SYSTEMATIC APPROACH TO THE SERIOUSLY ILL OR INJURED CHILD

PEDIATRIC ADVANCED LIFE SUPPORT -DR.HARDIK SHAH

Initial impression

• First quick “from the doorway” observation.• This initial visual and auditory observation of

the child’s consciousness, breathing and color is accomplished within seconds of encountering the child.

Initial impression

Consciousness Level of Consciousness(eg. Unresponsive, irritable, alert)

Breathing Increased work of breathing, absent or decreased respiratory effort, or abnormal sounds heard without auscultation

color Abnormal skin color, such as cyanosis, pallor or mottling

Evaluate-Identify-Intervene

• Use the evaluate-identify – intervene sequence.

• Always be alert to a life-threatening problem.• If any point , identify a life-threatening problem,

immediately activate emergency response.

Evaluate Clinical

AssessmentBrief Description

Primaryassessment

A rapid, hands-on ABCDE approach to evaluate respiratory , cardiac and neurologic function; this step includes assessment of vital signs and pulse oxymetry

secondaryassessment

A focused medical history and a focused physical examination

Diagnostic test

laboratory, radiological and other advanced tests that help to identify the child’s physiologic condition and diagnosis

Identify Type severity

Respiratory •Upper airway obstruction•Lower airway obstruction•Ling tissue disease•Disordered control of breathing

•Respiratory distress•Respiratory failure

Circulatory •Hypovolemic shock•Distributive shock•Cardiogenic shock•Obstructive shock

•Compensated shock•Hypotensive shock

Cardiopulmonary failure

Cardiac arrest

Intervene

On the basis of identification of child’s problem, intervene with appropriate action.

• Positioning the child to maintain a patent airway• Activating emergency respone• Starting CPR

obtaining the code cart and monitor• Placing the child on a cardiac monitor and pulse oximeter• Support ventilation• Starting medications and fluids

Primary assessment

Primary assessement uses an ABCDE model:• Airway• Breathing• Circulation• Disabilyty• Exposure

A B

C

D

E

Airway

To assess upper airway patency:• Look for movement of chest or abdomen• Listen for air movement and breath soundsDecide if UA is clear , maintainable or not maintainableSigns suggest UA obstruction:• Increase inspiratory effort with retraction• Abnormal inspiratory sounds• Episodes where no airway or breath sounds are present

despite respiratory effort

Status Description

Clear Airway is open and unobstructed for normal breathing

Maintainable Airway is obstructed but can be maintainable by simple measures (eg head tilt-chin lift)

NotMaintainable

Airway is obstructed but cannot be maintainable without advanced intervention (eg intubation)

Simple measures:• Allow the child to assume a position of comfort or position the child

to improve airway patency• Use head tilt-chin lift or jaw thrust to open the airway:- If cervical spine injury suspect, open airway by using a jaw thrust

without neck extension. If this maneuver does not open the airway, use head tilt-chin lift without neck extension.

• Avoid overextending the head/neck in infants because this may occlude the airway.

• Suction the nose and oropharynx.• Perform foreign- body airway obstruction releif tech if suspect that

child has aspirated foreign body:- <1 yr old, a combination of 5 back blows and 5 chest thrusts - >1 yr old, providers should give a series of 5 abdominal thrusts

(Heimlich maneuver)• Use airway adjuncts (NPA or OPA) to keep the tongue from falling

back and obstructing the airway.

Head tilt-chin lift

Jaw thrust

Advanced interventions• Endotracheal intubation or placement of a laryngeal

mask airway• Application of continuous positive airway pressure

(CPAP) or noninvasive ventilation• Removal of a FB; whis intervention may require

direct laryngoscopy• Cricothyrotomy

Breathing

Assessment of breathing includes:• Respiratory rate• Respiratory effort• Chest expasion and air movement• Lung and airway sound• O2 saturation by pulse oxymetry

Normal respiratory rateAge Breaths / min

Infants (< 1 year) 30 – 60

Toddler (1-3 yrs) 24-40

Preschooler (4-5 yrs) 22-34

School age (6-12 yrs) 18-30

Adolescent (13-18 yrs) 12-16

Abnormal respiratory rate

Tachypnea : • First sign of respiratory distress in infants.• Quite tachypnea- tachypnea without signs of increased

respiratory effort.Bradypnea:• Possible caused are resp muscle fatigue, central nervous

system injury or infection, hypothermia or medication that depress resp drive.

Apnea:• Cessation of breathing for 20 secs or cessation for less than

20 secs if accompanied by bradycardia, cynosis or pallor.

Respiratory effort

• Increase respiratory effort results from conditions that increase resistance to airflow or that cause lungs to be stiffer and difficult to inflate.

Signs of increase respiratory effort include.• Nasal flaring• Retractions• Head bobbing or seesaw raspirations

Nasal flaring:• Dilatation of nostrils with each inhalation.• Most common in infant and younger childrenRetractions:• Inward movement of the chest wall or tissues, neck or

sternum during inspiration.Head bobbing or seesaw respiration:Indicate increased risk of deterioration- Head bobbing- caused by use of neck muscles to assist

breathing.• Most frequently seen in infants and sign of respiratory

failure- Seesaw respiration- chest retract and abdomen expand

during inspiration.

Retractions:Breathing difficulty Location of retraction Description

Mild to moderate subcostal Retraction of abdomen just below ribcage

Substernal Retraction of abdomen at the bottom of breast bone

intercostal Retraction between ribs

Severe Supraclavicular Retraction in the neck just above the collar bone

Suprasternal Retraction in the chest just above breast bone

sternal Retraction of sternum toward the spine

Chest expansion and Air movement

• Evaluate magnitude of chest wall expansion and air movement to assess adequecy of the child’s tidal volume.

• Normal tidal volume- 5-7 ml/kg• Tidal volume is difficult to measure unless a

child is mech ventilated, so clinical assessment imp.

Chest wall expansion:• Chest expansion during inspiration should be symmetric.• Decreased or asymmetric chest expansion may result

from in adequate effort, airway obstruction, atelectasis, pneumothorax, hemothorax, PE, mucosal plug or FB aspiration.

Air movement:• Auscultation for air movement is critical.• Listen for the intensity of breath sounds and quality of

air movement, particularly in the distal lung fields.• Decreased chest excrusion or air movement

accompanies poor resp effort.• Diminished distal air entry suggests air flow obstruction

or lung tissue disease.

Lung and airway sounds

• Stridor: - coarse, usually higher pitched breathing sound

typically heard on inspiration.- Sign of upper airway obstruction- Indicate – obstruction is critical and requires

immediate intervention.Causes: FBAO, Croup , laryngomalacia, tumor or

cyst, upper airway edema

• Grunting- Typically a short, low pitched sound heard during

expiration.- Misinterpreted as soft cry- Sign of lung tissue disease resulting from small

airway collapse or alvelolar collapse.- Indicate progression of RD to RF.- Causes: pneumonia, ARDS, Pulmonary contusion.• Gurgling:- Bubbling sound heard during inspiration or

expiration.- Results from upper airway obstruction d/t airway

secretions, vomting or blood.

• Wheezing- High pitched or low pitched whistling sound heard

most often during expiration.- Indicate lower airway obstruction.- Causes: Bronchiolitis and Asthma• Crackles/ Rales: - Sharp creckling inspiratory sounds.- Dry crackles: atelectasis and interstitial lung

disease..- Moist crackles: indicate accumulation of alveolar

fluid.

Oxygen saturation by pulse oxymetry

• Monitor the % of HB that is saturated with O2.(SPo2)

• Interpret pulse oxymetry readings in conjuction with clinical assessment and other signs.

• Pulse oxymeter does not accurately recognize methemoglobin or carboxyHB.

Circulation

Circulation assessed by evaluation of • Heart rate and rhythm• Pulse• Capillary refill time• Skin color and temp• Blood pressure

Heart rate and rhythmAge Awake rate mean

New bon to 3 months

85-205 140

3 month to 2 yrs 100-190 130

2 yrs to 10 yrs 60-140 80

> 10 yrs 60-100 75

Bradycardia: heart rate slower than normal for child’s age.

- Most common cause- hypoxia- If bradycardia associated with poor perfusion

immediately support ventilation wth B&M and administer supplementry O2..

Tachycardia: heart rate faster than normal for child’s age.

Pulses:

• Evaluation of pulses is critical to assessment of systemic perfusion in an ill or injured child.

• Palpate both central and peripheral pulses.Central pulses: Brachial (In infants) , Carotid (older

children) , femoral , axillaryPeripheral: radial, dorsalis pedis , post. tibial.• Weak central pulses are worrisome and indicate need

for very rapid intervention to prevent cardiac arrest.• Beat to beat fluctuation in pulse volume may occur in

children with arrythemias.

Capillary refill time

• Time takes for blood to return to tissue blanched by pressure.

• Increase as skin perfusion decrease.• Prolonged CFT indicate low cardiac out put.• Normal CFT <= 2• To evaluate CFT lift extremity slightly above

the level of the heart, press on the skin and rapidly release the pressure.

Skin color and Temperature

• Mucous membrane, nail beds, palms and soles should be pink.

• When perfusion deteriorates and O2 delivery to tissue becomes inadequate the hands and feet are typically affected 1st.

• They may become cool , pale, dusky or mottled.• If perfusion become worst skin over the trunk

and extremities may under go similar changes.

• Pallor: - Decreased blood supply to the skin (cold, stress,

shock )- Anemia- Decreased skin pigmentation• Mottling:- Irregular or patchy discoloration of the skin.- Serious condition such as hypoxemia, hypovolemia

or shock, may cause intense vasoconstriction from an irregular supply of oxygenated blood to the skin, leading to mottling.

• Cyanosis:- Peripheral cyanosis: bluish discoloration of hands

and feet. Seen in shock , CCF , PVD- Central cyanosis: bluish discoloration of lips and

other mucous membranes. - Causes :- low ambient O2 tension -alveolar hypoventilation -diffusion defect -ventilator/ persion imbalance -intracardiac shunt

Blood pressure

• Cuff bladder should cover about 40% of the mid upper arm circumference.

• BP cuff should extend at least 50-75% of the length of the upper arm.

Hypotension

Age Systolic blood pressure (mmhg)

Term neonate(0- 28 days)

< 60

Infants (1-12 months)

<70

Children (1-10 yrs)

< 70 + (age in yrs x 2 )

Children > 10 yrs < 90

Disability

• Disability assessment is a quick evaluation of neurologic function.

• Clinical signs of brain perfusion are imp indicators of circulatory function in the ill or injured patient.

• Signs include level of consciousness, muscle tone and pupil response.

• Signs of inadequate O2 delivery to the brain correlate with the severity and duration of cerebral hypoxia.

• Standard evaluations include- AVPU pediatric response scale- GCS- Pupil response to light

• Mild head injury- GCS score 13-15• moderate head injury- GCS score 9-12• Mild head injury- GCS score 3-8

Pupils response to light

• Indicator of brainstem function.• If the pupils fail to constrict in response to

direct light, suspect brain stem injury.• Irregularities in pupil size or response to light

may occur as result of ocular trauma or ICP.Assess and record size of pupils , equality of

pupil size , constriction pupil to light.

Exposure

• Undress the seriously ill and injured child as necessary to perform a focused physical examination.

• Maintain cervical spine precaution when turning any child with suspected neck or spine injury.

• Assess core temperature and maintain temp.• Look any trauma such as bleeding , burns and

unusual marking that suggest nonaccidental trauma.• Look for petechiae and purpura s/o septic shock

Secondary assessement

• Focused history• Focused physical examination

• Focused history: to identify imp aspects of the child’s presenting complaint.

- Signs and symptoms: breathing difficulty, decrease level of consciousness, agitation, anxiety, fever, decrease oral intake, diarrhea, vomiting , bleeding , fatigue, time course of symptoms

- Allergies: medication, foods , latex- Medications: name of drug, duration, last dose- Past medical history: Health history (premature birth),

Significant underlying medical problem, Past surgeries , Immunization

- Last meal: time and nature of last intake of lipid or food- Events: event leading to current illness or injury, hazards at

scene , treatment during interval from onset of disease or injury until evaluation, estimated time of arrival

Diagnostic test

• ABG• VBG• HB• Central venous O2 saturation• Arterial lactate• Central venous pressure monitoring• Invasive arterial pressure monitoring• Chest X-ray• ECG• Echocardiography• Peak expiratory flow rate

ABG/ VBG:- Measures Pao2 and paco2 dissolved in blood

plasma. Measurement indicates

Pao2 Adequacy of O2 tension in arterial blood

Paco2 Adequacy of ventilation

Diagnosis ABG result

Hypoxemia Low pao2

Hypercarbia High paco2

Acidosis PH < 7.35

Alkalosis PH >7.45

• Hemoglobin concentration:- Determine O2 carrying capacity of blood.• Central Venous Oxygen Saturation:- Venous blood gases may provide a useful indicator of changes in

balance between O2 delivery to the tissues and tissue O2 consumption.

- Normal SvO2 is about 70 – 75%, assuming arterial O2 saturation is 100%.

• Arterial lactate:- concentration of lactate reflect the balance between lactate

production and use.- Good prognostic indicator.- With the treatment of shock lactate concentration should

decrease.- Lack of response to therapy is more predictive of poor outcome

than the initial elevated lactate concentration.

• Central Venous Pressure monitoring:- Central venous pressure can be monitor through a

central venous catheter.- Measurement of CVP may provide helpful

information to guide fluid and vasoactive therapy.• Invasive arterial Pressure monitoring:- Require arterial catheter , monitoring line ,

transducer and monitoring system.- Enable cont evaluation and display of the SBP and

DBP.- Arterial waveform pattern may provide information

about SVR and visual indication of compromised cardiac out put.

• CXR: - Useful in respiratory illness- airway obstruction,

lung tissue disease, barotraumas, pleural disease.- Evaluation of circulatory abnormality to assess

heart size and presence or absence of CCF.• ECG: - To assess for cardiac arrhythmias.• Echocardiogram:- Noninvasive cardiac imaging- Cardiac chamber size, ventricular wall thickness,

ventricular wall motion, valve configuration, pericardial space, estimated ventricular pressure etc

• Peak expiratory flow rate:- Represents the maximum flow rate generated

during forced expiration.- Decreases in the presence of airway obstruction.