PAEDIATRIC EMERGENCIES Dr Matthew Ngetich. OBJECTIVES 1. Know the three components of the Paediatric Assessment Triangle 2. Describe abnormal appearance.

PAEDIATRIC EMERGENCIES Dr Matthew Ngetich

OBJECTIVES1. Know the three components of the

Paediatric Assessment Triangle2. Describe abnormal appearance and

its significance in the evaluation of paediatric injury and illness

3. List three key features of increased work of breathing

4. List three skin signs of abnormal perfusion

THE PAT The PAT is rapid, simple, reproducible

and useful for children of all ages with all levels of illness and injury severity. The paradigm is generic and fits medical, traumatic and neonatal patients.

For the critically ill or injured child, inadequate oxygenation, ventilation or perfusion from any cause will eventually progress to the generic picture of cardiopulmonary failure.

THE PAT

FEATURES OF PAT1. It does not require a stethoscope, blood

pressure cuff, cardiac monitor, pulse oximeter, or any other equipment or test.

2. It entails simply observing a properly exposed child.

3. Early recognition of problems4. Prioritization of problems,5. Basis for an organized resuscitation,

general support and specific treatment.

Characteristics of Appearance

The child's general appearance is the single most important parameter when assessing severity of illness or injury.

Appearance reflects the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and CNS function.

It is more accurate than any other clinical characteristic of the patient in predicting overall distress, need for treatment and response to treatment.

Components of Appearance 1. “tickles” (TICLS):

Tone, Interactability Consolabilty, Look/Gaze, Speech/Cry.

2. AVPU (Alert, responsive to Verbal, Painful stimuli, or Unresponsive)

Most children with mild to moderate illness or injury, even when they are progressing to more severe degrees of distress, are “alert” and have a “normal” neurologic exam, although they have an abnormal appearance.

The “tickles” (TICLS) mnemonic1. TONE

Is she moving around or resisting examination vigorously and spontaneously?

Is there good muscle tone? 2. INTERACTABILITY

How alert is she? How readily does a person, object, or sound

distract her or draw her attention? Will she reach out, grasp and play with a toy

or new object, like a penlight or tongue blade?

“tickles” (TICLS) continued.. CONSOLABILITY

Can she be consoled or comforted by the caregiver or by the clinician?

LOOK/GAZE Can she fix her gaze on the clinician’s or

caregiver’s face or is there a “nobody home,” glassy-eyed stare?

SPEECH/CRY Is her speech/cry strong and spontaneous? Or weak, muffled, or hoarse?

Caution in assessing Appearance1. Poisoning e.g. acetaminophen may

appear stable only to crash later and rapidly

2. Blunt trauma may be able to maintain adequate core perfusion despite internal bleeding by increasing cardiac output and systemic vascular resistance. When these compensatory mechanisms fail, she may acutely “crash”, with rapid progression to clinical shock.

Caution in assessing Appearance3. The appearance of an infant with early shock

or decreased brain perfusion may include irritability and failure to console. When the noxious stimulus is removed, lethargy returns quickly. As symptoms progress, lethargy becomes the dominant observation. The “glassy-eyed” or “nobody home” stare is a sign of altered consciousness in infants.

4. A high-pitched screeching or cephalic cry may indicate poor brain perfusion, brain injury or a central nervous system infection in infants.

REMEMBER

While appearance reflects the presence of real illness or injury, it does not

necessarily indicate the source of the distress.

Work of breathing aka Respiratory Distress This a more accurate immediate

indicator of oxygenation and ventilation than conventional adult measures, such as counting RR or chest auscultation.

It reflects the child’s physiologic compensatory response to cardiopulmonary stress.

It entails careful listening for abnormal airway sounds and observing for specific visual information about breathing effort.

Characteristics of Work of Breathing/Respiratory Distress1. Abnormal airway sounds

Altered speech Stridor Wheezing Grunting

2. Abnormal positioning Head bobbing Tripoding

Characteristics of Work of Breathing/Respiratory Distress3. Retractions

Supraclavicular Intercostal Substernal

4. Flaring of nose

Appearance and work of breathing 1. A child with normal appearance and

increased work of breathing is in respiratory distress.

2. Abnormal appearance and increased work of breathing means early respiratory failure.

3. Abnormal appearance and abnormally decreased work of breathing is late respiratory failure.

Characteristics of circulation to skin When cardiac output is inadequate, the

body shuts down circulation to non-essential anatomic areas such as the skin in order to preserve blood supply to vital end organs (e.g. brain, heart and kidney).

Pallor, mottling and cyanosis are key visual indicators of reduced circulation to skin.

Characteristics of Circulation to Skin1. Pallor

White skin coloration from lack of peripheral blood flow.

Early compensation to shock.2. Mottling

Patchy skin discoloration, with patches of cyanosis, due to vascular instability or cold

Loss of compensatory mechanism to shock3. Cyanosis

Bluish discoloration of skin and mucus membranes.

Shock or respiratory failure

Summary The PAT only takes seconds, identifies need for life-

saving interventions, and blends rapidly into the primary survey.

It does not require any tools or specialist equipment. It can be taught to the lay public and caregivers. The three components of PAT can be assessed in any

order. Any sequence of the ABCs (appearance, breathing, circulation) works, regardless of which is first or second or third, and the ABC order is purely for easy recall in an emergency.

Do ensure that you are trained in basic emergency services

Do identify and quickly refer any life-threatening conditions.

Acknowledgements Bibliography: 1. Dieckmann RA, Gausche M, Brownstein D: Textbook of

Paediatric Education for Prehospital Professionals, Jones and Bartlett, 2005

2. Zitelli B, Davis H: Atlas of Paediatric Physical Diagnosis, 4th Edition. Philadelphia, Mosby, 2002

3. Anne M, Agur A, Dalley A: Grant’s Atlas of Anatomy, 11 th Edition, Lippincott Williams & Wilkins, 2004

4. Hazinski M, Zaritsky A, Nadkarni V, et al: PALS Provider Manual, American Heart Association, 2002

5. American Academy of Paediatrics and the American College of Emergency Physicians. Textbook for APLS: The Paediatric Emergency Medicine Resource. 4th ed. Sudbury, MA. Jones and Bartlett Publishers. 2004.