Recognition of the sick and deteriorating child

Question 1

What is the paeds assessment triangle?

Answer 1

• work of breathing
• circulation
• appearance

Question 2

Differences between adults and children: Airway

Answer 2

• Smaller airway = increase resistance —> same amount of oedema so airway becomes blocked faster
• relatively large lounge in small mouth = airway obstruction
• large heads which they can’t control
• soft laryngeal cartilage & different shaped larynx
• infants: preferential nose breathers
• short soft trachea

Question 3

Differences between adults and children: Respiratory

Answer 3

• reduced lung capacity at birth
• less compensatory research
• diaphragmatic breathing —> if anything impacts diaphragm from moving it will impact their breathing
• poorly developed accessory muscles

Question 4

Differences between adults and children: Circulatory

Answer 4

• circulating blood volume higher per Kg absolute blood volume small
• cardiac output = HR x Stroke volume
• stroke volume smaller and can’t significantly increase
• changes in blood pressure is a late sign
• increase in cardiac output = increase in HR
• cardiac problems in kids usually congenital

Question 5

Differences between adults and children: Neurological

Answer 5

• Proportionally large heavy head and short stature
• thin but flexible skull
• rapid brain growth
• neurological assessment more difficult due to cognitive development

Question 6

Differences between adults and children: Muscole-skeletal

Answer 6

• bones flexible and plastic —> incomplete calcification (green stick injuries)
• active growth plates
• underdeveloped abdominal muscles
• large solid organs, weak attachments

Question 7

Differences between adults and children: immune

Answer 7

• immature immunity at birth
• limited maternal antibodies
• immature antibody function

Question 8

Differences between adults and children: Metabolic and thermoregulation

Answer 8

• Large body surface to weight ration
• higher % body water
• reduced renal concentration capacity
• less insulating subcutaneous tissue/ muscle
• infants cannot shiver

Question 9

Structured Assessment of a child

Answer 9

ABCDEEF

A: Airway 
B: Breathing 
C: Circulation 
D: Disability/ LOC/ Pain 
E: Exposure, fever, rashes 
F: Fluids IN 
F: Fluids OUT

Question 10

Assessment of child at risk

Answer 10

• Assessment of injury in young children important
• where there are concerts (actual suspected) regarding child being
  
  • a victim of violence
  • sexually assulted
  • neglected
  • non-accidentally injured
  • exposed to domestic violence
  • cared for by a parent with known mental health disorder
  • at risk of harm

Question 11

A: Airway

Answer 11

Obstructed - complete or partial

- inspiratory noises are the feature of a partially obstructed airway (bubbly noises, snoring or stridor) 
- partial airway obstruction rapidly progress to complete 
- assess severity of obstruction with RR, amount of respiratory effort, HR & alertness 
- children with severe airway obstruction may be agitated or drowsy

example: croup

Question 12

What is the cause of croup?

Answer 12

• Viral
• Anxiety,
• Influenza B,
• Staphylococcus

Question 13

What the pathophysiology of croup?

Answer 13

• mucosal inflammation/ oedema (trachea, larynx, epiglottis)
• airway obstruction, hypoxia

Question 14

What are the symptoms of croup

Answer 14

• inspiratory stridor
• sudden onset of harsh, Barky cough
• hoarseness, sore throat
• worse at night

Question 15

What is the initial management of croup

Answer 15

• positioning
• keeping child calm
• frequent assessment, close observation
• emergency airway/ intubation equipment on hand
• Humidified O2 PRN
• Administer medications: Dexmethasone, nebuliser adrenaline
• PO/ IV fluids
• encourage parent involvement, offer education and support

Question 16

Assessment of breathing?

Answer 16

1. Effort = how hard is the baby/ child working
   
   • Rate and depth
   • chest symmetry
   • breath sounds (wheeze, stridor, cradles)
   • Cough
   • use of accessory muscles/ head bobbing
   • grunting, gasping, positioning
2. Efficacy = how effective is gas exchange?
   
   • LOC, behaviour, agitation to exhaustion, muscle tone
   • colour: mucous membrane and cyanosis or history of
   • Hypoxia (low O2) or Hypercapnia (high CO2)

Question 17

What are the effects of breathing on circulation in children?

Answer 17

Heart rate - Hypoxia produces tachycardia —> so does fear, anxiety and pain

- severe or prolonged hypoxia leads to bradycardia 
- THIS IS PRE-TERMINAL SIGN

Skin Colour - hypoxia produces vasoconstriction and skin pallor

- central cyanosis is a late sign in acute respiratory disease (pre arrest state)
- skin colour is an unreliable sign in an anaemic child

Question 18

What is the cause of bronchiolitis?

Answer 18

• Severe LRTI (Most common)
• RSV (respiratory syncytial virus)
• Rhinovirus

Question 19

What is the pathophysiology of bronchiolitis?

Answer 19

• mucosal inflammation/ oedema
• bronchioles constrict during expiration causing air trapping in alveoli and hyperinflation lungs
• impaired gas exchange, hypoxemia

Question 20

What are the symptoms of bronchiolitis?

Answer 20

• rhynorrhoea, cough, fever
• tachypnoea, tachycardia
• increased respiratory effect/ distress
• apnoea
• chest overexpansion

Question 21

What is the initial management of bronchiolitis?

Answer 21

• frequent assessment (respiratory) close observation (Sp02 and apnoea)
• Humidifed 02
• Nasopharyngeal suctioning
• PO/ IV fluids: hydration assessments, feeding tolerance
• no meds

Question 22

Examination of asthma?

Answer 22

• breath sounds coarse and loud
• prolonged expiration
• generalised wheeze

Question 23

Initial management of asthma?

Answer 23

AIM: the relief of airway obstruction and restoration of oxygenation/ ventilation

- oxygen (high flow) 
- Beta-agonists e.g. salbutamol 
- Anticholinergics (ipratropium bromide) 
- Oral corticosteroids (prednisolone)

Question 24

C: Circulation

Answer 24

• circulating blood volume of baby/ child is less than adult = small fluid loos can represent a large % or total circulating blood

Question 25

Assessment of circulation?

Answer 25

1. HR & BP: normal values
2. Capillary refill time: measured centrally
3. Secondary signs of circulatory compromise
   
   • decreased LOC, confusion, agitation may indicate inadequate circulation to brain
   • reduced urine output indicated inadequate circulation to kidneys
   • prolonged capillary refill time, pallor, mottled skin or cold extremities = inadequate C

Question 26

D: Disability Primary assessment

Answer 26

AVUP
	A = alert 
	V = responds to VOICES 
	P = responds to PAIN 
	U = unresponsive

Question 27

F: Fluids IN

Answer 27

• Normal or maintenance fluid requirements are based on size of the child, smaller children have proportionately higher fluid needs
• Consider: Childs dependency on breastfeeding, urine output (weigh nappies)

Question 28

Assessing hydration status

Answer 28

• Lethargy, irritability and Reduced LOC
• Reduced skin turgor
• pale, mottled cool limbs
• weight loss
• reduced urine output
• prolonged cap refil
• tachypnoea & tachycardia
• Dry mucous membranes
• Sunken eyes

Question 29

F: Fluids OUT assessment

Answer 29

• urine, stool, blood loss and vomit

- a urine output of fewer than 4 wet nappies in an infant in 24 hours is a concern

Question 30

Treatment of Dehydration

Answer 30

Goals

• PREVENTION
• managing underlying cause of dehydration
• Rehydrate
• promote adequate nutrition

Question 31

What is Gastroenteritis?

Answer 31

• infection causing nausea, vomiting and diarrhoea

- usually viral but can be bacterial, parasitic

Question 32

E: Exposure

Answer 32

• Fevers
• Pain
• Rashes
• Trauma