Lecture Day 1 Recognition of ill child Flashcards
Common causes of 0-4 weeks
prematurity, congenital, trauma including asphyxia
1-12 months
prematurity, congenital, sudden unexplained death, resp infections, other infections
Main causes of cardiac arrest in children
Circulatory:
- fluid loss (vomit, burns, blood loss)
- Fluid maldistribution (septic shock, anaphylaxis
Respiratory - Obstruction (foreign body, asthma, croup) Resp depression (convulsions, poisoning, ↑ ICP
How to take Hx from serious ill
Respiratory distress
Sudden onset
Febrile
Been to PICU before?
Rash
Glass test?
Ingestion of poison
What taken?
Head injury
Mechanism of injury?
LOC?
Vomiting? Etc.
Examination ABC
Go through recognition A
Assess patency by
Looking for chest and/or abdominal movement
Listening for breath sounds and
Feeling for expired air.
Vocalisations, such as crying or talking, indicate ventilation and some degree of airway patency.
Paradoxical chest and abdominal movements
Signs of airway obstruction?
Foreign body visible?
Fully obstructed airway will be silent
Cyanosis/hypoxia is a late sign
Response for A
Call for help if signs of airway obstruction Basic airway manoeuvres Older child: Head tilt, chin lift Infant: neutral position Jaw thrust Airway adjuncts Oropharyngeal airway Nasopharyngeal airway Suction secretions (Yankauer) Give oxygen (O2) Call an anaesthetist for definitive airway management
What happens to a childs airway if they become frightened
can obstruct futher
infective causes of obstruction in child
epiglottis
croup
trachyitis
Assessment of breathing
Sings of respiratory distress
Effort, efficacy, effects
Signs of respiratory distress: Subcostal recession Intercostal recession Tracheal tug Grunting Nasal flare Head bobbing Sounds: inspiraptory stridor
When can increased effort be absent?
How to investigate
- Exhaustion
- Central respiratory depression
- Neuromuscular disease
Do ABG
How to investigate efficacy?
Chest expansion adequate? Auscultation - Air entry OK? Pulse oximetry (>94%) Blood gas High CO2?
Effects of ↓ Resp effort
Heart rate
Tachycardia
Bradycardia
Skin colour
Pallor
Mottling
Mental status Agitated Restless Decreased GCS LOC
Pre-terminal signs
Silent chest
cyanosis
O2 sats < 88%
hypotension
Response to breathing
- No breath: bag-mask
- 15 L/min NRM
- O2 sat, ABG, CXR
- Insert nasogastric tube
Assessing Circulation
Vital signs Heart rate Pulse volume Blood pressure Skin & mucous membrane perfusion: Capillary refill time (central & peripheral) Skin temperature Skin colour Organ Perfusion: Effects on breathing Mental status Urine output
Responding to C
Response
IV/IO access.
Blood gas (including lactate and ionised calcium), glucose stick test and laboratory tests including full blood count (FBC), urea & electrolytes (U&Es), renal and liver function, CRP, blood culture, cross-match & coagulation studies, (consider an ammonia level).
3-lead cardiac monitoring and/or a 12-lead ECG.
Fluid bolus (20mls/kg) and assess response
What fluid bolus
20mls/kg 0.9% bolus
Assessing Disability
Patient response: alert, verbal, pain, unresponsive (AVPU)
Pupils - size and reaction to light (dilated/constricted, fix or responsive, equal size?
Posture
- ↑ ICP decorticate or decerebrate
Blood glucose
Evidence of seizure activity?
Responding to disability
Protect airway
Endotracheal tube if GCS < 8 (call for anaesthetic help)
Recovery position if airway not protected
Give glucose if hypoglycaemia (glucose < 4 mmol/L)
Treat seizure activity with benzodiazepines
Exposure
RASHES TEMPERATURE INJURIES Fractures/bruising/burns SMELLS Ketones Poisons
What charts are child obs recorded on
PAWS chart
5 month old baby girl
Poor feeding 2-3 days
More sleepy
‘Not herself’
What would u do
Airway Patent Breathing Respiratory rate 70/min Sternal + Subcostal recessions O2 sats 92% Pale Circulation Pulse 180/min CRT – 3 seconds Disability AVPU – V Exposure Temp 39.2 oC No rashes Glucose 1.5mmol/l
A - patent B - oxygen C - i.v. fluids D - E – i.v. antibiotics, paracetamol G - i.v.10% dextrose Senior help
THEN Full history + examination Send bloods (at first i.v. access) + Full septic screen (Urine, blood culture, LP, CXR)
X-R: can’t see R diaphragm or R boarder of heart. RL+M lobe pneumoia
Management of this child
Child improves on iv antibiotics and fluids
Discharged home well on day 3 with oral antibiotics
8 year old boy Known asthmatic Having difficulty breathing Very thirsty Passing frequent urine
Airway Patent Breathing Respiratory rate 60/min O2 sats 100% No wheeze Good air entry Pale Circulation Pulse 140/min CRT – 4 secondsDisability AVPU – A Exposure Temp 37.5 oC Smells of ketones
BM 20 mmol/l
Respiratory distress: no wheeze, high glucose
GIVE 10mls/kg risk of cerebral oedema
If you recognise DKA what is your fluid replacement
10mls/kg NaCl
Response to this scenario
A - patent B - oxygen C – i.v. fluids D - E - G -insulin
GET Senior help
THEN
Full history + examination
Blood gas
Urine dipstick
Insulin infusion
i.v. fluids (and K+ when passing urine)
Monitor blood sugars
Monitor for signs ↑ICP
Diagnosis of diabetes. Must discharge with insulin pens and diabetic nurse input.
