Recognizing the Sick Child
William Beaumont Hospital
Department of Emergency Medicine
Overview
 Review of vitals
 Who’s sick at a glance
 What can babies do?
 Rashes: a quick review
 History and diagnosis that should raise a red flag
 Pediatric fluids and resuscitation
 Pediatric fever
Who is sick?
 The concept of the “toxic child”
 The “L” word
Toxic? Sick?
Toxic? Sick?
Nelson: Pediatrics
No Stethoscope Assessment
 What can you see, hear and feel right when the patient
walks through the door?
Step 1 – Eyeball
 What can you see
 Retractions
 Subcostal, intercostal, supraclavicular
 Tachypnea
 Cyanosis
 Nail beds, lips and mucosa
 Circumoral or facial cyanosis can fool you
 Decreased level of consciousness
 Obvious fracture/deformity
 Rashes
Step 2 - Listen
 What can you hear
 Stridor
 With Crying
 At Rest
 Abnormal Cry
 What don’t you hear
- Asthmatics too tight to wheeze
- Septic child with weak cry
Step 3 - Feel
 Check Pulse
 Tachycardia, bradycardia
 Cap Refill
 Extremity injuries - fractures and lacerations
 Neuro status
What is Normal: Vitals Signs
 Vitals vary by age
 Simple rules to demystify pediatric vitals
What is Normal: Vitals Signs
 Respiratory
 Assess Airway
 Respiratory Rate
Rate
Newborn
<40
1 year
24
18 years
18
What is Normal: Vitals Signs
 Air Entry
 Chest rise, breath sounds, stridor or wheezing
 Quiet versus noisy tachypnea
 Mechanics
 Grunting or retractions
 Color
What is Normal: Vitals Signs
 Take home, bottom line
 Respiratory rate > 60 is abnormal
What is Normal: Vitals Signs
 Circulation
 Normal heart rates:
1-3mo
85-200
3mo-2yr
100-190
2-10yr
60-120
>10yr
75
What is Normal: Vitals Signs
 Abnormal
 Less than 5 years >180, <80
 Greater than 5 years > 160
 Anything greater than 220 = SVT
What is Normal: Vitals Signs
 Blood Pressure
Systolic
Newborn
1 year
>1 year
>60
>70
70+(2 x age)
What is Normal: Vitals Signs
 Blood pressure
 Cap Refill – < 2 Seconds normal
 CNS Perfusion
 Recognize parents, responsive
What is Normal: Vitals Signs
 Take home, bottom line
 Pulse > 220 consider SVT
 Cap refill > 2 seconds not normal
 BP in kids > 1 year = 70 + (2 x age)
What is Normal: Development
 Easy social and motor milestones:
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2 month olds smile
4 month olds roll over
6 month olds sit
9 month olds cruise
12 month olds walk
Review of Rashes
 Rashes are visual things
 Usually can’t tell what to do for rashes over the phone have to see them
Rash 1
Habif: Clinical Dermatology
Rash 2
Habif: Clinical Dermatology
Rash 3a
Habif: Clinical Dermatology
Rash 3b
Habif: Clinical Dermatology
Rash 4
Nelson: Pediatrics
Rash 5a
Habif: Clinical Dermatology
Rash 5b
Habif: Clinical Dermatology
Rash 6a
Habif: Clinical Dermatology
Rash 6b
Habif: Clinical Dermatology
Rash 7
Habif: Clinical Dermatology
Rash 8
Habif: Clinical Dermatology
Rash 9
Habif: Clinical Dermatology
Rash 10
Habif: Clinical Dermatology
Rash 11
Habif: Clinical Dermatology
Rash 12
Rashes
 Take home, bottom line
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Check for blanching – petechiae and purpura do not blanch
Toxic vs. nontoxic
Check for oral lesions
Check the palms and soles
Most rashes are benign
Red Flags
 Diagnostic categories or history that should heighten
your concern and raise your triage class
 Mnemonic: CATNITS
Red Flags
 CATNITS
 Congenital problems
 Inborn errors of metabolism
 Neurologic Disease, seizures
 Vomiting, acidosis, hypoglycemia
 Liver or cardiac disease
 Congenital Heart Disease
 Chromosomal Abnormalities
Red Flags
 CATNITS
 Allergic
 History of anaphylaxis or significant medication reaction
 History of respiratory distress with previous reactions
Red Flags
 CATNITS
 Trauma
 Loss of consciousness > 2 minutes
 Altered LOC now
 Limb threatening injury
 Bleeding not controlled
Red Flags
 CATNITS
 Neoplasm
 Recent chemotherapy - Fever and neutropenia
 Anemia or thrombocytopenia
Red Flags
 CATNITS
 Infectious
 Signs and symptoms of septic shock/meningitis, including rash
 Any reason to be immune compromised
 Examples: Immune deficiency, protein loosing enteropathy,
on steroids
Red Flags
 CATNITS
 Toxins
 Ingestion of dangerous vs. non toxic substance
 Many interventions are time dependent
 Patients may deteriorate rapidly
Red Flags
 CATNITS
 Social/Psychiatric
 Patient threat to himself/herself or others
 Possibility of abuse or neglect
Pediatric Fluids
 Bolus
 10 to 20 cc/kg
 0.9 NS only, ever, always
 Maintenance Fluids
 4 – 2 – 1 rule
 Neonates and infants: D5 0.2 NS
 Children: D5 0.45 NS
Pediatric Fluid Problem
6 mos old child comes in with 24 hours of n/v/d. Not
made urine for 12 hours.
Wt = 8kg
Would you bolus, how much, what fluid?
What is maintenance?
Pediatric Resuscitation Doses
 Defibrillation
2J/kg then 4J/kg, 4J/kg
 Epinephrine
0.01mg/kg (1:10,000)
 Atropine
0.01mg/kg
 Glucose
D10 2-4ml/kg (not D50)
 Drugs you can give through an ET tube (NAVEL)
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Narcan
Atropine
Valium
Epi
Lidocaine
Pediatric Fever = 38 C rectally
 Tylenol 15 mg/kg for kids < 6 mos
 Tylenol or Motrin 10 mg/kg > 6 mos
 0 to 4 weeks of age
 Admit for IV abx and apnea monitoring
 CBC, BMP, U/A, UCX, BCX, CXR, LP
 Ampicillin and cefotaxime
Pediatric Fever
 4 – 12 weeks of age
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Look sick = admit
Most of these will be admitted
CBC, BMP, U/A, UCX, BCX
? Lumbar puncture
Abx  ampicillin + cefotaxime or ceftriaxone
 If meningitis then add vancomyocin
The End
Any Questions?