In outpatient practice pediatric specialist as well as general practitioner comes across common pediatric illnesses frequently. It is important to recognize potentially life-threatening conditions as well as conditions requiring immediate intervention and transfer to a higher level medical facility.
Besides accidental trauma, poisoning, insect bites, allergic reactions, common medical problems that bring the child to medical attention are fever, cough, respiratory distress, cyanosis, ear ache, poor feeding, vomiting, diarrhea, irritability, lethargy, convulsions and unresponsiveness. Common conditions that require immediate attention are—respiratory distress, shock, lethargy and coma.
Since our main goal as a medical practitioner is to prevent unnecessary mortality and morbidity by prompt and early recognition of potential problems leading to respiratory or cardiorespiratory arrest, it is important to pay attention to following during history and physical examination done simultaneously:
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Listen carefully to the mother
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Do not ignore, it will not get better if something is not done.
EVALUATE, IDENTIFY AND INTERVENE (Fig. 1.1)
A carefully performed clinical assessment, including observation, history and physical examination, will detect serious illness with 90% sensitivity. Each component of the evaluation is effective in identifying serious illness.
The assessment of a seriously unwell child involves the following:
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Pediatric assessment triangle (PAT) (initial impression)
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Primary assessment (ABCDE assessment)
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Secondary assessment:
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Vital signs
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Focused history
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Detailed physical examination.
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Diagnostic tests: Laboratory and radiological.
INITIAL IMPRESSION (Fig. 1.2)
Initial impression is the rapid assessment of a child with an emergency condition, through visual and auditory evaluation of the child's consciousness, work of breathing and color. It is ‘from the door’ observation to be completed within seconds and no equipment is required. The initial assessment of the child's overall condition is of crucial importance. If the child exhibits abnormal findings, proceed immediately to the primary assessment part of eevaluation.4
Consciousness
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Reflects the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and central nervous system function
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What is the child's state of consciousness: unresponsive, irritable, alert?
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Does the child look ill?
Work of Breathing
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Assess body position, visible movements of chest/abdomen and breathing pattern
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Listen for abnormal audible airway sounds (snoring, hoarse speech, grunting and wheezing)
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Look for visual signs of increased work of breathing such as abnormal position or posture (i.e. sniffing position, tripod position, head bobbing), retractions, nasal flaring, grunting, gasping and tachypnea
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Reflects the adequacy of airway, oxygenation and ventilation. Are the airways obstructed? Is the child short of breath?
Circulation to Skin
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Assess skin color
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Look at the skin and mucous membranes for abnormal color (pallor, mottling and cyanosis)
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Reflects the adequacy of cardiac output and perfusion of vital organs. Is the skin unusually pale, mottled or cyanotic?
The initial impression will help to decide if the child problem is life-threatening or not.
PRIMARY ASSESSMENT
Primary assessment uses an ABCDE (‘ABCDE’ stands for Airway, Breathing, Circulation, Disability and Exposure) approach. During the evaluation primary assessment and management occurs simultaneously. The primary assessment should be periodically repeated, particularly after major intervention or when a change in the patient's condition is detected (evaluate, identify and intervene).
Airway
The goal is to assess, if the airway is patent or if there are signs of obstruction (e.g. stridor, dyspnea and hoarse voice). If the child is unresponsive and cannot talk, cry oor cough, valuate for possible airway obstruction. Is the airway noisy (e.g. 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 stabilize the head and neck in a neutral, in line position (jaw thrust without head tilt manoeuvre to open the airway).
Look in the mouth for blood, broken teeth, gastric contents and foreign objects. If solid material is visualized, remove it with a gloved finger covered in gauze under direct vision. If a foreign body is suspected, but not visualized, a combination of back blows and chest thrusts is recommended in infants. In an older child back blows in a forward leaning position is recommended. Abdominal thrusts in children are not recommended as their effectiveness and safety have not been established.
Insert an airway adjunct (e.g. oropharyngeal or nasopharyngeal airway, or laryngeal mask airway) as needed to maintain a patent airway. If airway patency cannot be maintained, perform tracheal intubation. Rapid sequence intubation (RSI) should be considered in all patients, except those in cardiac arrest, to provide optimum conditions and to minimize the potential for aspiration. Cricothyrotomy or emergency tracheostomy can be done as a last resort to maintain airway patency. Not many pediatricians would be familiar with performing these procedures, therefore in anticipation a consult should be obtained from an airway expert such as anesthesia or an ears, nose and throat (ENT) consultant.
Breathing
The goal in assessing breathing is to determine whether there is adequate gas exchange:
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Will the child lie flat? Is he in the tripod or ‘sniffing’ position?
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Are accessory muscles being used (head bobbing in infants)? Or, is there minimal movement of the chest wall?
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Is there sternal, supraclavicular, substernal, or intercostal recession present?
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Is nasal flaring present?
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Is the respiratory rate fast, slow, or normal?
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Is cyanosis present?
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Is air movement audible on auscultation?
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What is the oxygen saturation (SpO2)?
Place your cheek near the child's face and mouth and feel/listen for air movement and look at the chest/abdomen for respiratory movement. The child with breathing difficulty often has a respiratory rate outside the normal limits for their age. Normal respiratory rate values according to age are listed in Table 1.1. Initially the child becomes tachypneic, and as fatigue begins and hypoxia wworsens, 5he child may progress to respiratory failure and bradypnea. On auscultation with a stethoscope over the mid axillary line, try to hear abnormal lung sounds (e.g. wheeze, crackles, snoring). Palpate the chest for tenderness, instability and crepitations (refer Table 1.1). The various grades of severity retractions is shown in Table 1.2.
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Intervention
All children with breathing difficulties should receive high flow oxygen through a face mask oxygen as soon as the airway has been assessed and demonstrated to be adequate. Pulse oximetry is an excellent tool to use in assessing a child's breathing. A pulse oximetry reading above 94% indicates that oxygenation is probably adequate. A reading below 90% in a child with 100% mask oxygen could be an indication for assisted ventilation.
If the child is breathing adequately but is unresponsive, place the patient in recovery position (lateral recumbent) after assessing ABCD with no other abnormal findings. If breathing is absent or the child is hypoventilating (slow respiratory rate or weak effort), respiration should be supported with oxygen via bag-valve-mask device and an airway adjunct needs to be inserted (e.g. laryngeal mask airway, endotracheal tube).
Circulation
The goals are to assess adequate cardiovascular function and tissue perfusion, ensure effective circulating volume, and in trauma, control of bleeding. Look for following points:
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Is skin color normal, or is it pale or mottled?
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Is there an increased respiratory rate without increased work of breathing?
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Is it cool peripherally, but warm centrally?
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Is the pulse rate fast, slow or normal?
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Is the pulse volume weak or strong?
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Is the capillary refill time (CRT) normal or prolonged?
It is important to determine the heart rate, pulse quality, skin temperature, CRT, and blood pressure (BP). Normal heart rate varies with age (Table 1.3); tachycardia can be an early sign of hypoxia or low perfusion, but it can also reflect less serious conditions (e.g. fever, anxiety and pain). Bradycardia (rate < 60/min in children or < 100/min in newborns) indicates serious illness and poor myocardial perfusion (refer Table 1.3).
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Pulse quality reflects the adequacy of peripheral perfusion. A weak central pulse may indicate decompensated shock, and a peripheral pulse that is difficult to find, weak or irregular suggests poor peripheral perfusion and may be a sign of shock. Check the femoral pulse in infants and young children, or the carotid pulse in an older child or adolescent. If no pulse is felt, and there are no, or minimal signs of life, commenced cardiopulmonary resuscitation (CPR).
Next, evaluate the CRT, skin color and temperature. Normal CRT is less than 2 seconds. The CRT should be done centrally (e.g. on the chest) to minimize the impact of environmental factors. Blood pressure (BP) determination and interpretation can be difficult. Normal BP values in children vary according to age and are difficult to remember (Table 1.4 is very useful in clinical practice). A llow BP 6ndicates decompensated shock.
An easy formula for determining the lower limit of acceptable BP is: Minimal systolic blood pressure = 70 + 2 × age in years (Table 1.5).
Blood pressure trends are useful in determining the child's condition and response to treatment.
Disability (Mental Status)
Assess the patient by looking at appearance as part of initial impression and at level of consciousness with the AVPU (alert, response to verbal stimuli, response to pain, unresponsive) scale (Table 1.6). The pediatric Glasgow Coma Scale is a second option (Table 1.7).
Evaluate the brainstem by checking the responses in each pupil to a direct beam of light. A normal pupil will constrict after alight stimulus. Evaluate the motor activity by looking for symmetrical movement of the extremities, seizures, posturing or flaccidity:
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What is the child's AVPU score?
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Is the child mobile? Or, is there limited movement with poor muscle tone?
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If the child is crying or speaking, is this strong or weak?
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If crying, can the child be consoled?
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Does the child fix their gaze on the carer(s), or does he/she have a ‘glazed’ appearance?
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Is the child's behavior normal for his/her developmental age?
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Is the child having convulsions, is he stiff or floppy?
With knowledge of the child's appearance from the initial appearance and AVPU scale, if the disability assessment demonstrates altered level of consciousness, begin with general life support/monitoring with oxygen, cardiac monitoring, and pulse oximetry. Intubation should be considered if GCS is less than 8.
Exposure
Proper exposure of the child is necessary for completing the initial physical assessment. The initial impression using pediatric assessment triangle (PAT) requires removal of part of the child's clothing to allow careful observation. Be careful to avoid rapid heat loss, especially in infants and children in a cold environment:
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Is there fever?
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Is there a non-blanching rash present?
SECONDARY ASSESSMENT
The secondary assessment focuses on advanced life- support interventions and management. 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:
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Obtaining a complete history, including mechanism of injury or circumstances of the illness. The ‘SAMPLE’ mnemonic can be helpful: S: Signs and symptoms; A: Allergies; M: Medications; P: Postmedical history; L: Last medical intake; E: Events
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Performing a detailed physical examination.
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Laboratory and Radiological Diagnostic Testing
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Establishing a clinical diagnosis
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Obtain a quick random blood sugar
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Performing laboratory investigations and imaging.
Ongoing Assessment
Always reassess the patient; the purpose is to assess the effectiveness of the emergency interventions provided and identify any missed injuries or conditions. This should be performed in every patient after the detailed physical examination and after ensuring completion of critical interventions.
Categorization by Severity (Respiratory Distress)
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Tachypnea
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Tachycardia
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Increased respiratory effort
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Abnormal airway sounds
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Pale cool skin
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Changes in mental status.
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Figure 1.3: Sick child algorithm (ET, endotracheal tube; GCS, Glasgow coma scale; IV, intravenous; PICU, pediatric intensive care unit)
Figure 1.4: Collapsed child algorithm (AED, automatic external defibrillator; CPR, cardiopulmonary resuscitation; PALS, pediatric advanced life support)
Respiratory Failure
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Marked tachypnea/Tachycardia (early)
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Bradypnea, apnea/Bradycardia (late)
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Increased/Decreased/No respiratory effort
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Cyanosis
Categorization by Severity
Shock
Compensated (normotensive)
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Tachycardia
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Cool pale diaphoretic skin
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Delayed CRT
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Weak peripheral pulses
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Narrow pulse pressure
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Oliguria.
Hypotensive Shock
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All features of compensated shock
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BP below the 5th percentile
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Change in mental status.
Things required at all practice locations (hospital or private practice clinic):
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Oxygen source and mask
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Bag-valve-mask device (Ambu)
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Laryngeal mask airway
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Intubation equipment
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Intraosseous needle
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IV cannula, IV fluids
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Suction
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Pulse oximeter
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Nebulizer.
Common Initial Interventions
Once the critically ill child is recognized: Do not waste time in detailed investigations and diagnosis.
Do the following regardless of diagnosis:
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Start oxygen.
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If respiratory distress:
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Ensure airway.
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Open by head tilt chin lift.
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Jaw thrust:
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If not maintainable intubate
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If cannot intubate ventilate with bag and mask.
If cannot intubate or ventilate, then use laryngeal mask airway and call the best expert in airway management.
Foreign Body Obstruction
If known foreign body obstruction:
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Then back blows, chest thrust and Heimlich maneuver
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Nebulize as required (adrenaline or beta-2 stimulant).
Monitor Oxygen Saturation, if
Pulse Oximeter is Available
Shock
Establish intravenous/intraosseous access:
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Do not waste more than 90 seconds trying for intravenous access or wasting time with attempting to place a central line.
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Intraosseous access can be used in all age groups.
Push fluid bolus 20 mL/kg up to 60–80 mL/kg of isotonic fluid (normal saline/ringers lactate).
After each intervention reassess airway breathing and circulation (capillary refill, color, heart rate, pulse, BP, mental status and urine output).
Other Supportive Therapy
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First dose of antibiotic for suspected sepsis.
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Anticonvulsants: If convulsions use diazepam IV/rectal, lorazepam or midazolam IV (caution: respiratory depression/arrest).
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Phenytoin/Phenobarbitone intravenously.
Fever Control
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Analgesics, if severe pain: Non-steroidal anti-inflammatory agents/narcotics as necessary.
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Antiemetics: If vomiting.
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Antiallergics: If allergic reaction/anaphylaxis.
The subcutaneous adrenaline, antihistamines and steroids.
Transport
After initial stabilization and ensuring airway, breathing and circulation under reasonable control with established IV access, transfer/transport to a higher level facility needs to be arranged.
KEY MESSAGES
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Solve immediate problem and do not waste time in establishing precise diagnosis.
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Recognize critical illness promptly and begin to Stabilize on priority.
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Arrange transfer to a pediatric ICU at the earliest.
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Ensure continued stabilization measures until care is handed over.