Acutely ill child Flashcards
https://www.rcemlearning.co.uk/foamed/the-unwell-neonate-and-infant/ Paediatric emergencies - ox handbook of emergency medicine https://teachmepaediatrics.com/emergency/emergency-medicine/approach-to-the-seriously-unwell-child/ http://www.emdocs.net/pem-playbook-the-undifferentiated-sick-infant/
Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:
Airways and Breathing?
- Effort of breathing
- RR and rhythm
- Stridor and wheeze
- Ausculation
- Skin colour
Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:
Circulation?
- Heart rate
- Pusle Volume
- Cap refill
- Skin temp
Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:
Disability?
- Conscious level
- posture
- pupils
Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:
Exposure?
- fever
- Rash
- Bruising
Airway assessment in a baby / child: once you have looked, listened and felt for airway patency. What manoevures can you use? What considerations for an infant vs a child?
- Head tilt chin lift.
Infant vs children
* * anatomical differences mean you want the degree of tilt to be neutral in an infant whereas in a child you want a ‘sniffing positon
- If this does not work - jaw thrust
What adjuncts could you use for airway in a child in hospital?
- naso-pharyngeal airways
- Guedel airways
In a conscious child what might stridor or a hoarse voice indicate? What should you do?
- Indicate a compromised airway
- senior help / anaesthetic urgently
What is stridor? Causes of stridor?
Breathing assesssment of an acutely ill child - 3 categories we are assessing
1.Assess the effort of breathing
* ‘How much work is going into breathing?’
2.Assess the efficacy of breathing
* Efficacy: ‘What are they achieving in terms of air movement and gas exchange?’
-
Assess the effects of respiratory failure
* ‘What is the effect of respiratory inadequacy on the rest of the body?’
Breathing: Assessing the effort of breathing. What looking for?
- RR (e.g. raised: airway, lung, metabolic acidosis)
- look for signs of respiratory distress: grunting, nostril flaring, tracheal tug intercostal /subcostal/ sternal recession (accessory muscle use)
- listen for gasping, stridor, wheeze, and grunting.
What is the significance of gasping in an unwell child?
gasping is a late sign of severe hypoxia.
Normal respiratory rate ranges for children?
Why might some children despite being hypoxic not have signs of increased resp effort?
- Those who have had severe respiratory problems for some time and have become fatigued. Exhaustion (seen in life threatening asthma) is a pre terminal sign.
- Neuromuscular disease – such as muscular dystrophy
- Central respiratory depression (from raised intracranial pressure, poisoning or encephalopathy)
Breathing: Assess the efficacy of breathing - what looking for?
Efficacy: air movement and gas exchange
- chest expansion?
- auscultation of the chest for air entry (view alongisde 02 sats)
- SpO2 sats
- ‘silent chest’ is a very worrying sign.
Breathing: what might asymmetrical air entry and bronchial breath sounds inmdicate?
pneumonia
Breathing: what might a wheeze and reduced air entry indicate?
acute asthma
Breathing: Assess the effects of respiratory failure: what looking for?
‘What is the effect of respiratory inadequacy on the rest of the body
- Assess mental status
- measuring HR (↑ with hypoxia, but bradycardia is a pre-terminal sign)
- skin colour (hypoxia causes pallor, and cyanosis is a late sign).
- Reduced breathing effort and gasping may indicate exhaustion (a pre-terminal sign), cerebral depression, or neuromuscular disease.
Breathing: Hypoxia will initially lead to ____?____ . However, if this is prolonged / severe it will lead to_____?_____
Hypoxia will initially lead to tachycardia . However, if this is prolonged / severe it will lead to bradycardia
Breathing: cyanosis is visible with saturations below ____?____ and again is a ____?____ sign
cyanosis is visible with saturations below 70% and again is a late and pre terminal sign
Breathing: Hypoxia or hypercapnia may lead to what signs in a child? How might this manifest when examining them?
Hypoxia or hypercapnia will lead to agitation or drowsiness
This may present as the child who will not cooperate with examination and seems very distressed or alternatively, unusually quiet and withdrawn.
Breathing: Interventions after identifying any child with resp difficulty or hypoxia….
- high flow oxygen (15litres/min) through an oxygen mask with a reservoir bag.
- use a bag-valve mask if inadequate respiratory effort, consider intubation and ventilation as appropriate.
Circulation: Assessment - what looking for?
- HR (bradycardia is a late sign of cardiovascular failure)
- Pulse volume
- Capillary refill
BP and skin T°. BP maintained until shock is advanced, so hypotension is a pre-terminal sign. - Look for circulatory failure: tachypnoea, mottled cold skin, poor urine output (defined as <2mL/kg/hr in infants or <1mL/kg/hr in children aged >1y)
- agitation
- drowsiness.
Circulation Assessment: What signs to look out for a child that might indicate a cardiac cause for the shock>
- cyanosis despite O2
- ↑ JVP
- heart murmurs
- enlarged liver.
Circulation: Interventions for acutely ill child
- venous / IO access and give a 20ml/kg bolus of 0.9% sodium chloride.
- Further boluses should be guided by reassessment and inotropic support considered if more than two boluses are needed (i.e. 60ml/kg)
- Note in DKA - initial bolus is 10ml/kg due to the risk of cerebral oedema.
- Blood samples e.g. FBC, U&Es, CRP, blood culture, venous gas (with lactate), glucose and ammonia
conisder IO access early if hard to cannulate
Disability: what looking for ?
- AVPU score (where A is alert, V is responds to voice, P is responds to pain and U is unresponsive) or paediatric GCS
- Floppy - severe illness
- Stiff posturing e.g. decorticate (flexed arms, extended legs) or decerebrate (extended arms and legs) suggests serious brain dysfunction.
- Pupil size and response
- Bedside BM
- Consider raised ICP in any child with depressed conscious level - HTN and bradycardia indicates impending coning.
Disability: Interventions
- Consider intubation to stabilise the airway in any child with a conscious level graded as P or U.
- Treat hypoglycaemia with a bolus of 2ml/kg 10% glucose IV or IO, followed by a glucose infusion to prevent recurrence.
- In cases of suspected raised ICP consider mannitol and neuroprotective measures.
Exposure: what looking for?
- temp
- rashes (eg meningococcal disease, anaphylaxis)
- bruising/injuries
- surgical scars
Once immediately life threatening problems have been addressed, what move onto in assesment of acutely unwell child?
- Reassessing the response to initial resuscitative measures
- Taking a focused history from parent/witness etc
- detailed secondary assessment - including systems based examinations
- Further investigations – these may include laboratory blood tests, ECG, radiographs or other imaging such as CT
When assessing the appearance of a child what does the TICLS mneumonic stand for?
a structured way to spot an unwell / abnormally behaving child
Tone – the newborn should have a normal flexed tone; the 6 month old baby who sits up and controls her head; the toddler cruises around the room.
Interactiveness – Does the 2 month old have a social smile? Is the toddler interested in what is going on in the room?
Consolability – A child who cannot be consoled at some point by his mother is experiencing a medical emergency until proven otherwise.
Look/gaze – Does the child track or fix his gaze on you, or is there the “1000-yard stare”?
Speech/cry – A vigorously crying baby can be a good sign, when consolable – when the cry is high-pitched, blood-curling, or even a soft whimper, something is wrong.
Sick Baby: 5 DDX for a presentation of a sick baby with vague / non localising signs?
Neonatal period (<28 days of age) and young infancy (< 3months ) = the most common time for congenital conditions to present and highest susceptibility for infection
Presentation of sepsis in baby?
You must always consider sepsis in any unwell infant (<3 months)
- irritability, ‘off feeds’, vomiting and diarrhoea, lethargy (not waking for feeds), not wetting nappies, high pitched cry, rapid or shallow breathing, apneoas, seizures or abnormal movements.
Clinical features on examination for sepsis?
- tachycardia, tachypnea, fever (>38°C) or hypothermia, hypotension, poor perfusion, respiratory distress, distended abdomen, bulging or tense fontanelle, pallor, mottled skin and decreased conscious level.
birth risk factors for neonatal infection?
- maternal fever or known infection in labour
- prolonged rupture of membranes over 24 hours
- Group B Streptococcus infection confirmed in this pregnancy
Congenital heart disease often presents in early infancy (often not picked up on scans)
Red flags in history….
poor weight gain, breathlessness (especially during feeding), sweating (again may be during feeding), blue episodes or episodes of pallor
Clinical features of Congenital heart disease on examination
- tachycardia
- tachypnea (Resp distress may be present, but tachypnea without respiratory distress is considered a red flag for cardiac disease)
- cyanosis
- pallor
- enlarged liver
- bibasal fine crepitations
- heart murmur or absent femoral pulses.
- check for differences in saturations and blood pressure between the right arm (pre-ductal) and right leg (post-ductal).
With any unwell child - what monitoring will they need?
Oxygen saturations (plus CO2 monitoring if intubated)
Pulse rate and rhythm
Blood pressure
Urine output
Core temperature
Breathing: A child has a bubbling sound when examine chest what diagnosis does it point to and what emergency treatment?
Breathing: on examination a child has harsh stridor and a barking cough
diagnosis?
treatment?
Croup
Oral dexamethesone
nebulised budenosdie or Adrenaline
What are signs of upper airway obstruction?
stridor, marked dyspnoea, drowsiness, subcostal/suprasternal recession, drooling of saliva, difficulty speaking, and cyanosis. Any of these warn of impending obstruction.
Breathing: find soft stridor, drooling and fever in a sick looking child
diagnosis?
treatment
Bacterial tracheitis or epiglottitis
Intubation by anaesthetist followed by IV antibiotics
What is stridor?
high-pitched inspiratory noise. It occurs in croup, acute epiglottitis, inhaled FB, laryngeal trauma, laryngomalacia (‘congenital laryngeal stridor’)
breathing: you find a child has Sudden onset stridor with history of inhalation
diagnosis?
treatment?
Inhaled foreign body
Laryngoscopy for removal
breathing: a child has Stridor following ingestion or injection of a known allergen
diagnosis ?
Treatment?
Anaphylaxis
IM adrenaline
