INTRODUCTION
While dealing with very sick child, time is premium, and hence a structured, objective and systemic approach should be adopted for optimum outcome.
SYSTEMATIC APPROACH TO IDENTIFY A SICK CHILD
The systematic approach to identify a sick child involves a series of evaluations followed by identification of the problem and then appropriate prioritized interventions. This is known as “Evaluation-Identification-Intervention” or “E-I-I” approach (Fig. 1).
Initial Assessment
It is done with the help of pediatric assessment triangle and also known as hand-off assessment (Table 1). Evaluation: The three components of initial assessment are appearance, breathing and color.
Primary Assessment (ABCDE Approach) (Fig. 2)
The primary assessment is the “hands-on” rapid cardiopulmonary and brain assessment of the child targeted to identify objectively the severity and type of physiological insufficiency and follow Evaluate–Identify–Intervene. There are five components of primary assessment. These are Airway, Breathing, Circulation, Disability and Exposure.
A: Airway
- Open/clear
- Maintainable
- Nonmaintainable.
B: Breathing
Evaluation: Evaluation of Breathing involves five components.
- Respiratory rate
- Work of breathing
- Chest wall movements and tidal volume,
- Auscultation (air entry and adventitious sounds
- Pulse oximetry.
C: Circulation
Evaluation: Shock is defined as inability of circulation to meet the metabolic demands of the body. Though causes of shock are manifold, it manifests by identical signs easily picked up on clinical evaluation. There are five components to be assessed during the circulatory assessment.
- Heart rate and rhythm
- Central and peripheral pulses
- Capillary refill time
- Skin color and temperature
- Blood pressure measurement.
Identify
Based on severity, circulatory insufficiency should be classified as:
- Compensated or normotensive shock
- Hypotensive shock
Based on the underlying etiology or clinically identifiable physiology, shock is classified as:
- Hypovolemic shock
- Distributive shock
- Cardiogenic shock
- Obstructive shock.
D: Disability
Evaluation of brain functions includes cortical assessment and brainstem assessment. The cortical assessment is undertaken usually by a Glasgow coma scale or AVPU scale response. Changes in the level of consciousness indicate the progress or deterioration of the cortical function, leading to6 further interventions. The brainstem assessment is done by the pupillary response to a beam of light. Abnormality in pupillary size and/or reaction may indicate the injury, drugs, toxins, hypoxemia or poor perfusion states. A raised intracranial pressure leading to herniation would result in unequal size of the pupils and warrants urgent intervention. Blood sugar should also be determined bedside to identify and treat hypoglycemia.
E: Exposure
To identify any bleeding, injury, swelling, distension, deformity and rashes that may be hidden under the clothes, the child should be appropriately exposed and evaluated maintaining the privacy. The bleeds may require immediate active intervention like pressure bandage or help from surgical team to control the blood loss. An abdominal distension may be compromising the respiration and may require appropriate intervention. Swelling, deformity and rashes may point to underlying disease process and further management. Peripheral and core temperature should also be measured to ensure specific intervention for fever or hypothermia.
Secondary Assessment
After the initial evaluation, identification and interventions to stabilize the child, more information is gathered from structured SAMPLE history and a complete physical head to toe examination to reach on etiological diagnosis.
Focused history has six components parameters which together can be remembered as a mnemonic SAMPLE:
- S is signs and symptoms
- A is allergies
- M is medication received
- P is past medical history
- L is last meal taken
- E is the event that led to bringing the child to the emergency room.
The physical examination focuses on areas that have not been covered in the primary assessment. These would be the neck, lymph nodes, throat, neck stiffness, cardiac evaluations including the murmurs and examination of the abdomen for any organomegaly, masses or fluids.
After completion of secondary assessment, one would be able to identify the underlying etiology of the clinical findings identified during the primary assessment.
DIAGNOSTIC EVALUATIONS
Diagnostic tests may be sent at any point of time while assessing the child according to need and feasibility. Blood sugar assessment is a point of care7 tool. Other diagnostic evaluations could be laboratory investigations for hematological profile, microbiological assays (cultures of blood, urine or sputum), metabolic profile or biochemical profile including the acid/base evaluations. The imaging evaluations could be an ultrasound evaluation, a skiagram, CT scan or MRI depending upon the need of the patient.
TRANSFER FROM EMERGENCY
After completion of evaluate-identify-intervention, ongoing care of the child should be ensured in emergency room or child should be transferred to specific unit or PICU as per severity level of the illness. During intrahospital or interhospital transport, structured approached should be followed. Suggested protocol is given as Appendix 1.
SUGGESTED READING
- Chameides L, Samson R, Schexnayder S, et al. Pediatric Advanced Life Support Provider Manual (New 2015). Dallas: American Heart Association; 2015. pp. 29–67.
- Hazinski MF. Children are different. In: Hazinski MF (Ed). Nursing care of critically ill child, 3rd edition. St Louis: Mosby; 2013. pp. 1–18.
- Rogers' Handbook of Pediatric Intensive Care, 5th edition. Philadelphia: Lippincott Williams and Wilkins; 2017. pp. 217–72.
- Taneja LN, Tiwari L. BLS for professionals, 3rd edition. Mumbai: IAP; 2018.