Approach To a Sick Child Ibrahim Alsaif Pediatric Emergency Consultant Al-Yamamah Hospital ped.emergency.Dr.Alsaif 10/19/2014

Objectives By the end of this tutorial , each student should be able to: Know if the child is sick or not sick Know the priorities and triaging of patients in ER Know what are the differences between the pediatric and adult cardiopulmonary assessment? Have a systematic approach to pediatric assessment by using: The initial Impression (appearanc, work of breathing, circulation to skin) Primary survey including ABCDE Secondary survey( focused history and physical exam) Diagnostic tests Clinical scenario Objectives and goals of this topic ped.emergency.Dr.Alsaif 10/19/2014

Comparison between pediatric and adult cardiopulmonary assessment Adult cardiopulmonary assessment begins with a “hands-on” approach. Alert child over six months of age, begin the assessment from a distance ( assess on entry). Compensatory mechanism Accuracy of Vital Signs in children ped.emergency.Dr.Alsaif 10/19/2014

Systematic Approach to a sick child In order to recognize the sick baby or child a structured assessment is required. ped.emergency.Dr.Alsaif 10/19/2014

Systematic Approach to a sick child Initial impression (appearance, work of breathing, circulation) Is the child need Resuscitation(CPR)? Yes No C A B Evaluate Primary assessment Secondary assessment Diagnostic tests Intervene Identify ped.emergency.Dr.Alsaif 10/19/2014

Initial Impression Initial visual and auitory assessment on entry Before hands on Non threatening approach Non invasive ped.emergency.Dr.Alsaif 10/19/2014

ped.emergency.Dr.Alsaif 10/19/2014

ped.emergency.Dr.Alsaif 10/19/2014

Pediatric Assessment Triangle Rapid cardiopulmonary assessment Three components of Pediatric Assessment Triangle (PAT): Appearance Work of breathing The pediatric assessment triangle (PAT) is a rapid assessment that relies on three observations to quickly identify a child with respiratory or circulatory compromise, or both, who requires immediate supportive care Circulation to skin ped.emergency.Dr.Alsaif 10/19/2014

Appearance Appearance reflects the adequacy of oxygenation, ventilation, brain perfusion and CNS function. Characteristics of a child's appearance: TICLS Tone: what is the infant’s muscle tone? normal - vigorous movement and normal muscle tone seriously ill – limp or abnormal muscle tone Interactiveness: Is the child playful and interactive? Consolability: consoled or distracted by a parent or caregiver? Look/Gaze: unfocused or stare look- abnormal mental status Speech/cry: weak cry? hoarsed or muffled voice suggest upper airway obstruction ped.emergency.Dr.Alsaif 10/19/2014

Appearance A child who is alert, easily consolable when crying, has good muscle tone, and responds to a caregiver is unlikely to be critically ill. On the other hand, the clinician should be very concerned about an infant who is limp, not interactive, listless, and has a weak cry. ped.emergency.Dr.Alsaif 10/19/2014

Work of Breathing RR: abnormal rate Abnormal airway sounds: Work of breathing reflects child’s physiological compensatory response to cardiopulmonary stress. Characteristics of (work of breathing): RR: abnormal rate Abnormal airway sounds: stridor, weezing or grunting Abnormal positioning: head bobbing, sniffing or tripoding Retractions: use of accessory muscles intercostals, subcostal and supraclavicular Flaring: nasal flaring ped.emergency.Dr.Alsaif 10/19/2014

Circulation to the skin Circulation to skin reflects the overall status of circulation to vital organs(heart, brain, kidneys). Characteristics of circulation to skin: Pallor: white skin coloration from lack of peripheral blood flow. Cyanosis: bluish discoloration of skin and mucous membranes. Mottling: patchy skin discoloration due to vascular instability or cold. ped.emergency.Dr.Alsaif 10/19/2014

Review of initial impression Assess on Entry by rapid visual and auditory assessment(PAT) Only few seconds. Appearance. Work of breathing. Circulation to skin. Overall Purpose of PAT( to decide whether sick or not sick). What is the next? Appearance Work of breathing Circulation to skin ped.emergency.Dr.Alsaif 10/19/2014

Systematic Approach to a sick child Initial impression (appearance, work of breathing, circulation) Is the child need Resuscitation(CPR)? Yes No C A B Evaluate Primary assessment Secondary assessment Diagnostic tests Intervene Identify ped.emergency.Dr.Alsaif 10/19/2014

What is the next? Primary survey Secondary survey Diagnostic tests ped.emergency.Dr.Alsaif 10/19/2014

Primary survey A rapid hands-on ABCDE approach to evaluate respiratory, cardiac, and neurologic function of a sick child regardless of complaint. Components of primary survey: Airway Breathing Circulation Disability or neurological status Exposure ped.emergency.Dr.Alsaif 10/19/2014

Components of Primary Survey(ABCDE) Airway Assessment Patent. Maintainable. ped.emergency.Dr.Alsaif 10/19/2014

ABCDE Airway Assessment ped.emergency.Dr.Alsaif 10/19/2014

ABCDE Breathing RR Pulse oximeter Respiratory Mechanics : Air Entry : Retractions, Accessory Muscles use and Nasal Flaring Head Bobbing Grunting Stridor Wheezing Air Entry : Chest Expansion Breath Sounds Color : Blue = Cyanosis Pink = Normal ped.emergency.Dr.Alsaif 10/19/2014

ABCDE Circulation Heart rate BP Peripheral pulses Skin perfusion Vol/strength of central pulses Peripheral pulses Present/absent Volume/strength Skin perfusion Cap. refill time Color : Mottling, Pallor Temperature CNS perfusion Responsiveness Recognizes parents Muscle tone Pupil size Posturing ped.emergency.Dr.Alsaif 10/19/2014

ABCDE Disability (neurological status) Appearance Pupillary Response to Light Level of Consciousness: AVPU A: Alert V: Verbal P: Pain U: Unresponsive Glasgow Coma Scale ped.emergency.Dr.Alsaif 10/19/2014

Children’s coma score (15) Best verbal response: 5 Orientated Smiles, follows 4 Disorientated Consolable crying Inappropriate interaction 3 Inappropriate words Sometimes consolable, moaning 2 Incomprehensible sounds Inconsolable, irritable 1 No response Eyes: 4 Spont open 3 Verbal command 2 Pain 1 No response Motor: 6 Obeys verbal 5 Localizes pain 4 Withdraws from pain 3 Abn, flexion to pain 2 Extends to pain (decer) 1 No responre ped.emergency.Dr.Alsaif 10/19/2014

ABCDE Exposure Skin Findings: Evidence of Trauma: Petechiae, purpura Rashes, urticaria Evidence of Trauma: Bruises, laceration Bleeding Raccoon eyes Battle's sign Ear bleeding Nasal discharge( CSF leake) ped.emergency.Dr.Alsaif 10/19/2014

What is the next? Primary survey Secondary survey Diagnostic tests ped.emergency.Dr.Alsaif 10/19/2014

Secondary Survey Focused medical history: SAMPLE S :Symptoms and Signs A :Allergies M:Medications P :Past medical history L :Last meal E :Events leading to current illness Focused Physical Examination: Head to Toe Wt Estimation: < 8 yrs: 8+ ( 2×age in yr ) > 8 yrs: 3×age Broselow tape: depends on Length measurement ped.emergency.Dr.Alsaif 10/19/2014

What is the next? Primary survey Secondary survey Diagnostic tests: ABG, serum electrolytes, renal function, X-ray, ECG, CT.scan…etc ped.emergency.Dr.Alsaif 10/19/2014

Review of systematic approach to sick child ped.emergency.Dr.Alsaif 10/19/2014

(appearance, work of breathing, circulation) Initial impression (appearance, work of breathing, circulation) Is the child need Resuscitation(CPR)? Yes No C A B Evaluate Primary assessment Secondary assessment Diagnostic tests Intervene Identify ped.emergency.Dr.Alsaif 10/19/2014

Clinical Scenario A 6 month old boy brought to ER by the mother with a frequent vomiting for 24 hrs. He is lethargic, irritable on touch and his cry is weak. No abnormal airway sounds, retractions or nasal flaring. He is pale and mottled. HR=180/min, RR=60/min, BP=70/50mmhg, T= 37c. CRT is 4 sec, skin is cool and brachial pulse is weak. Chest exam showed normal equal air entry and normal breath sound. Other systemic exam is unremarkable. What are the key signs of illness? What is the clinical impression? What will you do next? ped.emergency.Dr.Alsaif 10/19/2014

Clinical Scenario(answer) A 6 month old boy brought to ER by the mother with a frequent vomiting for 24 hrs. He is lethargic, irritable on touch and his cry is weak. No abnormal airway sounds, retractions or nasal flaring. He is pale and mottled. HR=180/min, RR=60/min, BP=70/50mmhg, T= 37c. CRT is 4 sec, skin is cool and brachial pulse is weak. Chest exam showed normal equal air entry and normal breath sound. Other systemic exam is unremarkable. What are the key signs of illness? General initial assessment use PAT: Appearance : Abnormal (lethargic, irritable on touch and decreased tone, weak cry). Work of breathing: Tachypnea Circulation to skin : Abnormal (pale and mottled). ped.emergency.Dr.Alsaif 10/19/2014

Clinical Scenario(answer) What is the clinical impression? Clinical impression: severely ill suggestive of Shock ped.emergency.Dr.Alsaif 10/19/2014

Clinical Scenario(answer) A 6 month old boy brought to ER by the mother with a frequent vomiting for 24 hrs. He is lethargic, irritable on touch and his cry is weak. No abnormal airway sounds, retractions or nasal flaring. He is pale and mottled. HR=180/min, RR=60/min, BP=70/50mmhg, T= 37c. CRT is 4 sec, skin is cool and brachial pulse is weak. Chest exam showed normal equal air entry and normal breath sound. Other systemic exam is unremarkable. What will you do next? Primary survey: ABCDE Circulation: Abnormal( Tachycardia, tachypnea, cool skin, prolonged CRT and weak pulse). This confirm the PAT impression of shock. ped.emergency.Dr.Alsaif 10/19/2014

Clinical Scenario(answer) What will you do next? After Identification of problem: hypovolemic shock Treat: Resuscitation with IV or IO 20ml/kg of NS. Reassess Secondary survey: history and physical exam Diagnostic test: ABG, blood sugar, urea and serum electrolytes…etc Stabilization ped.emergency.Dr.Alsaif 10/19/2014

ped.emergency.Dr.Alsaif 10/19/2014