Approach to a Sick Child

1.  Jogeshwar Pd. Bosak
 MBBS
 AIIMS Patna

2. Quick recognition
Immediate intervention
( Life saving)

3. Signs of:
A. Respiratory distress/ respiratory failure
B. Circulatory insufficiency
C. Altered mentation

5.  Structured
 Objective
 Systemic

6. 1) Prevention of arrest
2) Early high quality bystander CPR
3) Rapid activation of Emergency Response System (ERS)
4) Effective Advanced Life Support (ALS)
5) Integrated post-cardiac arrest care

7. Tier 1: Hands only CPR
Tier 2: Compression and
breathing CPR
 Out-of hospital setting
 Lay rescuers( limited BLS
skills)
 Chest compressions only
 Skilled BLS rescuer
 30:2 compression- ventilation
ratio

8. Tier 3: Multi-rescuer coordinated CPR
 Compression
 Ventilation
 Defibrillation
 Team of multiple skilled rescuers.

9.  Start compression within 10 s of recognition of cardiac arrest.
 Push hard ( >1/3 anteroposterior diameter of chest)
 Push fast (100-120 compressions per minute)
 Allow complete chest recoil
 Minimize interruptions
 Avoid excessive ventilation
 Compression ventilation ratio ( single rescuer 30:2; multiple
rescuer 15:2)
 If advanced airway is in place , one breath should be given
every 6s with continuous chest compressions.

10. 1. Scene safety, assessment and circumstantial evidence
2. Activate ERS and get equipments
3. Breathing and pulse check
4. Determine next action
5. Begin high quality CPR
6. Attempt defibrillation with AED
7. Resume high- quality CPR

12.  Level 1( Resuscitation)
 Level 2 ( Emergent)
 Level 3 ( Urgent)
 Level 4 ( Less Urgent)
 Level 5 ( Non- urgent)

13.  Evaluation
 Identification
 Intervention

14. 1. Initial assessment: PAT Triangle
2. Primary assessment: ABCDE
3. Secondary assessment: SAMPLE history and focused
examination
4. Diagnostic tests

15. Clinical assessment Brief description
Primary assessment Rapid hands on ABCDE approach to
evaluate respiratory, cardiac and
neurological functions,
Includes assessment of vital signs &
pulse oximetry
Secondary assessment A focused medical history and a
focused physical exam
Diagnostic assessments Laboratory, radiological and other
advanced tests that helps the child’s
physiological condition and
diagnosis

16. Type and severity of potential problems:
TYPE SEVERITY
RESPIRATORY Upper airway obstruction
Lower airway obstruction
Lung tissue disease
Disordered control of breathing
Respiratory distress
Respiratory failure
CIRCULATORY Hypovolemic shock
Distributive shock
Cardiogenic shock
Obstructive shock
Compensated shock
Hypotensive shock
CARDIOPULMONARY FAILURE
CARDIAC ARREST

17.  A- Appearance (Consciousness)
 B- Breathing
 C- Colour
Rapid Cardiopulmonary assessment
Three components:

18.  T- Tone
 I- Interactivity
 C- Consolability
 L- Look/Gaze
 S- Speech/Cry
 Appearance reflects the adequacy of oxygenation,
ventilation, brain perfusion and CNS function.
A child who is alert, easily consolable when crying, has good
muscle tone, and responds to a caregiver is unlikely to be
critically ill.

19.  Apnea/Tachypnea/Bradypnea
 Audible sounds
 Abnormal respiratory pattern
 Use of accessory muscles

20.  Pallor (anemia)
 Bruises, ecchymosis, petechial spots (bleeding
diathesis)
 Mottling or dusky hue (vasomotor instability)
 Cyanosis

23.  Hands on approach.
 Rapid cardiopulmonary and brain assessment.
 TARGET-Identify severity and type of physiological
insufficiency and follow E-I-I.
 5 components-
A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure

24. EVALUATE IDENTIFY INTERVENE
• Look at the airway patency,
secretions, vomitus ,FB, etc
Open/clear No interventions needed
• Listen for any noisy
breathing
Maintainable Positioning, suctioning,
noninvasive simple airway
adjuncts like oropharyngeal
airway or nasopharyngeal
airway
Nonmaintainable Requires invasive airway
adjuncts like tracheal tube or
tracheostomy tube

25.  Evaluate [5 components]
1. Respiratory rate (RR)
2. Work of breathing (WoB)
3. Chest wall movements and tidal volume.
4. Auscultation (Air entry and adventitious sounds)
5. Pulse oximetry

26. AGE R.R
Infant (1month-1yr) 30-53
Toddler (1-3yrs) 22-37
Preschooler (4-5yrs) 20-28
School age (6-12yrs) 18-25
Adolescent (13-18yrs) 12-20

27.  TACHYPNEA
 First sign of respiratory distress
 Always pathological when associated with increased WoB.
 Quiet tachypnea d/t fever , anxiety , cardiac , sepsis ,
metabolic , or central causes(without use of any
accessory muscles)

28.  BRADYPNEA
 More ominous than the fast breathing
 Any breathing rate less than 10 per min. at all ages is
abnormal
: Respiratory muscle fatigue
: CNS injury or infection
: Hypothermia
: Respi. Depressant drugs and toxins

29.  APNEA
 Cessation of breathing for 20s or more/ earlier if associated
with cyanosis , bradycardia , pallor , hypotonia
 Central: CNS injury , drugs , infection.
 Obstructive: FB , vocal cord paralysis , craniofacial anomalies
, sleep apnea
 Mixed

30. GROUP OF MUSCLES INVOLVED RESPIRATORY TRACT LOCATION
Alae nasi , suprasternal, supraclavicular,
sternocleidomastoid
Upper airway
Subcostal, sternal Lower airway
Intercostal, grunting Lung parenchyma
Head bobbing and see-saw respirations mostly
indicate respiratory failure

31.  Abnormal movements indicate
 Underlying airway obstruction
 Pulmonary , pleural or neuromuscular abnormalities

32. ADVENTITIOUS SOUNDS ANATOMICAL LEVEL CLINICAL CORRELATE
Stridor Upper airway obstruction Croup/foreign body
Wheeze Lower airway obstruction Asthma/foreign body
Crackles Lung parenchymal
disease(fluid/mucus /blood
Pneumonia, pulmonary
hemorrhage/edema
Grunting Alveolar atelectasis Pneumonia, drowning
Asymmetric breath
sounds
Pleural
fluid/consolidation/pneumothorax
Foreign body, pleural effusion,
pneumothorax

33.  Normal SPO2 is 94%or more in room air
 Indicates the oxygen saturation in the blood
 With oxygen support one should target 94-95%saturation

34.  SEVERITY
 Respiratory distress-inc. WoB
 Respiratory failure- resp. distress+(fatigue/deranged
consciousness/SPO2 below 92% despite oxygen
supplementation/cyanosis

35.  TYPE
 Upper airway obstruction
 Lower airway obstruction
 Lung parenchymal disease
 Disordered control of breathing

36.  Signs of Shock (inability of circulation to meet the metabolic
demands of the body) picked up on clinical evaluation
 5 components
1. Heart rate (HR) and rhythm
2. Central and peripheral pulses
3. Capillary filling time (CFT)
4. Skin color and temperature
5. Blood pressure (BP) measurement

37. AGE Awake HR Sleeping HR
Infant (1month-1yr) 100-180 90-160
Toddler (1-3yrs) 98-140 80-120
Preschooler (4-5yrs) 80-120 65-100
School age (6-12 yrs) 75-118 58-90
Adolescent (13-18 yrs) 60-100 50-90

38. HEART RATE CLINICAL CORRELATE
< 60bpm Bradycardia
>220 bpm in infant Tachyarrhythmia
>180bpm in a child Tachyarrhythmia
Upto 220 in infant Sinus tachycardia
Upto 180 in child Sinus tachycardia

39.  Central pulses
Examine- femoral and axillary arteries (infants), carotid artery
( others)
 Peripheral pulses
Examine-radial , temporal, posterior tibial
Low CO states= weak peripheral pulses f/b fall in bp f/b low
volume central pulsations

40.  Evaluated under the nail bed or skin
 CRT in a normal individual- within 2 secs
 Increased CRT indicative of shock

41.  Normal pink color [ appreciable on skin over the face, ear
lobes, palms and soles, oral mucosa and conjunctival mucosa]
 Pale – low Hb / poor circulation /N in individuals with thick
skin
 Ashen gray/ mottled/cyanosed- ineffective circulation
 Distributive shock

42.  Hypotension BP below fifth centile for the age
 NB: urine output indirect indicator of kidney perfusion and
circulatory status of the child
AGE CUT OFF
1-12months <70 mm Hg
1-10yrs 70+(age in yrs*2)mm Hg
Above 10 yrs Atleast 90 mm Hg

43.  SEVERITY
 Compensated or normotensive shock (low CO but preserved
BP)
 Hypotensive shock(fails to maintain BP)
 BASED ON ETIOLOGY
 Hypovolemic shock
 Distributive shock
 Cardiogenic shock
 Neurogenic shock

44.  Evaluates brain functions= cortical assessment +brainstem
assessment
 Cortical assessment- Glasgow Coma Scale(GCS) or AVPU
Scale(Alert, Voice , Pain , Unresponsive)
 Brainstem assessment- pupillary reflex?
 NB: raised ICP leading to herniation-unequal pupil size
(urgent intervention)
: bedside blood sugar testing and treat hypoglycemia

45.  Identify bleeds, injury, swelling distension , deformity and
rashes
 Peripheral and core temperature measured
specific interventions for fever and hypothermia

46. EVALUATE IDENTIFY LIFE THREATENING
CONDITION
IMMEDIATE INTERVENTION
Airway Partial or complete airway
obstruction
Heimlich’s maneuver,
suction, reposition of airway,
naso or oropharyngeal airway
Breathing No breathing/ineffective
breathing, asymmetric chest
rise, tension pneumothorax
Oxygen, chest
compressions/ventilation,
needle thoracocentesis
Circulation Pulse feeble /not detected,
hypotension/blood loss
CPR, fluid/blood bolus.
Inotropes as reqd.
Disability Unresponsive, GCS <8,
hypoglycemia
If absent pulse start CPR.
Elective intubation, 10%
dextrose bolus
Exposure Fever/hypothermia, bleeds Antipyretics/controlled
warming, pressure bandage/
surgical intervention

47.  After the initial Evaluation,Identification ,and
Interventions to stabilize the chid more information is
gathered from
 Focussed history
 Focussed physical exam
 Ongoing reassessment

48.  Focused history has six component parameters which
together can be remembered as mnemonic ''SAMPLE''.
 S - Signs & symptoms (Symptoms are important but they
are subjective)
 A - Allergies
 M - Medication
 P - Past medical history
 L - Last meal/last oral intake
 E - Events leading to present illness/injury

49.  The physical examination Focuses on areas that have
not been covered in the primary assessment. These
would be the neck, lymph nodes, throat, neck
stiffness, and cardiac evaluations including the
murmurs and examination
 Severity of the child’s illness or injury should
determine the extent of the physical exam

50.  Essential to evaluate the response to treatment and to track the
progression of identified physiological and anatomical
problems
 Elements :
PAT
ABCDE with vital signs & SpO2
Assessment of abnormal anatomical and physiological findings
Review of the effectiveness of treatment interventions

51.  ABG (Arterial Blood Gas)/VBG (Venous)/CBG
(Capillary Blood Glucose)
 Hb count
 Central venous O2 saturation
 Arterial lactate
 CVP (Central Venous Pressure)
Helps detect and identify the presence and severity of
respiratory and circulatory problems.

52.  IBP monitoring
 CXR/ECG/ECHO
 PEFR (Peak Expiratory Flow Rate)
 Serum electrolyte
 Renal Function Test (RFT)
 CT scan

53.  A 6 month old boy brought to Emergency 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.
1. What are the key signs of illness ?
2. What is the clinical impression ?
3. What will you do next ?

54.  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).
 Clinical impression: severely ill suggestive of Shock

55.  Primary survey: ABCDE
 Circulation: Abnormal ( Tachycardia, tachypnea, cool
skin, prolonged CRT and weak pulse).
 This confirm the PAT impression of shock.

56.  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

57. Thank