Pocket Pediatric Emergency Medicine Course for Interns Indumathy Santhanam
Chapter Notes

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Recognition of Critical IllnessCHAPTER 1

Triage is the method of recognizing whether a child brought to the OPD, is very sick or not. Snake envenomation, toxin ingestion, accidents, drowning, etc. are easily recognized as “bad history” and rapidly shifted into the emergency department (ED).
The level of consciousness (LOC) or “appearance” is rapidly evaluated using the AVPU scale.
Alert (A)
“Alert”, is based on mother's perception that her child is “as usual”. It is based on her history that he is interacting normally, is playful or is consolable.
Responsive to Voice (V)
  • 2Even if the child looks “alert”, remember, mom knows best! If she feels the child is not alright, she is probably right!
  • Perform the rapid cardiopulmonary cerebral assessment.
Responsive to Pain (P)
  • Sudden flexor or extensor stiffening associated with an upward gaze or hypotonia in a neurologically normal child with breathlessness, fever or diarrhea may be secondary to respiratory failure or shock.
  • Anti-seizure medications, could have lethal effects when posturing occurs secondary to severe hypoxia or/and shock.
  • In older children with fever, diarrhea or breathlessness, lethargy, inability to sit, stand or walk, agitation, fighting the oxygen mask, abusive behavior or combativeness suggest cerebral hypoperfusion or shock.
Unresponsiveness (U)
The most common causes of respiratory distress are bronchiolitis, pneumonia and asthma. However, severe insults due to drowning, prolonged status epilepticus, severe sepsis, scorpion venom can also cause respiratory distress. These insults can directly affect the heart and the vessels (Figure 1).
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Figure 1: Shocked children often present with respiratory distress.
3Hypoxia, cytokine storm, venom, etc. can cause vasodilation and capillary leak in both the systemic and pulmonary circulation.
  1. Does your child with fever, diarrhea, cough, cold, etc. have drop in mental status? If yes, consider shock.
  2. Does your child, with fever or diarrhea, etc. also have breathlessness?
If yes, confirm whether the breathlessness is present since early infancy (?congestive heart failure) or whether it is episodic in nature? (?Asthma or recurrent aspiration)
If fall in mental status or breathlessness is confirmed, perform the following assessment.
  1. A stepwise, systematic method known as the “Rapid Cardiopulmonary Cerebral Assessment” is used to find out whether a child is seriously ill or not.
  2. The clinical findings are then incorporated into the pediatric assessment triangle (PAT) (Figure 2).
  3. As assessment is being made, life-saving interventions are also implemented without loss of time.
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Figure 2: Pediatric assessment triangle.
The airway is the passage that connects the oropharynx to the glottis. This narrow tube is kept open by the inherent tone of the surrounding palatopharyngeal muscles and the tongue. Entry of liquid or solid into this passage, is prevented by “cough” a powerful airway protective reflex. Deglutition reflex is the other reflex that prevents liquid from entering the air passage.
Maintainable or Stable Airway
Crying, talking or coughing.
Obstructed Airway: Stridor
Stridor in an alert child implies the presence of a structural 4obstruction to the air passage such as glottic edema, foreign body, laryngomalacia, laryngeal web, hemangioma, angioedema, etc.
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Figures 3A and B: (A) The most common cause of airway obstruction: Falling back of tongue in unresponsive victim; (B) The head tilt-chin lift maneuver aids in relieving the obstruction caused by the tongue.
Unmaintainable Airway
When a child becomes unresponsive or convulsing the inherent tone of the palato-pharyngeal muscles are lost resulting in collapse and falling back of the tongue (Figures 3A and B). Loss of airway protective reflexes, such as cough and deglutition result in pooling of secretions.
Physiological Status
Airway is classified as maintainable (crying, talking) obstructed (stridor) or not maintainable.
Airway Management
  • If crying or stridor is noted, the child may be assessed and managed on the mother's lap.
If the child is unresponsive with or without posturing or fits, then he should be placed on the resuscitation trolley.
  • Open the airway using the head tilt chin lift maneuver (Figure 4).
  • Suction oropharyngeal secretions, if noted.
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    Figure 4: This unresponsive child is unable to sit or stand since he has lost his tone and posture. It is presumed, that the internal tone of the palate-pharyngeal muscles and tongue is also lost resulting in falling back of the tongue (obstruction of the air-passage). In addition, he has also lost the ability to cough, cry or swallow (airway protective reflexes).
  • Insert an age appropriate nasogastric tube and decompress stomach (to avoid risk of aspiration).5
  • Breathing is assessed by counting respiratory rate for 6 seconds and multiplying by 10 (Figure 5).
  • If not breathing or respiratory rate is in the lower range for normal in the unresponsive child, initiate bag valve mask ventilation. The 2nd responder will continue the assessment.
  • If the child is tachypneic, the assessment is continued; While counting respiratory rate, the work of breathing must be concurrently noted. Is the child having retractions, grunt, abdominothoracic or thoracic respiration? (Grunt and abdominal respiration are suggestive of impending respiratory failure).
  • Auscultate the infra-axillary region for air-entry and added sounds (all three lobes are represented in this area).
  • Color is evaluated by comparing the palm of the physician with that of the child's sole (Figure 6). Pallor, dusky hue, ashen, mottling is documented as abnormal.
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Figure 5: Both hands are placed, one on the thorax and the other on the abdomen, to assess whether thoracic respiration or abdominal respiration.
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Figure 6: Comparing the color of physician's palm with the color of the sole of the child.
Physiological Status
Breathing is classified as:
  • Normal
  • Effortless tachypnea
  • Respiratory distress
  • Impending respiratory failure
  • Apnea
Management of Breathing
  • Apnea: Bag valve mask ventilation is initiated.
  • Effortless tachypnea: Oxygen is provided using a nonrebreathing mask.
  • Respiratory distress or impending respiratory failure: 6Oxygen is provided using a flow inflating ventilation device (Jackson-Rees circuit).
    If the child is breathing spontaneously, then the assessment is continued.
Heart rate is assessed for 6 seconds and multiplied by 10 (Figure 7).
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Figure 7: Assessment of both heart rate and quality of heart sounds.
If heart sounds are difficult to hear, or heart rate is in the lower range of normal in the unresponsive child with apnea, chest compressions are initiated in the ratio of 15 : 2 (Figure 8).
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Figure 8: Initiating chest compression in a young infant.
(The 1st responder should have already initiated bag valve mask ventilation). A 3rd responder continues with the assessment.
Heart sounds should also be assessed for gallop or muffling (ominous signs). If tachycardic, then peripheral perfusion is evaluated.
Since this sign can be precipitated by anxiety or stranger distress, children with patent airway and spontaneous breathing must be evaluated in their mom's lap with minimal disturbance.
  • Compare core and peripheral temperature by placing the dorsum of one hand on the abdomen and sliding the other hand over the thigh, knee and the ankle (Figure 9).
  • Compare the strength of the femoral (central pulses) with the strength of the dorsalis pedis (peripheral pulse) (Figure 10 and Table 1).
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Figure 9: Comparison of core-peripheral temperature.
Table 1   Comparison of femoral and dorsalis pedis.
Dorsalis pedis
Pulse pressure
30–40 mm Hg
> 40 mm Hg
Bounding (vasodilation)
< 40
+++: Easy to feel femorals, ++: Difficult to feel femoral
++: Easy to feel dorsalis pedis, +++: Dorsalis pedis as well felt as femoral pulse
+: Just felt dorsalis pedis, 0: not felt dorsalis,
SBP: Systolic blood pressure
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Figure 10: Comparison of femoral pulse with dorsalis pedis.
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Figure 11: Blanching skin to assess for capillary refill time. It is essential to elevate limb above the level of the heart.
  • The capillary refill time is assessed by lifting the extremity slightly above the level of the heart and applying enough pressure to blanch the skin (Figure 11). Normal CRT is 2 seconds or less. A prolonged CRT may be seen in shock, rising fever or a cold ambient temperature and is also influenced by lighting, site and age.
  • Color is assessed by comparing the palm of the physician with the color of the child's sole.
  • Assess BP using age appropriate cuffs.
  • In early shock, children compensate by pushing up their BP (similar to tachycardia). As shock worsens, systolic pressures fall to the normal range. In children who are responsive to pain or unresponsive, BP that is within the lower normal range for age is dangerous (Table 2).8
Table 2   Hypotensive (5th percentile) range of blood pressure for age
Term newborn (0–28 day)
SBP < 60 mm Hg
For infant < 12 months
< 70 mm Hg
1–10 years
SBP 70 + (2 × age)
> 10 years
SBP < 90 mm Hg
When the diastolic pressure is less than 50% of systolic pressure, it is suggestive of vasodilatory shock.
Liver Span
Often, in children with shock, the heart is failing. Pulmonary congestion secondary to cardiac dysfunction manifests as respiratory distress (common symptom of serious illness). Coexisting hepatomegaly, is useful in finding out whether respiratory distress is due to a primary respiratory cause or cardiac dysfunction. The upper border of liver is identified by percussion (Figure 12A) and the lower border by palpation (Figure 12B) and the total span is marked (Figure 12C) and measured in the evaluation of serious illness (Figure 12D).
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Figures 12A and B:
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Figures 12A to D: How do we measure liver span. (A) Percuss for upper border for liver; (B) Mark upper border of liver dullness; (C) Palpate for lower border of liver from below upwards. The hand should be placed parallel to the right costal margin. Mark the lower border of liver; (D) Measure the distance between two lines in the mid-clavicular line.
Physiological Status
Circulation is classified as:
  • Heart rate: Normal/tachycardia/relative bradycardia/bradycardia,
  • Perfusion: Normal/shock
  • Hepatomegaly: Yes/No
  • BP: Normal/ high/low
  • MAP: Normal/low.
Management of Circulation
  • If bradycardic, chest compressions are initiated. Refer to BLS section
  • If tachycardic shock,
    1. Secure IV/IO
    2. Type of fluid: Administer isotonic nonglucose containing fluids such as normal saline (NS) or Ringer's lactate (RL)
    3. Volume: 20 mL/kg
    4. Break 20 mL/kg to smaller aliquots of 5–10 mL/kg, if shock is associated with respiratory distress.
      Mark the calculated volume on the bottle containing the fluid to avoid excess fluid administration.
    5. Rate: over 20 minutes by gravity (the stop cock in the IV tubing should be fully open and the calculated amount of fluid runs by gravity).
      If tachycardic and hypotensive for age use pull-push technique to rapidly infuse fluids (Figures 13A to C).
An acute onset of altered behavior, incoherent speech, agitation or fighting the mask in children with history of fever, diarrhea, etc. is indicative of severe cerebral hypoxia or cerebral hypoperfusion.10
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Figure 13A: The three-way stopcock that is being used to withdraw aliquots of fluids from the bottle and pushed into the patient while bagging is in progress.
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Figure 13B: Note that the three-way stopcock has been turned to permit aspiration of NS from the bottle. The patient end has been blocked.
Loss of consciousness and generalized tonic-clonic seizures is a common pediatric emergency (Refer section of Status epilepticus). Conjugate eye deviation, nystagmus or eyelid twitch may indicate subtle seizures or hypoxic-ischemic compromise of the brain from shock.
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Figure 13C: Pull-push technique is used to rapidly administer NS or RL in the shortest possible time. Note that the three-way stopcock has been turned to permit NS push into the patient end. The reservoir end has been blocked.
Unequal pupils (Figure 14) may often be noted from increased intracranial pressure or nonconvulsive status. Pupils provide important information regarding response to therapy and normalization of abnormal pupillary size, reaction or symmetry indicates resolution of cerebral hypoperfusion and hypoxia.
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Figure 14: Noting eyes for position and movements while concurrently evaluating pupillary response to light.
  • ALC (due to hypoxia or shock)
  • Nonconvulsive status epilepticus/Convulsive status epilepticus.
  • Raised intracranial pressure (ICP).
Even as the assessment and life-saving interventions are being provided, capillary glucose levels must be checked and documented in all seriously ill-children.
  • If hypoglycemic, rapidly correct with 2 mL/kg of 25% dextrose, if capillary blood glucose is less than 60 mg/dL.
Concurrently, temperature is also checked and documented.
Assess Weight Using the Broselow Tape (Figure 15)
Measure length, using this tape. The approximate weight for length is marked on this tape.
As the child is being assessed, clothes should be removed to pick-up other significant clinical findings.
  • Findings should be documented within 30 seconds.
  • The time of assessment must be documented.
  • Respiratory rates, heart rates, BP and liver span measurements must be counter-checked with a card containing vital signs for age (Figures 16A to C).
  • The findings are now inserted into the pediatric assessment triangle to help understand the physiological status. The findings are interpreted based on the other parts of the pediatric assessment triangle (PAT) (Figure 17).
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Figure 15: Broselow tape is being used to measure the approximate weight.
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Figure 16A:
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Figures 16A to C: (A) Check the vital signs card to interpret the vital signs in relation to the other parts of the pediatric assessment triangle (absolutely low, relatively low or increased); (B and C) Card with vital signs and liver span for age.
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Figure 17: Interpretation of the physiological status using the pediatric assessment triangle.
(ALOC: Altered level of consciousness; CSE/NCSE: Convulsive status epilepticus/Nonconvulsive status epilepticus)
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Figure 18: How to perform life-saving interventions based on physiological status until therapeutic goals are achieved.
(PERL: pupils equal and reactive to light)
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(ECM: External chest compression; EOM: Extraocular movements; DEM: Doll's eye movement)
Emergency Reg No:
Air entry
Added sounds
Central/Distal pulse
CPT gap
Liver span
Eye deviated/ MP
Lid twitch
Urine output
Physiological Status
A & B
C: Fluids
D: Anti-epilep/3%NS
Total volume
No of drug
Inotrope trigger
ET: Trigger
16Match the physiological status with appropriate pediatric assessment triangle to decide on the correct treatment.
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Protocol 1.1: Pediatric emergency medicine course (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