1. Recognising the Sick Child

2. Why Teach Recognition of the Sick Child? Failure of Recognition of Serious Illness is a significant cause of preventable mortality in children This failure can be by: Parents and Carers GP's Specialist Paediatricians ED consultants…

3. Just occasionally...

4. Why might signs be 'missed'? Multi-factorial Least likely to be a lack of knowledge or experience More often failure to follow best practice Usually because early signs of many illnesses in childhood look similar

5. How to Assess Use a structured approach Assess in a systematic way Make a reasoned judgement on basis of findings

6. The Structured Approach Airway Breathing Circulation Disability Exposure Further reading: Advanced Paediatric Life Support V5 (Library)

7. Airway and Breathing Need to recognise potential respiratory failure Look at the Effort and Effectiveness of Breathing

8. Effort of Breathing Respiratory Rate Signs of increased effort

9. Increased Respiratory Rate Respiratory Rate Varies with age Upper Limits of Normal Newborn 60 bpm Infant 50 bpm Adult 16 bpm

10. Signs of Increased Effort of Breathing Subcostal Recession

11. Signs of Increased Effort of Breathing Tracheal Tug This is a sign of upper airways obstruction. You can also see severe subcostal recession

12. Other Signs of Increased Effort of Breathing? Nasal Flaring Nasal flaring is commonly seen in infants and is a much more subtle sign of respiratory distress

13. Signs of Increased Effort of Breathing Wheeze Audio samples from http://www.thinklabsmedical.com/sound-library.html

14. Signs of Increased Effort of Breathing Audio samples from http://www.thinklabsmedical.com/sound-library.html Stridor Stridor can be inspiratory or inspiratory and expiratory,

15. Effectiveness of Breathing Chest Expansion Air Entry –Beware the silent chest in asthma Oxygen Saturations –Normal saturations for a child are 97-100% in air

16. Effects of Respiratory Compromise on Other Systems Recognition of these effects of compromise in the primary system on other systems is key to picking up the severity of illness We are comprised of many physiologically integrated systems. When one system is severely affected by illness others will either compensate or be affected themselves.

17. Effects of Respiratory Compromise on Other Systems As part of the compensating mechanisms hypoxia leads to effects in the cardiovascular system Tachycardia Pallor Cyanosis Effects on the Central Nervous System Agitated Obtunded

18. Cyanosis Cyanosis is a late effect, representing serious patient compromise. It must be addressed immediately.

19. Circulation Need to recognise potential circulatory failure Look at the response of the cardiovascular system and the effects on other systems

20. Cardiovascular Status Heart Rate Age (years)Heart Rate (bpm) <1110 - 160 1-2100 - 150 2-595 - 140 5-1280 - 120 >1260 - 100

21. Cardiovascular Status Pulse Volume Capillary Refill Blood Pressure –A fall in blood pressure is a pre-terminal sign of circulatory failure

22. Cardiovascular Status - Blood Pressure Why is blood pressure a potentially misleading sign? Multiple compensatory mechanisms Have to exhaust these before BP falls So a low blood pressure is BAD A normal blood pressure is not necessarily good

23. Effects of Circulatory Compromise on Other Systems Respiratory System –Tachypnoea –May be absence of other respiratory signs Mental Status Renal System –Reduced urine output

24. Disability Have seen the effects of compromise of other organ systems Recognition of potential neurological failure

25. Disability To assess disability we look at three factors Level of Consciousness Posture Pupils And then effects upon other systems.

26. Conscious Level Glasgow Coma Scale (GCS) –Several variants for differing ages. Too complex for rapid, accurate recall

27. Conscious Level AVPU Pupils Unilateral Pupillary Dilatation AALERT VResponds to VOICE PResponds only to PAIN UUNRESPONSIVE

28. Posture Decerebrate Decorticate

29. Effects of Neurological Compromise on Other Systems Cardiovascular –Systemic hypertension with bradycardia (Cushing’s response) Respiratory –Abnormal patterns of respiration (eg Cheyne- Stokes respiration)

30. Pupils In acute situation mainly concerned with signs of impending neurological failure: –Pupillary unresponsiveness, or dilatation –May be unilateral or bilateral. Pupillary signs need to be addressed immediately with appropriate treatment.

31. Exposure Temperature Rash

32. Rashes

35. Putting it all together Jack, one month old baby, coughing for 24 hours, off feeds and crying more than usual Any cause for concern? Sick or not sick?

36. Need more info? Assess A+B Effort Respiratory rate 65 Subcostal recession No tracheal tug Efficacy Saturations 88% in 2L oxygen

37. What to assess next? Assess C Pulse 165 Cap Refill 3s Sick or not sick?

38. Synthesis Driving system Respiratory Abnormalities greatest in this system Significant rise in parameters Two other systems involved Cardiac - increased HR / Prolonged CR Off feeds and crying ++ Sick or not sick?

39. Recognition of the Seriously Ill Child It is possible to recognise most critically ill children by the careful use of the structured approach. If there is any doubt: –Ask someone else to see –Reassess later

40. Questions ?