and assessment of disability (CNS function). This assessment and stabilisation occurs before any illness-specific diagnostic assessment or treatment takes place. Once the patient’s vital functions are supported, secondary assessment and emergency treatment begins. Illness-specific pathophysiology is sought and emergency treatments are instituted. During the secondary assessment vital signs should be checked frequently to detect any change in the child’s condition. If there is deterioration then primary assessment and resuscitation should be repeated.
A discussion of definitive care is outside the scope of this text.
PRIMARY ASSESSMENT AND RESUSCITATION
In a severely ill child, a rapid examination of vital functions is required. The physical signs described in Chapter 3 are used in an ABC approach. This primary assessment and any necessary resuscitation must be completed before the more detailed secondary assessment is performed.
CHAP TITLE
• Primary assessment
• Resuscitation
• Secondary assessment
• Emergency treatment
• Definitive care
Airway
Primary assessment
Patency of the airway must be assessed. It is important to remember that the “look, listen, and feel” method of assessing airway patency is only effective if there is some spontaneous ventilation present.
• If the child can speak, this indicates that the airway is patent, that breathing is occurring and there is adequate circulation. The child may not respond to a health professional but may be induced to speak by the accompanying adult.
• If the child is too young or frightened to give a response then he or she may cry: this is an equally adequate indication that the airway is patent.
• 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 (see Basic Life Support, Chapter 4).
• If there is stridor, upper airway pathology is implicated.
Resuscitation
If the airway is not patent when assessed by the “look, listen, and feel” technique, but patency can be secured by a chin lift or jaw thrust, then an airway adjunct may be required to maintain it. Intubation should be considered.
Breathing
Primary assessment
A patent airway does not ensure adequate ventilation. The latter requires an intact respiratory centre and adequate pulmonary function augmented by coordinated movement of the diaphragm and chest wall. The adequacy of breathing can be assessed as shown in the box.
The normal range of respiratory rate by age is given in Table 8.1.
THE STRUCTURED APPROACH TO THE SERIOUSLY ILL CHILD
Assessment of the adequacy of breathing
• The effort of breathing Recession
Respiratory rate
Inspiratory or expiratory noises Grunting
Accessory muscle use Flare of the alae nasi
• Effectiveness of breathing Breath sounds Chest expansion Abdominal excursion
• Effects of inadequate respiration Heart rate
Skin colour Mental status
BMJ Paediatrics 9/11/0 10:04 pm Page 72
Table 8.1. Respiratory rate by age
A pulse oximeter should be put in place and the oxygen saturation while breathing air noted. A saturation of less than 90% while breathing air or less than 95% while breathing oxygen is very low.
Resuscitation
High-flow oxygen should be given to all children with respiratory difficulty or hypoxia. In the non-intubated patient the high-flow oxygen should be delivered via a non re-breathing mask with a reservoir bag.
In the child with inadequate breathing, this should be supported either with bag-valve-mask oxygenation or intubation and intermittent positive pressure ventilation.
Circulation Primary assessment
Circulation is assessed as shown in the box. Circulation is more difficult to assess than breathing and individual measurements must not be over-interpreted.
The normal circulatory parameters are as shown in Table 8.2.
Table 8.2. Heart rate and systolic blood pressure by age
THE STRUCTURED APPROACH TO THE SERIOUSLY ILL CHILD
Age (years) Respiratory rate (breaths per minute)
<1 30–40
1–2 25–35
2–5 25–30
5–12 20–25
>12 15–20
Assessment of the adequacy of circulation
• Cardiovascular status Heart rate
Pulse volume Capillary refill Blood pressure
• Effects of circulatory inadequacy on other organs Respiratory rate and character
Skin appearance and temperature Mental status
Urinary output
• Signs of heart failure Raised JVP Gallop rhythm Crepitations in lungs Enlarged liver
Heart rate Systolic blood pressure
Age (years) (beats per minute) (mmHg)
<1 110–160 70–90
2–5 95–140 80–100
5–12 80–120 90–110
>12 60–100 100–120
The child’s heart rate and 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 CRT is less than 2 seconds.
The blood pressure should be measured using an appropriately sized cuff.
Resuscitation
Every child with an inadequate circulation (shock) should have oxygen at a high flow rate through a non re-breathing mask with a reservoir bag or via an tracheal tube if intubation has been necessary for airway control.
Venous or intraosseous access should be gained and an immediate infusion of crystalloid or colloid (20 ml/kg) given. Urgent blood samples may be taken at this point.
Disability (neurological evaluation) Primary assessment
Both hypoxia and shock can cause a decrease in conscious level. Any problem with ABC must be addressed before assuming that a decrease in conscious level is due to a primary neurological problem.
The assessment proceeds as follows:
The level of consciousness should be recorded using the AVPU scale.
A ALERT
V Responds to VOICE P Responds to PAIN
U UNRESPONSIVE
Pupillary size and reaction should be noted as a baseline.
The presence of convulsive movements should be noted.
Any patient with a decreased conscious level or convulsions must have an initial glucose stick test performed.
Resuscitation
In a child with a conscious level recorded as P or U (only responding to painful stimuli or unresponsive), consideration should be given to intubation to stabilise the airway.
Hypoglycaemia should be treated with 0·5 g/kg of dextrose (i.e. 5 ml/kg of 10%
dextrose). Before the dextrose is given, blood must be taken for glucose measurement in the laboratory and a clotted sample for further studies.
Prolonged or recurrent fits require active intervention. Intravenous lorazepam or rectal diazepam should be given.
SECONDARY ASSESSMENT AND EMERGENCY TREATMENT
The secondary assessment takes place once vital functions have been assessed and the initial treatment of life threat to those vital functions has been started. It includes a medical history, a clinical examination and specific investigations. It differs from a standard medical history and examination in that it is designed to establish which emergency treatments might benefit the child. Time is limited and a focused approach is essential. At the end of secondary assessment, the practitioner should have a better understanding of the illness affecting the child and may have formulated a differential diagnosis. Emergency treatments will be appropriate at this stage – either to treat specific conditions (such as asthma) or processes (such as raised intracranial pressure).
The establishment of a definite diagnosis is part of definitive care.
The history often provides the vital clues that help the practitioner identify the disease
THE STRUCTURED APPROACH TO THE SERIOUSLY ILL CHILD
process and provide the appropriate emergency care. In the case of children, the history is often obtained from an accompanying parent, although a history should be sought from the child if possible. Do not forget to ask the paramedic about the child’s initial condition and about treatments and response to treatments that have already been given.
Some children will present with an acute exacerbation of a known condition such as asthma or epilepsy. Such information is helpful in focusing attention on the appropriate system but the practitioner should be wary of dismissing new pathologies in such patients. The structured approach prevents this problem. Unlike trauma (which is dealt with later), illness affects systems rather than anatomical areas. The secondary assessment must reflect this and the history of the complaint should be sought with special attention to the presenting system or systems involved. After the presenting system has been dealt with, all other systems should be assessed and any additional emergency treatments commenced as appropriate.
The secondary assessment is not intended to complete the diagnostic process, but rather is intended to identify any problems that require emergency treatment.
The following gives an outline of a structured approach in the first hour of emergency management. It is not exhaustive but addresses the majority of emergency conditions which are amenable to specific emergency treatments in this time period.
The symptoms, signs and treatments relevant to each emergency condition are elaborated in the relevant chapters of Part III.
Respiratory
Secondary assessment
The box below gives common symptoms and signs which should be sought in the respiratory system. Emergency investigations are suggested.
Emergency treatment
• If “bubbly” noises are heard, the airway is full of secretions requiring clearance by suction.
• If there is a harsh stridor associated with a barking cough and severe respiratory distress, upper airway obstruction due to severe croup should be suspected and the child given nebulised adrenaline (5 ml of 1:1000 nebulised in oxygen).
THE STRUCTURED APPROACH TO THE SERIOUSLY ILL CHILD
Symptoms Signs
Breathlessness Tachypnoea
Coryza Recession
Cough Grunting
Noisy breathing (grunting, stridor, Flaring of alae nasi
wheeze) Stridor
Hoarseness Wheeze
Drooling and inability to drink Chest wall crepitus
Abdominal pain Tracheal shift
Cyanosis Abnormal percussion note
Recession Crepitations on auscultation
Chest pain Apnoea
Feeding difficulties Acidotic breathing Investigations
Peak flow if asthma suspected, chest X-ray (selective), arterial blood gases (selective), oxygen saturation
• If there is a quiet stridor in a sick-looking child, consider epiglottitis. (Rare but not gone!) Intubation may be required. Contact a senior anaesthetist urgently. Do not jeopardise the airway by unpleasant or frightening interventions.
• With a sudden onset and significant history of inhalation, consider a laryngeal foreign body. If the “choking child” procedure has been unsuccessful, the patient may require laryngoscopy. Do not jeopardise the airway by unpleasant or frightening interventions but contact a senior anaesthetist/ENT surgeon urgently.
However, in extreme cases of life threat immediate direct laryngoscopy to remove a visible foreign body with Magill’s forceps may be necessary.
• Stridor following ingestion/injection of a known allergen suggests anaphylaxis.
Children in whom this is likely should receive IM epinephrine (10 µg/kg).
• Children with a history of asthma or with wheeze and significant respiratory distress, depressed peak flow and/or hypoxia should receive nebulised ß2 agonists and ipratropium driven with oxygen. Infants are likely to have bronchiolitis and require only oxygen.
• In acidotic breathing, take arterial blood sample for acid–base balance and blood sugar. Treat diabetic ketoacidosis with IV normal (physiological) saline and insulin.
Cardiovascular (circulation) Secondary assessment
The box below gives common symptoms and signs which should be sought in the cardiovascular system. Emergency investigations are suggested.
Emergency treatment
• Further boluses of fluid should be given to shocked children who have not had a sustained improvement to the first bolus given at resuscitation. Consider inotropes and intubation with the third bolus.
• Consider IV antibiotics in shocked children with no obvious fluid loss. Sepsis is likely.
• If a patient has a cardiac arrhythmia the appropriate protocol should be followed.
• If anaphylaxis is suspected in a shocked patient adrenaline should be given intramuscularly in a dose 10 micrograms/kg, in addition to fluid boluses.
• Consider duct-dependent congenital heart disease in infants with unresponsive shock. Give alprostadil.
THE STRUCTURED APPROACH TO THE SERIOUSLY ILL CHILD
Symptoms Signs
Breathlessness Tachycardia
Fever Bradycardia
Palpitations Abnormal pulse volume or rhythm
Feeding difficulties Abnormal skin perfusion or colour
Cyanosis Hypotension
Pallor Hypertension
Hypotonia Abnormal ventilation rate or depth
Drowsiness Hepatomegaly
Fluid loss Auscultatory crepitations
Oliguria Cardiac murmur
Peripheral oedema
Raised jugular venous pressure Investigations
Urea and electrolytes, arterial blood gas, ECG, chest X-ray (selective), full blood count, blood culture (selective)
BMJ Paediatrics 9/11/0 10:04 pm Page 76
Neurological (disability)
Secondary assessment
The box below gives common symptoms and signs which should be sought in the nervous system.
Emergency treatment
• If convulsions persist, continue the status epilepticus protocol.
• If there is evidence of raised intracranial pressure, that is, an acutely unconscious patient with a decreasing conscious level and abnormal posturing and/or abnormal ocular motor reflexes, then the child should be intubated and ventilated. Consider giving mannitol 0·5 g/kg IV.
• In a child with a depressed conscious level or convulsions, consider meningitis/-encephalitis. Give cefotaxime/acyclovir.
• In drowsiness with sighing respirations check blood sugar, acid–base balance or salicylate level. Treat diabetic ketoacidosis with IV normal saline and insulin.
• In unconscious children with pin-point pupils, consider opiate poisoning. A trial of naloxone should be given.
External (exposure)
Secondary assessment
The box below gives common symptoms and signs which should be sought externally.
Emergency treatment
• In a child with circulatory or neurological symptoms and signs, a purpuric rash suggests septicaemia/meningitis. The patient should receive cefotaxime preceded by a blood culture.
• In a child with respiratory or circulatory difficulty, the presence of an urticarial rash or angio-oedema suggests anaphylaxis. Give epinephrine (10 µg/kg) IM.
THE STRUCTURED APPROACH TO THE SERIOUSLY ILL CHILD
Symptoms Signs
Headache Altered conscious level
Convulsions Convulsions
Change in behaviour Altered pupil size and reactivity Change in conscious level Abnormal posture
Weakness Abnormal oculo-cephalic reflexes
Visual disturbance Meningism
Fever Papilloedema or retinal haemorrhage
Altered deep tendon reflexes Hypertension
Slow pulse Investigations
Urea and electrolyte, blood sugar, blood culture (selective)
Symptoms Signs
Rash Purpura
Swelling of lips/tongue Urticaria
Fever Angio-oedema
Gastrointestinal
Gastrointestinal emergencies usually present with shock from fluid loss. This will become apparent during the primary assessment of the circulation or the secondary assessment of the cardiovascular system. The symptoms and signs shown in the box below may be useful in that they may suggest the need for surgical involvement.
Further history
Developmental and social history
Particularly in a small child or infant, knowledge of the child’s developmental progress and immunisation status may be useful. The family circumstances may also be helpful, sometimes prompting parents to remember other details of the family’s medical history.
Drugs and allergies
Any medication that the child is currently on or has been on should be recorded and in addition any medication in the home that the child might have had access to if poisoning is a possibility.