Essential Education Recognition Of the Sick child

Paediatric examination and assessment What do we need to include?

Recession:intercostalincreased subcostalwork sternalof tracheal tugbreathing Respiration Rate, effort, efficacy, effects Beware of recession in the older child

Sternal Recession

Pulse Site:< 1 yr = brachial > 1 yr= carotid Causes of tachycardia:Hypoxia Fear & anxiety Pyrexia Capillary Refill Ambient temperature Forehead or sternum Apply digital pressure for 5 seconds Refill should occur within 2 seconds Blood pressure – of little value

Airway Look & listen for possible obstructions Inspiratory stridor indicative of upper airway obstruction Wheezing indicating lower airway obstruction Volume does not indicate severity No blind finger sweeps Neonate & infants neutral alignment No hyperextension in young children

Breathing Assess the effectiveness of breathing Respiratory rate Tachypnoea at rest gives cause for concern Sternal recession - intercostal recession Use of accessory muscles Flaring of the nostrils Presence of expiratory grunt (infants) Falling respiratory rate in presence of other worsening parameters is suggestive of exhaustion – indicating imminent respiratory arrest

Bradycardia or tachycardia Bradycardia = prolonged hypoxia – pre-terminal Hypoxia = vasoconstriction = pallor Cyanosis is late & pre-terminal Mental status impaired Drowsiness leading to unconsciousness Agitation in infants (use parents perception) Effects of Respiratory Inadequacy/ Hypoxia

Circulation Pulse volume (actually feel the pulse) Absent peripheral and weak central pulses = advanced shock Capillary refill (forehead or sternum) Do not rely on feeling peripheral pulses to estimate blood pressure as in adults – children react differently

Tachycardia Can reach 200 plus in young children Breathing rate increase without recession characteristic failing circulation in children Mottled, cold, pale skin peripherally = poor perfusion Mental status compromised BP monitoring pre-hospital of lesser value BP is maintained until shock is very severe Unconscious due to poor cerebral perfusion Effects of Circulatory Compromise

Disability Recognition of potential neurological failure Conscious levels – AVPU Observe pupils – size – reactivity Glasgow coma scale

Posture? Sick babies often floppy (hypotonic) Babies – meningitis – stiff, arched back or neck Abnormal breathing pattern Apnoea suggests cerebral malfunction Bradycardia may be due to raised intracranial pressure Effects of Diminished Neurological Response

A B C D D E F G Don’t ever forget the glucose

Time Critical Any child with significant difficulties with Airway, Breathing, Circulation or Disability Must be treated as time critical! The recognition of the seriously ill child is of greater importance than establishing a specific diagnosis

CLINICAL GUIDANCE BULLETIN Admission to hospital for Infants under the age of Two To: All Operational A&E staff – Control From: Dr John Stephenson Medical Director Date 3rd February 2009 Dear Colleagues We have recently had a significant increase in the amount of concerns being raised across the trust by Paediatricians involving infants under the age of two being left at home following a 999 call. Several infants have had a full assessment by ambulance staff and then left in the care of their parents/carers and then been subsequently admitted.These calls have ranged from convulsions to generally unwell and have resulted in either another 999 call or admission via the GP. Following consultation with the Paediatricians it has been agreed that all infants presenting with any medical problem under the age of two will be admitted following a 999 call. The only exceptions will be if the parent/carer refuses or a GP arrives whilst you are on scene and takes over the care of the infant; in all cases it should be documented on the PRF. It should be remembered that to refuse advice for further treatment or assessment of a child may need to be raised as a potential safeguarding issue. If this occurs then you should follow the Child protection Policy. Thank you for your cooperation with this and if you require any further advice please contact one of the clinical team. Regards Dr John Stephenson Medical Director

Common Childhood Illnesses

Feverish illness in children: Is the most common reason for children to be taken to the doctor Is a cause of concern for parents and carers Can be a result of a simple self-limiting infection or a life- threatening infection Can have no apparent source. NICE Guidelines – Feverish Illness in Children

Tool for identifying the likelihood of serious illness Children with only symptoms and signs in the ‘green’ column are at low risk Children with one or more symptom or sign in the ‘amber’ column are at intermediate risk Children with one or more symptom or sign in the ‘red’ column are at high risk The Traffic Light System

ColourNormal colour of skin, lips and tongue ActivityResponds normally to social cues Content/smiles Stays awake or awakens quickly Strong/normal cry/not crying HydrationNormal skin and eyes Moist mucous membranes OtherNone of the amber or red symptoms or signs Traffic light system: green

ColourPallor reported by parent/carer ActivityNot responding normally to social cues Wakes only with prolonged stimulation Decreased activity No smile RespiratoryNasal flaring Tachypnoea: RR>50/min age 6-12 months, RR>40/min age >12 months Oxygen saturation ≤ 95% in air Crackles HydrationDry mucous membranes Poor feeding in infants CRT ≥3 seconds Reduced urine output OtherFever for ≥5 days Swelling of a limb or joint Non-weight bearing/not using an extremity A new lump >2cm Traffic light system: amber

ColourPale/mottled/ashen/blue ActivityNo response to social cues Appears ill to a healthcare professional Unable to rouse or if roused does not stay awake Weak/high pitched/continuous cry RespiratoryGrunting Tachypnoea: RR>60 /min Moderate or severe chest indrawing HydrationReduced skin turgor OtherAge 0-3 months, temperature ≥38°C Age 3-6 months, temperature ≥39°C Non blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures Bile-stained vomiting Traffic light system: red

Check for any immediately life-threatening features. Use traffic light system to check for symptoms and signs that predict the risk of serious illness. Look for a source of fever and check symptoms and signs associated with specific diseases. Measure and record temperature, heart rate, respiratory rate, capillary refill time and assess for dehydration. Clinical assessment

Febrile Convulsion Until the age of 5 years children unable to regulate body temperature due to immature hypothalamus. Treatment of pyrexia PharmacologicalEnvironmental 34 % of all children between the ages of 3/12 & 5 years will have a febrile convulsion. Caused by height & rapidity of the temperature elevation. Temp usually above 38.8C Occurs during rise of the temperature.

Occurs early in a viral illness. Seizures usually brief – 1 – 2 minutes, are generalised. 1:3 risk of further convulsion. Higher risk of recurrence if seizure before 1 yr of age and/or a family history of febrile convulsion. 1% go onto develop epilepsy

Management A B C Management of pyrexia Rectal diazepam (as per JRCALC) 1st febrile convulsion = admission

Croup Onset over a few days Preceding coryza Stridor only when upset Stridor sounds harsh Voice harsh Barking cough Unwell < 38.5°C Can swallow oral secretions Epiglotitis Sudden onset No preceding coryza Continuous stridor Stridor softer (snoring) Voice muffled / whispering Cough not prominent Toxic, very ill 39 0 C Drooling of secretions

Croup Occurs from 6/12 to 6 yrs of age. Peak incidence age 2 yrs Often worse at night Mucosal inflammation & increased secretions affecting the larynx, trachea & bronchi Oedema of subglottic area potentially dangerous Is the commonest cause of stridor 95% are due to viral illness Parainfluenza virus most common cause, also RSV & influenza

Examination Hands off approach! Observe: Respiratory compromise: rate, grunting, recessions, colour, work associated with breathing. Engagibility with carer: tiredness, agitation, drowsiness, lethargy, altered mental state. Croup score. Management Pulse oximetry Anti-pyretics

MILDMODERATESEVERE STRIDOROnly if agitatedAudible at restMarked at rest RESPIRATORY DIFFICULTY No recession No tachypnoea Recession + Tachypnoea + Recession ++ Tachypnoea ++ COLOUR/ O2 SATURATIONS Pink in air 02 sat > 92% in air Pink in air 02 sat > 90% in air ? Cyanosed 02 sat < 90% in air LEVEL OF CONSCIOUSNESS Normal conscious level Depressed conscious level Exhaustion, restless, confused Croup score

TREATMENT 02 if sats < 92%02 100% Oral dexamethasoneNebulised adrenaline 0.15mg/kg0.4ml/kg 1:1000 (max 5ml) If vomiting/unable to Contact aneasthetist/snr Take = nebulised Paediatrician Budesonide 2mg statDo not distress child (no IVI) DischargeAdmit for obsAdmitTheatre HomePICUfor intubation RE-ASSESS MILD/MODERATESEVERE IN HOSPITAL USE

Epiglottitis Inflammatory oedema of the supraglottic area, which includes the epiglottis and pharyngeal structures. Children aged 2 – 5 years. Usually HIB. Becoming rare because of immunization.

Causes stridor which by itself is a terrifying experience for child/family The fear may lead to hyperventilation which makes symptoms worse Avoid examining the throat; may precipitate obstruction Avoid any unnecessary interventions Act quickly & calmly Reduce anxiety – child to sit wherever happy

Bronchiolitis Most common lower respiratory tract infection affecting children under 1 year. Caused by RSV (respiratory syncytial virus) The virus replicates in epithelial cells of the bronchioles causing necrosis and shedding of the cells. New epithelial cells not cilliated. Lack of cillia and > secretions cause obstruction of small airways. Impairs gaseous exchange. Work of breathing and O2 consumption > Diagnosis made on clinical findings.

Characteristics Dry cough & wheezeNasal discharge Pyrexia (+/-)Anorexia TachycardiaTachypnoea RecessionHead bobbing Nasal flaringHypoxia Grunting Fine inspiratory crackles and/or high pitched expiratory wheeze If toxic look for other causes Take seasonality into account

High Risk Factors Born at < 35/40 < 3/12 old Congenital heart disease Chronic lung disease of prematurity Comorbidity O2 sats < 92 % in O2 Deteriorating resp status, increasing resp distress and/or exhaustion Recurrent apnoea

Supportive Therapies Nasal suction NG feeding Supplemental O2 Feed little & often Sit upright Maintain constant room temp Treatments – Nil Around ½ of infants will be asymptomatic by 2 wks some have symptoms after 4 wks.