The Structured Approach to the Seriously Ill Child

• Primary Assessment and Resuscitation
• Secondary Assessment
• Further History

Primary Assessment and Resuscitation

Airway

Speaking and crying are indications of an adequate airway. If there is no evidence of air movement then chin lift or jaw thrust manoeuvres should be carried out and the airway reassessed. If there continues to be no evidence of air movement then airway patency can be assessed by performing an opening manoeuvre and giving rescue breaths.

Stridor indicates upper airway pathology.

Resuscitation

Airway opening manoeuvre, airway adjunct, consider intubation.

Breathing

Assessment of the adequacy of breathing:

• The effort of breathing: recession, respiratory rate, inspiratory/expiratory noises, grunting, accessory muscle use, nasal flaring.
• Effectiveness of breathing: breath sounds, chest expansion, abdominal excursion.
• Effects of inadequate respiration: heart rate, skin colour, mental status.

Saturation monitoring should be performed in air.

Resuscitation

High-flow oxygen should be given to all children with respiratory difficulty or hypoxia, via a non re-breathing mask with reservoir. If breathing is inadequate, this should be supported either with bag-valve-mask ventilation or intubation and positive pressure ventilation.

Circulation

Assessment of the adequacy of circulation:

• Cardiovascular status: heart rate, pulse volume, capillary refill, blood pressure.
• Effects of circulatory inadequacy: respiratory rate and character, skin appearance and temperature, mental status, urinary output.
• Signs of heart failure: raised JVP, gallop rhythm, lung crepitations, enlarged liver.

Pulse volume should be assessed by palpating both central and peripheral pulses. Capillary refill time (CRT) should be assessed with due allowance for ambient temperature (normal is less than 2 seconds).

Resuscitation

High flow oxygen, venous or intraosseous access, infusion of crystalloid of colloid (20 ml/kg). Urgent blood samples may be taken at this point.

Disability

Both hypoxia and shock can cause a decrease in conscious level. Any problem with ABC must be addressed before assuming a primary neurological problem.

Assess

• Level of consciousness using AVPU scale
• Pupil size and reaction
• Presence of convulsive movements
• Initial glucose stick test

Resuscitation

A child with a conscious level recorded as P or U should be considered for intubation to stabilise the airway. Hypoglycaemia should be treated with 5 ml/kg of 10% dextrose (before giving, take blood for glucose and clotted blood for further studies. Prolonged/recurrent fits should be treated with IV lorazepam or PR diazepam.

Secondary assessment and emergency treatment

Not a standard medical history! Designed to establish which emergency treatments might benefit the child, not a definite diagnosis. History should be obtained from child, parent and paramedic.

Respiratory

The following symptoms and signs should be sought:

• Symptoms: breathlessness, coryza, cough, noisy breathing (grunt, stridor, wheeze), hoarseness, drooling, abdominal pain, cyanosis, recession, chest pain, apnoea, feeding difficulty, acidotic breathing.
• Signs: tachypnoea, recession, grunting, nasal flaring, stridor, wheeze, chest wall crepitus, tracheal shift, abnormal percussion, crepitations
• Peak flow, CXR (selectively), arterial blood gases (selectively), oxygen saturation

Emergency treatment

• Bubbly noises - suction
• harsh stridor, severe respiratory distress (croup) - nebulised adrenaline 5 ml 1:1000 in oxygen
• quiet stridor, sick looking (epiglottitis) - senior anaesthetist, avoid unpleasant/frightening intervention
• Sudden onset, history of inhalation - if "choking child" procedure unsuccessful, senior anaesthetist or ENT surgeon, avoid unpleasant/frightening intervention unless in extreme life threatening cases then direct laryngoscopy with Magill's forceps
• Stridor after contact with known allergen (anaphylaxis) - IM epinephrine (10 mcg/kg)
• History of asthma or wheeze and respiratory distress with decreased peak flow and/or hypoxia - nebulized beta agonists and ipratropium with oxygen (infants with bronchiolitis require only oxygen)
• In acidotic breathing take arterial blood gas and blood sugar - treat DKA with IV normal saline and insulin

Cardiovascular

The following symptoms and signs should be sought:

• Symptoms: breathlessness, fever, palpitations, feeding difficulty, cyanosis, pallor, hypotonia, drowsiness, fluid loss, oliguria
• Signs: tachycardia, bradycardia, abnormal pulse volume or rhythm, abnormal skin perfusion or colour, hypotension, hypertension, abnormal ventilation rate or depth, hepatomegaly, creps, cardiac murmur, peripheral oedema, raised JVP
• Investigations: Urea and electrolytes, ABG, ECG, CXR (selective), FBC, Blood culture (selective)

Emergency treatment:

• Further boluses of fluid for shocked children without sustained improvement to the first bolus at resuscitation. Consider inotropes and intubation with the third bolus
• consider IV antibiotics in shocked children with no obvious fluid loss (sepsis)
• If cardiac arrhythmia, follow appropriate protocol
• If anaphylaxis and shock, give IM epinephrine 10 mcg/kg in addition to fluid boluses
• In infants with unresponsive shock, consider Alprostadil (duct dependent congenital cardiac disease)

Disability

The following symptoms and signs should be sought:

• Symptoms: headache, convulsions, change in behaviour, change in conscious level, weakness, visual disturbance, fever
• Signs: altered conscious level, convulsions, altered pupil size and reactivity, abnormal posture, abnormal oculo-cephalic reflexes, meningism, papilloedema or retinal haemorrhage, altered deep tendon reflexes, hypertension, slow pulse
• Investigations: urea and electrolytes, blood sugar, blood culture (selective)

Emergency treatment:

• If convulsions persist, follow status epilepticus protocol
• If evidence of raised intracranial pressure ie acutely unconscious patient with a decreasing conscious level and abnormal posturing and/or abnormal ocular motor reflexes, then intubate and ventilate. Consider mannitol 0.5 mg/kg IV
• If depressed conscious level or convulsions, consider cefotaxime/aciclovir (meningitis/encephalitis)
• If drowsy with signing respirations check blood sugar, acid-base balance or salicylate level
• In unconscious children with pin-point pupils consider naloxone (opiate poisoning)

Exposure

The following symptoms and signs should be sought:

• Symptoms: rash, swelling of tongues/lips, fever
• Signs: purpura, urticaria, angio-oedema

Emergency treatment

• Purpuric rash with circulatory or neurological symptoms and signs, do blood culture and give cefotaxime (septicaemia/meningitis)
• Urticaria with respiratory or circulatory difficulty, give epinephrine (10 mcg/kg) IM (anaphylaxis)

Gastrointestinal

Consider surgical involvement for:

• Symptoms: vomiting, blood PR, abdominal pain
• Signs: abdominal tenderness/mass

Further history

Developmental progress, immunization status, family circumstances, any medication that the child is on or has been on, any medication in the home that the child might have had access to if poisoning possible.