Helps in easy recognition of sick children during your emergency duties and even in OPD's. Brief description along with pictures.

1. Recognition of a Sick
Child
Dr. Ankur Puri
Pediatric Intensivist
Amritdhara Hospital

2. Children are not simply “Miniature Adults.”
• Bones are much more likely to bend than break
• Tongues take up a larger percentage of their oral cavities
• Airways are sufficiently narrow that even slight inflammation
can cause distress
• Blood volume—which is significantly smaller than that of
adults—is another differentiator

3. EARLY RECOGNITION OF CRITICAL ILLNESS
AND PROMPT TREATMENT CAN SAVE LIVES!
The initial assessment will answer the question
Sick or not sick?

4. Early recognition and management of potential
respiratory, circulatory, or central neurological failure will
reduce mortality and secondary morbidity

5. SICK CHILD
Critical illness or sickness is a clinical state
that may result in respiratory or cardiac arrest
or severe neurological complication if not treated
properly

6. EVALUATE
IDENTIFYINTERVENE

7. CARDIOPULMONARY ASSESSMENT
• Initial impression(Hands free): Appearance
Breathing,
Circulation
• Primary assessment : ABCDE assessment
• Secondary assessment : Focused history,
thorough physical examination
• Diagnostic tests: Lab tests,
radiology etc.

8. First assessment or Doorway assessment
Circulation to Skin
Work of
BreathingAppearance

9. PEDIATRIC EARLY WARNING SCORE

10. PEDIATRIC EARLY WARNING SCORE
• General examination is the most important part of physical
examination - begins the moment the clinician sees the patient.
• Young children are unable to verbalize their complaints – so
evaluation by a health care provider depends upon general and
specific features.

11. PEDIATRIC EARLY WARNING SCORE
• Many of early signs of distress are subtle – early recognition can
increase the likelihood that timely intervention will be successful and
more serious disease progression will be prevented.
• A PEWS score >= 3 should prompt an escalation in care, such as
information senior staff, increasing the frequency of vital sign checks
and clinical assessments, and/or transfer to an ICU.

12. Appearance
• Unresponsive
• Irritable
•Consolable
•Non consolable
• Alert

13. Appearance
Unresponsive

14. Appearance
• Irritable
• Non consolable
• Consolable

15. Appearance
Alert

16. • Observe
oAbnormal airway
sounds
oAbnormal
positioning
oRetractions
oFlaring
Work of Breathing

17. Circulation to skin
•Bad sign
⁻ Pallor
⁻ Mottling
⁻ Cyanosis
⁻ Petechiae
⁻ Purpura
(In children with dark skin tones look at the lips, tongue, palms or soles)

18. Circulation to skin
Mottling

19. Circulation to skin
Cyanosis

20. Circulation to skin
Petechiae &
Purpura

21. Primary Assessment
• Hands-on evaluation (in contrast to PAT)
• Airway
• Breathing
• Circulation
• Disability
• Exposure
A B
C
D
E

22. Rapid cardiopulmonary assessment
(Time is of essence!)
Quick head to toe examination is essential
“Treat as you go”

23. Airway
• Use look, listen, feel
• Any adventitious breath sounds including hoarseness, cough,
stridor, snoring, or gurgling sounds.
• Status
• Clear
• Maintained by simple measures
• Needs advance measures (Call for experts)
A B
C
D
E

24. Breathing
1.Respiratory rate
2.Respiratory effort
3.Chest wall expansion
4.Lung and airway sounds
5.Pulse oximetry
A B
C
D
E

25. Breathing
RESPIRATORY RATE
• Tachypnea is the first sign of respiratory distress
• Bradypnea is more ominous than tachypnea
• RR above 60 or below 10 at any age group: Significant
A B
C
D
E

26. Breathing
RESPIRATORY EFFORT
• Nasal flaring
• Retractions
• Sea‐saw breathing, head bobbing
• Retractions with stridor: Upper airway obstruction
• Retractions with wheeze: Lower airway obstruction
• Grunting: Lung tissue disease
A B
C
D
E

27. Breathing
A B
C
D
E

28. Breathing
A B
C
D
E

29. Breathing
Respiratory
Distress,
head
bobbing
A B
C
D
E

30. Breathing
Impending
Respiratory
Failure
A B
C
D
E

31. Breathing
Chest wall expansion
• Chest wall expansion and air movement
• Look for symmetrical chest rise
• Auscultate to listen air entry in distal areas of lungs
A B
C
D
E

32. Breathing
Lung and airway sounds
• Stridor
• Grunting
• Gurgling
• Wheeze
• Crackles
A B
C
D
E

33. Breathing
PULSE OXIMETRY
•Oxygen saturation (sPO2)>94% in room air : Adequate
oxygenation.
•SPO2 <90% while on 100% oxygen : Additional interventions
required.
A B
C
D
E

34. RESPIRATORY INSUFFICIENCY :
CATEGORISATION BY SEVERITY
Distress
• Tachypnea
• Tachycardia
• Increased work of
breathing
• Abnormal airway sounds
Failure
• Marked
tachypnea/bradypnea Apnea
• Bradycardia
• Increased or decreased work
of breathing
• Cyanosis
• Altered sensorium
A B
C
D
E

35. Cardiovascular assessment
• Heart Rate (ECG rhythm)
• Central and peripheral pulses
• CRT (capillary refill time)
• Core to peripheral temperature difference
• Urine output
• Blood pressure
Normal blood pressure and a strong central pulses are maintained in
compensated shock
A B
C
D
E

36. Cardiovascular assessment
A B
C
D
E
Palpation of Central and Distal Pulses

37. Cardiovascular assessment
•Normal: < 2 seconds
•Consider ambient environmental conditions while interpreting capillary refill
A B
C
D
E
Capillary Refill Time

38. Cardiovascular assessment
A B
C
D
E
Brisk CRT

39. Cardiovascular assessment
Blood Pressure
A B
C
D
E
Hypotension
AGE SYTSOLIC BP ( mmHg )
Term Neonates (0 -28 days ) < 60
Infants ( 1 -12 months ) < 70
Children 1- 10 years 70 + ( age x 2 )
Children > 10 years < 90

40. Cardiovascular assessment
Urine Output
Indirect indicator of cardiac output
Indicates kidney perfusion
Helps to monitor response to treatment
A B
C
D
E

41. Cardiovascular assessment
Compensated
• Tachycardia
• Cool pale skin
• Delayed CRT
• Weak peripheral pulses
• Narrow pulse pressure
• Oliguria
Hypotensive
• BP below 5th centile
• Change in mental status
A B
C
D
ECIRCULATORY INSUFFICIENCY: CATEGORIZATION BY
SEVERITY

42. Disability
• Quick evaluation of cerebral cortex & brainstem
• Evaluate during Primary as well as Secondary Assessment –
to monitor changes in neurologic status:
• AVPU
• GCS
• Pupillary response to light
Continued spinal immobilization with trauma patients
A B
C
D
E

43. A B
C
D
E

44. EXPOSURE
Undress as appropriate
Avoid exposure to cold environment
Look for deformities / bruises / bleeds/fever or hypothermia
A B
C
D
E

45. PRIMARY ASSESSMENT CLASSIFICATION OF
SEVERITY
Respiratory insufficiency: Respiratory distress/failure
Circulatory failure‐compensated or hypotensive

46. PRIMARY ASSESSMENT CLASSIFICATION OF
TYPE
Identify
Type Severity
Respiratory Problem Upper airway obstruction
Lower airway obstruction
Lung parenchymal disease
Disordered control of
breathing
Respiratory Distress
Circulatory Problem Hypovolemic
Distributive
Cardiogenic
Obstructive
Compensated Shock
Hypotensive Shock

47. SECONDARY ASSESSMENT
Focused history
Focused physical examination

48. SECONDARY ASSESSMENT FOCUSED
HISTORY, EXAMINATION
•Symptoms
•Allergies
•Medications
•Past history
•Last meal
•Events leading to the present problem

49. DIAGNOSTIC TESTS
Appropriate Laboratory investigations/Radiology

50. MANAGEMENT PRIORITIES
Depend on the physiological status
• Stable
• Respiratory distress/failure
• Circulatory failure‐Compensated/Hypotensive
• Cardiopulmonary failure/arrest

51. STABLE CARDIOPULMONARY STATUS
• Begin further work up
• Provide specific therapy as indicated
• Reassess frequently

52. PRIORITIES OF INITIAL MANAGEMENT
Respiratory distress
• Keep with the caregiver
• Position of comfort
• Oxygen as tolerated
• Nothing by mouth
• Monitor pulse oximetry
• Consider cardiac monitor
Respiratory failure
• Control airway
• 100% Fio2
• Assist ventilation
• Nothing by mouth
• Monitor pulse oximetry
• Consider cardiac monitor
• Establish vascular access

53. PRIORITIES OF INITIAL MANAGEMENT
Shock
• Administer 100% oxygen and ensure adequate airway
and ventilation
• Establish vascular access
• Provide volume expansion
• Monitor oxygenation, heart rate, and urine output
• Consider vasoactive infusions

54. Initial stabilisation
• Things recommended at all practice locations (hospital or private practice
clinic):
• Oxygen source and mask
• Bag mask valve device (Ambu)
• Intubating equipment
• Intra-osseous needle
• Iv cannula, Iv fluids, Emergency drugs
• Suction
• Pulse oximeter
• Nebulizer

55. Once the critically ill child is recognized:
Do not waste time in detailed investigations and diagnosis.

56. Do the following regardless of diagnosis
• Start oxygen
• If respiratory distress
• Ensure airway
• open by head tilt chin lift
• jaw thrust
• If not maintainable intubate.
• If can not intubate ventilate with bag and mask
• If not able to maintain with bag and mask the use LMA

57. TAKE HOME MESSAGE
Rapid cardiopulmonary assessment & appropriate initial
treatment improves survival in critically ill children