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
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.
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)
