Lectures
Recognition of the
seriously ill child
Recognition of the
seriously ill child
Objectives
• To understand the structured approach to
the recognition of the seriously ill child
• To learn a rapid clinical assessment
sequence to identify serious illness in a child
• To introduce the equipment used for the
resuscitation of a seriously ill child
Recognition of the
seriously ill child
Causes of death worldwide <5 years
Neonates < 1m
Children aged 1m-5yrs
Preterm birth complications
12%
Diarrhoea
14%
Birth asphyxia
9%
Pneumonia
14%
Sepsis
6%
Other infections
9%
Other
5%
Malaria
8%
Recognition of the
seriously ill child
Causes of cardiac arrest in children
Airway
Obstruction
Foreign body, asthma,
croup, bronchiolitis
Respiratory
Depression
Convulsions, sepsis,
poisoning, ↑ICP
Alveolar/Chest
Wall Failure
Respiratory
Failure
Pneumonia, chest
trauma & myopathy
Fluid Loss
Bleeding, burns,
diarrhoea, vomiting
Fluid Maldistribution
Sepsis, anaphylaxis
Heart Failure
Myocardial depression,
congenital abnormality
Cardiac
Arrest
Circulatory
Failure
Recognition of the
seriously ill child
Systematic approach
Airway
Breathing
Circulation
Disability
Exposure
• Primary assessment
• Resuscitation
• Secondary assessment
• Emergency treatment
• Stabilisation, transfer to
definitive care
Recognition of the
seriously ill child
Recognition of serious illness
• Potential respiratory failure
• Potential circulatory failure
• Potential central neurological failure
Recognition of the
seriously ill child
Potential respiratory failure
Effort of Breathing
Effectiveness
of Breathing
Effects of Respiratory
Inadequacy
Recognition of the
seriously ill child
Effort of breathing – subcostal recession
• Mild
• Severe
Recognition of the
seriously ill child
Subcostal recession
Recognition of the
seriously ill child
Effort of breathing
• Respiratory rate
• Accessory muscle use
• Flaring of the nostrils
• Child's position
Recognition of the
seriously ill child
Effort of breathing – associated sounds
• Stridor
• primarily inspiratory noise
• upper airway pathology
• Wheeze
• primarily expiratory noise
• lower airways pathology
• Grunting
• expiration with partially closed glottis
• alveolar pathology
Recognition of the
seriously ill child
Exceptions to the effort of breathing
Increased effort absent in:
•
•
•
exhaustion
central respiratory depression
neuromuscular disease
Recognition of the
seriously ill child
Potential respiratory failure
Effort of Breathing
Efficacy of Breathing
Effects of Respiratory
Inadequacy
Recognition of the
seriously ill child
Efficiacy of breathing
• Chest expansion
• Air entry
• Pulse oximetry
Recognition of the
seriously ill child
Efficiacy of breathing
A SILENT CHEST IS
A PRE–TERMINAL SIGN
Recognition of the
seriously ill child
Potential respiratory failure
Effort of Breathing
Efficacy of Breathing
Effects of Respiratory
Inadequacy
Recognition of the
seriously ill child
Effects of respiratory inadequacy
• Heart rate
• Skin colour
• Mental status
Recognition of the
seriously ill child
Effects of respiratory inadequacy
CYANOSIS IS
A PRE–TERMINAL SIGN
OXYGEN SATURATION OF
<85% IN AIR
IS A PRE-TERMINAL
SIGN
Recognition of the
seriously ill child
Potential respiratory failure –
resuscitation equipment
Recognition of the
seriously ill child
Potential circulatory failure –
early recognition of shock
Cardiovascular Signs
Effects of Circulatory
Inadequacy
Recognition of the
seriously ill child
Cardiovascular signs
• Heart rate
• Pulse volume
• Capillary refill time
• Blood pressure
Recognition of the
seriously ill child
Cardiovascular signs – capillary refill
(1) press for 5s
(2) release
(3) colour should return <2s in
well-perfused, warm child
Recognition of the
seriously ill child
Cardiovascular signs – capillary refill
• A delay of >2s with other signs of
shock and in a warm child suggests
poor peripheral perfusion
Recognition of the
seriously ill child
Cardiovascular signs
HYPOTENSION IS
A PRE–TERMINAL SIGN
Recognition of the
seriously ill child
Potential circulatory failure –
early recognition of shock
Cardiovascular Signs
Effects of Circulatory
Inadequacy
Recognition of the
seriously ill child
Effects of circulatory inadequacy
• Respiratory rate
• Skin temperature/colour
• Mental status
Recognition of the
seriously ill child
Distinguishing cardiac problems
• Cyanosis despite O2
• Marked tachycardia
• Raised jugular venous pressure
• Gallop rhythm / murmur
• Enlarged liver
• Absent femoral pulses
Recognition of the
seriously ill child
Potential circulatory failure –
resuscitation equipment
Recognition of the
seriously ill child
Case report 1
Case Report: 2 months old
Cough and wheeze for 1 week
Sign
Observation
Skin colour
Respiratory rate
Heart rate
Capillary refill time
Mental status
Pale
20/min (recession ++)
200/min
Normal
Unresponsive
Recognition of the
seriously ill child
Case report 2
Case Report: 2 months old
Poor feeding and vomiting for 1 day
Sign
Observation
Skin colour
Respiratory rate
Heart rate
Capillary refill time
Mental status
Pale
70/min (no recession)
220/min
Poor
Unresponsive
Recognition of the
seriously ill child
Potential central neurological failure
Conscious level
Posture
Pupillary signs
Recognition of the
seriously ill child
Potential central neurological failure:
conscious level
A-V-P-U approach:
Alert
Responds to Voice
Responds only to Pain
Unresponsive to all stimuli
Recognition of the
seriously ill child
Potential central neurological failure
Conscious level
Posture
Pupillary signs
• assess with
painful stimulus
Recognition of the
seriously ill child
Potential central neurological failure:
postures
• Decorticate
• Decerebrate
Recognition of the
seriously ill child
Potential central neurological failure
Conscious level
Posture
Pupillary signs
Q&A
Recognition of the
seriously ill child
Recognition of the
seriously ill child
Summary: rapid assessment
Airway and Breathing
• Effort
• Efficacy
• Effects
Circulation
• Heart rate
• Capillary refill time
• Blood pressure
• Skin temperature
Disability
• Conscious level
• Posture
• Pupils