Lectures

Recognition of theseriously ill child

Recognition of the seriously ill child

• To understand the structured approach to the recognition of the seriously ill child

• To learn a rapid clinical assessment sequence to identify serious illness in a child

• To introduce the equipment used for the resuscitation of a seriously ill child

Objectives

Recognition of the seriously ill child Causes of death worldwide <5 years

Neonates < 1m Children aged 1m-5yrs

Preterm birth complications

12% Diarrhoea 14%

Birth asphyxia 9% Pneumonia 14%

Sepsis 6% Other infections 9%

Other 5% Malaria 8%

Recognition of the seriously ill child Causes of cardiac arrest in children

Airway Obstruction

Respiratory Depression

Alveolar/Chest Wall Failure

Fluid Loss

Fluid Mal-distribution

Heart Failure

Foreign body, asthma, croup, bronchiolitis

Respiratory Failure

Cardiac Arrest

Circulatory Failure

Convulsions, sepsis, poisoning, ↑ICP

Pneumonia, chest trauma & myopathy

Bleeding, burns, diarrhoea, vomiting

Sepsis, anaphylaxis

Myocardial depression, congenital abnormality

Recognition of the seriously ill child Systematic approach

• Primary assessment• Resuscitation• Secondary assessment• Emergency treatment• Stabilisation, transfer to definitive care

AirwayBreathingCirculationDisabilityExposure

Recognition of the seriously ill child Recognition of serious illness

• Potential respiratory failure

• Potential circulatory failure

• Potential central neurological failure

Recognition of the seriously ill child Potential respiratory failure

Effort of Breathing

Effectivenessof Breathing

Effects of RespiratoryInadequacy

Recognition of the seriously ill child Effort of breathing – subcostal recession

• Mild • Severe

Recognition of the seriously ill child Subcostal recession

Recognition of the seriously ill child Effort of breathing

• Respiratory rate

• Accessory muscle use

• Flaring of the nostrils

• Child's position

Recognition of the seriously ill child Effort of breathing – associated sounds

• Stridor• primarily inspiratory noise• upper airway pathology

• Wheeze• primarily expiratory noise• lower airways pathology

• Grunting• expiration with partially closed glottis• alveolar pathology

Recognition of the seriously ill child Exceptions to the effort of breathing

Increased effort absent in:• exhaustion• central respiratory depression• neuromuscular disease

Recognition of the seriously ill child Potential respiratory failure

Effort of Breathing

Efficacy of Breathing

Effects of RespiratoryInadequacy

Recognition of the seriously ill child Efficiacy of breathing

• Chest expansion

• Air entry

• Pulse oximetry

Recognition of the seriously ill child Efficiacy of breathing

A SILENT CHEST IS

A PRE–TERMINAL SIGN

Recognition of the seriously ill child Potential respiratory failure

Effort of Breathing

Efficacy of Breathing

Effects of RespiratoryInadequacy

Recognition of the seriously ill child Effects of respiratory inadequacy

• Heart rate

• Skin colour

• Mental status

Recognition of the seriously ill child Effects of respiratory inadequacy

CYANOSIS IS

A PRE–TERMINAL SIGN

OXYGEN SATURATION OF

<85% IN AIR

IS A PRE-TERMINAL SIGN

Recognition of the seriously ill child Potential respiratory failure – resuscitation equipment

Recognition of the seriously ill child Potential circulatory failure – early recognition of shock

Cardiovascular Signs

Effects of CirculatoryInadequacy

Recognition of the seriously ill child Cardiovascular signs

• Heart rate

• Pulse volume

• Capillary refill time

• Blood pressure

Recognition of the seriously ill child Cardiovascular signs – capillary refill

(1) press for 5s

(2) release(3) colour should return <2s in well-perfused, warm child

Recognition of the seriously ill child Cardiovascular signs – capillary refill

• A delay of >2s with other signs of shock and in a warm child suggests poor peripheral perfusion

Recognition of the seriously ill child Cardiovascular signs

HYPOTENSION ISA PRE–TERMINAL SIGN

Recognition of the seriously ill child Potential circulatory failure – early recognition of shock

Cardiovascular Signs

Effects of CirculatoryInadequacy

Recognition of the seriously ill child Effects of circulatory inadequacy

• Respiratory rate

• Skin temperature/colour

• Mental status

Recognition of the seriously ill child Distinguishing cardiac problems

• Cyanosis despite O2

• Marked tachycardia

• Raised jugular venous pressure

• Gallop rhythm / murmur

• Enlarged liver

• Absent femoral pulses

Recognition of the seriously ill child Potential circulatory failure – resuscitation equipment

Recognition of the seriously ill child Case report 1

Case Report: 2 months oldCough and wheeze for 1 week

Sign Observation

Skin colour PaleRespiratory rate 20/min (recession ++)Heart rate 200/minCapillary refill time NormalMental status Unresponsive

Recognition of the seriously ill child Case report 2

Case Report: 2 months old Poor feeding and vomiting for 1 day

Sign Observation

Skin colour PaleRespiratory rate 70/min (no recession)Heart rate 220/minCapillary refill time PoorMental status Unresponsive

Recognition of the seriously ill child Potential central neurological failure

Conscious level

Posture

Pupillary signs

Recognition of the seriously ill child Potential central neurological failure:conscious level

A-V-P-U approach:

AlertResponds to VoiceResponds only to PainUnresponsive to all stimuli

Recognition of the seriously ill child Potential central neurological failure

Conscious level

Posture

Pupillary signs

• assess with painful stimulus

Recognition of the seriously ill child Potential central neurological failure:postures

• Decorticate • Decerebrate

Recognition of the seriously ill child Potential central neurological failure

Conscious level

Posture

Pupillary signs

Recognition of theseriously ill child

Q&A

Recognition of the seriously ill child Summary: rapid assessment

Airway and Breathing• Effort • Efficacy • Effects

Disability• Conscious level• Posture• Pupils

Circulation• Heart rate• Capillary refill time • Blood pressure • Skin temperature