Lectures Recognition of the seriously ill child

Recognition of the seriously ill child To understand the structured approach to the recognition of the seriously ill child To learn a rapid clinical assessment sequence to identify serious illness in a child To introduce the equipment used for the resuscitation of a seriously ill child Objectives

Recognition of the seriously ill child Causes of death worldwide <5 years Neonates < 1mChildren aged 1m-5yrs Preterm birth complications12%Diarrhoea14% Birth asphyxia9%Pneumonia14% Sepsis6%Other infections9% Other5%Malaria8%

Recognition of the seriously ill child Causes of cardiac arrest in children Airway Obstruction Respiratory Depression Alveolar/Chest Wall Failure Fluid Loss Fluid Mal- distribution Heart Failure Foreign body, asthma, croup, bronchiolitis Respiratory Failure Cardiac Arrest Circulatory Failure Convulsions, sepsis, poisoning, ↑ ICP Pneumonia, chest trauma & myopathy Bleeding, burns, diarrhoea, vomiting Sepsis, anaphylaxis Myocardial depression, congenital abnormality

Recognition of the seriously ill child Systematic approach Primary assessment Resuscitation Secondary assessment Emergency treatment Stabilisation, transfer to definitive care Airway Breathing Circulation Disability Exposure

Recognition of the seriously ill child Recognition of serious illness Potential respiratory failure Potential circulatory failure Potential central neurological failure

Recognition of the seriously ill child Potential respiratory failure

Recognition of the seriously ill child Effort of breathing – subcostal recession Mild Severe

Recognition of the seriously ill child Subcostal recession

Recognition of the seriously ill child Effort of breathing Respiratory rate Accessory muscle use Flaring of the nostrils Child's position

Recognition of the seriously ill child Effort of breathing – associated sounds Stridor primarily inspiratory noise upper airway pathology Wheeze primarily expiratory noise lower airways pathology Grunting expiration with partially closed glottis alveolar pathology

Recognition of the seriously ill child Exceptions to the effort of breathing Increased effort absent in: exhaustion central respiratory depression neuromuscular disease

Recognition of the seriously ill child Potential respiratory failure

Recognition of the seriously ill child Efficiacy of breathing Chest expansion Air entry Pulse oximetry

Recognition of the seriously ill child Efficiacy of breathing A SILENT CHEST IS A PRE–TERMINAL SIGN

Recognition of the seriously ill child Potential respiratory failure

Recognition of the seriously ill child Effects of respiratory inadequacy Heart rate Skin colour Mental status

Recognition of the seriously ill child Effects of respiratory inadequacy CYANOSIS IS A PRE–TERMINAL SIGN OXYGEN SATURATION OF <85% IN AIR IS A PRE-TERMINAL SIGN

Recognition of the seriously ill child Potential respiratory failure – resuscitation equipment

Recognition of the seriously ill child Potential circulatory failure – early recognition of shock

Recognition of the seriously ill child Cardiovascular signs Heart rate Pulse volume Capillary refill time Blood pressure

Recognition of the seriously ill child Cardiovascular signs – capillary refill (1) press for 5s (2) release (3) colour should return <2s in well-perfused, warm child

Recognition of the seriously ill child Cardiovascular signs – capillary refill A delay of >2s with other signs of shock and in a warm child suggests poor peripheral perfusion

Recognition of the seriously ill child Cardiovascular signs HYPOTENSION IS A PRE–TERMINAL SIGN

Recognition of the seriously ill child Potential circulatory failure – early recognition of shock

Recognition of the seriously ill child Effects of circulatory inadequacy Respiratory rate Skin temperature/colour Mental status

Recognition of the seriously ill child Distinguishing cardiac problems Cyanosis despite O 2 Marked tachycardia Raised jugular venous pressure Gallop rhythm / murmur Enlarged liver Absent femoral pulses

Recognition of the seriously ill child Potential circulatory failure – resuscitation equipment

Recognition of the seriously ill child Case report 1 Case Report: 2 months old Cough and wheeze for 1 week SignObservation Skin colourPale Respiratory rate20/min (recession ++) Heart rate200/min Capillary refill timeNormal Mental statusUnresponsive

Recognition of the seriously ill child Case report 2 Case Report: 2 months old Poor feeding and vomiting for 1 day SignObservation Skin colourPale Respiratory rate70/min (no recession) Heart rate220/min Capillary refill timePoor Mental statusUnresponsive

Recognition of the seriously ill child Potential central neurological failure

Recognition of the seriously ill child Potential central neurological failure: conscious level A-V-P-U approach : A lert Responds to V oice Responds only to P ain U nresponsive to all stimuli

Recognition of the seriously ill child Potential central neurological failure assess with painful stimulus

Recognition of the seriously ill child Potential central neurological failure: postures Decorticate Decerebrate

Recognition of the seriously ill child Potential central neurological failure

Recognition of the seriously ill child Q&AQ&A

Summary: rapid assessment Airway and Breathing Effort Efficacy Effects Disability Conscious level Posture Pupils Circulation Heart rate Capillary refill time Blood pressure Skin temperature