Acutely ill child

Dr Syed Imran Khilji

Assess-categorize-decide-act
ASSESS

ACT

CATEGORIZE

DECIDE

ASSESSMENT/EVALUATION
1. General assessment 2. Primary assessment 3. Secondary assessment 4. Tertiary assessment
 Purpose: to enable to recognise signs of

Cardiorespiratory failure and shock to provide life saving interventions

 ASSESS
Clinical assessment General assessment Brief description Rapid assessment of overall appearance, work of breathing and circulation in few seconds of encounter

Primary assessment

ABCDE approach to evaluate cardiopulmonary and neurologic function including vital signs and saturations

Secondary assessment

Medical history using SAMPLE mnemonic and head to toe physical examnination

Tertiary assessment

lab, radiographic and other advanced tests to establish physiologic condition and diagnosis

 CATEGORIZE:  Clinical condition by type and severity to

determine the best course of action

Type Respiratory -upper/lower airway obstruction -lung parenchymal disease -disordered control of breathing -hypovolemic shock -distributive shock -cardiogenic shock -obstructive shock Severity -Respiratory distress -Respiratory failure

Circulatory

-compensated shock -hypotensive shock

 DECIDE:

Based on assessment and initial categorization

 ACT:

Treatment / actions appropriate -CPR including defibrillator -monitoring -o2 -starting treatment
 Repeat assess-categorize-decide-act cycle as

interventions are provided

 General assessment:

appearance

breathing

circulation
General assessment Appearance Work of breathing Circulation Muscle tone, interaction, consolability, look/gaze, speech/cry Increased work of breathing, decreased/absent resp efforts, or abnormal sounds Abnormal skin colour(pallor/mottling) or bleeding

Determine whether life threatening or not

 Signs of life threatening condition

Airway Complete or severe airway obstruction

Breathing

Apnea, significant work of breathing,tachyp, bradyp

Circulation

Absence of pulses, poor perfusion, hypotension, brady

Disability

Unresponsiveness, depressed consciousness

Exposure

Significant hypothermia, bleeding, petechiae/pupura,

 Primary assessment:

-ABCDE approach -Airway Breathing Circulation Disability Exposure -Cardiopulmonary and neurological assessment -Vital signs and sats

 AIRWAY: Look, listen, and feel.

Look: chest or abdominal wall movement Listen: adventitious breath sounds such as stridor, stertor, or gurgling Feel: air movement with your face near the child's mouth and nose
Status Clear Maintainable Description Open and unobstructed Simple measures(positioning, suctioning, FBAO relief techniques like <1 year-back slaps/chest thrusts; >1 yearabdominal thrusts, NPA/OPA) Advanced measures(ET intubation, FB removal via laryngoscopy, cricothyrotomy)

Not Maintainable

Correct positioning of the child younger than age 8 years for optimal airway alignment: a folded sheet or towel is placed beneath the shoulders to accommodate the occiput and align the oral, pharyngeal, and tracheal airways.

A:Opening the airway with the head tilt and chin lift in patients without concern for spinal trauma: gently lift the chin with one hand and push down on the forehead with the other hand. B: Opening the airway with jaw thrust in patients with concern for spinal trauma: lift the angles of the mandible; this moves the jaw and tongue forward and opens the airway without bending the neck.

 BREATHING: rate, efforts, tidal volume, airway

and lung sounds, pulse oximetry  Respiratory rate

Age Infant(<1 year) Toddler(1-3 years) Preschooler(4-5 years) School age(6-12 years) Adolescent(13-18 years) Breaths per minute 30-60 24-40 22-34 18-30 12-16

Tachypnea: first sign of RD Bradypnea: ominous sign; impending arrest Apnea: cessation of breathing for 20 secs or for a shorter period with brady/cyanosis/pallor

 central apnea-absence of insp mucle activity

-brain/spinal cord  Obstructive apnea-insp muscle activity without airflow  Mixed apnea  Respiratory effort: nasal flaring/chest retractions/head bobbing or seesaw resp
Breathing diff Mild-moderate Location Subcostal Substernal intercostal Supraclavicular Suprasternal Sternal Description Retraction below ribcage Retraction at bottom of sternum Retraction between ribs Retraction above collar bone Retraction above sternum Retraction of sternum toward anterior spine

Severe

-Retractions with stridor/insp snoring-UAO -Retractions with exp wheezing-LAO -Retractions with grunting/laboured breathinglung parenchymal disease -Head bobbing- use of neck muscles for resp Lifts the chin and extends the neck during insp and the chin falls forward during exp sign of respiratory failure -Seesaw resp- chest retracts and abd expands during insp and chest expands and abd moves inwards during exp UAO/LA disease/infants/neuromuscular dis

 Auscultation:

-Air movt- below axilla(farthest from large airway) -Abnormal soundsstridor-coarse, high pitched, insp/exp UAO Grunting-short, low pitched, exp exhales against partially closed glottis sign of severe resp disease or failure Gurgling-bubbling sound during insp/exp airway secretions, vomit or blood Wheezing-high/low pitched whistling/sighing sound during exp; LAO

Crackles/rales-sharp, crackling sounds in insp moist crackles-pneumonia/pulm oedema dry crackles-atelectasis/ILD

 Pulse oximetry: percent of Hb sat with O2

>94% on RA-adequate <94%-o2 <90% on 100% 02-additional intervention

 CIRCULATION  Evaluation of CV funcn & end organ perfusion  CV func- skin colour and temp, heart rate,

rhythm, BP, pulses(peripheral and central), CRT

 End organ perfusion- brain perfusion(mental

status), skin perfusion, renal perfusion(urine OP)

 Skin colour and Temp:

-Consistent over trunk and extremities -Mucous memb, nail beds, palms and soles-pink -Inadequate perfusion causes cool, pale, dusky or mottled hands and feet -Use back of hand to determine the point of cool to warm skin change

 Heart rate:

-Appropriate for age, activity and clinical condn

Age Newonate-3 months 3 months-2 years 2-10 years >10 years Awake rate 85-205 100-190 60-140 60-100 Mean 140 130 80 75 Sleeping rate 80-160 75-160 60-90 50-90

 Heart rhythm:

-Normally regular with min fluctuations in HR -Sinus arrhythmia- increase HR in insp and decrease during exp -Irregular rhythm without relation to resparrhythmia

 BP

-Cuff covering 40% of mid-upper arm circumference or 50-75% of length of upper arm
age Neonate(1st day) infant(1 mon) Infant(3 mon) infant(6 mon) 1 year 2 years 7 years 15 years Systolic BP Female male 60-74 73-91 78-100 82-102 68-104 71-105 79-113 93-127 60-74 68-84 74-94 81-103 87-105 67-103 70-106 79-115 95-131 Diastolic BP Female male 31-45 37-53 36-56 44-64 46-66 22-60 27-65 39-77 47-85 30-44 35-53 37-55 45-65 48-68 20-58 25-63 38-78 45-85

Neonate(4th day) 67-83

 BP: shock may be present before the BP falls

below the normal limits for age. As intravascular volume falls, PVR increases. BP is maintained until there is 35 40% depletion of blood volume, followed by precipitous and often irreversible deterioration.  Shock with signs of decreased perfusion but normal BP is compensated  When BP also falls, decompensated shock is present.  BP determined manually, using an appropriately sized cuff

-Hypotension
age Term neonates Infants(1-12 mon) 1-10 years 5th percentile >10 years Systolic BP <60 <70 <70+age in yearsx2 <90

 Pulses

-Both central(femoral, carotid & axillary) and peripheral(brachial, radial, dorsalis pedis & posterior tibialis) -Difference between central and peripheral seen in vasoconstriction assoc with shock -Beat-beat fluctuation/fluctuation in pulse vol with respiration(pulsus paradoxus)

 CRT

-Reflects skin perfusion -Time taken for blood to return to tissue blanched with pressure -Lift the extremity above heart level/room temp - > 2 secs abnormal -Warm septic shock can present with > 2 secs

 End organ perfusion  BRAIN: signs of inadequate perfusion=signs of

cerebral hypoxia Sudden-Hypotonia, seizures, mydriasis, LOC Gradual-altered consciousness with confusion, irritability, lethargy r/o drugs, metabolic conditions and ICT AVPU scale/GCS scale  SKIN: -Colour/temp/CRT -Pallor/mottling/cyanosis -Petechiae/purpura

 pallor

-Decrease blood supply-cold, stress, shock -Decrease RBC-anemia -Decrease skin pigmentation -more significant if central
 Mottling

-Irregular/patchy discoloration -Due to irregular blood supply of skin caused by hypoxia, hypovolemia or shock

 Cyanosis
-Bluish discoloration of skin and mucus memb -Atleast 5g% desaturated Hb -O2 sat at which cyanosis appears depends on Hb conc. -Peripheral- palms and soles Diminished O2 to tissues as in shock, CHF, peripheral vascular dis or venous stasis -Central-lips and mucus memb Low ambient O2(high altitude), alveolar hypoventilation(brain injury/drugs), diffusion defect(pneumonia), VQ mismatch, intracardiac shunt(cyanotic CHD)

Central cyanosis indicates need for O2 or ventilatory support

 Renal perfusion
Age Infants and young children Older children and adolescents Normal urine op 1.5-2ml/kg/hr 1ml/kg/hr

 DISABILITY

-Quick evaluation of cortex and brain stem -AVPU pediatric response scale -GCS scale -Pupillary response to light

 AVPU scale
A Alert V Voice P Painful Awake, active, responsive to stimuli Responds only when spoken aloud Responds only to painful stimulus

U Unrespon Doesn t respond sive

 GCS scale

-Objective, reproducible and simple -Change of 2 points indicate clinically important change in neurological status -More useful in head injury

 Pupillary response to light

-Indicator of brainstem function -Diameter -Equality -Constriction to light(magnitude & rapidity) PERRL-pupils equal round reactive to light

 EXPOSURE

-Final component of primary assessment -Remove clothing as necessary -Look for evidence of hypothermia, trauma, bleeding, burns, abuse -Palpate for tenderness

 SECONDARY ASSESSMENT  History and physical examination  History: SAMPLE mnemonic

Signs & symptoms Breathing diff, altered consciousness, agitation/anxiety, fever, decreased intake, diarrhea/vomitings, bleeding and time course of symptoms Allergies Medications Past medical history Last meal events Medications, food, etc Last time and dose of any medications Health h/o, past surgeries, immunization status Time and nature of last liquid or food Events leading to illness, hazards at scene, any treatment, time of arrival

 Physical examination: detailed head to toe exam,

extent determined by childs illness or injury

 TERTIARY ASSESSMENT

-Investigations to detect the presence and severity of cardiac and respiratory abnormality
 Assessment of respiratory abnormality

-Lab studies- ABG, Hb conc -Non lab studies- pulseox, end tidal CO2, capnography, chest x-ray, PEFR

 ABG- measures po2 and pco2

-Normal PO2 doesn t confirm adeq O2 content -Used to confirm clinical impression or to evaluate childs response to therapy but it is not required to identify respiratory failure  VBG- pH corelates with ABG -PO2 and PCO2 doesnt correlate -free flowing peripheral or central venous blood correlates well  Hb conc-determines O2 carrying capacity

 Pulse oxymetry

-Non-invasive measurement of oxyHb sats -Indicates adequacy of oxygenation and increase in oxygenation in response to treatment -Monitors only oxyHb sats, doent indicate o2 content or delivery or effectiveness of ventilation(elimination of CO2)
 Exhaled CO2 monitoring

-Estimate arterial CO2 tension & confirm ET tube placement

 Capnography

-Continuous quantitative measurement of ET CO2(PaCO2) conc displayed as a wave form -Repeat ABGs can be avoided
 CXR  PEFR

 ASSESSMENT OF CIRCULATORY

ABNORMALITIES
 Lab-ABG, VBG, CVO2 sats, total serum CO2,

arterial lactate, Hb conc  Non lab- IBP monitoring, CVP monitoring, CXR, 2DECHO

 Central venous O2 sats

-70-75% of arterial o2 sats -Surrogate marker of adequacy of tissue o2 delivery

 Total serum CO2

-Bicarbonate/carbonic acid/dissolved CO2 -Predominently reflects s. bicarb conc -Severity of acid base imbalance, anion gap calcualtion

 Arterial lactate

-Increased production in hypoxia, stress hyperglycemia -Good prognostic indicator; sequential values to assess response to therapy
 IBP monitoring

-Continuous evaluation and wave form display of systolic and diastolic BP -SVR and visual indications of compromise in cardiac OP

 Echo :

-Cardiac chamber size/ wall thickness/ wall motion/ valve configuration and motion/ pericardial space/ ventricular pressures/ interventricular septal position/ congenital anomalies

THANK U

PRISM score
 Assesses the severity of illness in a population  The PRISM, in its 3rd iteration (PRISM III), to    

compare and evaluate performance and resource use among various PICUs. 17 physiologic variables subdivided into 26 ranges The patient's medical history is also taken into account, particularly chronic illness and previous PICU days. Relationship between the number of malfunctioning organ systems at 12 and 24 hr and the mortality risk in a given PICU. PRISM is designed for population assessments and is not valid for decision-making for an individual patient.

 Most useful in assessing case mix adjustments

between units and the overall outcomes for a population of patients in a PICU.  Determine if a PICU is performing on a par with standards that are periodically calibrated to a reference population. If performance is below standard, a chart review may show the reasons  Changes in the score over time may document improvement or deterioration.  As a performance assessment tool, PRISM is applied either periodically or constantly, depending on institutional data-collecting capabilities. PRISM is also useful in research in ensuring that control and experimental groups are similar.

CVS/neurological vital signs

ABG

Chemistry tests

Hematology tests

Other factors