ASSESSING SEVERITY OF ILLNESS IN THE CHILD By Dr. Derek Louey

ASSESSING SEVERITY OF ILLNESS Applies particularly to neonates/infants/toddlers Don’t be intimidated Follow a systematic approach Assess severity first - diagnosis comes later

ASSESSING SEVERITY OF ILLNESS Initial assessment Occurs without needing to touch the child Can be performed rapidly in less than 1 minute Done at triage Taking of vital signs

ASSESSING SEVERITY OF ILLNESS Airway Breathing Circulation Disability (Neurological) Exposure LIFE-THREATENING ILLNESSES ACT BY EXERTING THEIR EFFECT ON THE ABOVE

AIRWAY Stridor Tracheal tug Drooling

BREATHING Increased work Increasing fatigue Decreased effectiveness

BREATHING Increased work Recession  RR Grunting Nasal flare Accessory muscle

BREATHING Increasing fatigue  RR  breath sounds  chest/abdominal movement Apnoeic spells (c.f. periodic breathing)

BREATHING Decreasing effectiveness Cyanosis  Alertness

CIRCULATION Pallor/Peripheral cyanosis  capillary refill

DISABILITY Conscious state Eye contact Activity Cry

DISABILITY Conscious state Lethargic/Dull/Expressionless Irritable Not recognizing mother Seizures Not responding to pain Quiet/Unresponsive

DISABILITY Eye contact/Smile Lack of social smile Not Fixing/Following/Focusing Glassy stare

DISABILITY Activity Require assistance Not ambulating

DISABILITY Cry Unable to be placated by mother Whimpering/Sobbing Irritable Weak/Moaning/High pitched

EXPOSURE Mottled Petechiae Unexplained bruising (NAI)

VITAL SIGNS Different reference range for different ages BP is an important value often forgotten Hypothermia is suggestive of sepsis Pulse oximetry - ‘the fifth vital sign’ Weigh the child Check blood sugar

WHY WEIGH THE CHILD? Changes of weight are a good guide to degree of dehydration Determines drug dosing Determines IV fluid calculations

SIGNS OF SEVERE ILLNESS Resting stridor Marked intercostal/sternal recession with accessory muscle use and tachypnea Cyanosis Capillary refill > 4sec (normal < 2 sec) /  HR Impalpable pulse or hypotension or  HR Not fixing/following or responding to environment

REASURRING SIGNS No stridor or only stridor with activity Mild recession Good colour Capillary refill < 2 sec Responding to mother and examiner/Able to be placated by mother

PRACTICAL TIPS Maintain a calm and reassuring manner (helps the parents and yourself) Keep a handy reference at triage of age- related ranges of paediatric vital signs When assessing capillary refill - choose an area of the trunk and apply pressure for 4 secs before releasing

PRACTICAL TIPS Assess pulse at brachial artery (inside elbow) Use age appropriate BP cuff (width 2/3 circumferance) Use paediatric probe for pulse oximetry

PRACTICAL TIPS Weighing the child use proper paediatric scales (NOT adult scales) ideally unclothed with small babies Record to within 0.1kg for a neonate Record to 0.5kg for an infant