Recognition of the sick and deteriorating child Flashcards
What is the paeds assessment triangle?
- work of breathing
- circulation
- appearance
Differences between adults and children: Airway
- 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
Differences between adults and children: Respiratory
- 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
Differences between adults and children: Circulatory
- 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
Differences between adults and children: Neurological
- Proportionally large heavy head and short stature
- thin but flexible skull
- rapid brain growth
- neurological assessment more difficult due to cognitive development
Differences between adults and children: Muscole-skeletal
- bones flexible and plastic —> incomplete calcification (green stick injuries)
- active growth plates
- underdeveloped abdominal muscles
- large solid organs, weak attachments
Differences between adults and children: immune
- immature immunity at birth
- limited maternal antibodies
- immature antibody function
Differences between adults and children: Metabolic and thermoregulation
- Large body surface to weight ration
- higher % body water
- reduced renal concentration capacity
- less insulating subcutaneous tissue/ muscle
- infants cannot shiver
Structured Assessment of a child
ABCDEEF
A: Airway B: Breathing C: Circulation D: Disability/ LOC/ Pain E: Exposure, fever, rashes F: Fluids IN F: Fluids OUT
Assessment of child at risk
- 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
A: Airway
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
What is the cause of croup?
- Viral
- Anxiety,
- Influenza B,
- Staphylococcus
What the pathophysiology of croup?
- mucosal inflammation/ oedema (trachea, larynx, epiglottis)
- airway obstruction, hypoxia
What are the symptoms of croup
- inspiratory stridor
- sudden onset of harsh, Barky cough
- hoarseness, sore throat
- worse at night
What is the initial management of croup
- 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
Assessment of breathing?
- 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
- 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)
What are the effects of breathing on circulation in children?
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
What is the cause of bronchiolitis?
- Severe LRTI (Most common)
- RSV (respiratory syncytial virus)
- Rhinovirus
What is the pathophysiology of bronchiolitis?
- mucosal inflammation/ oedema
- bronchioles constrict during expiration causing air trapping in alveoli and hyperinflation lungs
- impaired gas exchange, hypoxemia
What are the symptoms of bronchiolitis?
- rhynorrhoea, cough, fever
- tachypnoea, tachycardia
- increased respiratory effect/ distress
- apnoea
- chest overexpansion
What is the initial management of bronchiolitis?
- frequent assessment (respiratory) close observation (Sp02 and apnoea)
- Humidifed 02
- Nasopharyngeal suctioning
- PO/ IV fluids: hydration assessments, feeding tolerance
- no meds
Examination of asthma?
- breath sounds coarse and loud
- prolonged expiration
- generalised wheeze
Initial management of asthma?
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)
C: Circulation
- circulating blood volume of baby/ child is less than adult = small fluid loos can represent a large % or total circulating blood
Assessment of circulation?
- HR & BP: normal values
- Capillary refill time: measured centrally
- 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
D: Disability Primary assessment
AVUP A = alert V = responds to VOICES P = responds to PAIN U = unresponsive
F: Fluids IN
- 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)
Assessing hydration status
- 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
F: Fluids OUT assessment
- urine, stool, blood loss and vomit
- a urine output of fewer than 4 wet nappies in an infant in 24 hours is a concern
Treatment of Dehydration
Goals
- PREVENTION
- managing underlying cause of dehydration
- Rehydrate
- promote adequate nutrition
What is Gastroenteritis?
- infection causing nausea, vomiting and diarrhoea
- usually viral but can be bacterial, parasitic
E: Exposure
- Fevers
- Pain
- Rashes
- Trauma
