Structured approach to the seriously ill child Flashcards
Describe the primary assessment of Airway & Breathing
A:
- Patent? Look, listen and feel for breath
- vocalisations?
- no air movement
- chin lift/ jaw thrust +/- rescue breaths –> reassess
- airway adjunct
- intubation
B:
- WOB/ effort of breathing
- COUNT = Obs
- RR
- Sats (N = 97 - 100%) - check the waveform!
- Give High flow O2 15 L/ min (mask with reservoir bag)
- Bag-valve-mask ventilation or ETT + intermittent positive pressure ventilation if inadequate effort
- LOOK - resp distress
- recessions (SC, IC, sternal, TT) - NB may decrease as child goes into resp failure
- grunting / nostril flaring/ accessory muscles (sternomastoid - head bobbing)
- drooling?
- degree of chest expansion/ abdominal excursion (infants)
- pallor/ cyanosis (SaO2 < 70% - pre-terminal)
- LISTEN
- gasping (pre-terminal - sign of severe hypoxia)
- stridor (laryngeal/tracheal obstruction - mainly insp. but also exp. if severe)
- wheeze (expiratory) & prolonged exp. phase (lower airway narrowing)
- asymmetrical or bronchial breathing sounds
- silent chest?
- COUNT = Obs
NB
- consider SUCTION
- mental status - hypoxic/ hypercapnic –> agitated/ drowsy / LOC + muscular hypotonia (hypoxic cerebral depression)
What is grunting caused by?
Exhalation against a partially closed glottis.
It is an attempt to generate PEEP (Positive End Expiratory Pressure) to keep the airways open at the end of expiration in children with ‘stiff’ lungs.
e.g. pneumonia, pulmonary oedema
Also - raised ICP, peritonism, abdominal distension.
In what 3 circumstances may there be absent or decreased evidence of increased work of breathing?
- Fatigue/ exhaustion
- Cerebral depression e.g. raised ICP, poisoning, encephalopathy (causes decreased resp. drive)
- Neuromuscular disease e.g. SMA, muscular dystrophy
In what 5 situations are O2 Sats unreliable?
- Severe shock
- Hypothermia
- Motion artefact
- High levels of ambient light
- Carboxyhaemoglobin
What is the effect of hypoxia on HR?
- Tachycardia in the older infant and child
- Bradycardia if severe or prolonged (pre-terminal)
Which children may not become cyanosed despite profound hypoxia?
Anaemic children.
Describe the primary assessment of Circulation.
- COUNT
- HR
- BP - use the correct size cuff! (NB hypotension is a pre-terminal sign - cardiac arrest is imminent! Hypertesion - consider coma and raised ICP)
- Urine output (inadequate renal perfusion - ask about wet nappies!)
- children < 1 ml/ kg/ hr
- infants < 2 ml/ kg/ hr
- LOOK
- mottled, cold, pale, cyanosed skin
- CRT (Normal = 2 secs) - less sensitive if cold env.
- raised JVP
- FEEL
- Skin - clammy? warm? cold?
- peripheral oedema?
- pulse volume
- peripheral vs central (absent peripheral and weak central = advanced shock)
- bounding = sepsis, hypercapnia, arteriovenous shunt e.g. PDA
- absent femoral pulses
- LISTEN
- gallop rhythm
- murmur
+ VENOUS/ intraosseous ACCESS FOR BLOODS INCL. CRP, culture, G+S, gas (BM)
+ crystalloid 20 ml/ kg (10 ml/kg for cardiac pts)
B -
- tachypnoea + increase TV
- NO recessions
= metabolic acidosis (circulatory failure)
D- mental status
- circulatory failure can lead to agitation/ drowsiness –> LOC (due to poor cerebral perfusion)
E - enlarged liver (a sign of heart failure)
What happens to HR in circulatory failure?
- Tachycardia initially in shock - to compensate for reduced SV, secondary to catecholamine release
- Bradycardia (<60 bpm or rapidly falling with reduced systemic perfusion) is pre-terminal
What width and bladder size should paediatric cuffs have?
- Width - more than 80% of the length of the upper arm
- Bladder size - more than 40% of the arm’s circumference
What are the 6 signs of cardiac failure?
From top to bottom:
- Cyanosis - not corrected by O2 therapy
- JVP - raised
- Tachycardia - out of proportion to WOB
- Gallop rhythm/ murmur
- Liver enlarged
- Femoral pulses absent
Describe the primary assessment of disability.
- AVPU
- alert
- responds to voice
- responds to pain (GCS 8 or less)
- supraorbital ridge/ sternal pressure/ trapezius/ achilles squeeze
- what kind of response? opens eyes/ localises to pain/ withdraws from pain?
- unresponsive (consider intubation if P or U)
- GCS
- Pupils
- dilatation
- unreactive
- unequal
- Fontanelle (full? raised ICP, meningitis)
- Posture
- hypotonia
- hypertonia - at rest or as pain response
- decorticate (flexed arms, extended legs)
- decerebrate (extended arms & legs)
- opisthotonos (severe extension of the neck - meningeal irritation) + stiff neck + full fontanelle
- G - don’t ever forget GLUCOSE!
- take a lab glucose sample
- give 2 mls/ kg 10% glucose
- follow with an IV infusion
NB
- always correct ABC bedore assuming that decrease in conscious level is due to a primary neurological problem
- Ix:
- Blood & urine toxicology
- ammonia
- carboxyhaemoglobin level
- CT head
What are the respiratory effects of central neurological failure?
- Hyperventilation
- Cheyne- Stokes breathing
- Apnoea
NB Coma + abnormal resp. pattern = mid or hind brain dysfunction
What is Cushing’s response?
- a circulatory effect of central neurological failure
- hypertension + bradycardia (sinus)
- compression of the medulla oblongata caused by herniation of the cerebellar tonsils through the foramen magnum
- late + pre-terminal sign
Describe the primary assessment of exposure.
- Temperature
- infection
- shivering
- prolonged convulsions
- Rashes
- urticaria
- purpura
- petechiae
- maculopapular
- erythematous
- Swelling
- of lips/ tongue
- angio-oedema
- Bruising - child abuse
What is the dose of adrenaline used in croup?
NEBULISED ADRENALINE 1:1000 (in oxygen)
0.4 mg/ kg OR 0.4 ml/ kg
MAX 5 ml
