Spotting the sick child Flashcards
T/F: children’s symptoms are often vague and tend to be quite non-specific
True - such as vomiting or a temperature whatever the cause (physical examination plays a greater part in diagnosis than it does in adults)
The 3 minute toolkit can help diagnose an acutely ill child - what does it encompass
A: obstructed? > secretions, foreign body, stridor B: struggling to breathe? > assess RR, look for recession/ accessory muscle use, check O2 sats, auscultate chest C: poor circulation? > assess colour of skin, HR, CRT (sternum + fingers/toes), BP, warm or cold hands/ feet D: neurological state > pupil response to light, limb tone and movement, AVPU/ GCS E: expose and examine top-to-toe > rashes, injury/ trauma, bruises (consider NAI) ENT: ear, nose and throat T: temperature (tympanic or axillary thermometer or rectal if very unwell) T: tummy > soft, distended, tender, BS, masses, hernias. Never forget the testes in boys. Urinalysis
A: SECRETIONS/ STRIDOR - check for secretions (e.g. in ____) - if you hear stridor consider what? - T/F: you must examine the throat if you hear stridor - airway opening manoeuvres - like what? - airway adjuncts - like what?
1) bronchiolitis 2) foreign body or coup 3) do NOT examine the throat if you hear stridor - risk that you could cause deterioration. Await senior help 4) Neutral in infant, head tilt chin lift in a child, jaw thrust 5) oro/nasopharyngeal airway (will also check if gag reflex)
A: UNPROTECTED AIRWAY When assessing decreased consciousness and you may need an anaesthetists, what is the most useful test you can do?
See if there is a gag reflex - try to insert an oropharyngeal airway and see if there is a reaction > coughing = they are protecting their airway. If not > maintain a jaw thrust and call an anaesthetist
normal RR and HR for a neonate?
RR: 30-40 HR: 110-160
normal RR and HR for 2-5 year olds?
RR: 25-35 HR: 95-140
normal RR and HR for 5-12 year olds?
RR: 20-25 HR: 80-120
normal RR and HR for 12-18 year olds?
RR: 15-20 HR: 60-100
Visual signs of cyanosis will not be detectable until the situation is very serious, i.e. saturations of what?
85% or less
Normal children should have sats of at least (1)%. Levels of less than (2)% imply significant illness. Below (3)% is alarming
1) 96 2) 94 3) 90
How to minimise the difficulties associated with auscultating a child’s chest?
- if they’re crying, try to catch the breath sounds as they breathe in - they may settle with a dummy or finger to suck - warm stethoscope if cold - let them play with the stethoscope and turn it into a game
T/F: auscultation is of less value than in adults
true, because the chest is small and therefore noises transmit all over the chest. Usually the most information you can get is whether there is wheezing (asthma) or wet crepitations (bronchiolitis)
How to assess colour in circulation?
if they’re pale, ask the parents what their normal colour is. Look for mottled arms/ legs - some children are mottled frequently so check with parents. If its unusual this is a sign of poor perfusion
How to measure pulse
ensure child is calm (crying can increase HR) measure radial pulse for 30s then x2 In babies <6/12 brachial is more easily felt If in hospital, pulse oximeter or cardiac monitor may give you a more accurate reading
How to measure CRT?
pressure for 5 seconds, >2 seconds is abnormal Central refill time (sternum/ forehead) produces less false positive results but peripheral (fingers/ toes/ hands/ feet) may be an earlier sign of decompensation
why is CRT a particularly useful measure of circulation in children?
as BP doesn’t drop until the child is extremely ill and tachycardia is not 100% reliable
why note temperature of hands and feet?
they will be cooler if there’s peripheral vasoconstriction e.g. sepsis or dehydration
T/F: BP is often not worth measuring in children
true - as they can get upset when the cuff tightens around their arm. Unless you’re v worried about circulation (e.g. drowsy/ very sick appearing child).
T/F: dropping BP is often one of the first clinical signs of shock in a child
false - BP is maintained until very late in shock cause kids have such good peripheral vasoconstriction to compensate
what size of cuff should be used when measuring BP?
2/3 of the length of the upper arm. May be easier to take from the high if infant is struggling
when might sluggish pupillary responses be seen?
after a fit or drug overdose
changing pupil sizes may be a sign of?
ongoing seizures, even if there are not tonic-clonic movements. abnormal gaze may also be seen after a seizure
asymmetry of the pupils implies what?
a SOL within the brain e.g. an extradural or subdural haemorrhage from a head injury
Comparison of the tone and movements of the limbs is important if you’re worried about what
a SOL in the brain, such as a haematoma from a head injury or a tumour causing seizures If you pick up a difference between right and left which hasn’t been previously noted, the child is likely to need a CT brain scan. These signs are only likely if a patient is not alert and orientated
Most important part of the Disability section?
observe the child’s behaviour - alert? (AVPU). Also irritability/ drowsiness and whether they are just upset or inconsolable
True irritability may indicate what? (i.e. child can’t be consoled)
raised ICP or meningitis
when is drowsiness common in children?
common after a fit also common when they have a high temperature
important points about ENT exam
- needed in any child with a fever - best left to the end in case the child gets upset - ensure the parent/ assistant holds the child still
T/F: pink eardrums are often an indication of infection in a child
false - their eardrums re often pink, just because of the temperature
T/F: large, red tonsils are pathognomonic of tonsilitis
false - large and a bit red is normal (the temp is high and they have an increased blood supply) In true tonsillitis, the tonsils are large with an exudate
what method of recording temperature is recommended in small babies?
axillary temperature (ears too small for a tympanic thermometer)
how to examine the abdo in kids
best lying flat on a trolley (if child is very upset can do on parents lap). Firstly feel around the abdomen gently, enquiring where it hurts. Once they’re relaxed you can feel deeper for tenderness, peritonism or masses.
What is the BM Stix?
the equipment used for testing blood glucose NB: not usually needed in a child who’s alert and orientated
T/F: a low blood sugar, or hypoglycaemia, occurs in children quite easily in children
true - if they have had a low calorie intake for a day or 2, have ingested alcohol, have severe sepsis or have a congenital metabolic abnormality
Normal range for blood glucose in a child?
3-5 millimoles per litre
most common reason for a young child to be taken to the doctor?
Difficulty in breathing or cough - often triggered by infection (viral most common)
the most common organisms causing respiratory problems in kids?
Strep pneumoniae, Haemophilus influenzae, Pertussis, Mycoplasma, and the influenza viruses
most common causes of breathlessness in kids?
asthma, bronchiolitis, pneumonia, and croup.
what causes asthma
hyper-reactive airways > bronchi constrict and secrete mucus > narrowed airways produce a wheeze
what is a wheeze
high pitched expiratory sound
T/F: the inspiration phase tends to be prolonged in asthmatics
false - the expiration phase
Under the age of __, children do not have typical asthma, and beta agonists tend to be less effective.
one little you can do - except admit the child if they’re not feeding or require oxygen
what is croup.
viral infection of the upper airway (most often parainfluenza virus) Commonest in toddlers, makes them miserable
characteristic symptoms of croup?
Airway inflammation > hoarse voice and barking cough Turbulent airflow through the narrowed airway > stridor (inspiratory or expiratory) Other signs of upper airway obstruction > intercostal recession, subcostal recession, sternal recession and tracheal tug
Croups responds well to what medication? What about severe croup?
Steroids - such as oral dexamethasone, predisolone or nebulised budesonide. Severe - adrenaline nebuliser can be used for a more immediate effect while waiting for steroids to kick in (5 mls of 1:1000 adrenaline into a nebuliser, and you should see an improvement over 20 minutes or so) - may need to be repeated
bronchiolitis age group?
mainly 1 month - 1 year olds
symptoms of bronchiolitis?
infects the lower airways causing secretions > shortness of breath, wheezing, a wheezy/ wet sounding cough, a runny nose - and sometimes a mild temperature (less than 38)
main causative virus of bronchiolitis?
RSV
treatment for bronchiolitis?
no specific treatment but if they are not feeding, have significant respiratory distress, or are hypoxic, they need to be admitted to hospital for oxygen and fluids
In children under 3 years old with signs of sepsis, what investigations is usually performed in children and why?
a chest X-ray to detect pneumonia, because the clinical signs are notoriously subtle
what subtle signs of a pneumonia may be noticed?
general signs of severe infection (using 3 minute toolkit) e.g. lethargy, fever and a high heart rate, particularly if out of proportion to the degree of fever. In bacterial pneumonia they will appear more unwell and lethargic than with common viral respiratory infections, with a temperature typically above 38.5 degrees centigrade, and they often refuse food and drink NB: compared with adults, cough is a less reliable symptom (sometimes there is no cough). Chest auscultation is also less reliable (small so transmits sounds all over - focal signs hard to detect)
When examining the respiratory system what is the most important discriminating sign for a pneumonia?
a raised respiratory rate - in kids < 3, a raised respiratory rate is sufficient to warrant a CXR low oxygen sats are another imp clue
T/F: the smaller the child the easier and quicker they can go into respiratory failure
true - babies under 3 months are particularly vulnerable to hypoxia and apnoeas Hx of apnoea is a red flag. Any baby who has had an apnoea needs to be admitted to hospital urgently.
what is an important aspect to cover in the history of any child with a respiratory illness
whether they were born prematurely - if they required care on the Neonatal Unit you should have a low threshold for admission to hospital (Can deteriorate quickly) Same for any babies with cardiac or respiratory diseases Healthy small infants often have noisy breathing simply because the airways are so small. If the parents say the baby has always been like this you don’t need to worry (most grow out of it by 6 months of age).
If an infant has bronchiolitis, the diagnosis is usually fairly obvious, unless the baby is only a few weeks old, in which case it may present with an ____
apnoea In most cases there is a snuffly nose, noisy breathing, wheezing and a wet cough.
Admission to hospital will be determined by what factors for respiratory illness?
whether the infant is feeding, is tiring, or needs supplemental oxygen.
T/F: Infants who have had bronchiolitis in the past often go on to get a recurrent cough and wheeze for a year or so.
true - usually triggered by viral upper respiratory tract infection. The coughing and wheezing usually starts a couple of days after the runny nose, and tends not to respond to standard asthma treatment so is usually described as post-viral wheeze rather than asthma.
when would a wheeze caused by previous bronchiolitis be able to be differentiated from asthma?
>2 years old they usually grow out of the wheezing associated with bronchiolitis as a baby. Those with FH of asthma, or who are atopic (hayfever/ ezcema) are more likely to have recurrent wheezing episodes, which we would call asthma.
Key points in the history when assessing acutely wheezy children?
assess activity level, eating and drinking, ability to sleep without disturbance and how ill they have become in the past, esp if they’ve needed to be admitted to ICU/ needed several courses of steroids in the past
things to look for when considering how unwell a child with difficulty breathing is
level of alertness and how interested they are in their surroundings, their posture and their ability to speak
A runny nose is described as ____ in medical terms, and this is a feature of (which condition).
coryza bronchiolitis
wheezing is a noise from the lower airways which may occur due because they are constricted, in ____, or full of secretions, as in _____.
asthma bronchiolitis
what is ‘grunting’ in a child with respiratory distress?
when infants close their glottis to generate end expiratory pressure, to keep their alveoli open when they have lots of secretions. Seen in bronchiolitis. Is a sign of significant respiratory distress. Crying in a strained fashion, with prolonged expiration, does a similar thing.
how is the expiration phase affected in children with In children with bronchoconstriction?
prolonged e.g. asthma or bronchiolitis
signs of increased work of breathing?
recession of the ribs, and the use of accessory muscles (amerians use the term ‘retractions’)
name the different types of recession
tracheal tug, supraclavicular recession, sternal recession, intercostal and subcostal recession (work from top to bottom to remember all) Categorised as mild, moderate or severe
T/F: an older child has to be in a greater degree of respiratory distress for you to see recession
true (chest wall less soft) and vice versa, recession i v common on neonatal unit, even when the baby isn’t that unwell
what kind of recession indicates more severe respiratory distress?
sternal - because the sternum is a large bone, and to draw it in means that severe effort is being put in sternal recession and tracheal tug are quite prominent in kids with upper airway obstruction such as croup
what signs of accessory muscle use may be seen in respiratory distress
Abdominal breathing (forced diaphragm movement) Head bobbping (pulling on the sternomastoid muscles in the neck) Nasal flaring can also be seen
why are O2 sats so important to measure in a child?
naked eye wont detect cyanosis until the patient is seriously ill. In children, obvious cyanosis in a normally healthy child implies a life threatening condition You can see that once oxygen saturations reach 90% or so, there is a rapid deterioration in the patient’s oxygen levels with each stage of decompensation after that point.
sats in normal healthy children?
98-100%
Supplemental oxygen should be given if the saturations are below what?
95%
With oxygen, saturations should pick up to 100% rapidly. If they remain low despite high flow oxygen, the child is very hypoxic and unwell.
when would bronchial breathing be heard in a child
happens when there is a pneumonia with consolidation of the lung, which creates a harsh, blowing, kind of noise in the area just above the consolidation
how to tell if a foreign body is stuck in the airway or oesophagus?
Airway: most have been coughed up, brought up by someone doing a Heimlich type maneuvre, or it is small enough to have gone down one of the 2 bronchi, and cause wheezing or a chest infection rather than persistent choking. If truly stuck in the larynx > hypoxic > apnoeic > unconscious/ in cardiac arrest by the time a health professional is present.
Oesophagus: much more common. They’re able to talk/ cry
Emergency management of a foreign body stuck in the larnyx and threatening the child’s life?
- bang on the back. Child upsidedown on knee for younger kids, chest thrusts for under 4s, Heimlich for over 4s.
- If these fail, call a senior anaesthetist and an ENT surgeon and try to leave the child alone. Can be given a short acting, inhaled, anaesthetic and the foreign body removed with Magill’s forceps.
- Lost consciousness: use a laryngoscope and retrieve the foreign body with Magill’s forceps without wating for futher help. If difficult to retreive, cricothyrotomy may be needed
Appearance and management of a child who has ingested a foreign body? (i.e. stuck in oesophagus)
uncomforable, drooling (hard to swallow), but not hypoxic or showing signs of respiratory distress
Is not immediately life threatening and you can refer the child to the anaesthetic and surgical teams for further management
How may a child present if the object goes down the left or right main bronchus?
- will present with wheezing or a chest infection, sometimes months after the event.
- if in the acute phase, listen for for localised wheezing and get a CXR which may show a ball-valve effect where air gets in past the foreign body, but can’t escape as the child breathes out, and the lung becomes progressively hyperinflated. The child will need to be referrred for bronchoscopy to retreive the object.
- (commonly peanuts or beads)
what is Apnoea?
a word used to describe a pause in breathing, or stopping breathing
T/F: Any infant who has had an apnoea should be referred to hospital by ambulance
true dat
Why might a child have an apnoea?
- Infants (esp 1-4 months) may have apnoeas as a sign of illness, not necessarily respiratory in origin
- can happen in various conditions such as bronchiolitis, whooping cough (which is due to Pertussis infection), sepsis, meningitis and fits
How to recognise apnoea from a history?
Can be hard to diagnose - should be regarded as having happened during any event which includes floppiness or cyanosis
These symptoms are called an apparent life-threatening event, as this is what it felt like to the parent
How does the presentation of whooping cough differ in young babies (i.e. a few weeks old) c.f. older children?
- young babies: tends to present with apnoeas
- It is only in older children that Pertussis causes coughing bouts followed by a big intake of breath which sounds like a whoop
What is Status asthmaticus?
acute severe asthma attack, which dodesn’t respond to the normal treatment of 2 or 3 nebulizers or repeated doses of an inhaler.
When an asthma attack is severe and prolonged, children can become very tired and go into respiratory failure and require intubation and ventilation to take over the work of breathing.
