1. Pediatric Critical Care Division Child Health Department, Faculty of Medicine University of Indonesia

2. Emergency sign Priority sign Non Urgent Triage

3. Emergency sign CNS Respiratory Cardiovascular Gastrointestinal Endocrine Etc

4. PAT ABCDE

5. The PAT Appearance Work of Breathing Circulation to Skin

6. Appearance (“Tickles” =TICLS) Tonus Interactiveness Consolability Look/Gaze Speech/Cry Appearance

7. Work of Breathings Abnormal airway sounds Abnormal positioning Retractions Nasal flaring

8. Pallor Mottling Cyanosis Circulation to Skin

9. Respiratory distress N N N  Cardiopulmonary failure // Shock NN NN Primary CNS dysfunction/ metabolic abnormality NN NN N N NN

10. The ABCDEs Airway Breathing Circulation Disability Exposure

11. Airway Assessment  Clear  Maintainable  Unmaintainable without intubation  Obstructed

12. Breathing Assessment  Rate  Effort / mechanics  Air entry  Skin color

13. Respiratory Rate by Age Age (years) Respiratory rate (breaths per minute) <1 2-5 5-12 >12 30-40 20-30 15-20 12-16

14. Circulation Assessment  Heart rate  Systematic perfusion  Peripheral pulses  Skin perfusion  Appearance  (Urine output)  Blood pressure

15. Heart Rate by Age AgeRange Newborn – 3 mos 85 – 200 bpm 3 mos – 2 yrs100 – 190 bpm 2 – 10 yrs 60 – 140 bpm

16. Skin Perfusion  Extremity temperature  Capillary refill  Color  Pink  Mottled  Pale  Blue

17. Minimal Systolic Blood Pressure by Age Age Fifth percentile mmHg Systolic BP 0 – 1 Mo60 > 1 mo – 1 yr70 > 1 yr70 + (2 x age in years)

18. Disability (neurologic status)  Cerebral cortex  Brain Stem  Motor activity

19. Level of Consciousness  A = Awake  V = Responsive to voice  P = Responsive to pain  U = Unresponsive

20. Brain Stem  Posture  Central respiration  Pupil response  Cranial nerve

21. Motor Activity  Symmetrical movements  Seizures  Posturing  Flaccidity

22. Exposure  Skin rashes  Bruises  Excoriation  etc.

23. Stable Respiratory dysfunction Potential respiratory failure Probable respiratory failure Shock Compensated Decompensated Cardiopulmonary failure Classification of Physiologic status

24. Case Scenario 1 15-month-old child History  Diarrhea, vomitting for 3 days  Refused bottle this morning  Sleepy, lethargic today

25. Physical Examination  PAT: A : Very lethargic child in mother’s lap WB: Normal CS : mottled  ABC A : clear B : RR 45/min, breath sounds clear bilaterally C : HR 178 regular, BP 90 mmHG systolic, CRT : > 4 sec, Temp 38 o C Weak peripheral pulses Cool, mottled extremities,dry mucous membranes CNS: V

26. What would be your approach to this patient?

27. UKKPGD IDAI 27 Initial Approach to the Patient in Shock  Evaluate the ABCs  Deliver high concentration of oxygen  Monitor oxygenation and heart rate  Achieve vascular access

28. UKKPGD IDAI 28 Case Scenario 1: progression  The patient receives oxygen and is placed on a monitor; attempts at peripheral vascular access fail What would you do now?

29. UKKPGD IDAI 29 What fluid would you give? How much and how fast?

30. Treatment of Shock Initial rapid fluid administration of 20 mL/Kg of:  Crystalloid  Colloid  Blood