Systematic Approach To The Seriously Ill Or Injured Child By Dr. Aksha
Jul 16, 2015
Systematic Approach To
The Seriously Ill Or
Injured Child
By Dr. Akshay
Objectives
Discuss the evaluate - identify – intervene sequence.
Explain the purpose & components of the primary assessment.
Describe ABCDE components of the primary assessment.
Interpret the clinical findings during the primary assessment.
Evaluate respiratory or circulatory problem by using the ABCDE model in the primary assessment.
Describe the components of secondary assessment.
List diagnostic & laboratory tests used to identify respiratory & circulatory problem.
Initial Impression
First quick “from the doorway”
observation.
This initial visual and auditory
observation of the child’s
consciousness, breathing and color is
accomplished within seconds of
encountering the child.
Initial impression
Consciousness Level of Consciousness
(eg. Unresponsive, irritable,
alert)
Breathing Increased work of breathing,
absent or decreased respiratory
effort, or abnormal sounds
heard without auscultation
Color Abnormal skin color, such as
cyanosis, pallor or mottling
Evaluate – Identify - Intervene
Use the evaluate-identify – intervene
sequence.
Always be alert to a life-threatening
problem.
If any point , identify a life-threatening
Evaluate
Clinical
Assessment
Brief Description
Primary
assessment
A rapid, hands-on ABCDE approach to evaluate
respiratory , cardiac and neurologic function; this step
includes assessment of vital signs and pulse oxymetry
secondary
assessment
A focused medical history and a focused physical
examination
Diagnostic
test
laboratory, radiological and other advanced tests that
help to identify the child’s physiologic condition and
diagnosis
Identify
Type severity
Respirator
y
Upper airway obstruction
Lower airway obstruction
Ling tissue disease
Disordered control of breathing
Respiratory distress
Respiratory failure
Circulatory Hypovolemic shock
Distributive shock
Cardiogenic shock
Obstructive shock
Compensated shock
Hypotensive shock
Cardiopulmonary failure
Cardiac arrest
Intervene
On the basis of identification of child’s problem, intervene with
appropriate action.
Positioning the child to maintain a patent airway
Activating emergency respone
Starting CPR
obtaining the code cart and monitor
Placing the child on a cardiac monitor and pulse oximeter
Administering oxygen
Support ventilation
Starting medications and fluids
Continuous Sequence
Remember to repeat the sequence until
the child is stable.
After each intervention.
When child’s condition changes or
deteriorates.
Primary Assessment
Airway Breathing
Exposure Circulation
Disability
Airway
? patency
To assess upper airway patency:
Look for movement of chest or abdomen
Listen for air movement and breath
sounds
Decide if Upper Airway is clear ,
maintainable or not maintainable,
Status Description
Clear Airway is open and unobstructed for
normal breathing
Maintainable Airway is obstructed but can be
maintainable by simple measures (eg
head tilt-chin lift)
Not
Maintainable
Airway is obstructed but cannot be
maintainable without advanced
intervention (eg intubation)
Airway
Signs suggest Upper Airway obstruction:
Increase inspiratory effort with retraction
Abnormal inspiratory sounds
Episodes where no airway or breath
sounds are present despite respiratory
effort
Allow the child to assume a position of comfort or position the child to improve airway patency
head tilt-chin lift or jaw thrust to open the airway:
Suction the nose and oropharynx.
Perform foreign- body airway obstruction relief technique if you suspect that child has aspirated foreign body:
- <1 yr old, a combination of 5 back blows and 5 chest thrusts
- >1 yr old, providers should give a series of 5 abdominal thrusts (Heimlich maneuver)
Use airway adjuncts (NPA or OPA) to keep the tongue from falling back and obstructing the airway.
Simple Measures
Head tilt-chin lift
Use head tilt-chin lift to
open the airway.
Avoid overextending the
head/neck in infants
because this may
occlude the airway.
Suction the nose and
oropharynx.
Jaw thrust
If cervical spine injury suspected, open airway by using a jaw thrust without neck extension, If this maneuver does not open the airway, use head tilt-chin lift without neck extension.
Avoid overextending the head/neck in infants because this may occlude the airway.
Suction the nose and
Advanced Interventions
Endotracheal intubation or placement of a laryngeal mask airway
Application of continuous positive airway pressure (CPAP) or noninvasive ventilation
Removal of a FB; This intervention may require direct laryngoscopy
Cricothyrotomy
Breathing
Assessment of breathing includes:
Respiratory rate
Respiratory effort
Chest expasion and air movement
Lung and airway sound
O2 saturation by pulse oxymetry
Normal respiratory rate
Age Breaths / min
Infants (< 1 year) 30 – 60
Toddler (1-3 yrs) 24-40
Preschooler (4-5 yrs) 22-34
School age (6-12 yrs) 18-30
Adolescent (13-18 yrs) 12-16
Abnormal Respiratory Rate
Tachypnea :
First sign of respiratory distress in infants.
Quite tachypnea- tachypnea without signs of increased respiratory effort.
Bradypnea:
Possible causes are respiratory muscle fatigue, central nervous system injury or infection, hypothermia or medication that depress respiratory drive.
Apnea:
Cessation of breathing for 20 secs or cessation for less than 20 secs if accompanied by bradycardia, cyanosis or pallor.
Respiratory effort
Increase respiratory effort results from
conditions that increase resistance to
airflow or that cause lungs to be stiffer and
difficult to inflate.
Signs of increase respiratory effort include.
Nasal flaring
Retractions
Head bobbing or seesaw raspirations
Respiratory Effort
Increase respiratory effort results from conditions that increase resistance to airflow or that cause lungs to be stiffer and difficult to inflate.
Signs of increase respiratory effort include.
Nasal flaring
Retractions
Head bobbing or seesaw respirations
Nasal flaring:
Dilatation of nostrils with each inhalation.
Most common in infant and younger children
Retractions:
Inward movement of the chest wall or tissues,
neck or sternum during inspiration.
Retractions
Breathing difficulty Location of retraction Description
Mild to moderate subcostal Retraction of abdomen
just below ribcage
Substernal Retraction of abdomen at
the bottom of breast bone
intercostal Retraction between ribs
Severe Supraclavicular Retraction in the neck just
above the collar bone
Suprasternal Retraction in the chest
just above breast bone
sternal Retraction of sternum
toward the spine
Head bobbing or seesaw respiration:
Indicate increased risk of deterioration
Head bobbing- caused by use of neck muscles to assist breathing.
Most frequently seen in infants and sign of respiratory failure
Seesaw respiration- chest retract and abdomen expand during inspiration.
Chest Expansion And Air
MovementEvaluate magnitude of chest wall
expansion and air movement to assess
adequecy of the child’s tidal volume.
Normal tidal volume- 5-7 ml/kg
Tidal volume is difficult to measure unless
a child is mechanically ventilated, so
clinical assessment imp.
Chest wall expansion:
Chest expansion (chest rise) during
inspiration should be symmetric.
Decreased or asymmetric chest expansion
may result from in adequate effort, airway
obstruction, atelectasis, pneumothorax,
hemothorax, Pleural Effusion, mucosal plug
or FB aspiration.
Air movement:
Auscultation for air movement is critical.
Listen for the intensity of breath sounds and quality of air movement, particularly in the distal lung fields.
Decreased chest excrusion or air movement accompanies poor respiratory effort.
Diminished distal air entry suggests air flow obstruction or lung tissue disease.
Lung And Airway Sounds
Stridor:
- coarse, usually higher pitched breathing
sound typically heard on inspiration.
- Sign of upper airway obstruction
- Indicate – obstruction is critical and
requires immediate intervention.
Causes: FBAO, Croup, laryngomalacia,
tumor or cyst, upper airway edema
Lung And Airway Sounds
Grunting
- Typically a short, low pitched sound heard during expiration.
- Misinterpreted as soft cry
- Sign of lung tissue disease resulting from small airway collapse or alveolar collapse.
- Indicate progression of Respiratory Distress to Respiratory Failure.
- Causes: pneumonia, ARDS, Pulmonary contusion.
Lung And Airway Sounds
Gurgling:
- Bubbling sound heard during inspiration
or expiration.
- Results from upper airway obstruction
due to airway secretions, vomitus or
blood.
Lung And Airway Sounds
Wheezing
- High pitched or low pitched whistling
sound heard most often during
expiration.
- Indicate lower airway obstruction.
- Causes: Bronchiolitis and Asthma
Lung And Airway Sounds
Crackles/ Rales:
- Sharp crackling inspiratory sounds.
- Dry crackles: atelectasis and interstitial
lung disease..
- Moist crackles: indicate accumulation of
alveolar fluid,
Oxygen Saturation By Pulse
OxymetryMonitor the % of Hb that is saturated with
O2.(SPo2)
Interpret pulse oxymetry readings in
conjunction with clinical assessment and
other signs.
Pulse oxymeter does not accurately
recognize methemoglobin or carboxyHB.
Circulation
Circulation assessed by evaluation of
Heart rate and rhythm
Pulse
Capillary refill time
Skin color and temp
Blood pressure
Heart Rate And Rhythm
Age Awake rate mean
New bon to 3 months 85-205 140
3 month to 2 yrs 100-190 130
2 yrs to 10 yrs 60-140 80
> 10 yrs 60-100 75
Bradycardia: heart rate slower than normal for child’s age.- Most common cause- hypoxia
- If bradycardia associated with poor perfusion immediately support ventilation with Bag &Mask and administer supplementary O2..
Tachycardia: heart rate faster than normal for child’s ageThe earliest & most reliable sign of shock.
Pulses
Evaluation of pulses is critical to assessment of systemic perfusion in an ill or injured child.
Palpate both central and peripheral pulses.– Central pulses: Brachial (In infants) , Carotid (older
children) , femoral , axillary
– Peripheral: radial, dorsalis pedis , post. tibial.
Weak central pulses are worrisome and indicate need for very rapid intervention to prevent cardiac arrest.
Beat to beat fluctuation in pulse volume may occur in children with arrythemias.
Capillary Refill Time
Time takes for blood to return to tissue blanched by pressure.
Increase as skin perfusion decrease.
Prolonged CRT indicate low cardiac out put.
Normal CRT <= 2 sec
To evaluate CRT lift extremity slightly above the level of the heart, press on the skin and rapidly release the pressure.
Skin Color And Temperature
Mucous membrane, nail beds, palms and soles should be pink.
When perfusion deteriorates and O2 delivery to tissue becomes inadequate the hands and feet are typically affected 1st.
They may become cool , pale, dusky or mottled.
If perfusion become worst skin over the trunk and extremities may under go similar changes.
Pallor:
- Decreased blood
supply to the skin
(cold, stress,
shock )
- Anemia
- Decreased skin
pigmentation
Mottling:
- Irregular or patchy
discoloration of the
skin.
- Serious condition
such as hypoxemia,
hypovolemia or shock,
may cause intense
vasoconstriction from
an irregular supply of
oxygenated blood to
Cyanosis:
- Peripheral cyanosis: bluish
discoloration of hands and feet.
Seen in shock , CCF , PVD
- Central cyanosis: bluish
discoloration of lips and other
mucous membranes.
- Causes :- low ambient O2
tension
-alveolar
hypoventilation
-diffusion defect
-ventilator/
perfusion imbalance
Blood Pressure
Cuff bladder
should cover
about 40% of the
mid upper arm
circumference.
BP cuff should
extend at least
50-75% of the
length of the
Hypotension
Age Systolic blood pressure
(mmHg)
Term neonate
(0- 28 days)
< 60
Infants
(1-12 months)
<70
Children
(1-10 yrs)
< 70 + (age in yrs x 2 )
Children > 10 yrs < 90
Disability
Disability assessment is a quick evaluation of neurologic function.
Signs include level of consciousness, muscle tone and pupil response.
Standard evaluations include
- AVPU pediatric response scale
- GCS
- Pupil response to light
Moves Spontaneously & purposefully
Withdraws In Response To Touch
Withdraws In Response To Pain
Decorticate Posturing In Response To Pain
Decerebrate Posturing In Response To Pain
None
• Decorticate • Decerebrate
Pupils Response To Light
Indicator of brainstem function.
If the pupils fail to constrict in response to
direct light, suspect brain stem injury.
Irregularities in pupil size or response to
light may occur as result of ocular trauma
or ICP.
Assess and record size of pupils , equality
of pupil size , constriction pupil to light.
Exposure
Undress the seriously ill and injured child as necessary to perform a focused physical examination.
Maintain cervical spine precaution when turning any child with suspected neck or spine injury.
Assess core temperature and maintain temp.
Look any trauma such as bleeding , burns and unusual marking that suggest non accidental trauma.
Look for petechiae and purpura s/o septic shock
Life Threatening Problems
Airway Complete Or Severe Airway Obstruction
Breathing Apnea, Significant Increased Work Of
Breathing, Bradypnea
Circulation Absence Of Palpable Pulses, Poor
Perfusion, Hypotension, Bradycardia
Disability Unresponsiveness, Decreased Level Of
Consciousness
Exposure Significant Hypothermia, Significant
Bleeding, Petichae Or Purpura
Consistent With Septic Shock
Secondary assessement
Focused history
Focused physical examination
Secondary assessment
Signs & Symptoms Allergy
Medications
Past Medical HistoryLast Food/Fluid intake
Events
Tertiary Assessment
Respiratory abnormalities • ABG / VBG
• Pulse Oximetry, CXR, PEFR
Circulatory abnormalities• ABG / VBG
• Serum lactate
• CVP Monitoring
• CXR
• Echocardiography
Case Scenario #1
6 month-old female with respiratory distress x 6
hours. As you approach the child, you can
hear her grunting with every breath.
Wheezing is also audible. She does not
appear to acknowledge your presence in the
room.
Begin your assessment?
What Do You See?No Eye
ContactNasal
Flaring
Accessory
Muscles
Skin is Pale
and Cyanotic
Increased
Respiratory Rate
What Do You Hear?
Audible
Wheezing
Grunting
What Do You Feel?
Cool Extremities Weak
Peripheral
Pulses
23-month-old toddler
a 23-month-old with “trouble breathing”
Child is on mom’s lap, sees you, and starts to wail!
Patient is alert, with retractions and audible wheezing. Skin color is normal.
23-month-old toddler
.
Circulation to Skin
Normal color
.
Work of
Breathing
Retractions, audible
wheezing
Appearance
Seated, alert,
strong cry
What is this child’s physiologic state?
What are your treatment priorities?
9-month-old infant
A 9-month-old
presents with 3
days of vomiting,
diarrhea and
poor oral intake.
9-month-old infant
Circulation to Skin
Pale skin color
Work of
Breathing
No retractions or
abnormal airway
sounds
Appearance
Agitated, makes
eye contact
Initial Assessment
– Airway - Open and maintainable
– Breathing - RR 50 breaths/min, clear lungs, good
chest rise
– Circulation - HR 180 beats/min; cool, dry, pale
skin; CRT 3 seconds; BP 74 mm Hg/palp
– Disability - AVPU=A
– Exposure - No sign of trauma, weight 8 kg
What is this child’s physiologic state?
What are your treatment priorities?
3-year-old toddler
Toddler is found cyanotic and
unresponsive
Child last seen 1 hour prior to discovery
Open bottle of “pedicloryl” found next to
child
3-year-old toddler
Circulation to Skin
Cyanotic, mottled
Work of Breathing
Gurgling breath sounds
Appearance
No spontaneous
activity;
unresponsive
Initial Assessment
– Airway - Partial obstruction by tongue
– Breathing - RR 15 breaths/min, poor air entry
– Circulation - HR 30 beats/min; faint femoral pulse;
CRT 3 seconds; BP 50/30 mm Hg
– Disability - AVPU=P
– Exposure - No sign of trauma
What is this child’s physiologic state?
What are your treatment priorities?
12-month-old child
a 12-month-old child.
Mother states the child has a history of congenital heart disease and has been fussy for the last 3 hours.
Mother states the child weighs 10kg.
12-month-old child
Circulation to Skin
Lips and nailbeds blue
Work of
Breathing
Mild retractions
Appearance
Alert but agitated
What is this child’s physiologic state?
What are your treatment priorities?
On initial assessment, you note clear breath
sounds, a RR of 60 breaths/min and a heart
rate that is too rapid to count.
What rhythm does the monitor show?
How can you distinguish SVT from sinus tachycardia?
SVT Sinus Tachycardia
Blow-by oxygen administered
IV started
Adenosine 0.1 mg/kg (1mg), given rapid
IVP with 5 ml saline flush
Five seconds of bradyasystole, followed
by conversion to Normal Sinus Rhythm
9-month-old infant
a 9-month-old infant with difficulty breathing
and fever.
What important information must you
gather from the history and assessment?
9-month-old infant
Circulation to Skin
Normal color
Work of Breathing
Retractions, nasal
flaring
Appearance
Alert, looking
around, crying
Initial Assessment
Airway - Open
Breathing - RR 80 breaths/min,
wheezing with good air
movement, SaO2 90%
Circulation - HR 180 beats/min;
skin warm and normal color;
CRT normal
How sick is this infant?
What is this child’s physiologic state?
What are your treatment priorities?
4-year-old child
a 4-year-old child with
trouble breathing.
Mother states that he
was playing with a
small super ball prior
to collapsing.
4-year-old child
Circulation to Skin
Pale skin color
Work of
Breathing
Stridor, severe
retractions
Appearance
Unresponsive,
poor muscle
tone
Initial Assessment
– Airway - Obstructed
– Breathing - RR 12 breaths/min, decreased breath sounds, little or no chest rise, unable to speak or cry
– Circulation - HR 100 beats/min and dropping; pulses present; BP deferred
– Disability - AVPU=U
– Exposure - No sign of trauma
What is this child’s physiologic state?
What are your treatment priorities?
3-year-old child
3 year old child who has had a fever for
one day
Prior to arrival she experiences a single
generalized seizure followed by
confusion
3-year-old child
Circulation to Skin
Normal color
Work of Breathing
Normal
Appearance
Drowsy, but
interacts
Initial Assessment
Airway - Open, no stridor
Breathing - RR 25 breaths/min, clear breath sounds
Circulation - HR 115 beats/min; skin warm to the touch; normal capillary refill; BP 106/66 mm Hg
Child begins to have another seizure
What are your treatment and transport priorities?
What is this child’s physiologic state?
What are your treatment priorities?
Etiologies of Seizures
• Fever • Hypoglycemia
• Head trauma • Metabolic disorder
• Hypoxia • Bleeding into brain
• Infection • Low level anti-seizure medicine
• Ingestion
What is the significance of fever in this patient?
Fever
Fever may indicate a serious infection in the
blood or central nervous system.
Ominous signs suggesting a serious cause:
bulging fontanelle, stiff neck, prolonged CRT,
purplish rash
Newborns and young infants may have
nonspecific symptoms of serious infection
such as fussiness, poor feeding, or
decreased activity.
Fever
Temperature < 105º F is not harmful and
does not cause brain damage.
Treatment: Body substance precautions,
passive cooling
Transport priorities: If initial assessment is
normal, do focused history and physical
exam, and detailed physical exam on scene;
if initial assessment is abnormal, treat en
route to the hospital
4-year-old child
a child “not acting right”.
She was recently diagnosed with
diabetes and is on insulin.
4-year-old child
Circulation to Skin
Normal color
Work of Breathing
Normal
Appearance
Disoriented
What is this child’s physiologic state?
What are your treatment priorities?
3-year-old child
You are called to the street where a
3-year-old child is found lying after a 20-
foot fall from a third-story window.
3-year-old child
Circulation to Skin
Pale skin color
Work of Breathing
Tachypnea, retractions
Appearance
Unresponsive
What is your assessment of this patient?
Initial Assessment
Airway - Clear, no stridor
Breathing – RR 40 breaths/min with good air movement bilaterally
Circulation – HR 190 beats/min; pulses thready; CRT 4 seconds; BP 70 mm Hg/palp
What is the child’s perfusion status?
What is this child’s physiologic state?
What are your treatment priorities?
This patient is in decompensated shock
due to hemorrhage.
7-year-old child
a 7-year-old child with trouble breathing.
He is lying in a PICU, with a ventilator and suction machine on the nightstand.
He is being ventilated through a tracheostomy tube.
7-year-old child
Appearance
Listless, poor
muscle tone
Work of Breathing
No chest rise visible
Circulation to Skin
Pale skin color
What is this child’s physiologic state?
What are your treatment priorities?
What immediate action should be taken to
manage this child?
Immediate Management
Disconnect the
ventilator, and begin
ventilation using
bag-valve device via
the tracheostomy
tube
Initial Assessment
Child is not breathing spontaneously
There is resistance to bagging
Poor chest rise with bag-valve-tracheostomy ventilation
HR 160 beats/min by palpation of femoral pulse
What is going on with this patient?
This child has an obstructed tracheostomytube, a common complication of tracheostomy tube placement
Usually due to mucus plugging
What are your management priorities now?
Treatment Priorities
Suction the tracheostomy tube– Instill 2 ml normal saline into
tube prior to suctioning
Treatment Priorities Attempt to ventilate again
If no chest rise, remove
tracheostomy tube
Begin BVM ventilation over
the mouth, while partner
covers stoma
If no chest rise, ventilate using
small mask over the stoma
Rapid transport
Treatment Priorities
If no chest rise after
suctioning tube,
immediately remove
and replace the
tracheostomy tube
Treatment Priorities
Parents may have replacement tracheostomy tube
Endotracheal tube may be substituted– Use tube of same internal diameter as
tracheostomy tube
– Insert into stoma 1/2 the length used for oral intubation
Begin bagging via the newly inserted tube
Tracheostomy tube suctioned
Good chest rise with bagging
HR decreases to 90 beats/min
Child becomes alert and interactive
This child also has a feeding tube in place.
What are some potential complications of this
device?
A feeding tube is used for nutritional
supplementation when the child cannot take
adequate nourishment by mouth
Common complications include:
– Dislodged tube
– Leakage of stomach/bowel contents around the
tube
– Infection of the insertion site