border of liver; B. Measuring the liver span. Assessment of liver span helps in the evaluation of myocardial dysfunction in critical illness.
  • The upper border is identified by percussion and the lower border by palpation (Figures 1.19A and B). Using a pen, both borders are marked and the total span is measured and documented.
  • These measurements are compared with normal values displayed in the ED.
  • If the liver span is increased in children presenting with respiratory distress, it is probable that myocardial dysfunction is the causative factor.
  • A normal liver span on the other hand points to primary lung pathology as causative of respiratory distress.
 
DISABILITY ASSESSMENT
Neurological assessment is an integral part of evaluation of a child with hypoxia, shock and seizure activity and may provide clues to the underlying etiology and response to therapy.
When examining for pupillary response, simultaneously, look at the position of eyes. Is it conjugating or mid-position? Note for presence of abnormal ocular movements.
Abnormal ocular movements in a child presenting with an exacerbation of asthma is suggestive of a near fatal attack. Identification of this sign in a child with respiratory failure and shock due to bronchiolitis suggests the need to aggressively resuscitate hypoxia.
Indeed, eye signs in children presenting with severe cardiopulmonary failure in the absence of seizure history, has been associated with increased risk of mortality.14
  • Conjugate eye deviation, nystagmus or eyelid twitch indicate presence of NCSE or severe hypoxic ischemic insult to the brain (Figures 1.20A to C). Other gaze abnormalities, which may mimic non-convulsive status epilepticus are upward gaze and roving nystagmus. Continuous epileptiform electroencephalogram (EEG) abnormalities have been noted in comatose adults with severe metabolic or anoxic encephalopathies.15
  • Avoid rushing to administer anticonvulsants.
  • The importance of early recognition and simultaneous management of status epilepticus (convulsive and non-convulsive) is important in ensuring successful outcomes in shock.8
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Figures 1.20A to C: Conjugate deviation in a child presenting with profound shock and posturing. The dolls eye movement is being performed in the figures. Usually, the deviation persists during the side-to-side movement performed for eliciting the DEM(Courtesy: Dr Gunda Srinivas).
 
Pupillary Examination (Figures 1.21 and 1.22)
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Figure 1.21: Pupillary examination is also performed to assess briskness of response and inequality
Unequal pupils may often be noted from increased intracranial pressure or non-convulsive status. Pupils provide important information regarding response to therapy and normalization of abnormal pupillary size, reaction or symmetry indicates resolution of cerebral hypoxia-ischemia.
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Figure 1.22: Unequal pupils.(Courtesy: Dr Gunda Srinivas).
Examination of the pupils can help pick up a wide variety of other unexpected conditions such as coloboma, xerophthalmia, etc. in seriously ill children
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  • Resuscitation from shock due to intracranial infections or head trauma will be incomplete if intracranial hypertension is not simultaneously identified and treated.
 
INTERPRETATION OF PAT
  • As the rapid cardiopulmonary cerebral assessment is being performed, simultaneously the heart rates, respiratory rates, BP and liver span should be verified with the normal values for age.
  • The variables are interpreted as normal for age, increased or decreased based on the other parts of the PAT.16 This helps to determine the physiological status and guide therapy.
  • No single variable should be taken in isolation. All sides of the PAT16 should be compromised to recognize respiratory failure or shock.
  • Decreased mental status, respiratory compromise, alteration in heart rates and alteration in skin perfusion suggestive of warm or cold shock with or without fall in blood pressure should be taken together in the recognition of critical illness.
 
PHYSIOLOGICAL STATUS AND APPROPRIATE INTERVENTIONS
Determine physiological status as Airway/Breathing/Circulation/Disability: Separate therapeutic interventions are necessary for each of the parameters (Figure 1.24).
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Figure 1.23: The Broselow tape
Often children who are critically ill cannot be weighed conventionally, for such children Broselow tape is useful to calculate approximate weight based on length of the child (Figure 1.23).
 
Airway
  • If stable or obstructed: No positioning is needed.
  • If airway is unstable or unmaintainable: Open the airway using the head tilt-chin lift maneuver (jaw thrust if head trauma is suspected).
 
Breathing
  • If effortless tachypnea: Provide O2 via the non-rebreathing mask.
  • If respiratory distress or impending respiratory failure: Provide O2 using the Jackson-Rees circuit.
  • If apnea: Suction oropharynx, decompress stomach with appropriate sized nasogastric tube and initiate bag-valve-mask ventilation.
 
Circulation
  • If bradycardia: Initiate chest compressions.
  • If tachypneic, tachycardic and shocked, without hepatomegaly: Administer 20 mL/kg over 20 minutes.
  • If respiratory distress, tachycardia, shocked with or without hepatomegaly: Administer smaller boluses of 5–10 mL/kg over 5–10 minutes.
  • If BP low: Use pull-push method for administering fluids until BP normalizes (Plan intubation and epinephrine infusion).
  • If pulse pressure wide, MAP < 65 mm Hg: Plan large volumes of fluids.
 
Disability
  • If child having altered level of consciousness: Correct hypoxia and shock and then reassess.
  • If NCSE/CSE: Treat seizure activity as discussed in Chapter 21.
  • If raised ICP: Treat ICP as discussed in Chapter 20.
Intervene appropriately for each of the parameters viz ABCDs (Figure 1.24).
Uncompromising standards are needed in terms of accuracy, speed and skill in performing rapid cardiopulmonary cerebral assessment and its interpretation in critical illness.
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Figure 1.24: Pediatric Assessment Triangle (PAT) to enable recognition of severity and decision making in seriously ill children in the emergency setting(Modified from Dieckmann RA, Brownstein D, Gausche-Hill M. The Pediatric Assessment Triangle–a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010 Apr;26(4):312–15)
16
Accurate documentation of clinical findings is crucial following each intervention (Table 1.1 and 1.2). Refer Figure 1.26A and B.
Stringent precautions need to be taken since error or negligence on the part of the physician could be fatal to children whose care depends so heavily on clinical assessment.
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Figure 1.25: This picture shows a very young infant making eye contact with his happy mother following successful shock resuscitation. His response to his mother, suggests neurologically intact survival.
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Figure 1.26A: Pediatric emergency case record: front page (assessment part)
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Figure 1.26B: Pediatric emergency case record: back page (monitoring and reassessment part)Note: Refer appendix for sample documentation of Pediatric Emergency Case Record
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Protocol 1.1: PEMC approach: Recognition of relative bradypnea and relative bradycardia
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Protocol 1.2: PEMC approach: Recognition of severity of illness on arrival to the ED
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  1. Santhanam I, et al. Implementation of Pediatric Emergency Medicine Course Guidelines (PEMC). Impact on mortality in critically ill children presenting to a large volume PED of an academic children's hospital in India. Pediatr Crit Care Med. 2011; (12): 3.
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