systematic approach to the seriously ill or injured child ag

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.

E:/jmotalk/Recession.mpg

E:/jmotalk/Recession.mpg

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


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.


Gurgling:

- Bubbling sound heard during inspiration

or expiration.

- Results from upper airway obstruction

due to airway secretions, vomitus or

blood.


Wheezing

- High pitched or low pitched whistling

sound heard most often during

expiration.

- Indicate lower airway obstruction.

- Causes: Bronchiolitis and Asthma


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.

E:/jmotalk/CapillaryRefill.mpg

E:/jmotalk/CapillaryRefill.mpg

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

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

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

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?

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

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?

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

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?

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 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


If no chest rise after

suctioning tube,

immediately remove

and replace the

tracheostomy tube


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

systematic approach to the seriously ill or injured child ag

Healthcare

childs problem

lifethreatening problem

evaulate child

childs consciousness

life threatning problem

abcde components

upper airway patency

childs physiologic condition