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

2. 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

3. 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

4. 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

5. 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

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

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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

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

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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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

27. 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

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

29. (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

30. 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

31. 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

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

33. 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

34. 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

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