2. Recognition of a Sick Child

3. Aims of Assessment LIFE THREATENING Not Life ThreateningPotentially Life Threatening

4. Clinical Parameters Whatever the cause and whichever the organ system involved, the clues to recognition of serious and deteriorating physiology can be found in just 3 clinical parameters ABNORMAL BEHAVIOR ABNORMAL RESPIRATION ABNORMAL CIRCULATION Interact!

5. In every Sick / Potentially Sick Child ASK Behavior, Feeding, Urine output LOOK Appearance, Breathing, Circulation, others LISTEN Speech, Cry, Breathing, MOTHER

6. In every Sick / Potentially Sick Child FEEL Pulses, Warmth, Extremities SMELL MEASURE HR, RR, BP, TEMP, O2 Saturation, Blood Sugar

7. Equipment for Assessment LOOKLISTENFEELMEASURE

8. Question What would be the three main things you would ask to rapidly assess a sick child? Interact!

9. Step 1 - Ask BEHAVIORFEEDING URINE OUTPUT

10. Step 2 – Look…..Appearance Behaviour Look/Gaze - Not playful, Lethargic Anxious – hypoxic Interactivity No / decreased Interactions with parents, surroundings Consolability Consolable, not consolable

11. Step 2 – Look…..Appearance Posture and Tone Limp, stiff, curled up, neck retraction Feeding Feeding well, Not feeding Pain facies Is the infant/child in moderate to severe pain?

12. Look…..Breathing Interact!

13. What are other Respiratory LOOK Signs that are Important? RATE : Fast or Slow TYPE : Thoraco-abd, Abd or Thoracic REGULARITY/RHYTHM RETRACTIONS : Mild, Moderate or Severe

14. Look…..Circulation Diaphoresis: excessive sweating Mottling of skin Colour: cyanosis present/absent, peripheral/central

15. Look…..Others Bleeding Fractures/ deformities Rashes

16. Listen Cry Respiratory Sounds Speech Mother’s concerns

17. Stridor Interact!

18. Wheeze Interact!

19. Grunt Interact!

20. Recognition of the Seriously Ill Child - Efficacy of Breathing A silent chest is a pre-terminal sign Interact!

21. Step 4 - Feel PULSES: Peripheral and central SKIN: Warmth, Turgor. Cold and sweaty palms and soles usually indicate poor perfusion CFT EXTREMITIES: injuries / fractures / hematomas

22. How do you Assess Capillary Refill Time? Where? How long? Position of limb? Normal? Physiological causes of prolonged CRT? Interact!

23. CRT

24. Step 5 – Smell, which Conditions would Help? DKA IEM POISONINGS Interact!

25. Step 6 – Measure Respiratory Rate, Heart Rate and Blood Pressure AGEAction RRAction BradycardiaHypotension Term to 3 months> 60 BPM< 100 BPM< 50 mm 4 – 12 months> 50 BPM<100 BPM<60 mm 1 – 4 years> 40 BPM<90 BPM< 70 mm 5 – 12 years> 30 BPM< 80 BPM< 80 mm > 12 years> 30 BPM<60 BPM< 90 mm Warning Signs for Impending Acute Deterioration For warning signs Refer SOS-HOPE APP For warning signs Refer SOS-HOPE APP

26. Measure Temperature Pulse Oximetry Capillary Blood Glucose level

27. Key Values in Practice Pulse > 220/min consider SVT Cap refill > 2 seconds is not normal BP in kids > 1 year = 70 + (2 x age) RR > 60/min NB, > 50/min till 1 yr, > 40 /min till 5 yrs Pulse oximetry < 92% In room air For key values Refer SOS-HOPE APP For key values Refer SOS-HOPE APP

28. Key Values in Practice Blood Glucose < 45mg/dl on day 1 of life newborn < 50mg/dl after day 1 of life in newborn Hypoglycemia in children - < 50mg/dl of whole blood glucose Hypothermia is diagnosed by identification of a core body temperature that is <35°C (95°F) Heat stroke is defined as a core temperature ≥40°C (104°F) accompanied by central nervous system dysfunction in patients with environmental heat exposure For key values Refer SOS-HOPE APP For key values Refer SOS-HOPE APP

29. We Have Done a Rapid Assessment - 6 Steps 1.Ask 2.Look 3.Listen 4.Feel 5.Smell 6.Measure

30. From the Assessment we need to TRIAGE What is the meaning of TRIAGE

31. Triage Levels

32. When Would You Call It Triage Level 1 BEHAVIOUR RESPIRATION CIRCULATION ASK LOOK LISTEN FEEL SMELL MEASURE

33. What to do? Severe Impairment of 1 or More Parameters Unresponsive or altered consciousness or lethargic HR NR +/- 2 SD, RR NR +/- 2 SD (Grossly abnormal) Inadequate breathing Moderate to severe respiratory distress/ marked stridor Shock: CFT > 4 secs, BP lower than normal for age Cyanosis THIS IS AN EMERGENCY: ACT FAST! STABILIZE

34. When Would You Call It Triage Level 2 BEHAVIOUR RESPIRATION CIRCULATION ASK LOOK LISTEN FEEL SMELL MEASURE

35. What to do? Mild-Moderate Impairment of 1 or More Parameters Infant – unconsolable, not feeding, atypical behaviour HR, RR outside NR for age Mild-Moderate stridor Mild distress Capillary refill > 2 sec but < 4 sec OBSERVE CLOSELY, TREAT, MAY DETERIORATE FAST!

36. When Would You Call It Triage Level 3 BEHAVIOUR RESPIRATION CIRCULATION ASK LOOK LISTEN FEEL SMELL MEASURE

37. What to do? Mild or No Impairment of any Parameter No history of recent behavior/appearance change HR & RR - normal for age/mildly deranged CFT < 2 sec BP in normal range for age THIS IS NON URGENT

38. There Are Always Exceptions in any Rule When would you triage a child more serious than he actually is? Interact!

39. Beware !! Sick infant, < 3 months of age Temp > 40 deg C or hypothermia Suspected ingestion of unknown substance or unknown quantity of known substance Severe pain

40. Beware !! Any illness in a child with severe malnutrition Burns: major - > 10% BSA &/or involving airway Purpuric rashes, target lesions Discordant Physical findings MOTHER

41. Case 1 11 months infant presents with Fever 2 days Cough 2 days, sleep disturbed, feeding well, passed urine twice in past 4 hours O/E: Behavior alright, interactive Breathing fast 46/min, mild retractions HR = 118 / min, peripheral pulses are well felt, his CRT < 2 secs, BP is within Normal limits Temp 39.2 deg C, Saturation 94% RS bilat fair AE, rhonchi+ CATEGORIZE Video

42. Case 1 – Response This child has got derangement of a mild nature of his breathing Other parameters are within normal limits

43. Case 2 2 yr old boy presents with Fever & Cough x 4 days Not feeding well, less active, decreased urine output O/E: Behavior Lethargic, Breathing fast 62/min, mod-severe retractions HR = 136/min, peripheral pulses are fast, his CRT 4 secs, BP is within Normal limits Temp 39.8 deg C, Saturation 88% CATEGORIZE Video

44. Case 2 - Response This child is sicker than case # 1, he is hypoxemia, he also may have compensated shock His categorization would be Urgent Action ?

45. Case 3 A 3 yr boy brought with Vomiting & watery loose stools for 3 days, inactive & no urination for past 24 hours O/E: Behavior – drowsy, reacting only to painful stimuli Breathing fast 56/min with intermittent sighing breathing HR = 176/min, peripheral pulses are feeble, his CRT > 5 secs, BP is un-recordable, Temp 35.6 deg, Saturation 82% CATEGORIZE

46. Case 3 - Response Measure his blood sugar. Found to be 20mg/dl This child is in decompensated shock, with probable acidosis, hypoxia, and hypothermia. He may be also in septic shock His category would be Red

47. In Every Sick/Potentially Sick Child ASK Behavior, feeding, urine output LOOK Appearance, Breathing, Circulation, Others LISTEN Speech, Cry, Breathing, MOTHER FEEL Pulses, Warmth, Extremities SMELL MEASURE HR, RR, BP, TEMP, O2 SATN, Blood Sugar

48. In Every Sick / Potentially Sick Child CATEGORIZE 1. Emergency needing Resuscitation 2. Potentially sick, can deteriorate fast 3. Non Urgent ACT 1. Stabilize & transfer 2. Stabilize & Observe closely 3. Treat and Follow up

49. So it is very important to triage a sick child rapidly and either initiate stabilization or resuscitation depending on the severity

50. Liverpool Primary Care Trust, Western Cheshire Basic Principles: III Children Regardless of the aetiology → information required for assessment and management is the same for all children Simple clinical tools are sufficient to recognize sick or potentially sick children kids ‘can deteriorate quickly……so act in time’