Recognition of the seriously
ill child
23/03/11
Dr. John Twomey,
Consultant Paediatrician,
Department of Paediatrics/ Emergency Department
Medical Students
Describe what you see
15th century, unknown artist
1664, Gabriel Metsu
1885, Eugene Carriers
2006, Life magazine
The sick child
Some Ground Rules!
Diverse range from infancy to
adolescence
Children Are Not “Little Adults”
What are the key differences to
consider in children?
• Weight
• Anatomical
• Physiological
• Psychological
Weight
• Centile Charts
• Broselow Tape
• Formula (1-10yrs):
Wt (kg) = (age + 4)2
• Estimate (0-1 yrs):
Newborn = 3.5 kg
6/12 = 7 kg
12/12 = 10 kg
• Estimate (>10 yrs):
10 yrs = 30 kg
12 yrs = 40 kg
14 yrs = 50 kg
16 yrs = 60 kg
Anatomical
Airway
-
Large head
Short & soft trachea
Small face & mandible
Loose teeth & Large tongue
Easily compressible floor of the mouth
Obligate nasal breathers (<6/12)
Adenotonsillar hypertrophy
Horse-shoe shaped epiglottis projecting posteriorly
High & anterior larynx (straight bladed laryngoscope)
Cricoid ring = narrowest part of the airway (Larynx in
adults) & is susceptible to oedema (uncuffed ett)
- Symmetry of carinal angles
Anatomical
Breathing
- Lung immaturity
- Small air-surface interface (<3m²)
- Less small airways (1/10 of adult)
- Small upper & lower airways
- R
1/r4
- Diaphragmatic Breathing
- More horizontal ribs
Anatomical
Circulation
- RV>LV (0-6/12) => LV>RV
- Blood circulating volume/body weight = 70-80 mls/kg
- Absolute volume is small (critical importance of
relatively small amounts of blood loss)
Body Surface Area
- BSA:Wt ↓ with ↑ age
- Small children have a high ratio => relatively more
prone to hypothermia
Physiological
Respiratory
Age (yrs)
- Infant - ↑ BMR & O2
<1
Consumption => ↑ RR
RR (bpm)
30-40
1-2
25-35
2-5
25-30
5-12
20-25
>12
15-20
Physiological
Cardiovascular
- CO = SV x HR
- Infant – small stoke
volume => ↑ HR
Age (yrs)
HR (bpm)
<1
110-160
1-2
100-150
2-5
95-140
5-12
80-120
>12
60-100
Physiological
Cardiovascular
- Infant - ↓ systemic
resistance => ↓ BP
- SBP = 80 + (age x 2)
Age (yrs) SBP(mmHg)
<1
70-90
1-2
80-95
2-5
80-100
5-12
90-110
>12
100-120
Physiological
Immune system
- Immature immune system
- Maternal antibodies (x 1st 6/12)
- Protective effect of breast feeding
Psychological
Communication
- No or limited verbal communication
- Many non-verbal cues
- Age-appropriate communication
Fear
- Additional distress to the child and adds to parental
anxiety => altered physiological parameters => difficult to
interpret
- Explain as clearly as possible (Knowledge allays fear)
- Parental presence at all times
A Structured Approach
• 1º Assessment - Resuscitation – identifying &
treating the immediate threats to life – closed or
obstructed airway, absent or distressed
respiration, pulselessness, shock
• 2º Assessment - Emergency Treatment – to
start to treat the underlying cause of the child’s
condition
• Reassessment - Stabilisation – achieving
homeostasis and system control
• Transfer – to a definitive care environment
(PICU)
A Structured Approach
• Preparation (before the child arrives)
• Teamwork (with a designated team
leader)
• Communication (with contemporaneous
recording of history, clinical findings,
treatments)
• Consent (assumed if acting in the best
interests of the child)
WETFAG
•
•
•
•
•
Weight = (Age + 4)2
Energy = 4 J/kg asynchronous shock
Tube = (Age/4) + 4 ---- +/- 0.5
Fluids = 20 mls/kg 0.9% NaCl
Adrenaline = Adrenaline 10 μg/kg IV/IO
(0.1ml/kg of 1:10,000); 100 μg/kg
(0.1ml/kg of 1:1,000) ETT
• Glucose = Dextrose 10% 5ml/kg IV
1º Assessment
&
Resuscitation
ABCD(E)
•
•
•
•
•
Airway
Breathing
Circulation
Disability
(Exposure)
Airway & Breathing
Effort of breathing:
• RR/Recession/Inspiratory & expiratory
noises/Grunting/Use of accessory muscles/Nasal
flaring/Gasping
Efficacy of breathing:
• Chest expansion/Abdominal excursion/ Chest
auscultation/Pulse oximetry
Exceptions:
• Exhaustion/↑ICP/NM d/o
Effect of respiratory inadequacy on other organs:
• ↑/↓ HR/Pallor/Cyanosis {NB anaemia}/Agitation/
Drowsiness/LOC/Hypotonia
=> BLS & Advanced Airway Support
Basic Life Support (BLS)
EMS activation before BLS:
• witnessed sudden collapse
with no apparent preceding
morbidity
• witnessed sudden collapse
in a child with a known
cardiac condition and in the
absence of a known or
suspected respiratory or
circulatory cause of arrest
BLS
Head tilt
position
Infant (<1)
Child (1-14)
Neutral
Sniffing
Initial rescue
breaths
5
Pulse
Brachial/femoral
Landmark
1 finger’s breadth
above xiphisternum
2 fingers/2 thumbs
Technique
5
Carotid
1 finger’s breadth
abovexiphisternum
1 or 2 hands
CPR ratio
15:2
15:2
Circulation
Cardiovascular status:
• HR/Pulse volume/CRT/BP
Effect of circulatory inadequacy on other organs:
• ↑RR (2º to metabolic acidosis)/Pallor/
Cyanosis/Agitation/Drowsiness/LOC/↓ UO (<1ml/kg/hr in
children; <2ml/kg/hr in infants)
Cardiac failure:
• Cyanosis not correcting with O2/Tachycardia out of
proportion to respiratory difficulty/↑JVP/Gallop
rhythm/Murmur/Enlarged liver/ Absent femoral pulses
=> IV/IO access x2; bloods incl. G&X-match; fluid bolus
(20ml/kg); inotropes, intubation & CVP monitoring if
>3 boluses
Disability
Conscious level:
• P ~ GCS </= 8/15
Posture:
• Decorticate/Decerebrate
Pupils:
• Dilatation/Unreactivity/
Inequality
Effect of central neurological
failure on other organs:
• Hyperventilation/CheyneStokes/Apnoea
• ↑BP, ↓HR, abnormal
breathing (Cushing’s Triad)
=> Intubation if “P” or “U”; Rx
hypoglycaemia; Rx seizure
A
V
P
U
ALERT
responds to VOICE
responds only to PAIN
UNRESPONSIVE
(Exposure) – Not part of 1º
Assessment but do early
ABC - DEFG
Don’t Ever Forget Glucose
Reassessment of ABCD(E) at
frequent intervals
2º Assessment &
Emergency Treatment
Airway & Breathing
Symptoms:
• Breathlessness/Coryza/Cough/Grunting/Stridor/Wheeze/
Hoarseness/Drooling & inability to drink/Abdominal pain/
Chest pain/Apnoea/Feeding difficulties
Signs:
• Cyanosis/Tachypnoea/Recession/Grunting/Stridor/
Wheeze/Chest wall crepitus/Tracheal shift/Abnormal
percussion note/Crepitations on auscultation/Acidotic
breathing
Investigations:
• O2 sats/Peak flow/End-tidal or trans-cutaneous CO2/
Blood culture/CXR/ABG
Airway & Breathing
↑ Respiratory secretions –
• Suction - ? Fatigued/depressed conscious level
Barking Cough in a well child –
• ?Croup – PO/IM Dexamethasone (0.6mg/kg stat or 0.15mg/kg BD
x 2-3/7)/Nebulised budesonide (2mg)/Nebulised adrenaline (5ml
of 1:1,000 nebulised in O2) – NB TRANSIENT ↑HR; REBOUND
Quiet stridor, drooling, sick-looking child –
• ?Epiglottitis/Bacterial Tracheitis (Pseudomembranous Croup) Intubation & IV ceftriaxone NB AVOID VENEPUNCTURE (BEFORE
INTUBATION) AND X-RAYS
Sudden onset of respiratory distress leading to apnoea in a conscious
toddler –
• ?Inhaled foreign body -“choking child” manoeuvre/direct
laryngoscopy & use of Magill’s forceps ONLY IN EXTREME
CASES OF A THREAT TO LIFE
• ?Anaphylaxis
Airway & Breathing
Cough, wheeze & ↑SOB –
• ?Acute exacerbation of asthma – Inhaled Salbutamol
(2.5mg{<5yo}; 5mg {>5yo}) & O2/PO prednisolone (2mg/kg) or IV
hydrocortisone (4mg/kg then 2mg/kg QDS)
• ?IFB
• ?Anaphylaxis
Infant with wheeze and respiratory distress –
• ?Bronchiolitis – Supportive Mx – PO/NG/IV fluids/O2
• ?IFB
• ?Anaphylaxis
Pyrexia, breathing difficulties but no stridor/wheeze –
• ?Pneumonia – Antibiotics/Adequate hydration/ +/- chest drain
Stridor following ingestion of a new food –
• ?Anaphylaxis - IM adrenaline (10μg/kg = 0.01ml/kg of
1:1,000)/Nebulised adrenaline (5ml of 1:1,000 nebulised in
O2)/Chlorphenaramine/Prednisolone
• ?IFB
Management of a Choking Child
Ineffective Cough & Conscious
Infants (<1)
• Back Blows (x5) and
Chest Thrusts (x5)
(1/second)
Ineffective Cough & Conscious
Children (1-14)
• Back Blows (x5)
and Abdominal
Thrusts (x5)
(1/second)
(Heimlich
Manoeuvre)
Circulation
Symptoms:
• Breathlessness/Fever/Palpitations/Feeding difficulties/
Drowsiness/Pallor/Fluid loss/Poor urine output
Signs:
• Tachy -or bradycardia/Hypo- or hypertension/Abnormal
pulse volume or rhythm/Abnormal skin perfusion or colour/
Cyanosis/Pallor/Hepatomegaly/Auscultatory
crepitations/Murmur/Peripheral
oedema/↑JVP/Hypotonia/Purpura
Investigations:
• U&E/FBC/ABG/Coag screen/Blood culture/ECG/CXR
Shock
Acute failure of circulatory function
Shock
Types:
• Cardiogenic – heart defects - arrhythmias
• Hypovolaemic – fluid loss – haemorrhage, GE
• Distributive – vessel abnormalities –
septicaemia, anaphylaxis
• Obstructive – fluid restriction – tension pnuemo,
cardiac tamponade
• Dissociative – inadequate O2-releasing
capacity of blood – CO poisoning,
methaemoglobinaemia
Shock
Types:
• Phase 1 - Compensated
• Phase 2 - Decompensated
• Phase 3- Irreversible
Phase 1- Compensated
• Compensatory mechanisms to preserve
vital organ function
• Sympathetic + => ↑Systemic Arterial
Resistance; ↑HR; ↑secretion of
angiotensin & vasopressin
Clinical Features:
• agitation/confusion, pallor, ↑HR, cold
peripheries, ↑CRT
Phase 2 - Decompensated
• Compensatory mechanisms start to fail
• Aerobic => anaerobic metabolism => lactic
acidosis
• Sluggish blood flow => platelet adhesion
• Release of numerous chemical mediators
=> ↑capillary permeability & other
deleterious consequences
Clinical Features:
• ↓BP, ↓LOC, acidotic breathing, ↓/no UO
Phases 3 - Irreversible
• Retrospective Dx
• Death is inevitable despite therapeutic
intervention resulting in adequate
restoration of circulation
• EARLY RECOGNITION & EFFECTIVE
TREATMENT OF SHOCK IS VITAL
Circulation
Shocked child with no obvious fluid loss –
• ?sepsis - IV ceftriaxone
Shock with rash & stridor –
• ?Anaphylaxis - IM adrenaline (10μg/kg =
0.01ml/kg of 1:1,000)
Neonate with unresponsive shock –
• ?duct-dependent CHD – Prostaglandin
(Alprostadil 0.05μg/kg/min)
Pallor with dark brown urine –
• ? Haemolysis ?SCD – O2, rehydration +/Transfusion, antibiotics, analgesia
Circulation
No pulse –
• ?Cardiac Arrhythmia - Assess cardiac rhythm –
asystolé, PEA, VF, PLVT
Poor feeding with HR 230bpm –
• ?SVT Algorithm – vagal stimulation, If IV access - IV
adenosine (100μg/kg; ↑x100μg/kg every 2 min to a
max of 500μg/kg {300μg/kg in < 1/12}), If No IV access
& shocked – DC cardioversion (1J/kg then 2J/kg)
Infant/young child with Hx vomiting, drawing up legs & pallor
++ +/- abdominal mass –
• ?intussusception/malrotation/volvulus etc. - Surgical
advice – Paediatric Surgeon - Dublin/Abdominal USS,
stabilisation & transfer
What is this rhythm?
Supraventricular Tachycardia
(SVT)
• Commonest non-arrest arrhythmia in childhood
• HR >220bpm
• Narrow QRS complex (< 0.08 sec)
•
•
•
•
•
Palpitations
Lightheadedness
Dizziness
Chest discomfort
Shock (if prolonged - younger)
SVT
• Vagal stimulation – glove containing ice over face;
immersion in iced water; unilateral carotid sinus
massage; valsalva (blow through a straw!)
• If IV access - IV adenosine (100μg/kg; ↑x100μg/kg
every 2 min to a max of 500μg/kg {300μg/kg in < 1/12})
• If No IV access & shocked – DC cardioversion (1J/kg
then 2J/kg)
• No response – SEEK SPECIALIST PAEDIATRIC
CARDIOLOGY ADVICE
• Amiodarone (5mg/kg over 20-60 min)
• Procainamide (15mg/kg over 30-60 min)
• Flecainide (2mg/kg over 20 min)
Intussusception – A Medical
Emergency!
• Infant/young child with Hx vomiting, drawing up
legs & pallor ++ +/- abdominal mass
• ABC
• High-flow O2
• IV fluid resuscitation
• PFA
• Abdominal USS
• Inform Paediatric Consultant
• Stabilisation & Transfer for definitive Mx
Fluids in Resuscitation
• 0.9% NaCl 20 ml/kg (10ml/kg in DKA or Trauma)
• >/= 3 boluses (60ml/kg = ¾ of total circulating blood
volume!) = consider RSI
• Larger volumes => haemodilution - Albumin??
• Use CVP (~cardiac preload) as a guide
• Blood –
 fully cross-matched = 1º
 type-specific non-cross –matched = 15 min
 O-negative = 0 min
• NOT dextrose because => hyponatraemia
Disability
Symptoms:
• Headache/Fits or Seizures/Change in behaviour/Change
in conscious level/Weakness/Visual disturbance/Fever
Signs:
• Altered level of consciousness/Convulsions/Altered pupil
size & reactivity/Abnormal posture/abnormal oculocephalic reflexes/ Meningism/Papilloedema or retinal
haemorrhage/Altered deep tendon reflexes/↑BP/↓HR/
Irregular breathing pattern
Investigations:
• U&E/blood glucose/ABG/Coag screen/Blood culture/Blood
& urine toxicology – salicylate/Neuroimaging
Disability
Seizure – 1st Ix –
• hypoglycaemia - IV glucose (5ml/kg of Dextrose 10%)
Seizure > 5 min duration –
• IV lorazepam (0.1mg/kg)/PR diazepam (0.5mg/kg {max
4mg})/Buccal midazolam (0.5mg/kg)
Decreasing level of consciousness/abnormal
posturing/abnormal ocular motor reflexes –
• ? ↑ICP - Intubation & ventilation/head in-line & 20-30º
head-up position/IV mannitol (0.25-0.5g/kg {1.252.5ml/kg of mannitol 20 %} over 20 min) + IV frusemide
(1mg/kg)/+/- Dexamethasone (0.5mg/kg BD)
Neurosurgery input
Depressed level of consciousness/irritability/convulsions –
• ?meningitis/encephalitis - IV ceftriaxone/acyclovir
Disability
Drowsiness with sighing respirations –
• ?DKA - IV Normal saline (0.9%) & insulin
Vomiting, hypoglycaemia & coma –
• ?metabolic encephalopathy – IV glucose,
ABCD & send metabolic screen esp ammonia
– Metabolic Team input
Unconscious with inconsistent history –
• ? NAI – Mx as per any unconscious child,
ophthalmology, bloods, skeletal survey,
neuroimaging (if not already done)
Unconscious with pin-point pupils –
• ? Opiate poisoning - IV naloxone (10μg/kg); IM
naloxone (100μg/kg)
Exposure
Symptoms:
• Rash/Swelling of lips/tongue/Fever
Signs:
• Purpura/Urticaria/Angio-oedema
Exposure
Shock/↓LOC/Purpuric rash
• ?Meningococcal septicaemia – Blood
culture, PCR & IV ceftriaxone
Shock/Stridor/Urticarial rash
• ?Anaphylaxis - IM adrenaline (10μg/kg =
0.01ml/kg of 1:1,000)
Reassessment,
Stabilisation
&
Transfer
A Structured Approach
• 1º Assessment - Resuscitation – identifying &
treating the immediate threats to life – closed or
obstructed airway, absent or distressed
respiration, pulselessness, shock
• 2º Assessment - Emergency Treatment – to
start to treat the underlying cause of the child’s
condition
• Reassessment - Stabilisation – achieving
homeostasis and system control
• Transfer – to a definitive care environment
(PICU)
The Hypocratic Oath!
Epiglottitis
• Don’t lie patient down!
• Don’t do a lateral x-ray
Management of shock
• Too much fluid too quickly can
=> cerebral oedema
• No dextrose as resuscitation fluid
(=> hyponatraemia)
Duct-dependent CHD
• Avoid excessive O2
(sats @ 88-92%)
No LP if altered level of consciousness
• ↑BP, ↓HR, irregular respirations (Cushing’s Triad)
Normal fundoscopy does not exclude acute ↑ICP
NaHCO3 has NO role in initial management of DKA
Steriods have NO role in the initial management of
Meningococcal Septicaemia (√refractory hypotension)
“Don’t Ever Forget Glucose”