Assessment in a systematic way Dr Anne Ingram

Objectives Assessment tool for rapid, thorough examination of children Give information required to use UCP and determine urgency of care

Information from History Physiological observations Examination Traffic light System: R A G

Common presenting complaints Fever Breathing difficulty Vomiting / Diarrhoea Rash Fits Accidental ingestion / overdose / intoxication Injuries – Accidental / Non accidental

Comorbidity Prematurity Neuromuscular conditions – CP Immunocompromised Metabolic conditions / diabetes Social concerns

Approach A – Airway B – Breathing C – Circulation D – Disability E – Exposure ENT Tummy In an unwell/lethargic child DEFG-don’t Ever Forget Glucose

Airway Is it patent – talking, crying Is it obstructed Is it at risk Swollen lips/tongue Burns to face/neck Unconscious Drooling Biphasic stridor

Breathing Work of Breathing Efficacy of breathing Rate Rhythm Breath sounds/added sounds Accessory muscle use Chest recession Efficacy of breathing Air entry Chest movement Adequacy of ventilation Tissue oxygenation Skin colour Mental status Cardiac assessment (HR)

Respiratory rate Varies with age, fever, pain, anxiety and respiratory failure Normal values Age (years) Resps per min < 1 30 - 40 1 – 2 25 - 35 2 – 5 25 - 30 5 – 12 20 - 25 > 12 15 - 20

Work of breathing / Respiratory distress Recessions Subcostal - Suprasternal / Tracheal tug Intercostal - Supraclavicular Sternal Use of accessory muscles Abdominal breathing Prominence of sternomastoid Head bobbing (in babies) Flaring of nostrils

Noisy breathing Blocked nose / snuffles Stridor – inspiratory noise Wheeze – expiratory noise Grunting – expiratory, attempt to maintain end expiratory lung volume

Auscultation Air entry – is it equal Wheeze Crepitations Transmitted noises SILENT CHEST Heart sounds

Oxygen saturations Pulse oximetry using appropriate probe Good wave form essential Saturations >=92% normal CYANOSIS ONLY APPARENT WHEN SATURATIONS LESS THAN 85%

Circulation Heart rate Capillary refill time Pulse volume Peripheral perfusion Blood pressure

Heart rate Varies with age, fever, dehydration, anxiety & pain Normal values Age (years) Pulse per min < 1 110 - 160 1 – 2 100 - 150 2 – 5 95 - 140 5 – 12 80 - 120 > 12 60 - 100

Capillary refill time Peripheral vs central Press for 5 seconds Time taken for colour to return Normal <2seconds

Pulse volume Comparison of central and peripheral pulses

Disability Assesses neurological status A – Alert V – responds to Voice P – responds to Pain (equivalent to 8 on GCS) U – Unresponsive to any stimulus Posture Pupils

Exposure Rash Bruises Temperature

ENT Examination If febrile child or presenting with symptoms alluding to ENT Lymphadenopathy Positioning really important

Tummy(abdomen) Distension Tenderness Masses Bowel sounds Hernia sites

Rapid Examination Airway Breathing Circulation Disability ENT RR, WOB, SaO2, auscultation Circulation Colour, HR, CRT, Temp hands and feet Disability Pupils, Limb tone and movement, AVPU ENT T – palpation, auscultation In an unwell/lethargic child DEFG-don’t Ever Forget Glucose

Red flags in history High temperature – risk of bacterial infection Bilious vomiting Bloody diarrhoea Rash which does not disappear on tumbler test Stopped breathing / gone blue Abnormal movements or behaviour

Red flags on examination Apnoea Biphasic stridor Silent chest Non blanching rash Poor perfusion / Thready pulse Responds to pain only or unresponsive Any unexplained injuries / bruises

Investigations Urine analysis Blood sugar

Any Questions?

Objectives Assessment tool for rapid, thorough examination of children Give information required to use UCP and determine urgency of care

Thank you References: www.spottingthesickchild.com Advanced Paediatric Life Support (APLS) European Paediatric Life Support (EPLS)