Paeds: Recognition of a Sick Child

Question 1

Clinical Severity Prompts

⇒ Airway

Answer 1

Obstruction - complete; partial (stridor)

Apnoea - including Hx of apnoea

Question 2

Clinical Severity Prompts

⇒ Breathing

Answer 2

Bradypnoea

Tachypnoea

Chest recession

Noises; grunting, gasping, wheeze

Accessory muscle use

Nasal flaring

O₂ saturations < 94% on room air

Question 3

Clinical Severity Prompts

⇒ Circulation

Answer 3

Tachycardia / Bradycardia

Hypotension (late sign & is indicative of impending arrest)

Capillary refill > 3secs centrally

Agitation

Poor perfusion

Neurovascular compromise

Altered alertness, level of activity / consciousness

Signs of dehydration

Question 4

Clinical Severity Prompts

⇒ Disability

Answer 4

AVPU - only responding to pain or unresponsive

Pain

Hyper / hypoglycaemia

Fever >38.5^oC → if < 3months, fever >38^oC per axilla or hypothermic

Rash → non-blanching petechiae or purpura

Question 5

History Prompts

Answer 5

Age especially neonates (<28 days old)

Parental concern

Onset

Events - trauma or Hx of trauma

Re-presentation

Co-morbidity

Immunosuppressed

Fluids in and out past 24 hours

Immunisation status

Exposure to anyone else who is sick

Relevant PmHx

Medication

Child at risk

Allergies

Question 6

Airway - Assessment

Answer 6

Assess patency

Question 7

Airway - Intervention

Answer 7

Maintain airway patency

Stabilise the C-spine with in-line immobilisation (if there is a possibility of injury)

Question 8

Breathing - Assessment

Answer 8

Respiratory rate & effort

SpO2

Auscultation

Question 9

Breathing - Intervention

Answer 9

Assist ventilation if required

Apply O2 via a non-rebreather mask to maintain SpO2 > 94%

Question 10

Circulation - Assessment

Answer 10

Skin temperature (touch)

Pulse - rate/rhythm

Capillary refill (sternum)

Blood pressure

Cardiac monitor

Colour

Question 11

Circulation - Intervention

Answer 11

IV cannulation / IO needle insertion & pathology

If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin → give IV/IO 0.9% NaCl 20ml/kg bolus

Monitor vital signs frequently

Question 12

Disability

Answer 12

AVPU/GCS + pupils → monitor LOC

Finger prick BGL → if <3.5 mmol/L administer IV/IO 10% Glucose at 2.5ml/kg stat.

or if no IV/IO access

administer IM Glucagon stat (0.5mg for <25kg child; 1mg for >25kg child)

Monitor BGL 15 minutely until within normal limits

Question 13

Measure and Test

Answer 13

Pathology → Bloods for FBC, UEC, BGL and blood culture (consider group and hold in trauma patients)

Pain score (1-3) → Oral Paracetamol 15mg/kg stat. Single dose never to exceed 1gm and max 4gm/24hrs

Pain score (4-6) → Oral Oxycodone 0.1 mg/kg (max. dose 5mg) stat

Pain score (7-10) → IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary) to a max. dose of 10mg) OR if child >10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (max 75 micrograms total dose)

Temperature → per axilla

U/A → urine for culture and analysis

Fluid input/output → Investigate hydration status; FBC